Neoadjuvant Chemotherapy Versus Upfront Surgery for Resectable Pancreatic Adenocarcinoma: An Updated Nationwide Study

OBJECTIVE

The objective of this study was to assess the association of survival with neoadjuvant chemotherapy (NAC) in resectable pancreatic adenocarcinoma (PDAC).

BACKGROUND

The early control of potential micrometastases and patient selection using NAC has been advocated for patients with PDAC. However, the role of NAC for resectable PDAC remains unclear.

METHODS

Patients with clinical T1 and T2 PDAC were identified in the National Cancer Database from 2010 to 2017. Kaplan-Meier estimates, and Cox regression models were used to compare survival. To address immortal time bias, landmark analysis was performed. Interactions between preoperative factors and NAC were investigated in subgroup analyses. A propensity score analysis was performed to compare survival between multiagent NAC and upfront surgery.

RESULTS

In total, 4041 patients were treated with upfront surgery and 1,175 patients were treated with NAC (79.4% multiagent NAC, 20.6% single-agent NAC). Using a landmark time of 6 months after diagnosis, patients treated with multiagent NAC had longer median overall survival compared with upfront surgery and single-agent NAC. (35.8 vs 27.1 vs 27.4 mo). Multiagent NAC was associated with lower mortality rates compared with upfront surgery (adjusted hazard ratio, 0.77; 95% CI, 0.70-0.85), whereas single-agent NAC was not. The association of survival with multiagent NAC were consistent in analyses using the matched data sets. Interaction analysis revealed that the association between multiagent NAC and a lower mortality rate did not significantly differ across age, facility type, tumor location, CA 19-9 levels, and clinical T/N stages.

CONCLUSIONS

The findings suggest that multiagent NAC followed by resection is associated with improved survival compared with upfront surgery.

Long distance multiplexed quantum teleportation from a telecom photon to a solid-state qubit

Quantum teleportation is an essential capability for quantum networks, allowing the transmission of quantum bits (qubits) without a direct exchange of quantum information. Its implementation between distant parties requires teleportation of the quantum information to matter qubits that store it for long enough to allow users to perform further processing. Here we demonstrate long distance quantum teleportation from a photonic qubit at telecom wavelength to a matter qubit, stored as a collective excitation in a solid-state quantum memory. Our system encompasses an active feed-forward scheme, implementing a conditional phase shift on the qubit retrieved from the memory, as required by the protocol. Moreover, our approach is time-multiplexed, allowing for an increase in the teleportation rate, and is directly compatible with the deployed telecommunication networks, two key features for its scalability and practical implementation, that will play a pivotal role in the development of long-distance quantum communication.

Association of Adjuvant Chemotherapy in Patients With Resected Pancreatic Adenocarcinoma After Multiagent Neoadjuvant Chemotherapy

Importance

The total number of patients with pancreatic ductal adenocarcinoma (PDAC) who receive neoadjuvant chemotherapy (NAC) is increasing. However, the added role of adjuvant chemotherapy (AC) in these patients remains unknown.

Objective

To evaluate the association of AC with overall survival (OS) in patients with PDAC who received multiagent NAC followed by curative-intent surgery.

Design, Setting, and Participants

This retrospective, matched-cohort study used data from the National Cancer Database and included patients with PDAC diagnosed between 2010 and 2018. The study included patients at least 18 years of age who received multiagent NAC followed by surgical resection and had available records of the pathological findings. Patients were excluded if they had clinical or pathological stage IV disease or died within 90 days of their operation.

Exposures

All included patients received NAC and underwent resection for primary PDAC. Some patients received adjuvant chemotherapy.

Main Outcomes and Measures

The main outcome was the OS of patients who received AC (AC group) vs those who did not (non-AC group). Interactions between pathological findings and AC were investigated in separate multivariable Cox regression models.

Results

In total, 1132 patients (mean [SD] age, 63.5 [9.4] years; 577 [50.1%] male; 970 [85.7%] White) were included, 640 patients in the non-AC group and 492 patients in the AC group. After being matched by propensity score according to demographic and pathological characteristics, 444 patients remained in each group. The multivariable Cox regression model adjusted for all covariates revealed an association between AC and improved survival (hazard ratio, 0.71; 95% CI, 0.59-0.85; P < .001). Subgroup interaction analysis revealed that AC was significantly associated with better OS (26.6 vs 21.2 months; P = .002), but the benefit varied by age, pathological T category, and tumor differentiation. Of note, AC was associated with better survival in patients with any pathological N category and positive margin status.

Conclusions and Relevance

In this cohort study, AC following multiagent NAC and resection in patients with PDAC was associated with significant survival benefit compared with that in patients who did not receive AC. These findings suggest that patients with aggressive tumors may benefit from AC to achieve prolonged survival, even after multiagent NAC and curative-intent resection.

Evaluation of Survival Following Surgical Resection for Small Nonfunctional Pancreatic Neuroendocrine Tumors

Importance

The number of patients with small nonfunctional pancreatic neuroendocrine tumors (NF-PanNETs) is increasing. However, the role of surgery for small NF-PanNETs remains unclear.

Objective

To evaluate the association between surgical resection for NF-PanNETs measuring 2 cm or smaller and survival.

Design, Setting, and Participants

This cohort study used data from the National Cancer Database and included patients with NF-pancreatic neuroendocrine neoplasms who were diagnosed between January 1, 2004, and December 31, 2017. Patients with small NF-PanNETs were divided into 2 groups: group 1a (tumor size, ≤1 cm) and group 1b (tumor size, 1.1-2.0 cm). Patients without information on tumor size, overall survival, and surgical resection were excluded. Data analysis was performed in June 2022.

Exposures

Patients with vs without surgical resection.

