Type I interferons, inflammation, and fatigue in a longitudinal RNA study of women with breast cancer

BACKGROUND

Fatigue is a common side effect of cancer and its treatment and is thought to be driven in part by activation of the proinflammatory cytokine network. However, the cellular and molecular underpinnings of cancer-related fatigue (CRF) have not been determined, nor have immune pathways beyond inflammation been carefully investigated. The goal of this study was to examine the association between CRF and activation of canonical proinflammatory gene regulation pathways and Type I interferon (IFN) signaling pathways in breast cancer patients during and after treatment.

METHODS

Women diagnosed with early-stage breast cancer (n = 181) completed assessments before and after treatment with radiation and/or chemotherapy and at 6, 12, and 18-month post-treatment follow-ups. Assessments included self-reported fatigue (Multidimensional Fatigue Symptom Inventory - Short Form) and expression of pre-specified sets of Type I IFN and pro-inflammatory immune response genes determined from mRNA sequencing of PBMCs. Mixed effect linear models examined changes in fatigue and immune gene expression over time and tested the hypothesis that fatigue would be associated with increased expression of Type I IFN and inflammatory response genes.

RESULTS

There were significant changes in fatigue and immune gene expression across the assessment period; all measures increased from pre- to post-treatment but showed diverging patterns over the follow-up, with declines in fatigue and persistent elevations in Type I IFN and proinflammatory gene expression. In mixed effect linear models, expression of Type I IFN response genes was elevated in association with fatigue across the assessment period, from pre-treatment to 18-month follow-up. In contrast, pro-inflammatory gene expression was associated with fatigue only at 6, 12, and 18-month follow-ups. Analyses controlling for changes in leukocyte subsets continued to show a significant association between fatigue and Type I IFN gene expression but reduced the time-dependent association with pro-inflammatory gene expression to non-significant.

CONCLUSIONS

Results revealed unexpected complexity in the immune underpinnings of CRF and identify a novel role for IFN signaling as a robust contributor to this symptom before, during, and after treatment. Pro-inflammatory gene expression emerged as a predictor of fatigue later in the cancer trajectory, and that effect was primarily accounted for by a concurrent increase in monocyte prevalence.

Work Productivity Among Younger Breast Cancer Survivors: The Impact of Behavioral Interventions for Depression

OBJECTIVES

The Pathways to Wellness randomized controlled trial found that 2 behavioral interventions, mindfulness awareness practices and survivorship education, reduced depressive symptoms in younger breast cancer survivors (BCSs) compared with wait-list control. This secondary analysis examines whether the interventions led to reduced loss of work productivity among younger BCSs and whether such reductions were mediated by reductions in depressive symptoms.

METHODS

The Work Productivity and Activity Impairment scale was used to measure work productivity loss at 4 assessment time points. Correlates of productivity loss at enrollment were examined using multivariable linear regression. Differences in change over time in productivity loss between each intervention group and control were assessed using linear mixed models. Reduced depressive symptoms were tested as a mediator of reduced productivity loss.

RESULTS

Of 247 trial participants, 199 were employed and included in the analyses. At enrollment, higher productivity loss was associated with chemotherapy receipt (P = .003), younger age (P = .021), more severe cognitive problems (P = .002), higher musculoskeletal pain severity (P = .002), more depressive symptoms (P = .016), and higher fatigue severity (P = .033). The mindfulness intervention led to significantly less productivity loss compared with control at all 3 postintervention assessment points (all P < .05), with about 54% of the effect mediated by reduction in depressive symptoms. Survivorship education was not associated with reduced loss of productivity.

CONCLUSIONS

These findings suggest that addressing depressive symptoms through behavioral interventions, such as mindfulness, may mitigate impacts on work productivity in younger BCSs.

Survivorship care in breast cancer: understanding implementation barriers through the lens of the Theoretical Domains Framework

BACKGROUND

Breast cancer survivorship guidelines with specific recommendations on managing long-term effects are available, but uptake in clinical practice remains low. Using the lens of the Theoretical Domains Framework, we aimed to understand key factors in guideline-concordant management of long-term effects to inform future implementation efforts in clinical practice contexts.

METHODS

As part of a broader survey of oncologists, a theory-guided questionnaire was developed. Oncologists were asked to report level of agreement with Theoretical Domains Framework-based statements, current usage and perceived value of survivorship resources, and frequency of managing long-term effects in routine care. Data analyses included psychometric assessment of the questionnaire, descriptive summaries of theoretical domains and survivorship resources, and multivariable logistic regression models.

RESULTS

In total, 217 oncologists completed the Theoretical Domains Framework-based questionnaire; 54% of oncologists reported "always or almost always" evaluating physical effects at routine survivorship appointments, while 34% did so for psychosocial effects. In regression models, Environmental Context and Resources was the only theoretical domain found to be statistically significantly associated with "always or almost always" evaluating both physical (odds ratio = 0.29, 95% confidence interval = 0.09 to 0.80) and psychosocial (odds ratio = 0.09, 95% confidence interval = 0.02 to 0.35) effects.

CONCLUSIONS

Findings support application of the Theoretical Domains Framework in understanding oncologists' behaviors and perceived barriers in managing long-term effects in breast cancer survivors. In future implementation efforts, this theory-informed approach can be used to target relevant domains and strategies focused on embedding guideline recommendations in the clinical context through structured resources and environmental supports.

Abstract B021: Breast cancer survivors and expression of p16INK4a, DNA damage, and the SASP prior to and following treatment

