Utilizing Social Determinants of Health Model to Understand Barriers to Medication Adherence in Patients with Ischemic Stroke: A Systematic Review

Introduction

Ischemic strokes and their recurrence create an immense disease burden globally. Therefore, preventing recurrent strokes by promoting medication adherence is crucial to reduce morbidity and mortality. In addition, understanding the barriers to medication adherence related to the social determinants of health (SDoH) could promote equity among persons with ischemic stroke.

Objective

To explore the barriers to medication adherence among patients with ischemic stroke through the SDoH.

Methods

This systematic review included studies published between January 2018 and December 2022 identified through PubMed, MEDLINE, Web of Science, and CINAHL Plus Full Text. The descriptions of the studies were systematically summarized and discussed based on the SDoH from the US Healthy People 2030 initiative.

Results

Eight studies met the inclusion criteria and were included in this review. The most common barrier to adherence was inappropriate medication beliefs, medication side effects, and patient-physician relationship, which relate to the dimensions of healthcare access and quality. Health literacy and health perception, dependent on education access and quality, frequently influenced adherence. Other social determinants, such as financial strain and social and community context, were found to alter adherence behaviors. No study addressed the neighborhood and built environment domain. We found that cognitive impairment is another factor that impacts adherence outcomes among stroke patients.

Conclusion

Multifaceted approaches are needed to address the SDoH to improve medication adherence among patients with ischemic stroke. This review emphasized strategies, including patient education, provider-patient communication, social support, health literacy, technology, and policy advocacy to enhance adherence.

Utilizing the Social Determinants of Health Model to Explore Factors Affecting Nurses' Job Satisfaction in Saudi Arabian Hospitals: A Systematic Review

The purpose of this systematic review was to explore factors affecting nurses' job satisfaction in Saudi Arabian hospitals by utilizing the social determinants of a health model. We conducted a systematic review using three databases (PubMed, PsychINFO, and CINAHL) following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. A total of 235 studies were screened. Of these studies, nine met the inclusion criteria. The studies were appraised using the Joanna Briggs Institute checklist tool. The majority of studies reported that salary, years of experience, nationality, and marital status were factors affecting nurses' job satisfaction. Gender and educational level did not impact job satisfaction for male and female nurses. Overall, the review highlighted some knowledge gaps in the assessment of the impact of social determinants of health regarding gender and educational level on nurses' job satisfaction. Further research is needed to address this knowledge gap.

Socioeconomic correlates of health outcomes and mental health disparity in a sample of cancer patients during the COVID-19 pandemic

AIMS AND OBJECTIVES

To investigate socioeconomic, behavioural and healthcare delivery factors that are associated with health outcomes of cancer patients during the COVID-19 pandemic, especially among underserved cancer patients.

BACKGROUND

Cancer patients are at a higher risk of adverse physical and mental health outcomes during the pandemic than those without cancer.

DESIGN

Cross-sectional online survey. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines in this study.

METHODS

The sample comprised 322 individuals diagnosed with incident cancer between January 2019 and January 2020. Demographically, 64% were female, 49% had a college degree, 12% were African American, and 88% were White (77% of the Whites were from metropolitan and 23% from nonmetropolitan areas). Descriptive analysis and multivariable regression analyses of global health status, depression and irritability were performed.

RESULTS

After adjusting for demographic variables and comorbidity, the feelings of loneliness, crowded living space, lower confidence in taking preventive measures and less satisfaction with telehealth visits were significantly associated with poorer global health, depression and irritability. Daily exercise was associated with better global health, and difficulty in getting medicine was associated with depression and irritability. Moreover, African Americans who felt lonely reported more depression and irritability and those who had less confidence in taking preventive measures reported more irritability than Whites. Respondents having low income and feeling lonely reported more depression than others.

CONCLUSIONS

In this study, socioeconomic factors (e.g. loneliness or crowded living conditions) were as important to health outcomes during the pandemic as behavioural (e.g. prevention and exercises) and quality-of-care factors (e.g. telehealth, access to medicine). Disparity was more pronounced in the mental health of African Americans and those with low incomes.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should promote social support and physical activity for improving health and reducing mental health disparities among cancer patients.

Associations Among Irritability, High-Sensitivity C-Reactive Protein/Interleukin-6, and Depression in Patients With Early-Stage Breast Cancer Undergoing Chemotherapy: A Prospective Study

BACKGROUND

Association between irritability and depression has been frequently reported, but the nature of this association in the adult population is poorly understood.

OBJECTIVES

We examined associations among irritability (e.g., a feeling of agitation), inflammatory biomarkers, and depression during chemotherapy.

METHODS

Forty-four patients with nonmetastatic breast cancer were assessed at baseline and after 3 months of chemotherapy on The Irritability Scale-Initial Version, severity and new onset of depressive symptoms using the Hamilton Depression Rating Scale, and serum levels of high-sensitivity C-reactive protein and interleukin 6.

RESULTS

At baseline, high-sensitivity C-reactive protein significantly correlated with physical and mood subscales of The Irritability Scale-Initial Version, but not with depression. Irritability and high-sensitivity C-reactive protein significantly predicted the severity and new onset of moderate to severe depressive symptoms over time, while irritability and interleukin 6 significantly predicted new onset of moderate to severe depressive symptoms.

CONCLUSION

The findings suggest that irritability is an independent risk factor of depression and associated with increasing high-sensitivity C-reactive protein. Irritability needs to be effectively managed in patients with cancer undergoing chemotherapy to prevent them from developing depressive symptoms. These preliminary findings should be investigated in future large-sample studies.