Main Outcomes and Measures

The primary outcome was overall survival of patients in group 1a or group 1b who underwent surgical resection compared with those who did not, which was evaluated using Kaplan-Meier estimates and multivariable Cox proportional hazards regression models. Interactions between preoperative factors and surgical resection were analyzed with a multivariable Cox proportional hazards regression model.

Results

Of the 10 504 patients with localized NF-PanNETs identified, 4641 were analyzed. These patients had a mean (SD) age of 60.5 (12.7) years and included 2338 males (50.4%). The median (IQR) follow-up time was 47.1 (28.2-71.6) months. In total, 1278 patients were in group 1a and 3363 patients were in group 1b. The surgical resection rates were 82.0% in group 1a and 87.0% in group 1b. After adjustment for preoperative factors, surgical resection was associated with longer survival for patients in group 1b (hazard ratio [HR], 0.58; 95% CI, 0.42-0.80; P < .001) but not for patients in group 1a (HR, 0.68; 95% CI, 0.41-1.11; P = .12). In group 1b, interaction analysis found that age of 64 years or younger, absence of comorbidities, treatment at academic institutions, and distal pancreatic tumors were factors associated with increased survival after surgical resection.

Conclusions and Relevance

Findings of this study support an association between surgical resection and increased survival in select patients with NF-PanNETs measuring 1.1 to 2.0 cm who were younger than 65 years, had no comorbidities, received treatment at academic institutions, and had tumors of the distal pancreas. Future investigations of surgical resection for small NF-PanNETs that include the Ki-67 index are warranted to validate these findings.

Evaluating surgical treatment options for small nonfunctional pancreatic neuroendocrine tumors in the NCDB

645

Background: The role of surgery for small (≤2 cm), nonfunctional pancreatic neuroendocrine tumors (NF-PNETs) remains controversial due to the wide range of tumor aggressiveness. Consensus guidelines of the US, Europe, and Japan offer different recommendations for treatment of small NF-PNETs. The objective of this study is to evaluate the survival benefit of surgical resection for small NF-PNETs. Methods: Patients with NF-PNETs were identified in the National Cancer Database from 2004 to 2018. Small NF-PNETs were divided into two groups: group 1a (tumor ≤1 cm) and group 1b (tumor 1.1 – 2.0 cm). Cox regression models were used to compare the overall survival between resected and unresected small NF-PNETs patients. Interactions between preoperative factors and surgery were estimated using subgroup analyses. Results: We identified 1,278 patients in group 1a and 3,363 patients in group 1b. After adjusting for preoperative factors, surgery was associated with longer survival for patients in group 1b (HR, 0.58; 95% CI, 0.42–0.80; P <0.001), but not for patients in group 1a (HR, 0.68; 95% CI, 0.41–1.11; P = 0.122). Interaction analysis found that age younger than 65 years, fewer comorbidities, treatment at academic institutions, distal pancreatic tumors, and clinical lymph node metastasis were factors associated with longer survival in group 1b by surgery. Conclusions: Findings from this large study support surgical resection for some patients with NF-PNETs (1.1 – 2.0 cm). This, of course, must be taken in context with the patient’s clinical situation. Based on data available for analysis in this study, resection for subcentimeter NF-PNETs does not appear to be of general benefit, but should also be investigated in the context of Ki-67 index.[Table: see text]

The impact of psychological distress on weight regain in post-bariatric patients during the COVID-19 pandemic: A latent profile analysis

OBJECTIVE

The COVID-19 pandemic has caused a global health crisis disrupting healthcare delivery for people with severe obesity who have undergone bariatric surgery. This study examined the role of psychological distress during the first Italian COVID-19 lockdown in predicting post-operative outcomes in post-bariatric patients reaching the end of the 12-18 months follow-up during the lockdown. By using a person-centered approach, groups of patients with different psychological distress profiles were identified. We hypothesized that compared to post-bariatric patients with low psychological distress, post-bariatric patients with high psychological distress will be more at risk of weight regain.

METHODS

A total of 67 patients (71.6% female, M_age = 45.9) participated in this observational retrospective cohort study. Patients' anthropometric data were gathered from medical records while the weight at the end of the lockdown through phone interviews. Psychological distress, operationalized with anxiety symptoms, depressive symptoms, and sleep disturbances, was assessed by an online self-report questionnaire.

RESULTS

Significant differences were highlighted in the high and low psychological distressed group in weight changes, F(1,58) = 5.2, p < 0.001, η² = 0.3. Specifically, compared to post-bariatric patients in the low psychological distress group, those in the high psychological distressed group reported weight regained (95% CI = 1.0, 2.6).

CONCLUSION

Results highlight the need to target post-bariatric patients with high psychological distress who are at risk for weight regain during the COVID-19 pandemic. Interventions mitigating psychological distress and obesogenic behaviors during future pandemics or in post-COVID times are needed in vulnerable post-bariatric patients reporting high psychological distress.

Surgeons' attitudes during laparoscopic appendectomy: do subjective intraoperative assessments affect the choice of peritoneal irrigation? A spin-off analysis from the REsiDENT-1 multicentre prospective observational trial

AIMS

Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL.

METHODS

Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL.

RESULTS

561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p < 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL.

CONCLUSION

This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process.

Storage and analysis of light-matter entanglement in a fiber-integrated system

The deployment of a full-fledged quantum internet poses the challenge of finding adequate building blocks for entanglement distribution between remote quantum nodes. A practical system would combine propagation in optical fibers with quantum memories for light, leveraging on the existing communication network while featuring the scalability required to extend to network sizes. Here, we demonstrate a fiber-integrated quantum memory entangled with a photon at telecommunication wavelength. The storage device is based on a fiber-pigtailed laser-written waveguide in a rare earth-doped solid and allows an all-fiber stable addressing of the memory. The analysis of the entanglement is performed using fiber-based interferometers. Our results feature orders-of-magnitude advances in terms of storage time and efficiency for integrated storage of light-matter entanglement and constitute a substantial step forward toward quantum networks using integrated devices.