Purpose: To examine whether breast cancer therapy accelerates aging via increasing expression of cellular senescence (p16INK4a), the DNA damage response (DDR), or the proinflammatory senescence associated secretory phenotype (SASP), we measured gene expression of these pathways in a cohort of women recruited following a diagnosis of breast cancer (Stage 0-III). Methods: The RISE study is a Los Angeles-based longitudinal, observational study of biological and behavioral processes following surgery, radiation (RT) and/or chemotherapy (CT); and more persistent changes in these processes in the months after adjuvant treatment completion and initiation of endocrine therapy (6, 12, 18 month post-treatment follow-ups). Of the 270 women enrolled in the study, gene expression data was available for 184 women (aged average of 55.5 years, SD 11.2). Peripheral blood mononuclear cells (PBMC) gene expression was determined using RNA sequencing on quality-verified RNA. We determined transcript abundance for cellular senescence marker p16INK4a, genes that express proteins of the SASP, and genes responsive to DNA damage. Longitudinal data for p16INK4a, DDR and SASP were modeled using mixed models, including a quadratic term for time and its interaction with four treatment groups (1: Surgery alone [no RT or CT], RT alone, CT alone, and CT+RT), and a zero-inflated two-part model with p16INK4a. Covariates included age, BMI, race, initial surgery type, receipt of interim surgery, and endocrine therapy. Results: Analyses testing whether there was a change in p16INK4a over time by treatment group revealed that all groups experienced increases in p16INK4a expression over time. At baseline 53% of women had no detectable p16INK4a transcripts in their PBMC samples, and this proportion changed over time across all groups indicating significant increases in women expressing the marker for cellular senescence, p&lt;0.0001. Women receiving CT or CT+RT had a 40% and 36% increase in percentage expressing p16INK4a (26% increase among those with surgery alone and 31% for RT alone) by 18 months post treatment compared to their pretreatment values. Analyses found a significant initial increase in DDR over time in all groups (p's&lt;0.002) followed by a deceleration in all three groups except CT+RT, which continued an upward trajectory. There were also significant increases in SASP across all groups (p’s&lt;0.05), with a significant quadratic effect in the RT group only (p&lt;0.001). Conclusions: These results indicate that there was activation of genes associated with acceleration of biological aging across all groups after breast cancer diagnosis. Survivors had increases in p16INK4a, DNA damage response genes, and SASP from pre to 18 months post treatment for breast cancer. (NCI R01 CA237535)

Citation Format: Judith E. Carroll, Catherine M. Crespi, Laura Petersen, Julie E. Bower. Breast cancer survivors and expression of p16INK4a, DNA damage, and the SASP prior to and following treatment [abstract]. In: Proceedings of the AACR Special Conference: Aging and Cancer; 2022 Nov 17-20; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2022;83(2 Suppl_1):Abstract nr B021.

Improving biobehavioral health in younger breast cancer survivors: Pathways to Wellness trial secondary outcomes

BACKGROUND

The Pathways to Wellness trial tested the efficacy of 2 interventions for younger breast cancer survivors: mindful awareness practices (MAPs) and survivorship education (SE). This planned secondary analysis examines intervention effects on stress, positive psychological outcomes, and inflammation (Clincaltrials.gov NCT03025139).

METHODS

Women diagnosed with breast cancer at or before age 50 years who had completed treatment and had elevated depressive symptoms were randomly assigned to 6 weeks of MAPs, SE, or wait-list control (WLC). Assessments conducted at pre- and postintervention and at 3- and 6-month follow-up measured general stress perceptions, cancer-related intrusive thoughts and worry, positive affect, meaning and peace in life, altruism and empathy, and markers of inflammation. Analyses compared change in outcomes over time in each intervention group relative to WLC using linear mixed models.

RESULTS

A total 247 women were randomly assigned to MAPs (n = 85), SE (n = 81), or WLC (n = 81). MAPs statistically significantly decreased intrusive thoughts and worry at postintervention and 3-month follow-up relative to WLC (P < .027) and statistically significantly increased positive affect and meaning and peace at postintervention, with positive affect persisting at 3-month follow-up (P < .027). SE statistically significantly decreased intrusive thoughts at 3-month follow-up and statistically significantly increased positive affect at 6-month follow-up relative to WLC (P < .01). Proinflammatory gene expression increased in WLC relative to MAPs (P = .016) but did not differ from SE. There were no intervention effects on other outcomes.

CONCLUSION

MAPs had beneficial effects on psychological and immune outcomes in younger breast cancer survivors and is a promising approach for enhancing biobehavioral health.

Oncologist-reported frequency of managing specific long-term and late effects in breast cancer survivors

193

Background: Breast cancer survivors may experience a broad range of physical and psychosocial long-term and late effects. Although disease-specific guidelines for breast cancer survivorship care are available, systematic approaches remain a challenge in clinical practice. The purpose of this study was to describe variations in how medical oncologists assess and manage specific long-term and late effects in breast cancer survivors. Methods: This study is a secondary analysis of data from a survey of medical oncologists about breast cancer survivorship care in the United States. Using a study-specific list, oncologists were asked to report the “most common” and “most distressing” concerns of breast cancer survivors in their clinical practice, as well as the frequency at which they assess and manage 16 specific long-term and late effects in routine survivorship care. Data was analyzed using descriptive statistics to rank perceived patient concerns and compare practice variations across specific post-treatment issues. Results: Data from 215 surveys were included. Oncologists perceived anxiety, fatigue, neuropathy, and menopausal symptoms as top-ranking common and distressing concerns in breast cancer patients. When asked how often they assess and manage specific long-term and late effects in routine survivorship visits, oncologists reported the highest frequency for neuropathy (55%), bone health (54%), and pain (52%), and the lowest frequency for cognitive impairment (19%), sexual dysfunction (15%), and body image concerns (13%). Cognitive impairment and body image were perceived as the fourth and fifth most distressing issues that breast cancer survivors face, yet oncologists reported routine assessment and management less than 20 percent of the time. Conclusions: Findings from this analysis indicate that oncologists routinely assess and manage certain long-term and late effects, while others remain neglected. Important disconnects between perceived patient concerns and the issues that are routinely addressed in clinical practice were also identified. Standardized approaches that incorporate brief patient-reported assessments across multidimensional issues may facilitate comprehensive, guideline-concordant survivorship care.[Table: see text]

Acute and chronic effects of adjuvant therapy on inflammatory markers in breast cancer patients

Background

Inflammation contributes to poor behavioral, functional, and clinical outcomes in cancer survivors. We examined whether standard cancer treatments—radiation and chemotherapy—led to acute and persistent changes in circulating markers of inflammation in breast cancer patients.

Methods

A total of 192 women diagnosed with early stage breast cancer provided blood samples before and after completion of radiation and/or chemotherapy and at 6-, 12-, and 18-month posttreatment follow-ups. Samples were assayed for circulating inflammatory markers, including tumor necrosis factor-α (TNF-α) and interleukin (IL)–6, downstream markers of their activity (soluble TNF receptor type II [sTNF-RII], C reactive protein), and other inflammatory mediators (IL-8, interferon-γ [IFN-γ]). Analyses evaluated within-group changes in inflammatory markers in 4 treatment groups: no radiation or chemotherapy (n = 39), radiation only (n = 77), chemotherapy only (n = 18), and chemotherapy with radiation (n = 58).