Psychosocial mechanisms of a behavioral treatment for urinary incontinence of prostate cancer survivors

Purpose: We examined underlying psychosocial processes of a behavioral treatment for urinary incontinence (UI) of prostate cancer survivors.Design: Secondary analysis of data collected from a clinical trial.Sample: Two hundred forty-four prostate cancer survivors who participated in a clinical trial of behavioral intervention to UI as intervention or control subjects.Methods: The participants had a 3-month behavioral intervention or usual care and were followed up for an additional 3 months. They were assessed at baseline, 3, and 6 months. Latent growth curve models were performed to examine trajectories of each study variable and relationships among the variables.Findings: Increasing self-efficacy and social support were significantly and independently associated with more reduction of urinary leakage frequency over time.Implications for psychosocial oncology: Providing problem-solving skills and social support, including peer support, are essential for empowering patients to reduce UI.

Mood outcomes of a behavioral treatment for urinary incontinence in prostate cancer survivors

PURPOSE

This study aimed to assess whether prostate cancer survivors who received a behavioral intervention to urinary incontinence had experienced a significant mood improvement.

METHODS

One hundred fifty-three prostate cancer survivors with persistent incontinence were included in this secondary data analysis. They were randomly assigned to usual care or interventions that provided pelvic floor muscle exercises and self-management skills. All subjects had measures of anxiety, depression, and anger at baseline, 3 months (post-intervention), and 6 months (follow-up). Negative binomial regression analysis was performed to examine the group status, daily leakage frequency at 3 months, and their interactions at 3 months as predictors for mood outcomes at 6 months, controlling for demographic and medical variables.

RESULTS

The main effect of daily leakage frequency at 3 months significantly predicted anxiety at 6 months (p < .01). The group main effect on any mood outcomes at 6 months was not statistically significant. The interaction between the group and 3-month leakage had a significant effect on anxiety; intervention subjects achieving a significant leakage reduction at 3 months exhibited significantly less anxiety at 6 months than other subjects (p = .04). Age, employment status, and receiving surgery at baseline were significantly associated with less anxiety, depression, and anger at 6 months.

CONCLUSIONS

Reduced urinary incontinence significantly predicted less anxiety, especially among the intervention subjects. The findings suggest a significant association between a behavioral therapy of urinary incontinence and anxiety reduction in prostate cancer survivors.

Prevalence, Burden, and Treatment of Lower Urinary Tract Symptoms in Men Aged 50 and Older: A Systematic Review of the Literature

We conducted a systematic review of literature from the years 2000 through 2017 on the prevalence and burden of lower urinary tract symptoms (LUTS) in men aged 50 and older, and medical treatments of and alternative nonmedical approaches to LUTS. EBSCOhost (Medline with Full Text) was searched for observational, experimental, and review studies in peer-reviewed journals in the English language. Our review found that LUTS were highly prevalent in the world and estimated to affect 2.3 billion people in 2018, with 44.7% being men. Men with LUTS suffer from not only burdensome symptoms such as nocturia and urgency but also adverse psychological consequences (e.g., anxiety and depression) and financial burden. Current medical treatments are clinically effective, but their efficacy is compromised by side effects and low compliance rates. Alternative nonmedical treatments for LUTS were also sought worldwide. There is evidence that lifestyle modifications such as pelvic muscle exercises and bladder training, physical activity, dietary modification, and nutritional supplements can alleviate LUTS and improve patient quality of life; however, evidence based on rigorous methodology remains minimal and cannot be generalized across populations. Evidence of effectiveness of weight loss programs to reduce LUTS is inconclusive. We conclude that although behavioral treatment is a promising approach to alleviating LUTS, especially when combined with medical treatments, well-designed randomized controlled and longitudinal clinical trials on behavioral treatments of LUTS are still needed. Minimally invasive procedures and neuromodulation therapy also show positive results of alleviating LUTS but require further research as well.

Author Correction: Chemotherapy with radiotherapy influences time-to-development of radiation-induced sarcomas: a multicenter study

Since the publication of this paper, the authors noticed an error in Fig. 1. The X-axis on all the figure panels should read 'Time (years)', not 'Time (months)'. The corrected Fig. 1 is shown below.

A prospective multicentre phase III validation study of AZGP1 as a biomarker in localized prostate cancer

Background

Prostate cancers (PCs) with similar characteristics at the time of diagnosis can have very different disease outcomes. Conventional biomarkers of PC still lack precision in identifying individuals at high risk of PC recurrence. While many candidate biomarkers are proposed in the literature, few are in clinical practice as they lack rigorous validation. This study prospectively enrolled an independent phase III cohort to evaluate the clinical utility of zinc-alpha 2-glycoprotein (AZGP1) as a prognostic biomarker in localized PC.

Patients and methods

In our multicentre, prospective phase III study, AZGP1 status in 347 radical prostatectomy specimens was assayed by immunohistochemistry in a NATA-accredited laboratory. The AZGP1 score was assessed in a multivariable model incorporating established prognostic factors. We also report extended outcomes from our previous phase II study. The primary endpoint was biochemical relapse-free survival (BRFS). Secondary endpoints were metastasis-free survival (MFS) and PC-specific survival (PCSS).

Results

In the phase II cohort, with a median follow-up of 15.8 years, low/absent AZGP1 expression was an independent predictor of poor BRFS (HR, 1.4; 95% CI, 1.1-1.9; P = 0.03), MFS (HR, 2.8; 95% CI, 1.2-6.6; P = 0.02) and PCSS (HR, 3.8; 95% CI, 1.5-9.5; P = 0.005). These results were validated in our prospective phase III cohort. Low/absent AZGP1 expression independently predicted for BRFS (HR, 1.9; 95% CI, 1.1-3.3; P = 0.02), with shorter MFS (HR, 2.0; 95% CI, 1.1-3.4; P = 0.02). AZGP1 improved the discriminatory value when incorporated into existing prognostic risk models.

Conclusion

Our study provides prospective phase III validation that absent/low AZGP1 expression provides independent prognostic value in PC. This study provides robust evidence for the incorporation of this biomarker into clinical practice.

Is a behavioral treatment for urinary incontinence beneficial to prostate cancer survivors as a follow-up care?

PURPOSE

The American Cancer Society (ACS) recommends a follow-up care plan for urinary incontinence of prostate cancer survivors that includes pelvic floor muscle exercise (PFME). We examined potential impacts and access barriers of this recommendation with consideration of patients who normally do not seek such care.

