Elaboration and refinement of a motivational communication training program for healthcare professionals in pediatric oncology: a feasibility and acceptability study

INTRODUCTION

A healthy lifestyle could have a positive impact in reducing the incidence of some long-term sequelae secondary to pediatric cancer treatments. Motivational communication (MC) is effective at improving healthy lifestyle habits, especially when patients experience change as a challenge. To date, there is no available intervention program using MC that promotes healthy lifestyles in pediatric oncology.

OBJECTIVES

The aim of this study was to develop the first MC training program for professionals in pediatric oncology and assess its feasibility and acceptability.

MATERIALS AND METHODS

Following standard procedures involving professionals, we developed a professional-targeted training named the Motivation Cafés, consisting in six sessions of core MC skills for healthcare professionals who wish to positively impact lifestyles of families in pediatric oncology. We used a mixed-methods quantitative-qualitative study to assess the program feasibility and acceptability. Professionals in nutrition and physical activity (N = 16) attended two rounds of the training and completed surveys to evaluate the training. They reported self-efficacy and knowledge in MC. Participation and retention rates were used to assess acceptability and feasibility, and a thematic analysis of the open-ended questions was performed to identify strengths and weaknesses of the program to further refine the program. We used non-parametric statistics to compare pre-post changes on measures of self-efficacy and knowledge in MC.

RESULTS

Attendance and retention (average 4.2/6 sessions completed) were high, suggesting very good adherence and feasibility. We also found high levels of acceptability and pertinence of the program (i.e. >90%). The results suggested probable improvements in self-efficacy and knowledge, but these were not statistically significant given the limited sample size.

CONCLUSION

The training Motivation Cafés is now ready to be pilot tested in pediatric cancer care centers.

Prognostic role of myocardial work in patients with heart failure and reduced ejection fraction treated by sacubitril/valsartan

Background

The non-invasive assessment of myocardial work (MW) by pressure-strain loops analysis (PSL) is a relative new tool for the evaluation of myocardial performance. Sacubitril/Valsartan is a treatment for heart failure with reduced ejection fraction (HFrEF) which has a spectacular effect on the reduction of cardiovascular events (MACEs).

Purposes of this study were to evaluate 1) the short and medium term effect of Sacubitril/Valsartan treatment on MW parameters; 2) the prognostic value of MW in this specific group of patients.

Methods

79 patients with HFrEF (mean age: 66±12 years; LV ejection fraction: 28±9%) were prospectively included in the study and treated with Sacubitril/Valsartan. Echocardiographic examination was performed at baseline, and after 6- and 12-month of therapy with Sacubitril/Valsartan.

Results

Sacubitril/Valsartan significantly increased global myocardial constructive work (CW) (1023±449 vs 1424±484 mmHg%, p<0.0001) and myocardial work efficiency (WE) [87 (78–90) vs 90 (86–95), p<0.0001]. During FU (2.6±0.9 years), MACEs occurred in 13 (16%) patients. After correction for LV size, LVEF and WE, CW was the only predictor of MACEs (Table 1). A CW<910 mmHg (AUC=0.81, p<0.0001, Figure 1A) identified patients at particularly increase risk of MACEs [HR 11.09 (1.45–98.94), p=0.002, log-rank test p<0.0001] (Figure 1 B).

Conclusions

In patients with HFrEF who receive a comprehensive background beta-blocker and mineral-corticoid receptor antagonist therapy, Sacubitril/Valsartan induces a significant improvement of myocardial CW and WE. In this population, the estimation of CW before the initiation of Sacubitril/Valsartan therapy allows the prediction of MACEs.

Funding Acknowledgement

Type of funding source: None

Relative associations between depression and anxiety on adverse cardiovascular events: does a history of coronary artery disease matter? A prospective observational study

OBJECTIVES

To assess whether depression and anxiety increase the risk of mortality and major adverse cardiovascular events (MACE), among patients with and without coronary artery disease (CAD).

DESIGN AND SETTING, AND PATIENTS

DECADE (Depression Effects on Coronary Artery Disease Events) is a prospective observational study of 2390 patients referred at the Montreal Heart Institute. Patients were followed for 8.8 years, between 1998 and 2009. Depression and anxiety were assessed using a psychiatric interview (Primary Care Evaluation of Mental Disorders, PRIME-MD). Outcomes data were obtained from Quebec provincial databases.

MAIN OUTCOME MEASURES

All-cause mortality and MACE.