Entanglement between a Telecom Photon and an On-Demand Multimode Solid-State Quantum Memory

Entanglement between photons at telecommunication wavelengths and long-lived quantum memories is one of the fundamental requirements of long-distance quantum communication. Quantum memories featuring on-demand readout and multimode operation are additional precious assets that will benefit the communication rate. In this Letter, we report the first demonstration of entanglement between a telecom photon and a collective spin excitation in a multimode solid-state quantum memory. Photon pairs are generated through widely nondegenerate parametric down-conversion, featuring energy-time entanglement between the telecom-wavelength idler and a visible signal photon. The latter is stored in a Pr^{3+}:Y_{2}SiO_{5} crystal as a spin wave using the full atomic frequency comb scheme. We then recall the stored signal photon and analyze the entanglement using the Franson scheme. We measure conditional fidelities of 92(2)% for excited-state storage, enough to violate a Clauser-Horne-Shimony-Holt inequality, and 77(2)% for spin-wave storage. Taking advantage of the on-demand readout from the spin state, we extend the entanglement storage in the quantum memory for up to 47.7  μs, which could allow for the distribution of entanglement between quantum nodes separated by distances of up to 10 km.

Long-term complete response in metastatic poorly-differentiated neuroendocrine rectal carcinoma with a multimodal approach: A case report

BACKGROUND

Neuroendocrine gastrointestinal tumors (NETs) are rare and have different natural behaviors. Surgery is the gold standard treatment for local disease while radiotherapy has been demonstrated to be ineffective. Poorly differentiated neuroendocrine carcinomas (NECs) represent only 5%-10% of digestive NETS. Due to aggressive growth and rapid metastatic diffusion, early diagnosis and a multidisciplinary approach are mandatory. The role of surgery and radiotherapy in this setting is still debated, and chemotherapy remains the treatment of choice.

CASE SUMMARY

A 42-year-old male with an ulcerated bleeding rectal lesion was diagnosed with a NEC G3 (Ki67 index > 90%) on May 2015 and initially treated with 3 cycles of first-line chemotherapy, but showed early local progressive disease at 3 mo and underwent sphincter-sparing open anterior low rectal resection. In September 2015, the first post-surgery total-body computed tomography (CT) scan showed an early pelvic disease relapse. Therefore, systemic chemotherapy with FOLFIRI was started and the patient obtained only a partial response. This was followed by pelvic radiotherapy (50 Gy). On April 2016, a CT scan and 18F-fluorodeoxyglucose positron emission tomography imaging showed a complete response (CR) of the pelvic lesion, but pathological abdominal inter-aortocaval lymph nodes were observed. Due to disease progression of abdominal malignant nodes, the patient received radiotherapy at 45 Gy, and finally obtained a CR. As of January 2021, the patient has no symptoms of relapse and no late toxicity after chemotherapy or radiotherapy.

CONCLUSION

This case demonstrates how a multimodal approach can be successful in obtaining long-term CR in metastatic sites in patients with high grade digestive NECs.

Psychosocial adjustment of young offspring in the context of parental type 1 and type 2 diabetes: a systematic review

AIMS

To identify all available research on psychosocial outcomes in young people who have a parent with type 1 or type 2 diabetes.

METHODS

Embase, PsychInfo, Scopus, Web of Science, PubMed and ProQuest Social Sciences databases were searched according to a registered study protocol (PROSPERO CRD42019125301). Quality assessment, data extraction and data synthesis were carried out.

RESULTS

The initial search yielded 11 599 articles, 10 of which met the criteria for this review: six for type 1 diabetes and four for type 2 diabetes. Through thematic analysis, five categories emerged related to offspring psychosocial adjustment: offspring mental health, offspring physical health, offspring personal resources, parental illness characteristics and offspring caregiving. Overall, there were few studies focusing solely on the effects of parental type 1 and type 2 diabetes on young people. From the limited available research, there is weak evidence suggesting both parental types of diabetes can adversely impact young offspring. Illness-related variables were only explored in parental type 1 diabetes studies, while offspring caregiving was only examined in parental type 2 diabetes studies.

CONCLUSIONS

Research on the effects of parental diabetes on young people is scarce; however, there was weak evidence to suggest some young people are at risk of adverse psychosocial impacts. Given the rise in the incidence of diabetes globally, there is a pressing public health need to conduct more rigorously designed studies to ascertain the extent to which young people are at risk of mental and physical health problems and to identify risk and protective factors associated with youth adjustment in the context of parental diabetes.

Enhancing safety of laparoscopic surgery in COVID-19 era: clinical experience with low-cost filtration devices

BACKGROUND

Surgery in the era of the current COVID-19 pandemic has been curtailed and restricted to emergency and certain oncological indications, and requires special attention concerning the safety of patients and health care personnel. Desufflation during or after laparoscopic surgery has been reported to entail a potential risk of contamination from 2019-nCoV through the aerosol generated during dissection and/or use of energy-driven devices. In order to protect the operating room staff, it is vital to filter the released aerosol.

METHODS

The assemblage of two easily available and low-cost filter systems to prevent potential dissemination of Coronavirus via the aerosol is described.

RESULTS

Forty-nine patients underwent laparoscopic surgeries with the use of one of the two described tools, both of which proved to be effective in smoke evacuation, without affecting laparoscopic visualization.

CONCLUSION

The proposed systems are cost-effective, easily assembled and reproducible, and provide complete viral filtration during intra- and postoperative release of CO_2.