METHODS

We compared 267 participants of a clinical trial that tested a PFME-based treatment of urinary incontinence and 69 nonparticipants who declined the trial. All subjects were assessed at baseline, 3, and 6 months on leakage frequency, disease-specific quality of life (QOL), and physical well-being. The nonparticipants were interviewed to examine reasons for intervention refusal.

RESULTS

The participating and nonparticipating groups did not differ in most baseline demographics and clinical variables except that the nonparticipants had lower baseline prostate-specific antigen (P ≤ 0.01), lower education levels, and higher likelihood of receiving surgery alone (both P ≤ 0.05). Nonparticipants exhibited significantly more frequent daily leakage, poorer urinary function and bother, and severer urinary problems at 3 and 6 months, as well as worse physical well-being at 6 months, relative to baseline, than the participants. The primary reason for refusal was economical, such as lacking transportation and time for participation.

CONCLUSIONS

Urinary function and QOL can worsen without appropriate follow-up care. It is important to make a PFME-based follow-up care program available to all incontinent prostate cancer survivors as recommended by ACS guidelines.

IMPLICATIONS FOR CANCER SURVIVORS

Seeking PFME-based treatment is crucial for long-term urinary health outcomes even if present leakage is minor or financial challenge is a concern.

Social Support and Self-Coping of Depressed African-American Cancer Patients

This study examined the differences among 57 depressed and nondepressed African-American cancer patients and their use of social support and self-coping resources. In-depth interviews were used to elicit narrative responses and Fisher's exact test was used to compare the 2 groups. The depressed patients, as determined by 3 depression scales, more frequently reported having no supportive family, lacking a support system, having sedentary hobbies, or using alcohol or drugs as coping strategies compared to the nondepressed patients. To better detect and treat depression, health-care providers must carefully evaluate the social support and coping resource needs in this vulnerable population.

Protective effect of the polarity of macrophages regulated by IL-37 on atherosclerosis

As an anti-inflammatory cytokine, interleukin-37 (IL-37) provides certain protective effects against inflammatory and autoimmune diseases. Recent reports indicate that IL-37 is expressed in foam cells of atherosclerotic plaques in both the coronary and carotid arteries of humans, suggesting the possible involvement of IL-37 in the pathogenesis and progression of atherosclerosis. Current evidence supports the protective role that IL-37 plays against atherosclerosis via the regulation of different subtypes of macrophage. Atherosclerosis was induced in apolipoprotein E -/- mice through diet, and the mice were then given IL-37 to observe patterns in the aorta plaque. Furthermore, human peripheral blood-derived monocytes were cultured for seven days to induce the differentiation of macrophages. Specifically, we observed the effect of IL-37 on oxygenated low density lipoprotein (ox-LDL)-induced macrophage polarity, in addition to conducting an expressional assay of the M1 cell markers tumor necrosis factor (TNF)-α and CD86 and the M2 marker CD206. IL-37 effectively decreased the area ratio between the aorta plaque and vascular cavity. We also observed that M1 macrophages can be induced from peripheral monocytes by ox-LDL, with significant elevation of marker molecules TNF-α and CD86. The co-stimulation of IL-37 and ox-LDL, however, inhibited the induction of M1 cells and facilitated the transformation of macrophages into M2 cells, as supported by the elevation of cell-specific marker CD206. These results indicate that IL-37 can prevent atherosclerosis by modulating macrophage polarity.

Effects of Patient Centered Interventions on Persistent Urinary Incontinence after Prostate Cancer Treatment: A Randomized, Controlled Trial

PURPOSE

We examined whether an intervention combining pelvic floor muscle exercise and symptom self-management would improve urinary continence and quality of life in patients with prostate cancer.

MATERIALS AND METHODS

In a randomized, controlled, longitudinal clinical trial 279 patients with prostate cancer with persistent urinary incontinence were randomized to 1 of 3 groups, including biofeedback pelvic floor muscle exercise plus a support group, the biofeedback exercise plus telephone contact and usual care without intervention. The biofeedback plus support and plus telephone groups received 1 session of biofeedback assisted exercise and 6 biweekly sessions of problem solving therapy. This delivered symptom management skills through a peer support group or telephone contacts for 3 months. All subjects were assessed in blinded fashion at baseline, and 3 and 6 months for urinary leakage frequency, leakage amount and disease specific quality of life.

RESULTS

A total of 244 subjects completed the study. The biofeedback plus support and biofeedback plus telephone groups had a lower frequency of daily urinary leakage than the group with usual care without intervention at 3 months (p=0.019 and p≤0.001, respectively) but not at 6 months. The biofeedback plus support group but not the biofeedback plus telephone group had 13.3 gm lower leakage at 6 months than the usual care group (p=0.003). Overall the biofeedback plus support and plus telephone groups reported less symptom severity (p≤0.001) and fewer incontinence problems (p≤0.01) than the usual care group at 6 months.

CONCLUSIONS

Study findings show that pelvic floor muscle exercise practice plus symptom self-management in a peer support setting can significantly improve urinary continence and quality of life in patients with prostate cancer.

Cost-effectiveness of a behavioral intervention for persistent urinary incontinence in prostate cancer patients

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of a behavioral intervention for urinary incontinence of prostate cancer patients. Study subjects were either participating in or eligible but declined (i.e., nonparticipating) the active intervention study.

METHODS

The intervention-participating subjects were randomized into three groups, including two intervention groups (support and telephone groups) and a usual care reference group. Intervention-nonparticipating subjects were concurrently enrolled. Intervention effectiveness was assessed on the EQ-5D measure. The costs included direct healthcare cost from medical billing data, patient out-of-pocket expense, caregiver expense, patient loss-of-work cost, and intervention cost. We calculated incremental cost-effectiveness ratios (ICERs) from societal, provider, and patient perspectives.