RESULTS

After adjustment for covariates, patients with depression were at increased risks of all-cause mortality (relative risk (RR)=2.84; 95% CI 1.25 to 6.49) compared with patients without depression. Anxiety was not associated with increased mortality risks (RR=0.86; 95% CI 0.31 to 2.36). When patients were stratified according to CAD status, depression increased the risk of mortality among patients with no CAD (RR=4.39; 95% CI 1.12 to 17.21), but not among patients with CAD (RR=2.32; 95% CI 0.78 to 6.88). Neither depression nor anxiety was associated with MACE among patients with or without CAD.

CONCLUSIONS AND RELEVANCE

Depression, but not anxiety, was an independent risk factor for all-cause mortality in patients without CAD. The present study contributes to a better understanding of the relative and unique role of depression versus anxiety among patients with versus without CAD.

A study of myocardial perfusion in patients with panic disorder and low risk coronary artery disease after 35% CO2 challenge

BACKGROUND

We have previously reported that 35% CO2 challenge induced myocardial ischemia in 81% of coronary artery disease (CAD) patients with comorbid panic disorder (PD) and previous positive nuclear exercise stress tests. However, it is yet unclear whether this is the case among CAD patients with PD and normal nuclear exercise stress test results. We hypothesized that a potent mental stressor such as a panic challenge among CAD patients with PD would also induce ischemia in patients with normal exercise stress tests.

METHODS

Forty-one coronary artery disease patients with normal nuclear exercise stress tests (21 patients with PD and 20 without PD) were submitted to a well-established panic challenge test (with 1 vital capacity inhalation of a gas mixture containing 35% CO2 and 65% O2) and injected with Tc-99m-tetrofosmin (Myoview), upon inhalation. Single photon emission computed tomography imaging was used to assess per-panic challenge reversible myocardial ischemia and HR, BP, and a 12 lead ECG was continuously measured during the procedure.

RESULTS

Fifty-eight percent of panic disorder patients (12/21) had a panic attack during the panic challenge vs 15% (3/20) of controls (p=0.005). Only 10% of patients in each group displayed myocardial ischemia per panic challenge.

CONCLUSIONS

These findings suggest that panic attacks among panic disorder patients with lower-risk coronary artery disease may not confer a risk for myocardial ischemia.

Gradient Boosting as a SNP Filter: an Evaluation Using Simulated and Hair Morphology Data

Typically, genome-wide association studies consist of regressing the phenotype on each SNP separately using an additive genetic model. Although statistical models for recessive, dominant, SNP-SNP, or SNP-environment interactions exist, the testing burden makes an evaluation of all possible effects impractical for genome-wide data. We advocate a two-step approach where the first step consists of a filter that is sensitive to different types of SNP main and interactions effects. The aim is to substantially reduce the number of SNPs such that more specific modeling becomes feasible in a second step. We provide an evaluation of a statistical learning method called "gradient boosting machine" (GBM) that can be used as a filter. GBM does not require an a priori specification of a genetic model, and permits inclusion of large numbers of covariates. GBM can therefore be used to explore multiple GxE interactions, which would not be feasible within the parametric framework used in GWAS. We show in a simulation that GBM performs well even under conditions favorable to the standard additive regression model commonly used in GWAS, and is sensitive to the detection of interaction effects even if one of the interacting variables has a zero main effect. The latter would not be detected in GWAS. Our evaluation is accompanied by an analysis of empirical data concerning hair morphology. We estimate the phenotypic variance explained by increasing numbers of highest ranked SNPs, and show that it is sufficient to select 10K-20K SNPs in the first step of a two-step approach.

Impact of anxiety and depression on chronic obstructive pulmonary disease exacerbation risk

Chronic obstructive pulmonary disease (COPD) exacerbations contribute significantly to morbidity and mortality. COPD is also associated with high levels of psychological distress, which has been linked with higher exacerbation rates. At a recent American Thoracic Society conference symposium titled "Depression and Obstructive Lung Disease: State of the Science and Future Directions" held in 2010 in New Orleans, clinicians and researchers identified a number of important research priorities related to psychiatric comorbidities, including the need to better understand their impact on COPD outcomes, such as exacerbations. This article reviews the current literature and quantifies the prospective impact of anxiety and depression on exacerbation risk in patients with COPD. The limitations of the existing literature and the perspectives for future research are addressed.