Multimodal Surgical Approach for Adult Patients With Chronic Intestinal Pseudo-Obstruction: Clinical and Psychosocial Long-term Outcomes

BACKGROUND

Clinical and psychosocial outcomes of a multimodal surgical approach for chronic intestinal pseudo-obstruction were analyzed in 24 patients who were followed over a 2- to 12-year period in a single center after surgery or intestinal/multivisceral transplant (CTx).

METHODS

The main reasons for surgery were sub-occlusion in surgery and parenteral nutrition-related irreversible complications with chronic intestinal failure in CTx.

RESULTS

At the end of follow-up (February 2015), 45.5% of CTx patients were alive: after transplantation, improvement in intestinal function was observed including a tendency toward recovery of oral diet (81.8%) with reduced parenteral nutrition support (36.4%) in the face of significant mortality rates and financial costs (mean, 202.000 euros), frequent hospitalization (mean, 8.8/re-admissions/patient), as well as limited effects on pain or physical wellness.

CONCLUSIONS

Through psychological tests, transplant recipients perceived a significant improvement of mental health and emotional state, showing that emotional factors were more affected than were functional/cognitive impairment and social interaction.

Fe3O4@SiO2 core-shell nanoparticles for biomedical purposes: adverse effects on blood cells

Magnetite nanoparticles coated with silica, obtained by a sol-gel process in the reverse micelle microemulsion, were characterized and homogeneously suspended in water in order to assay their biocompatibility toward blood cells, in view of a potential medical use of this material. Their hemolytic, pro-thrombotic and pro-inflammatory properties were observed.

Stable, single-photon emitter in a thin organic crystal for application to quantum-photonic devices

Single dibenzoterrylene (DBT) molecules offer great promise as bright, reliable sources of single photons on demand, capable of integration into solid-state devices. It has been proposed that DBT in anthracene might be placed close to an optical waveguide for this purpose, but so far there have been no demonstrations of sufficiently thin crystals, with a controlled concentration of the dopant molecules. Here we present a method for growing very thin anthracene crystals from super-saturated vapour, which produces crystals of extreme flatness and controlled thickness. We show how this crystal can be doped with an adjustable concentration of dibenzoterrylene (DBT) molecules and we examine the optical properties of these molecules to demonstrate their suitability as quantum emitters in nanophotonic devices. Our measurements show that the molecules are available in the crystal as single quantum emitters, with a well-defined polarisation relative to the crystal axes, making them amenable to alignment with optical nanostructures. We find that the radiative lifetime and saturation intensity vary little within the crystal and are not in any way compromised by the unusual matrix environment. We show that a large fraction of these emitters can be excited more than 10¹² times without photo-bleaching, making them suitable for real applications.

Growth of optical-quality anthracene crystals doped with dibenzoterrylene for controlled single photon production

Dibenzoterrylene (DBT) molecules within a crystalline anthracene matrix show promise as quantum emitters for controlled, single photon production. We present the design and construction of a chamber in which we reproducibly grow doped anthracene crystals of optical quality that are several mm across and a few μm thick. We demonstrate control of the DBT concentration over the range 6-300 parts per trillion and show that these DBT molecules are stable single-photon emitters. We interpret our data with a simple model that provides some information on the vapour pressure of DBT.

Demoralization: a systematic review on its clinical characterization

BACKGROUND

Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope.

METHODS

We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word 'demoralization' in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected.

RESULTS

Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes.

CONCLUSIONS

Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.

Quantum process nonclassicality

We propose a definition of nonclassicality for a single-mode quantum-optical process based on its action on coherent states. If a quantum process transforms a coherent state to a nonclassical state, it is verified to be nonclassical. To identify nonclassical processes, we introduce a representation for quantum processes, called the process-nonclassicality quasiprobability distribution, whose negativities indicate nonclassicality of the process. Using this distribution, we derive a relation for predicting nonclassicality of the output states for a given input state. We experimentally demonstrate our method by considering the single-photon addition as a nonclassical process and predicting nonclassicality of the output state for an input thermal state.

Type A behaviour: a reappraisal of its characteristics in cardiovascular disease

AIMS

  The role of type A behaviour in cardiovascular disease is controversial and most of the research is based on self-rating scales. The aim of this study was to assess the prevalence of type A behaviour in cardiology and in other medical settings using reliable interview methods that reflect its original description.

METHODS

A sample of 1398 consecutive medical patients (198 with heart transplantation, 153 with a myocardial infarction, 190 with functional gastrointestinal disorders, 104 with cancer, 545 with skin disorders and 208 referred for psychiatric consultation) was administered the Structured Clinical Interview for the DSM-IV and the Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) which identifies 12 clusters, including type A behaviour.

RESULTS

A cardiac condition was present in 366 patients. There was a significant difference in the prevalence of type A behaviour in cardiovascular disease (36.1%) compared with other medical disorders (10.8%). Type A behaviour frequently occurred together with psychiatric and psychosomatic disturbances, particularly irritable mood, even though in the majority of cases it was not associated with DSM-IV diagnoses. Among cardiac patients, those with type A behaviour were less depressed, demoralised and worried about their illness.

CONCLUSIONS

Type A behaviour was found to occur in about a third of cases of patients with cardiovascular disease. Only in a limited number of cases was it associated with depression. It has a lifestyle connotation that may have important clinical consequences as to stress vulnerability and illness behaviour.

A cluster analysis-derived classification of psychological distress and illness behavior in the medically ill

BACKGROUND

The classification of psychological distress and illness behavior in the setting of medical disease is still controversial. Current psychiatric nosology does not seem to cover the spectrum of disturbances. The aim of this investigation was to assess whether the joint use of DSM-IV categories and the Diagnostic Criteria for Psychosomatic Research (DCPR), that provide identification of syndromes related to somatization, abnormal illness behavior, irritable mood, type A behavior, demoralization and alexithymia, could yield subtyping of psychosocial variables in the medically ill.