Results

Patients treated with chemotherapy showed statistically significant increases in circulating concentrations of TNF-α, sTNF-RII, IL-6, and IFN-γ from pre- to posttreatment, with parameter estimates in standard deviation units ranging from 0.55 to 1.20. Those who received chemotherapy with radiation also showed statistically significant increases in IL-8 over this period. Statistically significant increases in TNF-α, sTNF-RII, IL-6, IFN-γ, and IL-8 persisted at 6, 12, and 18 months posttreatment among patients treated with chemotherapy and radiation (all P < .05). Patients treated with radiation only showed a statistically significant increase in IL-8 at 18 months posttreatment; no increases in any markers were observed in patients treated with surgery only.

Conclusions

Chemotherapy is associated with acute increases in systemic inflammation that persist for months after treatment completion in patients who also receive radiation therapy. These increases may contribute to common behavioral symptoms and other comorbidities in cancer survivors.

Preparing railway stakeholders against CBRNe threats through better cooperation with security practitioners

This paper presents partial results from the Horizon2020 PROACTIVE project, following a set of literature reviews and surveys conducted with first responder organisations and rail security experts. Qualitative and quantitative data from two surveys are being presented. The results provide an overview of the CBRNe (Chemical, Biological, Radiological, Nuclear and explosive) preparedness and response capabilities of railway stakeholders and how these relate to a wider context represented by CBRNe first responders. The results highlight a set of challenges as well as five core skills that railway staff need to develop or improve: 1) understand the specific characteristics of the CBRNe threat, 2) develop basic response measures, 3) cooperate with authorities and train with specialised first responders, 4) improve public awareness about this threat, and 5) optimise crisis communication. In line with these, project PROACTIVE will further help update rail crisis management plans with practical recommendations concerning the CBRNe threat.

Current practice patterns and gaps in guideline-concordant breast cancer survivorship care

PURPOSE

Breast cancer-specific survivorship care guidelines for the more than 3.8 million survivors in the U.S. are available, but implementation in clinical practice remains challenging. We examined current practice patterns and factors associated with guideline-concordant survivorship care among oncologists.

METHODS

A national sample of medical oncologists, recruited using two databases, participated in a survey focused on practice patterns for breast cancer survivorship care. A "survivorship care composite score" was calculated for each respondent based on provision of services recommended in the survivorship guidelines. Descriptive statistics and multivariable linear regression analyses examined associations between physician and practice characteristics and composite scores.

RESULTS

The survey was completed by 217 medical oncologists, with an overall response rate of 17.9% and eligibility rate of 56.9% for those who responded. Oncologists reported high engagement in evaluation of disease recurrence (78%). Performed less frequently were the provision of survivorship care plans (46%), assessment of psychosocial long-term and late effects (34%), and screening for subsequent cancers (34%). Lack of survivorship care training (p = 0.038) and not routinely informing patients about potential late effects (p = 0.003) were significantly associated with poorer survivorship care composite scores.

CONCLUSIONS

Despite the availability of disease-specific survivorship care guidelines, adherence to their recommendations in clinical practice is suboptimal. Survey results identified key gaps in survivorship care for breast cancer survivors, particularly related to subsequent primary cancers and psychosocial long-term and late effects.

IMPLICATIONS FOR CANCER SURVIVORS

Improving the delivery of comprehensive survivorship care for the growing population of breast cancer survivors is a high priority. Disease-specific clinical guidelines for cancer survivorship provide valuable recommendations, but innovative strategies are needed to integrate them into the care of long-term breast cancer survivors.

Targeting Depressive Symptoms in Younger Breast Cancer Survivors: The Pathways to Wellness Randomized Controlled Trial of Mindfulness Meditation and Survivorship Education

PURPOSE

Younger women are at risk for depression and related symptoms following breast cancer. The Pathways to Wellness study, a randomized, multi-institution, three-arm trial, tested the efficacy of two behavioral interventions for younger breast cancer survivors with elevated depressive symptoms: mindful awareness practices (MAPs) and survivorship education (SE) (Clincaltrials.gov identifier: NCT03025139).

METHODS

Women diagnosed with breast cancer at or before 50 years of age who had completed treatment and had elevated depressive symptoms were randomly assigned to 6 weeks of MAPs, SE, or wait-list control (WLC). Assessments were conducted preintervention and postintervention and at 3-month and 6-month postintervention follow-ups. Analyses compared each intervention to WLC using linear mixed models. The primary outcome was change in depressive symptoms from preintervention to postintervention on the Center for Epidemiologic Studies-Depression Scale; secondary outcomes included change in fatigue, insomnia, and vasomotor symptoms.

RESULTS

Two hundred forty-seven women (median age = 46 years) were randomly assigned to MAPs (n = 85), SE (n = 81), or WLC (n = 81). MAPs and SE led to significant decreases in depressive symptoms from preintervention to postintervention relative to WLC (mean change relative to WLC [95% CI]: MAPs, -4.7 [-7.5 to -1.9]; SE, -4.0 [-6.9 to -1.1]), which persisted at 6-month follow-up for MAPs (mean change relative to WLC [95% CI]: MAPs, -3.7 [-6.6 to -0.8]; SE, -2.8 [-5.9 to 0.2]). MAPs, but not SE, also had beneficial effects on fatigue, insomnia, and vasomotor symptoms that persisted at 6-month follow-up (P < .05).

CONCLUSION

Mindfulness meditation and SE reduced depressive symptoms in younger breast cancer survivors. These interventions can be widely disseminated over virtual platforms and have significant potential benefit for quality of life and overall survivorship in this vulnerable group.

Association of APOE4 genotype and treatment with cognitive outcomes in breast cancer survivors over time

This prospective longitudinal study of breast cancer survivors (n = 167) examined the association of apolipoprotein ε4 (APOE ε4) genotype with cognition and interactions with chemotherapy or endocrine therapy up to 6 years after treatment. In general, we found no effects of ε4 across timepoints and treatment exposures; post hoc analysis at 3-6 years suggested a trend towards worse cognition in the domains of attention and learning among ε4 carriers exposed to endocrine therapy. Further study is needed.

Do all patients with cancer experience fatigue? A longitudinal study of fatigue trajectories in women with breast cancer

BACKGROUND

Fatigue is a common and expected side effect of cancer treatment. However, the majority of studies to date have focused on average levels of fatigue, which may obscure important individual differences in the severity and course of fatigue over time. The current study was designed to identify distinct trajectories of fatigue from diagnosis into survivorship in a longitudinal study of women with early-stage breast cancer.