The research on endothelial function in women and men at risk for cardiovascular disease (REWARD) study: methodology

Background

Endothelial function has been shown to be a highly sensitive marker for the overall cardiovascular risk of an individual. Furthermore, there is evidence of important sex differences in endothelial function that may underlie the differential presentation of cardiovascular disease (CVD) in women relative to men. As such, measuring endothelial function may have sex-specific prognostic value for the prediction of CVD events, thus improving risk stratification for the overall prediction of CVD in both men and women. The primary objective of this study is to assess the clinical utility of the forearm hyperaemic reactivity (FHR) test (a proxy measure of endothelial function) for the prediction of CVD events in men vs. women using a novel, noninvasive nuclear medicine -based approach. It is hypothesised that: 1) endothelial dysfunction will be a significant predictor of 5-year CVD events independent of baseline stress test results, clinical, demographic, and psychological variables in both men and women; and 2) endothelial dysfunction will be a better predictor of 5-year CVD events in women compared to men.

Methods/Design

A total of 1972 patients (812 men and 1160 women) undergoing a dipyridamole stress testing were recruited. Medical history, CVD risk factors, health behaviours, psychological status, and gender identity were assessed via structured interview or self-report questionnaires at baseline. In addition, FHR was assessed, as well as levels of sex hormones via blood draw. Patients will be followed for 5 years to assess major CVD events (cardiac mortality, non-fatal MI, revascularization procedures, and cerebrovascular events).

Discussion

This is the first study to determine the extent and nature of any sex differences in the ability of endothelial function to predict CVD events. We believe the results of this study will provide data that will better inform the choice of diagnostic tests in men and women and bring the quality of risk stratification in women on par with that of men.

The impact of psychological distress on exacerbation rates in COPD

BACKGROUND

exacerbations are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to COPD morbidity and mortality. COPD is also associated with high levels of psychological distress, which has been shown to be associated with higher exacerbation rates. However, the existing literature on the association between psychological distress and exacerbation risk remains largely misunderstood.

OBJECTIVES

to critically review the current literature on the association between psychological distress (defined as anxiety and depressive symptoms or anxiety and depressive disorders) and COPD exacerbations in COPD patients, to highlight the limitations of the existing literature, and to provide recommendations for future research.

METHODS

a critical review of English-language peer-reviewed longitudinal and retrospective studies was conducted. The Ovid portal to Medline, EMBASE, and PsycINFO databases were accessed.

RESULTS

some acceptable evidence suggested that psychological distress confers greater risk for exacerbations, more specifically symptom-based exacerbations or those treated in the patient's own environment. However, most studies showed an absence of a positive association, especially with exacerbations leading to hospitalization.

CONCLUSIONS

methodological weaknesses and the use of a wide range of psychological tools mean that there is an inconsistent association between psychological distress and exacerbations in the current literature. However, psychological distress may confer greater risk for symptom-based rather than event-based defined exacerbations. Further studies are needed to more comprehensively assess the question, particularly in light of the high levels of both anxiety and depression in COPD patients.

Sex Differences in the Prevalence of Psychiatric Disorders and Psychological Distress in Patients With COPD

BACKGROUND

Psychiatric disorders are highly prevalent in patients with COPD. In general, psychiatric disorders are more common in women than in men. The extent to which women with COPD suffer from greater psychiatric and psychological morbidity is not known. The present cross-sectional study evaluated the prevalence of mood and anxiety disorders, levels of psychological distress, and quality of life in 62 women and 54 men with documented, stable COPD.

METHODS

All patients (n = 116) underwent a sociodemographic and medical history interview, followed by a structured psychiatric interview and standard spirometry. Patients also completed a battery of questionnaires measuring psychological distress and quality of life.

RESULTS

The overall prevalence of psychiatric disorders was 49%. Significantly more women than men met the diagnostic criteria for anxiety disorders (56% vs 35%), and a trend for greater levels of major depression in women was found (18% vs 7%). Women had significantly higher anxiety sensitivity and depressive symptoms compared to men but did not report more limitations in psychological functioning. Women also reported being less confident in their ability to control respiratory symptoms, and more daily physical limitations compared to men, despite having comparable COPD severity, dyspnea scores, and exacerbation rates.

CONCLUSIONS

Results indicate that psychiatric disorders are at least three times higher in COPD patients compared to the general population, and nearly two times higher in women than in men. Women also have greater psychological distress, worse perceived control of symptoms, and greater functional impairment. Greater efforts should be made to identify and treat psychiatric disorders in COPD patients, particularly in women.