METHOD

A cross-sectional assessment using both DSM-IV and the DCPR was conducted in eight medical centers in the Italian Health System. Data were submitted to cluster analysis. Participants were consecutive medical out-patients and in-patients for whom a psychiatric consultation was requested. A total of 1700 subjects met eligibility criteria and 1560 agreed to participate.

RESULTS

Three clusters were identified: non-specific psychological distress, irritability and affective disturbances with somatization.

CONCLUSIONS

Two-step cluster analysis revealed clusters that were found to occur across clinical settings. The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of somatization, illness behavior and subclinical distress encompassed by the DCPR.

Psychological adaptation and quality of life of adult intestinal transplant recipients: University of Bologna experience

INTRODUCTION

Intestinal transplantation has become an accepted therapy for individuals permanently dependent on total parenteral nutrition (TPN) with life-threatening complications. Quality of life and psychological well-being can be seen as important outcome measures of transplantation surgery.

METHODS

We evaluated 24 adult intestinal transplant recipients and 24 healthy subjects (a control group). All subjects were administered the Italian Version of the Psychological Well-Being Scales (PWB) by C. Ryff, the World Health Organization Quality of Life-Brief (WHOQOL), and the Symptom Questionnaire (SQ) by R. Kellner and G.A. Fava, a symptomatology scale. Quality of life and psychological well-being were assessed in transplant recipients in relationship to the number of rejections, the number of admissions, and the immunosuppressive protocol.

RESULTS

Intestinal transplant recipients reported significantly higher scores in the "personal growth" category (P = .036) and lower scores in the "positive relation with others" (P = .013) and "autonomy" (P = .007) dimensions of PWB, compared with the controls. In the WHOQOL, the scores of transplant recipients were lower only in the psychological domain (P = .011). Transplant recipients reported significantly higher scores in the "somatic symptom" (P = .027) and "hostility" (P = .018) dimensions of the SQ, compared with the controls. Transplant recipients with number of admissions >8 reported higher scores in "anxiety" (P = .019) and "depression" (P = .021) scales of the SQ, and the patients with a Daclizumab protocol reported higher scores in "depression" (P = .000) and "somatic symptom" (P = .008) of the SQ. There were no significant differences regarding number of rejections and socio-demographic variables.

CONCLUSION

Improvement of psychological well-being in the transplant population may be related to the achievement of the goal of transplantation: recovery of bowel function. But the data confirmed that the transplant experience required a long and difficult adaptation trial to the new condition of "transplant recipient."

Twofold co-ordinated Ge defects induced by gamma-ray irradiation in Ge-doped SiO2

We report an experimental study by photoluminescence, optical absorption and Electron Paramagnetic Resonance measurements on the effects of exposure of Ge-doped amorphous SiO2 to gamma ray radiation at room temperature. We have evidenced that irradiation at doses of the order of 1 MGy is able to generate Ge-related defects, recognizable from their optical properties as twofold coordinated Ge centers. Until now, such centers, responsible for photosensitivity of Ge-doped SiO2, have been induced only in synthesis procedures of materials. The found result evidences a role played by gamma radiation in generating photosensitive defects and could furnish a novel basis for photosensitive pattern writing through ionizing radiation.

Prevalence of substance-related disorders in heart transplantation candidates

Substance abuse cessation is one of the leading factors in determining the eligibility for the heart transplantation waiting list, as noncompliance with this issue may seriously endanger posttransplantation outcomes. Yet, the prevalence of substance-related disorders among candidates for heart transplantation has not been evaluated enough. Eighty three heart transplantation candidates were assessed for prior or current substance-related disorders through the Structured Clinical Interview for mental disorders according to DSM-IV. A prior history of at least one substance-related disorder was found in 64% of patients, with nicotine dependence as the most prevalent diagnosis (61.4% of the sample). Ten subjects were currently smokers, despite heart failure. A prior history of alcohol abuse and caffeine intoxication was found in 9.6% and 2.4% of patients, respectively. Substance abuse or dependence behaviors should be monitored during all the phases of heart transplantation program. Early identification of current substance-related disorders may allow better allocation of organ resources and proper lifestyle modification programs provision. A prior history of substance-related disorders should alert physicians to assess patients for possible relapse, especially after transplantation. The inclusion of a specialist in the assessment and treatment of substance-related disorders in the heart transplantation unit may reduce the risk of unsuccessful outcomes due to noncompliance with an adequate lifestyle.

Coping Strategies in Intestinal Transplantation

The psychological construct of coping has been studied extensively in other medical populations and has more recently been applied in the field of transplant psychology. Coping can be defined as all abilities used by people to face problematical and stressful situations, as the data in literature describe the experience of transplantation. The purpose of this study was to describe the coping styles used by 25 intestinal transplant recipients. To assess the coping strategies, we used the Italian version of Coping Orientation to Problems Experienced (COPE) by Sica, Novara, Dorz, and Sanavio (1997). The authors divided these strategies into three classes: problem-focused, emotion-focused, and potentially disadaptive strategies. This questionnaire is usually used in a medical setting. Even if the long process of psychological-clinical adaptation required by intestinal transplantation put patients in a passive acceptance of their situation and their incapacity to face it, our patients showed high levels of problem-focused strategies, indicators of positive outcomes for this intervention. Anyway, this is a slow and gradual path that goes with the psychological distress and the need for a peculiar psychological support of problem-focused strategies. The result suggested that assessment of coping strategies should be explored in intestinal transplant to encourage the use of action-oriented methods and discourage those with possible negative effects.