RESULTS

Two hundred and sixty-seven intervention-participating and 69 intervention-nonparticipating post-cancer treatment patients were included. The support and telephone groups, but not the usual care group, had significantly higher EQ-5D index scores (0.054, p = 0.033, and 0.057, p = 0.026, respectively) than the intervention-nonparticipating group at month 6. Within 6 months, intervention cost per subject was $252 and $484, respectively, for providers, and $564 and $203, respectively, for the support and phone group subjects. The final ICERs were $16,759 per quality-adjusted life year (QALY) and $12,561/QALY for support and telephone groups, compared with those of the intervention-nonparticipating group. These ICERs are much smaller than $50,000/QALY, the consensus threshold to determine cost-effectiveness for society.

CONCLUSIONS

The study interventions are cost-effective in consideration of eligible patients who declined the interventions. The interventions can provide meaningful outcome improvement on urinary continence at a low cost. This evidence provides critical information for future health policy decision-making of healthcare providers and payers.

Attitudes toward cancer and implications for mental health outcome in African-American cancer patients

This study examined African-American cancer patients’ attitudes toward cancer and their relationship with long-term mental health outcomes. Using mixed methods, 74 breast and prostate cancer patients including 34 depressed and 23 nondepressed African-Americans and 17 depressed Whites were interviewed. The interviews were audiotaped and transcribed. Qualitative data analysis identified themes that were coded. The codes were entered into SPSS software. Fisher’s exact test was performed to examine group differences in the identified themes. Nondepressed African-Americans more frequently reported cancer as an adaptive experience (p = 0.047) and less frequently as a struggle (p = 0.012) than the depressed African-Americans and Whites. Groups did not significantly differ in the belief that cancer has no cure (p = 0.763), but depressed African-Americans more frequently reported unwillingness to share a cancer diagnosis with family or friends than depressed Whites (p = 0.50). African-Americans’ adaptive attitudes to cancer exhibit a pragmatist approach and a worldview shaped by their lived experience. Participants’ narratives were examined to illuminate the meanings of these findings. Adaptive attitudes to cancer are associated with better long-term mental health outcomes, and conversely, unpreparedness and inability to cope are associated with a higher risk of depression among African-American cancer patients. Education about cancer and supports for treatment navigation are important measures for improving the long-term mental health of African-Americans living with cancer.

Exploration of depressive symptoms in African American cancer patients

BACKGROUND

Accurately assessing depression in African American cancer patients is difficult because of the similarities of physical symptoms observed in cancer and depression.

AIM

To identify universal and distinctive depressive symptoms in African American cancer patients.

METHODS

Seventy-four cancer patients (34 depressed and 23 non-depressed African Americans, and 17 depressed Whites) were interviewed. Qualitative and quantitative analyses were conducted.

RESULTS

Compared to non-depressed African Americans, depressed African Americans reported irritability, social isolation, insomnia, fatigue and crying (p ≤ 0.05) more frequently over time. Compared to depressed Whites, they reported sadness, frustration and intrusive thoughts less frequently (p ≤ 0.05), but insomnia and fatigue more frequently (p ≤ 0.05) during cancer treatment. There was little racial difference at the time of interview.

CONCLUSION

Depressed African American cancer patients may benefit from more culturally sensitive depression measures that consider symptoms of irritability, social isolation and altered expressions of depressive mood.

Discord of Measurements in Assessing Depression among African Americans with Cancer Diagnoses

OBJECTIVE

This study examined the level of agreement among the Center for Epidemiologic Studies-Depression Scale (CES-D), Hamilton Rating Scale for Depression (HAM-D), Beck Depression Inventory (BDI-II), and Observers' Rating on assessing depression of African American adults with cancer.

METHODS

75 breast and prostate cancer patients (57 African Americans and 18Whites) were interviewed and administered the depression measures. Nonparametric tests were performed to examine the level of measurement agreement by group and the symptom items of CES-D, HAM-D and BDI-II to which African American patients responded differently across measures.

RESULTS

The four measures showed agreement on approximately 75% of the cases in both racial groups. However, the difference between measures in identifying depressive cases is marked. The item analysis indicated that most measurement disagreements about African American patients occurred on two items: self-report of depression and sleeping disturbance.

CONCLUSION

Measurement discord may be explained by African American's reporting behavior that varies from a self-reported measure to an interviewer-administrated measure of depression. African American patients showed a reluctance to use the word "depression" and a tendency to report sleep disturbance. The findings suggest that accurately assessing depression in these patients requires a consideration of their culturally shaped life experiences.

Initial evidence of religious practice and belief in depressed african american cancer patients

Objective:

This study examined spiritual coping (beliefs and practices) of depressed African American cancer patients through a comparison with depressed White cancer patients and non-depressed African American cancer patients.

Methods:

Using mixed methods, 74 breast (n=41) and prostate (n=33) cancer survivors including 34 depressed and 23 nondepressed African Americans and 17 depressed Whites were interviewed. The interviews were audiotaped and transcribed. Qualitative data analysis identified themes that were coded. The codes were entered into SPSS software. The Fisher’s exact test was performed to examine group differences in self-reported spiritual coping.

Results:

Significantly more depressed African Americans questioned God when learning of a cancer diagnosis than the non-depressed African Americans (p=.03), but they did not differ from the depressed Whites in this regard (p=.70). Significantly more depressed African Americans reported having faith in God (p=.04), reading the bible (p=.02), and conversing with God (p=.01) than did the depressed Whites. They also reported praying alone (p=.01) more frequently than the depressed Whites who, on the other hand, reported praying with others (non-family members) together for one’s own health more frequently (p=.04).

Conclusions:

Depression is associated with a deepening need for spirituality and it affects religious beliefs and practices more in African American than White cancer patients. Given its important role in the lives of African American cancer patients, spirituality may be utilized as a reasonable, culturally-based approach to better assess and treat depression in these patients.

What precipitates depression in African-American cancer patients? Triggers and stressors

OBJECTIVE

This study examined general and cancer-related stressors of depression that are unique to African-American cancer patients.