Myocardial perfusion study of panic attacks in patients with coronary artery disease

Panic disorder (PD) and panic-like anxiety have been associated with an increased risk of cardiovascular death. No study has specifically examined the association between panic attacks and ischemia in patients who have coronary artery disease (CAD). We hypothesized that panic attacks would induce myocardial perfusion defects in patients who have CAD and PD. Sixty-five patients who had CAD and positive results with nuclear exercise stress testing (35 with PD and 30 without PD served as controls) underwent a well-established panic challenge test (1 vital capacity inhalation of a gas mixture containing 35% carbon dioxide and 65% oxygen) and were injected with technetium-99m sestamibi at inhalation. Single-photon emission computed tomography was used to assess per-panic challenge perfusion defects, and heart rate, blood pressure, and 12-lead electrocardiogram were continuously measured during the procedure. Patients were not withdrawn from their cardiac medications. Patients who had PD were significantly younger than the controls; otherwise groups did not differ with respect to gender, cardiac medications, nuclear exercise test results, and baseline heart rate and blood pressure. Seventy-four percent of patients (26 of 35) who had PD had a panic attack at inhalation versus 6.7% of controls (2 of 30, p <0.001). As hypothesized, patients who had PD and demonstrated a panic attack were more likely to develop a reversible myocardial perfusion defect than were controls who did not have an attack (80.9% vs 46.4% p = 0.009). Thus, despite being on their cardiac medications, panic attacks preferentially induced significant perfusion defects in patients who had CAD and PD. In conclusion, panic attacks in patients who have CAD appear to be bad for the heart.

Heart rate variability in coronary artery disease patients with and without panic disorder

Panic disorder (PD) and coronary artery disease (CAD) often co-occur, and CAD patients with comorbid PD suffer greater cardiovascular morbidity and mortality relative to CAD patients without PD. However, the mechanisms underlying these associations are still unknown. Reduced heart rate variability (HRV), a non-invasive measure of cardiac autonomic modulation, is an important predictor of adverse cardiac events. Interestingly, reduced HRV has been observed in patients with panic-like anxiety and PD, as well as in various CAD populations. However, the extent to which HRV is altered in patients with both PD and CAD is unknown. This study evaluated HRV in 42 CAD patients with (n=20) and without (n=22) PD. Patients underwent 48-h electrocardiographic monitoring. Power spectral analysis of HRV indicated that CAD patients with PD exhibited significantly lower LF/HF ratios, which may reflect lower sympathetic modulation, compared with non-PD patients. Additionally, total power in PD patients was made up of a significantly higher proportion of HF power and a significantly lower proportion of VLF power than in non-PD patients. No other significant differences in HRV indices were observed. Results suggest that contrary to what has been observed in the majority of PD-only and CAD-only populations; patients with both PD and CAD appear to exhibit lower sympathetic modulation during ordinary daily life conditions. Though preliminary, these findings suggest that changes in HRV may not be the mechanism underlying greater cardiovascular morbidity and mortality among CAD patients with PD.

Are exercise stress tests appropriate for assessing myocardial ischemia in patients with major depressive disorder?

BACKGROUND

Major depressive disorder (MDD) disproportionately affects patients with coronary artery disease (CAD). Evidence of myocardial ischemia with electrocardiography (ECG) or single-photon-emission-computed-tomography (SPECT) assessments during exercise testing is an important determinant of CAD prognosis. However, many key symptoms of MDD, such as reduced interest in daily activities, lack of energy, and fatigue, may affect exercise performance and the detection of ischemia in patients with MDD. This study evaluated the extent to which MDD and depressive symptomatology moderate exercise test performance and compared the ability of ECG versus SPECT for detecting ischemia in 1367 consecutive patients who underwent exercise testing.

METHODS

All patients underwent a brief, structured psychiatric interview (PRIME-MD) and completed the Beck Depression Inventory (BDI) on the day of their exercise (treadmill) test.

RESULTS

A total of 183 patients (13%) met diagnostic criteria for MDD. Patients with MDD achieved a significantly lower percent of maximal predicted heart rate (%MPHR), exhibited lower peak exercise mets, and spent less time exercising compared with patients without MDD (all P values <.05). BDI scores were also negatively correlated with all 3 indices of exercise performance (all P values <.01). There were no differences in rates of SPECT ischemia in patients with MDD (40%) versus patients without MDD (45%; P =.23); however, rates of ECG ischemia were significantly lower (30%) in patients with MDD than in patients without MDD (48%; P <.0001).

CONCLUSIONS

Results suggest that patients with CAD who have MDD, depressive symptomatology, or both exhibit poor exercise tolerance and performance and that ECG, as compared with SPECT, may not be as reliable in detecting ischemia in patients who are depressed.