[The rehabilitation of the tongue in hypoglossal-facial anastomosis]

End to end hypoglossal-facial nerve anastomosis (tt HFA) is a traditional technique for rehabilitation of facial palsy. The sacrifice of the hypoglossal nerve generates a paralysis and an atrophy of the tongue which is thought to lead to speech, chewing and swallowing disorders. In a previous study, we demonstrated that tt HFA does not lead to speech disorders (Gatignol et al 2003).

OBJECTIVES

In this work, we were interested in the functional consequences of the lingual atrophy and in the possibilities of rehabilitation with early therapy.

MATERIAL AND METHODS

Nine patients were distributed in two groups, in one patients received a specific and early lingual rehabilitation in the other no specific treatment. These two groups (paired with control subjects) were subjected to a series of tests studying the motor function, the articulation (using palatograms).

RESULTS

This study highlights the interest of early rehabilitation of the tongue in the first post-operative days. Early rehabilitation was associated with a reduction in lingual atrophy, an improvement in motility of the tongue thus generating a better management of saliva and stagnant food in the oral vestibule on the paralysed side.

Psychological evaluation after cardiac transplantation: the integration of different criteria

BACKGROUND

The psychological evaluation of patients undergoing cardiac transplantation is currently based on DSM-IV criteria. An alternative diagnostic and conceptual framework has been proposed by an international group of psychosomatic investigators. The aim of this study was to compare these new criteria (Diagnostic Criteria for Psychosomatic Research, DCPR) with DSM-IV in a population where a high prevalence of psychological problems is expected (heart-transplanted patients).

METHOD

129 consecutive patients who underwent heart transplant surgery were assessed according to DSM-IV and DCPR criteria.

RESULTS

The results showed a higher number of diagnoses made using the DCPR than with the use of the DSM-IV. At least one DCPR diagnosis was found in 85 (66%) patients, whereas at least one DSM diagnosis was present in 23 (18%) patients. The number of DCPR diagnoses was almost the triple of DSM criteria. While patients who were given a DSM diagnosis frequently had additional DCPR diagnoses, many patients with DCPR criteria did not fulfill any DSM criteria. Four DCPR syndromes appeared to be particularly frequent: demoralization, type A behavior, irritable mood and alexithymia.

CONCLUSIONS

The joint use of DSM and DCPR criteria was found to improve the identification of psychological factors which could result in a worsening of quality of life in heart-transplanted patients.

Long-term outcome of social phobia treated by exposure

BACKGROUND

There is very little information on long-term follow-up of social phobia.

METHODS

A consecutive series of 70 patients satisfying the DSM-IV criteria for social phobia was treated in an out-patient clinic with behavioural methods based on exposure homework. Forty-five patients were judged to be remitted after eight individual sessions of psychotherapy. A 2 to 12 year (median = 6 years) follow-up was performed. Survival analysis was selected to characterize the clinical course of patients. Assessments were performed before treatment, at the end of therapy, after 1 year, and subsequently on a yearly basis, and utilized selected items of Paykel's Clinical Interview for Depression.

RESULTS

Six of the 45 patients (13%) had a relapse of social phobia at some time during follow-up. The estimated cumulative percentage of patients remaining in remission was 98 after 2 years, 85 after 5 years and 85 after 10 years. Such probabilities increased in the absence of a personality disorder, of residual social phobic avoidance after exposure, and of concurrent use of benzodiazepines.

CONCLUSIONS

The findings suggest that, even though one patient out of three is unable to complete treatment or does not benefit sufficiently from it, exposure treatment can provide lasting effects to the majority of patients with social phobia. Disappearance of residual, subclinical social phobic avoidance appears to be the target of treatment.

Psychological well-being and residual symptoms in remitted patients with panic disorder and agoraphobia

BACKGROUND

Little is known about psychological well-being in remitted patients with panic disorder and agoraphobia and its interactions with residual symptoms.

METHODS

Thirty patients with panic disorder and agoraphobia who displayed a successful response to exposure therapy, and 30 control subject matched for sociodemographic variables, were administered both observer-rated and self-rated scales for assessing residual symptoms and well-being.

RESULTS

Patients had significantly more residual symptoms -- as assessed by the Clinical Interview for Depression (CID) and the Symptom Questionnaire (SQ) -- than controls. They also had significantly less environmental mastery, personal growth, purpose in life and self-acceptance -- as measured by the Psychological Well-being Scales (PWB) -- and less SQ physical well-being than controls.

LIMITATION

The findings apply to patients with panic disorders who had been treated by behavioral methods and may be different in drug-treated subjects.

CONCLUSIONS

The results indicate that successful reduction of symptomatology in panic disorder cannot be equated to a pervasive recovery (encompassing psychological well-being) and may pave the way for sequential therapeutic strategies of more enduring quality.

Long-term outcome of panic disorder with agoraphobia treated by exposure

BACKGROUND

There is a paucity of long-term outcome studies of panic disorder that exceed a 2-year follow-up. The aim of the study was to evaluate the long-term follow-up of patients with panic disorder with agoraphobia treated according to a standardized protocol.

METHODS

A consecutive series of 200 patients satisfying the DSM-IV criteria for panic disorder with agoraphobia was treated in an out-patient clinic with behavioural methods based on exposure homework. One hundred and thirty-six patients became panic free after 12 sessions of psychotherapy and 132 were available for follow-up. A 2- to 14-year (median = 8 years) follow-up was performed. Survival analysis was employed to characterize the clinical course of patients.

RESULTS

Thirty-one of the 132 patients (23%) had a relapse of panic disorder at some time during follow-up. The estimated cumulative percentage of patients remaining in remission was 93.1 after 2 years, 82.4 after 5 years, 78.8 after 7 years and 62.1 after 10 years. Such probabilities increased with younger age, and in the absence of a personality disorder, of high pre-treatment levels of depressed mood, of residual agoraphobic avoidance after exposure, and of concurrent use of benzodiazepines and antidepressant drugs.