METHODS

Women with stage 0 to stage IIIA breast cancer (270 women) were recruited before (neo)adjuvant therapy with radiotherapy, chemotherapy, and/or endocrine therapy and completed assessments at baseline; posttreatment; and at 6 months, 12 months, and 18 months of follow-up. Growth mixture modeling was used to identify trajectories of fatigue, and differences among the trajectory groups with regard to demographic, medical, and psychosocial variables were examined.

RESULTS

Five distinct trajectories of fatigue were identified: Stable Low (66%), with low levels of fatigue across assessments; Stable High (13%), with high fatigue across assessments; Decreasing (4%), with high fatigue at baseline that resolved over time; Increasing (9%), with low fatigue at baseline that increased over time; and Reactive (8%), with increased fatigue after treatment that resolved over time. Both psychological and treatment-related factors were found to be associated with fatigue trajectories, with psychological factors most strongly linked to high fatigue at the beginning of and over the course of treatment.

CONCLUSIONS

There is considerable variability in the experience of fatigue among women with early-stage breast cancer. Although the majority of women report relatively low fatigue, those with a history of depression and elevated psychological distress may be at risk of more severe and persistent fatigue.

Abstract GS2-10: Targeting depressive symptoms in younger breast cancer survivors: A randomized controlled trial of mindfulness meditation and survivorship education

Purpose Breast cancer before age 50 comprises 25% of incident breast cancer cases in women. Younger breast cancer survivors (YBCS) are at increased risk for the negative effects of cancer diagnosis and treatment, including elevated levels of depression and related symptoms (i.e., anxiety, stress, fatigue, sleep disturbance, vasomotor symptoms), leading to significantly diminished quality of life. Patients and Methods This Phase III, randomized, multi-institution trial was designed to examine the efficacy of two brief interventions- mindfulness meditation and survivorship education - for YBCS (ClinicalTrials.gov NCT03025139). We recruited women diagnosed at age 50 or younger with early-stage breast cancer who had completed cancer treatment between 6 months and 5 years earlier and endorsed at least mild depressive symptoms. Participants were randomly assigned to Mindful Awareness Practices (MAPs), Survivorship Education (SE), or wait-list control (WL). Both intervention programs were tailored for YBCS and included 6 weeks of structured content delivered in a group format. Assessments were conducted at baseline, post-intervention, and at 3- and 6- month post-intervention follow-ups. The primary outcome was depressive symptoms (Center for Epidemiologic Studies Depression scale; CESD) at post-intervention; secondary outcomes included anxiety (Generalized Anxiety Disorder-7), fatigue severity (Fatigue Symptom Inventory), sleep disturbance (Insomnia Severity Index), and hot flashes (BCPT symptom checklist). Results We enrolled and randomized 247 women (85 MAPS, 81 SE, 81 WL). On average, participants were 45.4 years old at study entry and had been diagnosed 2.6 years earlier. Linear mixed models were conducted to compare each intervention group to WL on primary and secondary outcomes, controlling for baseline differences across groups in study site, race, and marital status. MAPs led to significant reductions in depressive symptoms at post-intervention and at 3- and 6-month follow-up relative to WL (Ps &lt; .01); see Table 1. SE also led to significant reductions in the CESD at post-intervention and 3-month follow-up (Ps &lt; .01). Both MAPs and SE produced reductions in anxiety at post-intervention relative to WL (Ps &lt; .05), though effects did not persist over follow-up. MAPs also had beneficial effects on other secondary outcomes, yielding significant decreases in fatigue severity, sleep disturbance, and hot flashes that persisted over the 6-month follow-up (Ps &lt; .05). In contrast, there was minimal evidence that SE impacted these outcomes. Conclusion Two brief behavioral intervention programs specially designed for YBCS were effective in reducing depressive symptoms and, in the case of mindfulness, improving related symptoms (fatigue, sleep disturbance) that pose serious threats to younger women’s health and well-being after cancer. These interventions are standardized, manualized, and have the potential for wide dissemination over virtual platforms. Table 1 Adjusted means and standard error (SE) for CESD depressive symptoms by group and time, controlling for study site, race, marital status. A CESD score of 16 or greater indicates moderately severe depressive symptoms. P-values are for differences between intervention and waitlist control groups in change over time between Baseline and Post-Intervention (1-2), Baseline to 3-month Follow-up (1-3), and Baseline to 6-month Follow-up (P 1-4).

BaselinePost-intvP (1-2)3 mo FUP (1-3)6 mo FUP (1-4)GroupCESDCESDCESDPCESDMindful Awareness Practices (MAPs)18.4 (1.0)13.6 (1.1).00113.4 (1.1)&lt;.00112.9 (1.1).013Survivorship Education (SE)17.4 (1.1)13.3 (1.1).00713.6 (1.2).00312.7 (1.2).063Waitlist (WL)16.5 (1.1)16.3 (1.1)17.3 (1.2)14.6 (1.1)

Citation Format: Patty Ganz, Julienne E Bower, Ann H Partridge, Antonio C Wolff, Elissa D Thorner, Hadine Joffe, Michael R Irwin, Laura Petersen, Laura Petersen, Catherine M Crespi. Targeting depressive symptoms in younger breast cancer survivors: A randomized controlled trial of mindfulness meditation and survivorship education [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr GS2-10.

Screening for Depression in Younger Breast Cancer Survivors: Outcomes From Use of the 9-item Patient Health Questionnaire

Background

Major cancer organizations recommend depression screening in patients and survivors. The 9-item Patient Health Questionnaire (PHQ-9) is often suggested, with limited information about its use.

Methods

Enrollment data collected from younger breast cancer survivors participating in a behavioral intervention trial were used to examine the relationship between PHQ-9 scores (range = 0-27), patient characteristics, and responses to standardized psychosocial assessment tools. Major depressive disorder criterion was met if responses to the first 2 PHQ-9 items (range = 0-6) were 3 or greater. The sample was categorized by total PHQ-9 scores: less than 5 (minimal depressive symptoms), 5-9 (mild to moderate depressive symptoms), and 10 or greater (moderate to severe depression). PHQ-9 category associations with medical, demographic, psychosocial, and behavioral characteristics were examined using analysis of variance for continuous variables and χ² tests for categorical variables.

Results

A total of 231 women met the study prescreening eligibility criterion of mild depressive symptoms and enrolled in the study. On average, they were 45.2 years old and 2.6 years since diagnosis. At enrollment, 22.1% met the screening criterion for possible major depressive disorder; among those with PHQ-9 scores of 10 or greater, 58.3% met this criterion. Anxiety, fatigue, insomnia, and intrusive thoughts about cancer were frequent and were associated with depressive symptom severity (all P < .001). In contrast, neither demographic nor cancer treatment characteristics were associated with depressive symptoms.