METHOD

The study used cohort design and mixed methods. Seventy-four breast and prostate cancer survivors including 34 depressed and 23 non-depressed African-Americans and 17 depressed whites were interviewed. Qualitative data analysis identified themes. The thematic codes were converted to a SPSS data set numerically. The Fisher's exact test was performed to examine group differences in the experience of stress.

RESULTS

Significantly more depressed African-Americans experienced a dramatic reaction to a cancer diagnosis (p = 0.03) or had concerns about functional decline (p = 0.01), arguments with relatives or friends (p = 0.02), and unemployment status (p = 0.03) than did non-depressed African-Americans, who reacted to the cancer diagnosis as a matter of reality (p = 0.02). Significantly more depressed African-Americans talked about feeling shocked by a cancer diagnosis (p = 0.04) and being unable to do things that they used to do (p = 0.02) than did depressed whites. Qualitative analysis shed light on the extent of such group differences.

SIGNIFICANCE OF RESULTS

Distress from the initial cancer diagnosis and functional decline were likely to have triggered or worsened depression in African-American cancer patients. This study highlighted racial differences in this aspect. It is critical to screen African-American cancer patients for depression at two critical junctures: immediately after the disclosure of a cancer diagnosis and at the onset of functional decline. This will enhance the chance of prompt diagnosis and treatment of depression in this underserved population.

Discord of biological and psychological measures in a group of depressed african american and white cancer patients

OBJECTIVE

This study examined racial differences in the self-report of depressive symptoms by reference to biological states.

METHODS

The study used a convenience sample of 20 depressed cancer patients (CES-D ≥16) (15 African Americans and 5 Whites). Subjects completed depression assessment on a battery of psychological measures and provided blood and saliva samples. Laboratory tests were performed on biomarkers (serotonin, cortisol and IL-6). T-test was computed to examine racial differences on biological and psychological measures.

RESULTS

Depressed Whites had a significantly higher cortisol level than depressed African Americans, but no significant group difference was found on any self-reported psychological measures of depression. There was a trend that African Americans reported fewer depressive symptoms on psychological measures but exceeded Whites on the domain of somatization; however, such group differences did not approach statistic significance in this small sample.

CONCLUSION

African Americans did not appear to underreport depression in consideration of their biological states, but had a tendency to report more somatic symptoms than Whites; this may be attributable to non-depression diseases or reporting behavior rather than somatic sensitivity. African Americans exhibited more mistrust in the health care system, which could affect the self-report of depression. There is a discord between biological and psychological measures of depression. Biomarkers prove to be useful for evaluating racial difference in the self-report of depression. IMPLICATION FOR NURSING: Nurses should be cautious of somatic complaints when assessing African American cancer patient's depression. Establishing trust is essential for an accurate assessment of depression in African American cancer patients.

Ethnic differences in the caregiver's attitudes and preferences about the treatment and care of advanced lung cancer patients

OBJECTIVE

This study examined differences in attitudes and preferences between African American and White caregivers about cancer treatment and care.

METHODS

There were 173 White and 26 African American caregivers of advanced lung cancer patients who were recruited as a convenience sample. A telephone interview was conducted to collect information using a semi-structured questionnaire. Using logistic regression, we examined differences between racial groups concerning therapeutic and caregiving issues controlling for socioeconomic and demographic variables.

RESULTS

The regression analyses showed that African American caregivers had higher expectations for treatment outcomes (p ≤ 0.05) but poorer understanding of hospice and a stronger preference for hospice care outside the home (p ≤ 0.05). They were more likely to believe that the patient communicates with the family about cancer treatment to meet the family's expectations rather than seek emotional support (p ≤ 0.01). They were also more reluctant to endorse children's responsibility to make a treatment decision and are less likely to be fully satisfied with the decision-making process (p ≤ 0.05).

CONCLUSIONS

The findings suggest some differences in beliefs and cultural values between African American and White caregivers. African American caregivers appear to believe more in the possibility of curative care for advanced lung cancer and eschew hospice care. The findings inform possible challenges regarding communication about end-of-life treatment and care with African American caregivers and a need for the provision of adequate information and education.

Differential patient-caregiver opinions of treatment and care for advanced lung cancer patients

This study examined the differences of opinion between cancer patients and caregivers with regard to treatment and care decisions. 184 advanced lung cancer patients and 171 primary caregivers were recruited as a convenience sample from hospitals in Cleveland, Ohio. A telephone interview was conducted to collect data using a semi-structured questionnaire. Nonparametric tests and regression analysis were performed. The findings showed that patients and caregivers reported significant disagreement on three main issues: trade-off between treatment side effects and benefits; reporting treatment side effects to physicians, and hospice care. Caregivers were more concerned about patient's quality of life and more willing to discuss hospice issues than were patients (p < or = 01). Perceived family disagreement is associated with depression in both patients and caregivers (p < or = 01; R(2)=8%). The study provided empirical evidence for patient-caregiver disagreement about treatment and care decisions and its significant adverse impact on both patients and caregivers.

The Cancer Communication Assessment Tool for Patients and Families (CCAT-PF): a new measure

OBJECTIVES

Caregivers and cancer patients frequently have conflicting and unmet communication needs. The Cancer Communication Assessment Tool for Patients and Families (CCAT-PF) is a new instrument that assesses congruence in patient-family caregiver communication for both research and clinical purposes.

METHODS

The scale was developed using a sample of 190 lung cancer patient-caregiver pairs. Standard psychometric procedures were used to develop and test the scale including qualitative item pool development, item reduction and ascertainment of scale properties.

RESULTS

The multiple correlation of the 18-item CCAT-PF scale with the longer 30-item scale was 0.94. All but three items had less than 20% variance accounted for when each item was regressed on the remaining 17, indicating that responses to an individual item were not readily predicted by the remaining items. Test re-test reliability was 0.35 and Cronbach's alpha was 0.49 as the CCAT-PF scale represents the sum of mostly independent items. Higher CCAT-PF scores were significantly correlated with greater patient depression, greater patient perceived family conflict, lower patient-caregiver assessment and well-being and less expressiveness and family cohesion. For both patients and caregivers, physical, functional and emotional well-being were not associated with CCAT-PF scores.