CONCLUSIONS

The findings suggest that exposure treatment can provide lasting relief to the majority of patients with panic disorder and agoraphobia. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.

Life events and prodromal symptoms in bulimia nervosa

BACKGROUND

Little is known about the interaction of life events with prodromal symptoms in bulimia nervosa.

METHODS

A semistructured research interview based on Paykel's Interview for Recent Life Events and on the Clinical Interview for Depression for eliciting prodromal symptoms was administered to 30 patients with bulimia nervosa and 30 healthy control subjects matched for sociodemographic variables.

RESULTS

Patients reported significantly more stressful life events than controls. Most of the patients reported prodromal symptoms. Anorexia, low self-esteem, depressed mood, anhedonia, generalized anxiety and irritability were the most common prodromal symptoms.

CONCLUSIONS

The prodromal phase of bulimia nervosa was found to be characterized by a combination of prodromal symptoms of affective type and stressful life events. Their joint occurrence may increase vulnerability to bulimia nervosa.

Explanatory therapy in hypochondriasis

OBJECTIVE

The aim of the study was to evaluate the effectiveness of individual explanatory therapy in hypochondriasis.

METHOD

Twenty patients with DSM-IV hypochondriasis were randomly assigned to 2 groups. One received explanatory therapy and was assessed again after a 6-month follow-up. The other was first assigned to a waiting list and subsequently treated with explanatory therapy. All patients received usual medical care from their physicians. Assessments involved both observer and self-rated instruments.

RESULTS

In both groups, explanatory therapy was significantly associated with a reduction of hypochondriacal fears and beliefs, improvement in affective disturbances and anxiety sensitivity, and a decrease in health care utilization. Therapeutic gains were maintained at follow-up. Substantial residual symptomatology, however, remained.

CONCLUSION

The results suggest that hypochondriasis is a treatable condition and that explanatory therapy is a viable therapeutic tool. Further research should disclose the actual components of the mechanism of change in hypochondriacal patients.

Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression

OBJECTIVE

The authors' goal was to determine whether cognitive behavioral treatment of residual symptoms of depression might have a significant effect on relapse rate.

METHOD

A 6-year follow-up assessment was conducted of 40 patients with primary major depressive disorder who had been successfully treated with antidepressants and were randomly assigned to either cognitive behavioral treatment of residual symptoms or standard clinical management.

RESULTS

Ten of the patients (50%) in the cognitive behavioral treatment group and 15 (75%) in the standard clinical management group relapsed. The difference did not attain statistical significance. When multiple relapses were considered, patients in the cognitive behavioral treatment group had a significantly lower number of depressive episodes than those in the standard clinical management group. Patients responded to the same antidepressant drug used in the index episode; in two cases (4%), resistance occurred.

CONCLUSIONS

The protective effects of cognitive behavioral treatment that were evident at 4-year follow-up faded afterward. Cognitive behavioral treatment of residual symptoms, however, improved the long-term outcome of major depression in terms of total number of episodes during the follow-up period.

Prevention of recurrent depression with cognitive behavioral therapy: preliminary findings

BACKGROUND

Cognitive behavioral treatment (CBT) of residual symptoms after successful pharmacotherapy yielded a substantially lower relapse rate than did clinical management in patients with primary major depressive disorders. The aim of this study was to test the effectiveness of this approach in patients with recurrent depression (> or = 3 episodes of depression).

METHODS

Forty patients with recurrent major depression who had been successfully treated with antidepressant drugs were randomly assigned to either CBT of residual symptoms (supplemented by lifestyle modification and well-being therapy) or clinical management. In both groups, during the 20-week experiment, antidepressant drug administration was tapered and discontinued. Residual symptoms were measured with a modified version of the Paykel Clinical Interview for Depression. Two-year follow-up was undertaken, during which no antidepressant drugs were used unless a relapse ensued.

RESULTS

The CBT group had a significantly lower level of residual symptoms after discontinuation of drug therapy compared with the clinical management group. At 2-year follow-up, CBT also resulted in a lower relapse rate (25%) than did clinical management (80%). This difference attained statistical significance by survival analysis.

CONCLUSIONS

These results challenge the assumption that long-term drug treatment is the only tool to prevent relapse in patients with recurrent depression. Although maintenance pharmacotherapy seems to be necessary in some patients, CBT offers a viable alternative for other patients. Amelioration of residual symptoms may reduce the risk of relapse in depressed patients by affecting the progression of residual symptoms to prodromes of relapse.

Well-being therapy. A novel psychotherapeutic approach for residual symptoms of affective disorders

BACKGROUND

There is increasing awareness of the prognostic value of residual symptomatology in affective disorders and of the need for specific therapeutic strategies in this phase of illness. The aims of the study were to apply a novel, short-term psychotherapeutic approach for increasing well-being, based on Ryff's conceptual model, to remitted patients with affective disorders and to compare the results with those obtained with symptom-oriented cognitive behavioural strategies.

METHODS

Twenty patients with affective disorders (major depression, panic disorder with agoraphobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder) who had been successfully treated by behavioural or pharmacological methods were randomly assigned to a well-being enhancing therapeutic strategy (well-being therapy) or cognitive-behavioural treatment of residual symptoms.

RESULTS

Both well-being and cognitive-behavioural therapies were associated with a significant reduction of residual symptoms. However, a significant advantage of well-being therapy over cognitive-behavioural strategies was observed with observer-rated methods.

DISCUSSION

These preliminary results suggest the feasibility of well-being therapy in the residual stage of affective disorders. Further research should determine its value as a relapse-preventive strategy in specific mood and anxiety disorders.