Conclusions

Depressive symptoms in this selected sample of younger breast cancer survivors were independent of demographic characteristics or cancer treatment history, suggesting that depression screening is necessary to detect uncontrolled depressive symptoms.

Gender differences in first-episode psychosis at 5-year follow-up – two different courses of disease? Results from the OPUS study at 5-year follow-up

Objective

Gender differences in psychosis have been investigated, and the results have contributed to a better understanding of the disease, but many questions are unanswered. In clinical terms, women and men with psychosis differ in terms of access to social support, tendency of substance abuse, level of functioning and symptom patterns. We aimed to investigate how gender differences at onset of psychosis develop during the first 5 years of treatment.

Method

A total of 578 patients with a first-episode psychosis in the schizophrenia spectrum were included in the Danish OPUS trial – a randomized clinical trial comparing 2 years of intensive early-intervention programme with standard treatment. All patients were assessed with validated instruments at inclusion, and after 2 and 5 years. Data were analysed for significant gender differences.

Results

Males have significantly higher levels of negative symptoms at all times, and are more likely to live alone and suffer from substance abuse. Females reach higher levels of social functioning at follow-up, and show a greater tendency to be employed or in education than males. Markedly more women than men live with children. More women than men reach a state of recovery and are more compliant with medication.

Conclusion

There are significant gender differences at 2- and 5-year follow-up in this large cohort of first-episode psychotic patients. Males and females show different symptomatology and different levels of social functioning.

A qualitative study of factors affecting personal protective equipment use among health care personnel

BACKGROUND

Health care personnel (HCP) use of personal protective equipment (PPE) reduces infectious disease transmission. However, PPE compliance remains low. The objective of this study was to better understand how HCP perceptions factor into PPE decision making as well as how organizational processes and the environment impact behavior.

METHODS

This qualitative study used observation and focus groups at 2 medical centers. Data were analyzed using thematic analysis.

RESULTS

The decision to use PPE and to follow precaution practices was influenced by risk perception as well as organizational and environmental factors. Perceived risk, related to certain organisms and work tasks, was considered by HCP when deciding to use PPE. Organizational processes, such as policies that were not applied uniformly, and environmental factors, such as clean versus contaminated space, also played a role in HCP PPE use.

DISCUSSION

Because HCP seemed focused on organisms and work tasks, education on specific organisms and helping HCP think through their workflow may be more effective in conveying the importance of PPE in reducing transmission. Additionally, isolation practices should be compared across disciplines to ensure they complement, rather than contradict, one another. Assessment of the environment may help protect HCP and patients from infectious organisms.

CONCLUSION

Preventing the spread of infectious organisms should not depend solely on PPE use, but should also be recognized as an organizational responsibility.

Using a Quitline to Deliver Opt-Out Smoking Cessation for Cancer Patients

PURPOSE

Although smoking by patients with cancer and survivors causes adverse outcomes, many patients with cancer do not receive access to evidence-based tobacco use treatment. The purpose of this article is to report on delivery of tobacco use treatment to patients with cancer using a state-supported Quitline.

METHODS

Statewide agencies in Michigan partnered with the Michigan Oncology Quality Consortium to develop and implement a clinical quality improvement initiative with the goal of addressing tobacco use by patients with cancer across Michigan oncology practices. The collaborative designed an opt-out approach for identifying tobacco users and referring them to the Michigan Tobacco Quitline (hereafter known as Quitline) within participating practices. As the initiative progressed, patients with cancer who were not referred through the initiative also became eligible for enrollment in the Quitline program.

RESULTS

A total of 4,347 patients with cancer enrolled in the Quitline between 2012 and 2017, and annual referrals from oncology practices increased from 364 (5% of Quitline participants) to 876 (17% of Quitline participants). The 2013-2016 Michigan Behavioral Risk Factor Surveillance System also demonstrated an increase from 60% to 80% of cancer survivors receiving smoking cessation resources. Of 3,892 patients with cancer who had Quitline follow-up data through 2017, 79% completed one or more counseling calls. The 6-month self-reported quit rate for patients with cancer assessed between 2013 and 2016 was 26%.

CONCLUSION

Using statewide resources to increase access to evidence-based smoking cessation assistance to patients with cancer is achievable. In an increasingly cost-conscious health care environment, collaborative initiatives that use or enhance existing resources should be considered and refined to deliver effective evidence-based care.

Identifying Cancer-Related Cognitive Impairment Using the FACT-Cog Perceived Cognitive Impairment

Cancer-related cognitive impairment (CRCI) is a concerning problem for many cancer survivors. Evaluating patients for CRCI has been a challenge, in part because of a lack of standardized practices. Self-report instruments are often used to assess CRCI, but there are no validated cutpoints. We present the results of receiver operating characteristic curve analysis identifying cutpoints of the Functional Assessment of Cancer Therapy-Cognition perceived cognitive impairment (PCI) in female breast cancer survivors for identifying CRCI cases. We defined presence of CRCI based on elevated complaints on the Patient's Assessment of Own Functioning Inventory compared with healthy control scores. Our results indicate that scores less than 54 in PCI scores using 18 items and scores less than 60 in PCI scores using 20 items exhibited good ability to discriminate CRCI cases from noncases (area under the receiver operating characteristic curve was 0.84 [95% CI = 0.73 to 0.94]). These preliminary results represent an important contribution toward standardizing practices across CRCI studies.

P2568Larger vectorcardiographic QRS area is associated with increased risk of heart failure development among left bundle branch block patients: a register-based cohort study

Background

QRS morphology including left bundle branch block (LBBB) and duration remain the most widely used surrogate markers in the 12-lead electrocardiogram (ECG) for assessing ventricular dyssynchrony and predicting future burden of heart failure (HF) and cardiovascular mortality. However, the vectorcardiographic QRS area has recently been proposed and evidence suggest that this marker may more accurately predict HF development.

Purpose

The aim of this study was to investigate the association between vectorcardiographic QRS area and risk of HF development in LBBB patients.

Methods

From 2001–2015, the Copenhagen General Practitioners' Laboratory was used to identify patients with a first-time LBBB ECG (QRS>120 ms; LBBB morphology), from which QRS area was derived using the Kors transformation method and grouped into quartiles. Outcome was a composite of HF diagnosis, redeemed prescriptions of loop diuretics, or death from HF. Death from other causes was accounted for as a competing risk.