CONCLUSION

The CCAT-PF is a brief but reliable and valid tool. Although administering both family and patient versions is optimal, administering it to a patient or family caregiver only also produces reliable information.

What it would take for men to attend and benefit from support groups after prostatectomy for prostate cancer: a problem-solving approach

Twenty-nine incontinent prostate cancer patients learned Pelvic Floor Muscle Exercises through biofeedback and were randomly assigned to a control group or a support group entailing six meetings over 3 months. The obtained consent rate (50%) is much higher than the previously reported rate for men (13%). The reasons for refusal were mainly due to actual barriers (48%) and less frequently due to psychological concerns (10.3%). Most support group participants (71.5%) attended five to six group meetings. The findings suggest that men are willing to attend support groups that focus on solving problems and that social supports help men improve continence and quality of life.

Gene expression analysis of Dupuytren's disease: the role of TGF-beta2

Dupuytren's disease is characterised by nodular fibroblastic proliferation of the palmar fascia leading to contracture of the hand. Transforming growth factor beta (TGF-beta) is thought to play a role in its pathogenesis. We performed a cDNA microarray analysis of Dupuytren's diseased cord tissue with an emphasis on TGF-beta isoforms. Normal-appearing transverse ligament of the palmar fascia from adjacent to the diseased cord and palmar fascia from patients undergoing carpal tunnel release were used as controls. TGF-beta gene expression was confirmed by quantitative real-time polymerase chain reaction. Over 20 unique genes were found to be significantly up-regulated, including several previously reported genes. A dominant increase in TGF-beta2 expression was seen in the cord tissue, whereas TGF-beta1 and TGF-beta3 were found not to be significantly up-regulated. Quantitative real-time polymerase chain reaction confirmed these findings. This gene expression profile allows for further experiments that may eventually lead to gene therapy to block the development and progression of Dupuytren's disease clinically.

Effects of Combined Pelvic Floor Muscle Exercise and a Support Group on Urinary Incontinence and Quality of Life of Postprostatectomy Patients

PURPOSE/OBJECTIVES

To examine the effect of combined pelvic floor muscle exercise (PFME) and a support group on postprostatectomy urinary incontinence and quality of life.

DESIGN

Pilot study of a randomized, controlled clinical trial.

SETTING

Two metropolitan hospitals in northeastern Ohio.

SAMPLE

29 men with postprostatectomy urinary incontinence.

METHODS

The participants learned PFME through biofeedback and were randomized to the control group (n = 15) or the support group (n = 14). The control group practiced PFME at home, whereas the support group attended six biweekly group meetings facilitated by a health psychologist. Assessment of urinary incontinence and quality of life was conducted at baseline and three months.

MAIN RESEARCH VARIABLES

Urinary incontinence and disease-specific quality of life.

FINDINGS

Eighty-six percent of the support group participants versus 46% of the control group participants practiced PFME four to seven days per week. The support group had a lower rating of urinary incontinence based on a 0- to 10-point visual analog rating scale than the control group (X = 3.2 versus 4.7), and fewer support group participants used pads (50%) than control group participants (85%) at three months. The support group also scored significantly lower on the severity of incontinence problems than the control group at three months, especially in relationship with spouse and social outing, despite no group difference in these areas at baseline.

CONCLUSIONS

The study provided promising evidence regarding the effect of the proposed intervention on adherence to PFME, urinary incontinence, and quality of life.

IMPLICATIONS FOR NURSING

Reports regarding nursing practice are lacking with respect to PFME. This study suggests that practicing PFME in a group with patients with incontinence who have undergone prostatectomy can be a useful nursing intervention.

Intervention of urinary incontinence and quality of life outcome in prostate cancer patients

This study examined the effect of combined Pelvic Floor Muscle Exercises (PFME) and support group on quality of life of postprostatectomy patients. Twenty-nine participants learned PFME through biofeedback and were randomized to the control group (n = 15) and support group (n = 14). Assessment of quality of life was conducted at baseline and 3-month follow-up. The findings indicated a trend of increased functioning and reduced perception of illness intrusiveness in the support group, compared with the control group. Improved urinary continence was significantly associated with reduced depression and symptom distress over time. The findings suggest that an intervention focusing on urinary continence improves quality of life in these patients.

Inhibition of ceramide-redox signaling pathway blocks glomerular injury in hyperhomocysteinemic rats

Ceramide-activated NAD(P)H oxidase has been reported to participate in homocysteine (Hcys)-induced abnormal metabolism of the extracellular matrix (ECM) in rat glomerular mesangial cells. However, it remains unknown whether this ceramide-redox signaling pathway contributes to glomerular injury induced by hyperhomocysteinemia (hHcys) in vivo. The present study was designed to address this question, defining the role of ceramide and activated NAD(P)H oxidase in the development of hHcys-induced glomerular injury. Uninephrectomized Sprague-Dawley rats were fed a folate-free diet for 8 weeks to produce hHcys and the de novo ceramide synthesis inhibitor myriocin or the NAD(P)H oxidase inhibitor apocynin was administrated. Rats with folate-free diet significantly increased plasma Hcys levels, renal ceramide levels, and NAD(P)H oxidase activity accompanied by marked glomerular injury. Treatment of rats with myriocin significantly reduced ceramide levels and improved glomerular injury, as shown by decreased urinary albumin excretion and reduced glomerular damage index. ECM components changed towards to normal levels with decreased tissue inhibitor of metalloproteinase-1 and increased matrix metalloproteinase-1 activity. NAD(P)H oxidase activity and Rac GTPase activity were reduced by 69 and 66%, respectively. In rats treated with apocynin, similar beneficial effects in protecting glomeruli from hHcys-induced injury were observed. These results support the view that de novo ceramide production is involved in Hcys-induced NAD(P)H oxidase activity in the kidney of hHcys rats and indicate the important role of ceramide-mediated redox signaling in hHcys-induced glomerular injury in rats.