CASH 2021: commercial access and space habitation

Issues about commercialization of space have been a growing concern in the past decade for the space community. This paper focuses on the work from a team of 51 students attending the Summer Session Program of the International Space University in Bremen, Germany. CASH 2021 (Commercial Access and Space Habitation) documents a plan that identifies commercial opportunities for space utilization that will extend human presence in space, and will chart the way forward for the next 20 years. The group selected four commercial sectors that show the most promise for the future: tourism, entertainment, space system service, assembly and debris removal, and research and development/production. The content of this document presents the results of their research. Historical activities in each of the commercial sectors are reviewed along with the current market situation. To provide a coherent background for future commercialization possibilities a scenario has been developed. This scenario includes a postulated upon ideal future and includes social, political and economic factors that may affect the space industry over the timeline of the study. The study also presents a roadmap, within the limited optimistic scenario developed, for the successful commercialization of space leading to future human presence in space. A broad range of commercially viable opportunities, not only within the current limits of the International Space Station, but also among the many new developments that are expected by 2021 are discussed.

[Idiopathic segmental infarct of the omentum. Differential diagnosis in an obese patient]

OBJECTIVE

Infarction of the greater omentum is a rare etiology of acute abdominal pain. The differential diagnosis, especially with appendicitis, is difficult to establish.

CASE REPORT

A 29 years-old male presented with acute abdominal pain. He underwent a laparoscopic resection on the 5th hospital day because of persistant pain despite conservative management. Histopathological examination confirmed the diagnosis of omental infarction.

DISCUSSION

Primary segmental necrosis of the omentum is a rare entity. Obesity and cardiovascular diseases are considered predisposing conditions. The infarctions tend to occur in the right side of the omentum. Abdominal pain is predominant in opposition to the patient's good general condition. Laboratory results are usually nonspecific. Abdominal ultrasound may show a solid, ovoid, hyperechoic lesion. CT-scan may depict a fatty oval-shaped mass below the right anterolateral parietal wall associated with a thickening of the anterior parietal peritoneum.

CONCLUSION

The correct diagnosis of omental infarction is important to establish preoperatively in acute abdominal pain, as in uneventful courses surgery can be avoided.

[Mental illness : a challenge for our collective consciousness.]

In this article, the author, an actor and a privileged observer of psychiatry in Quebec over the past twenty-five years, outlines the development of that area. He describes the events before 1962, the after effects of the Bedard Commission and the influence of the Castonguay-Nepveu Commission on psychiatric services. Then, he analyses the growth of those services from the angle of institutionaksation, desinstitutionalisation, research and community approach. He queries the ideological theories, the bio-psychosocial approach and speaks of the patients' role in the defense of their rights, and of their families. He ends by proposing ways to improve the actual services.

Femoral head defect following anterior hip dislocation

Impaction fractures of the femoral head following anterior hip dislocation were noted in eight of 11 patients. This fracture is characterized by a depression or a flattening of the posterosuperior and lateral portion of the femoral head. It is usually seen on the standard anteroposterior view of the pelvis.

Late results of activator-treatment: a cephalometric study

The purpose of this study was to analyse cephalometrically the long-term effect of Activator treatment on the dentofacial skeleton in 50 consecutively treated cases of postnormal and prenormal occlusion. Comparisons of dentofacial form between successful and unsuccessful cases were performed. The results of the study showed that the sagittal relationship between the jaws became normal in postnormal and prenormal cases during Activator treatment. The effect was achieved mainly by reciprocal dentoalveolar changes of the maxilla and mandible supported by a retardation of the forward growth of the maxilla in Class II cases and a stimulation of the forward growth of the maxilla in Class III cases. The normal downward-forward growth of the mandible appeared unaffected. The effect of Activator treatment on the vertical growth of the jaws was a significant increase in lower face height (bite-raising). No tendency to induce a harmful posterior growth rotation of the mandible was noted. Before treatment there was no highly significant difference in the morphology of the dentofacial skeleton between successfully and unsuccessfully treated Activator cases, except for the basal relationship between the jaws (ss-n-sm) which was larger in the successful cases. It would rather appear that good cooperation, high growth intensity and a favourable growth pattern of the patient together with a well constructed appliance is of decisive importance for a successful result of treatment.

Sagittal mobility of the normal ankle

In children and adults, there is a physiological anterior sagittal displacement of the talus which decreases when the examination is repeated in equinus. The displacement occurs when the examination is performed with or without apparatus, with manual stress or with weights. The diminution of the normal sagittal mobility of the talus when the examination is performed with the ankle in the position of equinus, it attributable to the intact anterior talofibular ligament which becomes taut when the ankle is in a position of flexion. A pathological drawer sign will be noted following an isolated tear of the anterior talofibular; under those circumstances sagittal instability is increased and is not appreciably affected by repeating the examination in a position of ankle equinus.