Results

We included a total of 2843 LBBB patients who were free of heart failure (median age, 70 years; female, 58%; ischemic heart disease, 9%). QRS area quartiles comprised Q1, 67–158 μVs; Q2, 159–189 μVs; Q3, 190–228 μVs; and Q4, 229–739 μVs. During 6-month, 1-year, and 5-year follow-up, 9%, 12%, and 28% of patients reached the combined HF endpoint, and 1%, 2%, and 8% of patients died from other causes, respectively (Figure 1). After multivariable adjustment, the highest QRS area quartile, Q4, was associated with increased HF risk (adjusted hazard ratio, 1.64; 95% confidence interval, 1.35–2.00) compared with the lowest quartile, Q1. We did not observe any significant increase in HF risk for remaining quartiles (Q2 or Q3 vs. Q1).

Figure 1

Conclusions

Among primary care patients with newly discovered LBBB, a large vectorcardiographic QRS area (229–739 μVs) is associated with increased risk of developing the incident, combined HF endpoint. This indicates that the QRS area derived using the Kors method may serve as a valuable prognostic marker when assessing risk of HF in patients with LBBB.

Understanding Workflow and Personal Protective Equipment Challenges Across Different Healthcare Personnel Roles

Background

Hospitals use standard and transmission-based precautions, including personal protective equipment (PPE), to prevent the spread of infectious organisms. However, little attention has been paid to the potentially unique challenges of various healthcare personnel (HCP) in following precaution practices.

Methods

From September through December 2016, 5 physicians, 5 nurses, and 4 physical therapists were shadowed for 1 hour 30 minutes to 3 hours 15 minutes at an academic medical center. Observers documented activities using unstructured field notes. Focus groups were conducted to better understand HCP perspectives about precautions and PPE-related challenges. Data were analyzed by comparing workflow and challenges (observed and stated) in precaution practices across HCP roles.

Results

Precaution patients were interspersed throughout physician rounds, which covered a broad geographic range throughout the hospital. Patient encounters were generally brief, and appropriate use of gowns and cleaning of personal stethoscopes varied among observed physicians. Nurses were unit based and frequently entered/exited rooms. Frustration with donning/doffing was especially apparent when needing supplies while in a precaution room, which nurses acknowledged was a time when practice lapses could occur. The observed physical therapists worked in one geographic location, spent extended periods of time with patients, and noted that given their close physical contact with patients, gowns do not fully protect them.

Conclusions

Movement patterns, time with patients, care activities, and equipment use varied across HCP, leading to a diverse set of challenges in following precaution practices and PPE use. Attention to these differences among HCP is important for understanding and developing effective strategies to prevent the potential spread of infectious organisms.

Success In Hospital-Acquired Pressure Ulcer Prevention: A Tale In Two Data Sets

Chart-based surveillance reviews indicate that the incidence of hospital-acquired pressure ulcers (HAPUs) declined 23 percent during 2010-14, equating to an estimated savings of $1 billion during that period. Yet it remains unclear whether the administrative data used to implement three Medicare value-based purchasing programs that target HAPUs indicate similar improvements, and how success varied by HAPU severity. These programs measure and penalize only for more severe ulcers (stage 3 or 4 or unstageable), which are much more costly than less severe cases (stage 1 or 2). We assessed HAPU incidence, severity, and trends using administrative data for 2009-14 from three states. The HAPU incidence we found was approximately one-twentieth of that found in chart-based surveillance review data. HAPU incidence in administrative data declined, but 96 percent of the change was due to a decline in the incidence of less severe HAPUs. Transitioning from administrative data to chart-based surveillance review to measure HAPUs (mirroring changes that have already been made in reporting hospital-acquired infections) and accounting for HAPU severity could improve the validity of HAPU measures for assessing the clinical and financial impact of value-based purchasing interventions.

Testing a biobehavioral model of fatigue before adjuvant therapy in women with breast cancer

BACKGROUND

Fatigue is one of the most common and disabling side effects of cancer and its treatment. Although research typically has focused on fatigue that occurs during and after treatment, patients may experience fatigue even before treatment onset. The current study was designed to identify biobehavioral risk factors associated with fatigue before adjuvant therapy in women with early-stage breast cancer.

METHODS

Patients with stage 0 to stage IIIA breast cancer (270 women) were recruited before the onset of adjuvant or neoadjuvant therapy with radiotherapy, chemotherapy, and/or endocrine therapy. Host factors that may influence fatigue were identified from an empirically based, biobehavioral model and assessed using self-report questionnaires, medical record review, and blood collection (for genetic data). Fatigue was assessed by questionnaire. Linear regression analyses were used to evaluate the association between host factors and dimensions of fatigue, with general fatigue as the primary dimension of interest.

RESULTS

Fatigue was elevated at the pretreatment assessment compared with published controls. Bivariate analyses identified demographic, cancer-related, and biobehavioral correlates of fatigue. In the multivariable model, predictors of general fatigue included younger age, lower educational level, lower cancer stage, and history of childhood maltreatment (all P values <.05), with the full model accounting for approximately 18.4% of the variance in fatigue. Secondary analyses identified common and specific predictors of emotional, mental, and physical dimensions of fatigue.

CONCLUSIONS

Among women who have not yet initiated treatment of breast cancer, demographic and psychosocial factors are associated with elevated fatigue and could be used to identify at-risk patients for early intervention.

Mixed messages to consumers from Medicare: Hospital Compare grades versus value-based payment penalty

OBJECTIVES

To (1) compare the 2015 hospital grades reported on Medicare's Hospital Compare website for heart failure (HF) and acute myocardial infarction (AMI) readmissions with the HF- and AMI-specific scores for excess readmissions used to assess Medicare readmission penalties and (2) assess how often hospitals were penalized for excess readmissions in only 1 or 2 conditions, given that hospitals received a penalty impacting all Medicare payments based on an overall readmission score calculated from 5 conditions (HF, AMI, pneumonia, chronic obstructive pulmonary disease, and total hip/knee arthroplasty).

STUDY DESIGN

Retrospective secondary data analysis.

METHODS

Descriptive analyses of hospital-specific, condition-specific grades and excess readmission scores and hospital-level penalties downloaded from Hospital Compare.

RESULTS

Of the 2956 hospitals that had publicly reported HF grades on Hospital Compare, 91.9% (2717) were graded as "no different" than the national rate for HF readmissions, which included 48.6% that were scored as having excessive HF admissions, and 87% received an overall readmission penalty. Of 120 (4.1%) hospitals graded as "better" than the national rate for HF, none were scored as having excessive HF readmissions and 50% were penalized. AMI data yielded similar results. Among 2591 hospitals penalized for overall readmissions, 26.6% had only 1 condition with excess readmissions and 27.5% had 2 conditions.