The Long-Term Relationships Between the Motivation for Change and Alcohol Use Severity Among Patients with Severe and Persistent Mental Illness

This study examined the long-term relationship of changes in the motivation to remedy alcohol abuse to alcohol use severity among patients with a dual diagnosis of substance abuse disorder and severe and persistent mental illness. Linear regression analyses showed that patients who increasingly recognized alcohol use problems over a 9-month period exhibited significantly greater alcohol use severity at 9 months and a significant increase in alcohol use severity over time. Moreover, patients who became increasingly determined to take actions against alcohol use over a 9-month period exhibited significantly lower alcohol use severity at 9 months and a significant decrease in alcohol use severity over time. The findings support Prochaska et al.'s transtheoretical model of the motivation for change. They suggest that the recognition of alcohol use problems comes along with learning adverse consequences of alcohol use and that increased determination to take actions is critical to the long-term behavioral changes in alcohol use.

Impacts of motivation for change on the severity of alcohol use by patients with severe and persistent mental illness

OBJECTIVE

This study examined the effect of motivation for change, measured by the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), on alcohol use severity among alcoholic patients with severe and persistent mental illness.

METHOD

At a Veterans Affairs hospital, 390 dually diagnosed patients were recruited and assessed for motivation for change, alcohol use severity, psychotic symptoms and global functioning at baseline and 9-month follow-up.

RESULTS

Regression analyses showed that patients who were highly ambivalent about their alcohol use at baseline consumed significantly more alcohol 9 months later, on the basis of Addiction Severity Index ratings (p < or = .01), than patients who felt less ambivalent.

CONCLUSIONS

The findings suggest that increased awareness of alcohol-related problems is essential to reducing alcohol use severity for alcoholic patients with severe and persistent mental illness. The implications and limitations of the findings are discussed.

Cultural correlates of self perceived health status among Chinese elderly

This study examines self-perceived physical and mental health among 213 Chinese elderly who visited the Geriatric Outpatient Clinic of Beijing Hospital, the People's Republic of China. The study hypothesizes that cultural factors, specified by family relations, along with demographic factors, number of diseases, economic well-being, and living conditions have a significant impact on subjects self-perceived health status. Pearson correlation, linear and logistic regression analyses are performed. Results indicate that age, number of diseases, perceived family respect, neighborhood relations, and percentage of income spent on rent are significant predictors of self-perceived physical health. These same factors plus preference to live with a son and personal monthly income are significant predictors of self-perceived mental health. Socio-cultural implications of these findings are examined.

Life satisfaction among Chinese elderly in Beijing

The present study examined correlates of life satisfaction among 350 Chinese elderly aged 65 or older. Subjects consisted of a clinic sample (n = 200) and a randomly selected community sample (n = 150) recruited from the same area in Beijing. Linear regression analysis was performed, using health, financial status, and family support as independent variables. Results showed that the regression model explained 38 percent of the variance in life satisfaction in the total sample, 34 percent and 43 percent of the variance respectively in the clinical and community samples. Life satisfaction was significantly predicted by health and financial status among community elderly and by health, financial status, as well as family support among outpatient elderly. Findings suggest that the socio-cultural context has exerted important impacts on the Chinese elderly's life satisfaction.

The role of the family in treatment decision making by patients with cancer

PURPOSE/OBJECTIVES

To examine family disagreements about treatment decisions for patients with advanced lung cancer.

RESEARCH APPROACH

Descriptive, qualitative study.

SETTING

A large comprehensive cancer center in Cleveland, OH.

PARTICIPANTS

37 patients with stage III or IV lung cancer and 40 caregivers (24 primary and 16 secondary) from 26 families were interviewed.

METHODOLOGIC APPROACH

Open-ended audiotaped interviews were transcribed verbatim. NUD*IST (non-numerical unstructured data indexing, searching, and theorizing) computer software (QSR International, Melbourne, Australia) was used to perform content analysis.

MAIN RESEARCH VARIABLES

Vast differences in opinions between patients and family caregivers about treatment decisions and care.

FINDINGS

Sixty-five percent of families reported various family disagreements that mainly concerned routine treatment decisions, discontinuation of therapeutic treatment, and use of hospice care.

CONCLUSIONS

Family disagreements about treatment decisions for patients with advanced lung cancer are common and include a wide range of issues. Family members play an important role in the selection of patients' doctors, hospitals, treatment options, and provisions of care.

INTERPRETATION

The findings suggest that nurses need to be aware of differences of opinion between patients with advanced cancer and their caregivers. Knowledge of family disagreements about treatment decisions can help nurses' efforts to integrate families into decision-making processes in clinical settings to facilitate family communications and improve patients' and caregivers' satisfaction with treatment decisions.

Silence and cancer: why do families and patients fail to communicate?

This study examined the phenomenon of avoidance of family communication about cancer. Thirty-seven Stage III or IV lung cancer patients and 40 caregivers, including 24 primary and 16 secondary caregivers, were interviewed; a total of 26 families were studied. The interviews were audiotaped and transcribed. Analysis of the interviews indicated that two thirds of the families (65%) experienced communication problems. The avoidance of family communication was associated with several underlying thought processes: avoidance of psychological distress; desire for "mutual protection;" and belief in positive thinking. Family communication was further hindered by the increasing difficulty of issues inherent to late-stage cancer. The adverse impact of communication avoidance and the implications of our findings are discussed.