CONCLUSIONS

Many hospitals with an HF and AMI readmission grade of "no different" than the national rate on Hospital Compare received penalties for excessive readmissions under the Hospital Readmissions Reduction Program. The value signal to consumers and hospitals communicated by grades and penalties is therefore weakened because the methods applied to the same hospital data produce conflicting messages of "average grades" yet "bad enough for penalty."

The cognitive effects of endocrine therapy in survivors of breast cancer: A prospective longitudinal study up to 6 years after treatment

BACKGROUND

After treatment of primary breast cancer, endocrine therapy (ET) is prescribed for patients with hormone receptor-positive cancers. Despite ET recommendations of 5 to 10 years of treatment, to the authors' knowledge there is little prospective study of its impact on cognitive function over an extended period of time. ET has known pharmacologic effects on the brain. Cognitive side effects are a concern for many women, with mixed findings reported in various studies. The current prospective longitudinal study examined the neuropsychological effects of ET over time, up to 6 years after treatment.

METHODS

A total of 189 survivors of early-stage breast cancer enrolled in the study prior to initiating ET if prescribed, and were followed at 6 months (175 patients), 12 months (173 patients), and for 3 to 6 years (102 patients) with self-report and neuropsychological assessments. Using linear mixed models, the authors examined whether neuropsychological performance or impairment rates differed over time based on whether or not ET was received.

RESULTS

The authors did not find any effect of ET on neuropsychological performance or impairment at any time point among survivors who received it compared with women who did not. However, those who participated in the 3-year to 6-year year visit demonstrated better executive function at baseline.

CONCLUSIONS

In the current observational cohort study, no detrimental effect of ET on cognitive function was identified in survivors of early-stage breast cancer receiving treatment with ET compared with those who were not.

Fatigue after breast cancer treatment: Biobehavioral predictors of fatigue trajectories

OBJECTIVE

Fatigue is a common side effect of cancer treatment, but there is considerable variability in fatigue severity and persistence among survivors. This study aimed to characterize longitudinal trajectories of fatigue after breast cancer treatment and to identify predictors of varying fatigue trajectories.

METHODS

Women (N = 191) from the Mind-Body Study completed assessments after primary treatment for early stage breast cancer and at regular follow-ups that occurred up to 6 years after treatment (M = 4.3 years). Growth mixture models were used to characterize fatigue trajectories, and demographic, medical, and biobehavioral risk factors were examined as predictors of trajectory group.

RESULTS

Five trajectories were identified, characterized as High, Recovery, Late, Low, and Very Low fatigue. The High and Recovery groups (40% of sample) evidenced elevated fatigue at posttreatment that declined in Recovery but persisted in the High group. In bivariate analyses, trajectory groups differed significantly on depressive symptoms, sleep disturbance, childhood adversity, body mass index, and the inflammatory marker soluble TNF receptor type II, which were higher in the High and/or Recovery groups. In multivariate models, depressive symptoms and childhood adversity distinguished High and Recovery from other groups. Rates of chemotherapy were higher in the Recovery than in the High or Late group, whereas rates of endocrine therapy were higher in the High than in the Recovery group.

CONCLUSIONS

There are distinct longitudinal trajectories of fatigue after breast cancer treatment. Psychological factors are strongly associated with adverse fatigue trajectories, and together with treatment exposures may increase risk for cancer-related fatigue. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Cognitive performance in survivors of breast cancer and markers of biological aging

BACKGROUND

Biological aging pathways accelerated by cancer treatments may be a mechanism for cognitive impairment in cancer survivors. The goal of the current study was to examine whether indicators of biological aging, namely elevated levels of DNA damage, reduced telomerase enzymatic activity, and shorter peripheral blood mononuclear cell (PBMC) telomere length (TL) would be related to cognitive function in a cohort of survivors of breast cancer.

METHODS

The authors evaluated a cross-sectional sample of 94 women aged 36 to 69 years who were treated for early-stage breast cancer 3 to 6 years previously. Leukocyte DNA damage, PBMC telomerase enzymatic activity, PBMC TL, and the inflammatory marker soluble tumor necrosis factor receptor II (sTNF-RII) were determined from blood samples. Cognitive function was assessed using a neuropsychological test battery and self-report. Linear regression models examined the relationship between biological aging predictors and cognitive outcomes.

RESULTS

Both higher DNA damage and lower telomerase were found to be statistically significantly related to lower executive function scores adjusting for age, body mass index, race, years from treatment, and intelligence score (standardized coefficients [B], -0.23 and 0.30; all P values <.05). In addition, lower telomerase activity was associated with worse attention and motor speed scores (B values, 0.30 and 0.24; P &lt;.05). sTNF-RII and TL were found to be unrelated to any of the neurocognitive domains.

CONCLUSIONS

The results of the current study suggest a significant association between measures of biological aging and objective measures of cognitive performance in survivors of breast cancer. Future prospective studies are needed to confirm a causal role of biological aging as a driver of declines in cognitive function after cancer treatment.

A Danish register-based study on involuntary treatment in anorexia nervosa

OBJECTIVE

Involuntary treatment is controversial and widely debated, but remains a significant component of treatment for severe anorexia nervosa. Given how little is known about this topic, we describe the frequency of various involuntary measures in a national cohort of all patients diagnosed with anorexia nervosa. In a subsample of patients, we explored predictors of the first involuntary measure recorded.

METHOD

Descriptive statistics and Cox proportional hazard analyses were conducted using the national registers of Denmark covering the total population. Data from the National Patient Register and the Psychiatric Central Research Register including all psychiatric visits from 1969 onwards were merged with data from the National Register on Coercion covering 1999 onward. Involuntary measures registered between 2000 and 2013 were analyzed.

RESULTS

A total of 4,727 patients with a diagnosis of anorexia nervosa representing 16,592 admissions were included. Eighteen percent experienced at least one involuntary measure. A variety of measures were used with tube feeding being the most frequent followed by mechanical restraint, involuntary medication, physical restraint, constant observation, and sedative medication. A subsample of 2% of AN patients had more than 100 involuntary measures recorded. The first recorded involuntary measure was predicted by most but not all psychiatric comorbidities, especially schizophrenia, autism spectrum, and personality disorders, older age at first diagnosis, and previous admissions.

DISCUSSION

It is important to develop a more granular understanding of patients at risk of requiring involuntary treatment and to determine how best to treat them effectively with minimal use of involuntary measures.

Identification and Characterization of Failures in Infectious Agent Transmission Precaution Practices in Hospitals: A Qualitative Study

IMPORTANCE

Using personal protective equipment (PPE) and transmission-based precautions are primary strategies for reducing the transmission of infectious agents.

OBJECTIVE

To identify and characterize failures in transmission-based precautions, including PPE use, by health care personnel that could result in self-contamination or transmission during routine, everyday hospital care.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study involved direct observation inside and outside patient rooms on clinical units from March 1, 2016, to November 30, 2016. Observations occurred in the medical and/or surgical units and intensive care units at an academic medical center and a Veterans Affairs hospital, as well as the emergency department of the university hospital. Trained observers recorded extensive field notes while personnel provided care for patients in precautions for a pathogen transmitted through contact (eg, Clostridium difficile, methicillin-resistant Staphylococcus aureus) or respiratory droplet (eg, influenza). Specific occurrences involving potential personnel self-contamination were identified through a directed content analysis. These occurrences were further categorized, using a human factors model of human error, as active failures, such as violations, mistakes, or slips.

MAIN OUTCOMES AND MEASURES

Number and type of failures involving use of transmission-based precautions.

RESULTS

In total, 325 room observations were conducted at 2 sites. At site 1, a total of 280 observations were completed (196 in medical/surgical units, 64 in intensive care units, and 20 in emergency departments). At site 2, there were 45 observations (36 in medical/surgical units and 9 in the intensive care unit). Of the total observations, 259 (79.7%) occurred outside and 66 (20.3%) inside the room. Two hundred eighty-three failures were observed, including 102 violations (deviations from safe operating practices or procedures), 144 process or procedural mistakes (failures of intention), and 37 slips (failures of execution). Violations involved entering rooms without some or all recommended PPE. Mistakes were frequently observed during PPE removal and encounters with challenging logistical situations, such as badge-enforced computer logins. Slips included touching one's face or clean areas with contaminated gloves or gowns. Each of these active failures has a substantial likelihood of resulting in self-contamination. The circumstances surrounding failures in precaution practices, however, varied not only across but within the different failure types.

CONCLUSIONS AND RELEVANCE

Active failures in PPE use and transmission-based precautions, potentially leading to self-contamination, were commonly observed. The factors that contributed to these failures varied widely, suggesting the need for a range of strategies to reduce potential transmission risk during routine hospital care.

Impact of a Statewide Oral Oncolytic Initiative on Five Participating Practices

PURPOSE

The shift from infusion to oral oncolytic therapy presents challenges to oncology practitioners. The purpose of this study was to describe how a statewide quality-improvement collaborative can enhance quality of care for patients receiving oral oncolytic therapy.

METHODS

The Michigan Oncology Quality Consortium hosted a series of learning sessions focused on oral oncolytic quality improvement, providing multiple resources to oncology community practices. The first five participating practices reported which of the evidence-based Michigan Oncology Quality Consortium resources provided were implemented at their site. They also performed prepost self-assessments in October 2013 and April 2015 and another in December 2017 to assess sustainability. Concordance with the ASCO Quality Oncology Practice Initiative oral chemotherapy standards, including documentation (five measures), patient education (seven measures), and follow-up/monitoring (four measures), was compared.

RESULTS

All practices showed improvement between 2013 and 2015 in documentation (32% to 88%; P = .03), patient education (37% to 100%; P could not be calculated), and monitoring (40% to 80%; P > .2). Overall, a significant improvement in concordance was observed (36% to 91%; P = .03). Use of resources from each practice varied, and practices that used more resources showed greater improvements. There was a slight decrease in overall concordance between 2015 and 2017, which was not found to be significant (91% to 84%; P = .53).

CONCLUSION

Use of tools from a quality-improvement collaborative improved concordance with national standards of care. Large-scale deployment of this model program may provide a clinically efficient and effective mechanism to enhance widespread change.

Adverse life events increase risk for postpartum psychiatric episodes: A population-based epidemiologic study

BACKGROUND

Trauma histories may increase risk of perinatal psychiatric episodes. We designed an epidemiological population-based cohort study to explore if adverse childhood experiences (ACE) in girls increases risk of later postpartum psychiatric episodes.

METHODS

Using Danish registers, we identified women born in Denmark between January 1980 and December 1998 (129,439 childbirths). Exposure variables were ACE between ages 0 and 15 including: (1) family disruption, (2) parental somatic illness, (3) parental labor market exclusion, (4) parental criminality, (5) parental death, (6) placement in out-of-home care, (7) parental psychopathology excluding substance use, and (8) parental substance use disorder. Primary outcome was first occurrence of in- or outpatient contact 0-6 months postpartum at a psychiatric treatment facility with any psychiatric diagnoses, ICD-10, F00-F99 (N = 651). We conducted survival analyses using Cox proportional hazard regressions of postpartum psychiatric episodes.

RESULTS

Approximately 52% of the sample experienced ACE, significantly increasing risk of any postpartum psychiatric diagnosis. Highest risks were observed among women who experienced out-of-home placement, hazard ratio (HR) 2.57 (95% CI: 1.90-3.48). Women experiencing two adverse life events had higher risks of postpartum psychiatric diagnosis HR: 1.88 (95% CI: 1.51-2.36), compared to those with one ACE, HR: 1.24 (95% CI: 1.03-49) and no ACE, HR: 1.00 (reference group).

CONCLUSIONS

ACE primarily due to parental psychopathology and disability contributes to increased risk of postpartum psychiatric episodes; and greater numbers of ACE increases risk for postpartum psychiatric illness with an observed dose-response effect. Future work should explore genetic and environmental factors that increase risk and/or confer resilience.

OPUS study: Suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis

Background

Patients with first-episode psychosis comprise a high-risk group in terms of suicide.

Aims

To identify predictive factors for suicidal behaviour and to examine the effect of integrated treatment on suicidal behaviour and hopelessness.

Method

A total of 341 patients with a first-episode schizophrenia-spectrum disorder were randomised to integrated treatment or treatment as usual.

Results

During the 1-year follow-up period, 11% attempted suicide. This was associated with female gender, hopelessness, hallucinations and suicide attempt reported at baseline, with the two latter variables being the only significant ones in the final multivariate model. The integrated treatment reduced hopelessness.

Conclusions

Hallucinations and suicide attempt before inclusion in the study were the most significant predictors of suicide attempt in the follow-up period.