Anthropophobia: its meaning and concomitant experiences

This study investigated the essential feature and concomitant experiences of anthropophobia, a culturally specific phobic disorder in China and Japan. One hundred and fifty subjects, including 50 anthropophobic, 50 neurasthenic and 50 normal subjects, were recruited from hospitals and downtown residential areas in Beijing. Measures of anthropophobic symptoms and DSM-III-R depressive and anxiety symptoms were administered to all subjects. Nonparametric analysis of variance, analysis of variance (ANOVA and MANOVA) and Fisher's exact test were performed to examine group differences on each symptomatic item of the three measures. Results indicate that the core anthropophobic symptoms include a fear of making eye contact with others and a fear of being watched by others, which essentially express fears of others' judgement or opinion of oneself. Anxiety and depression are associated features of anthropophobia. However, these concomitants are experienced more cognitively and less somatically in the case of anthropophobia than neurasthenia.

Sociocultural contexts of anthropophobia: a sample of Chinese youth

BACKGROUND

Anthropophobia, a subtype of social phobia, is prevalent in Chinese and Japanese societies. This study investigated sociocultural influences on the course of this culturally specific mental disorder.

METHOD

One hundred and fifty subjects, including 50 anthropophobic, 50 neurasthenic, and 50 community subjects, were interviewed in Beijing, China for the assessment of their early life experiences (child-parent relationships and sexual experiences), collectivism disposition, sexual attitudes, and communication behaviors. Logistic and linear regression analyses were performed to examine significant predictors of the occurrence and the symptom level of anthropophobia.

RESULTS

Regression models explained 69% of variance in the diagnosis and 57% of variance in the symptom level of anthropophobia among anthropophobic and community subjects. They also explained 48% and 47% of variance respectively in the diagnosis and the level of symptoms among anthropophobic and neurasthenic subjects. Anthropophobic subjects had more problematic relationships with parents than did community and neurasthenic subjects. They also exhibited significantly stronger characteristics of collectivism than did community subjects. Sexual contact with a non-family member prior to age 19 and a feeling of discomfort when interacting with the opposite sex were significantly associated with the diagnosis and symptom level of anthropophobia.

CONCLUSIONS

It was concluded that anthropophobic subjects' early sexual experiences and need for parental approval shaped their conformity to social norms and negative sexual attitudes, which were reinforced by the collective-orientated cultural environment, and contributed to the development of anthropophobia.

Ethnic characteristics of mental disorders in five U.S. communities

The study examined the ethnic ratio of 16 DSM-III mental disorders among White, Black, Hispanic, and Asian Americans. A total of 18,126 residents from 5 sites and 2,939 residents from the Epidemiological Catchment Area's Los Angeles site were studied separately. Logistic regression analysis was performed. Results showed that Blacks were significantly less likely than Whites to have major depressive episode, major depression, dysthymia, obsessive-compulsive disorder, drug and alcohol abuse or dependence, antisocial personality, and anorexia nervosa, but they were significantly more likely than Whites to have phobia and somatization. Lifetime prevalence rates of schizophrenia, obsessive-compulsive disorder, panic, and drug abuse or dependence were significantly lower among Hispanics than among Whites. Asians also had significantly lower rates than Whites of schizophreniform, manic episode, bipolar disorder, panic, somatization, drug and alcohol abuse or dependence, and antisocial personality. Compared with the overall findings, ethnic differences at the Los Angeles site were lessened between Blacks and Whites, enhanced between Hispanics and Whites, and basically unchanged between Asians and Whites.

Family and cultural correlates of depression among Chinese elderly

This study hypothesized that depressive experiences of the elderly could be aggravated by universal factors such as low social status, poor health, financial strain, and unhealthy lifestyle, as well as by factors specific to an indigenous socio-cultural environment (stressful family dynamics) of a given population. Three hundred and fifty Chinese subjects aged 65 or older were interviewed either at their homes or in the geriatric out-patient clinic of Beijing Hospital. Hierarchical logistic regression was used to examine significant predictors of depression. Results showed that certain social status, poor physical health, financial strain, unhealthy lifestyle, and stressful family situation explained 47 percent of the variance in depression. However, stressful family situation alone explained 13 percent of the variance in depression, indicating that family factors were important predictors of depression for Chinese elderly. Furthermore, this study demonstrated for the first time that verbal abuse within Chinese families is a significant correlate of depression among the elderly. Cultural implications of these findings are discussed.

The association between breast cancer and diet and other factors

To explore the effects of diet and other factors on breast cancer development, a case-control study was conducted in Tianjin between 1986-87. After adjusting for confounding factors, it was found that factors associated with increased risk of breast cancer included --early age at menarche; late age at menopause; late age at first birth; high Qutelet's index; histories of breast wound, disease and benign tumor; and a family history of malignant tumor, high fat, high calorie, low vegetable intake; elevated serum cholesterol and LDL-cholesterol; and lower levels of serum HDL-cholesterol and whole blood selenium.

[Risk factors of breast cancer among women in Tianjin, China and Adelaide, Australia]

In order to study the possible explanation of the marked difference in the incidences of breast cancer between Chinese and Australian women, the authors have compared and analysed the results of two case-control studies completed recently in Tianjin, China and Adelaide, Australia. Of 9 potential risk factors studied, 8 are significantly higher in Adelaide (Ad) women than in Tianjin women. Women in Ad were much taller, heavier, more obese, earlier at menarche, later at first full-term pregnancy, more nulliparous, less parity, more in history of breast cancer in first degree relatives. In addition, they were well educated. The findings obtained by analysis of logistic regression model indicated that increased risk for breast cancer was associated with early menarche, late first full-term pregnancy, less parity, nulliparity, histories of benign breast diseases and breast cancer in first degree relatives in the Tianjin study, but not in Ad study. Late menopause and history of oral contraceptive were not associated with the increased risk in both studies. These factors being not associated with breast cancer in Ad women was unexpected. The explanation of the indefinite findings in Ad study was due to the fact that the level of the risk factor is higher, more uniform, and lack of stratum. The difference in the level of the risk factor will not appear among cases and controls in case-control study, and significance of the risk factor therefore may not be found. According to data on diet survey in these two cities, the amount of fat intake was significantly higher in Ad women than in Tianjin women.(ABSTRACT TRUNCATED AT 250 WORDS)