Cognitive-behavioral management of drug-resistant major depressive disorder

BACKGROUND

The application of cognitive-behavioral treatment to drug-resistant major depression has received little research attention.

METHOD

Nineteen patients who failed to respond to at least two trials of antidepressant drugs of adequate dosages and duration were treated by cognitive-behavioral methods in an open trial.

RESULTS

Three patients dropped out of treatment. The remaining 16 patients displayed a significant (p < .001) decrease in scores on the Clinical Interview for Depression after therapy. Twelve patients were judged to be in remission at the end of the trial; only 1 of these patients was found to have relapsed at a 2-year follow-up. Antidepressant drugs were discontinued in 8 of the 12 patients who responded to cognitive-behavioral treatment.

CONCLUSION

These preliminary results suggest that a trial of cognitive-behavioral therapy by an experienced therapist should be performed before labeling an episode of major depression as "refractory" or "treatment resistant." These latter terms should apply only when a psychotherapeutic effort has been made. Until then, it seems more appropriate to define depression as "drug refractory" or "drug treatment resistant."

Overcoming resistance to exposure in panic disorder with agoraphobia

The issue of panic disorder resistant to treatment (whether pharmacological or psychological) has attracted little research attention, despite its clinical frequency and importance. The aim of this study was to compare three treatment modalities, namely exposure alone (E), exposure associated with imipramine (EI) and cognitive therapy supplementing exposure (EC), in a sample of 21 patients with DSM-IV panic disorder and agoraphobia, who failed to respond to a first standard course of individual behavioural treatment based on exposure in vivo. Treatments were administered according to a cross-over, controlled design (E-EI-EC, EI-EC-E, EC-E-EI). Twelve of the 21 patients achieved remission (panic-free status) during the trial. In 8 cases this occurred after exposure alone (E) and in two cases each after the other treatments (EI and EC). The results revealed a significant effect of the factor time on a number of variables, and the superiority of exposure alone compared to other treatment modalities with regard to some variables. These findings suggest that long-term behavioural treatment based on exposure may be necessary in some patients, and may induce clinical remission. However, patients who do not respond to exposure show poor tolerance of and compliance with pharmacological treatment, and are unlikely to achieve remission with imipramine or cognitive therapy, even though this may occur in individual cases.

Four-year outcome for cognitive behavioral treatment of residual symptoms in major depression

OBJECTIVE

The authors' goal was to determine whether cognitive behavioral treatment of residual symptoms of depression might have a significant effect on relapse rate.

METHOD

In an earlier study, 40 patients with primary major depressive disorder who had been successfully treated with antidepressant drugs were randomly assigned to either cognitive behavioral treatment of residual symptoms or standard clinical management. In both types of treatment, antidepressant drugs were gradually tapered and discontinued. In this study, a 4-year follow-up assessment was performed.

RESULTS

Cognitive behavioral treatment resulted in a substantially lower relapse rate (35%) than did clinical management (70%).

CONCLUSIONS

Cognitive behavioral treatment of residual symptoms reduces the risk of relapse in depressed patients, probably by affecting the progression of residual symptoms to prodromes of relapse.

Hypochondriacal fears and beliefs in obsessive-compulsive disorder

The relationship of obsessions and compulsions with hypochondriasis is receiving increasing attention, but has not been substantiated by adequate research. The Illness Attitude Scales (IAS), which identify hypochondriacal patients, were administered to 30 patients with DSM-IV obsessive-compulsive disorder and 30 healthy control subjects matched for sociodemographic variables. All IAS scales were significantly higher in patients with obsessions and compulsions. However, there were no significant differences between patients and controls in the number of subjects whose symptom intensity exceeded a clinical threshold for hypochondriasis and disease phobia. Furthermore, hypochondriacal fears and beliefs were poorly correlated with obsessions and compulsions. The results suggest the presence of mild abnormal illness behaviour in patients with obsessive-compulsive disorder, unlike the situation in patients with panic disorder and depression.

Prodromal symptoms in obsessive-compulsive disorder

Prodromal symptoms were investigated in 30 patients with obsessive-compulsive disorder. The large majority of patients (93%) reported at least one prodromal symptom before disease onset. Generalized anxiety, irritability, indecision, phobic and somatic anxiety occurred in about half of patients. Also common were depressive symptoms such as fatigue, lowered self-esteem, depressed mood, pessimism, impaired work, and guilt. The results suggest a close association of obsessions and compulsions with affective symptoms.

Long-term effects of behavioural treatment for panic disorder with agoraphobia

BACKGROUND

There are few long-term follow-up studies of panic disorder treatments, particularly when patients have been treated by behavioural methods only and have recovered.

METHOD

110 consecutive patients satisfying the DSM-III-R criteria for panic disorder with agoraphobia were treated in an out-patient clinic with behavioural methods based on exposure. After 12 sessions of psychotherapy, 81 patients became panic-free. A 2-9 year follow-up was available. Survival analysis was employed to characterise the clinical course of patients. Regular assessments by a clinical psychologist were based on the Clinical Interview for Depression.

RESULTS

The estimated cumulative percentage of patients remaining in remission was 96.1% for at least two years, 77.6% for at least five years, and 67.4% for at least seven years. These outcomes greatly improved in the absence of a personality disorder or residual agoraphobia after treatment.

CONCLUSIONS

The findings suggest that, even though one patient in four is unable to complete treatment or does not benefit sufficiently from it, exposure treatment can provide lasting relief for the majority of patients. Disappearance of residual and subclinical agoraphobic avoidance, and not simply of panic attacks, should be the aim of exposure therapy.

Benzodiazepines and anxiety sensitivity in panic disorder

1. Benzodiazepines were discontinued in 16 patients who had recovered from panic disorder with agoraphobia after exposure treatment. 2. Drug discontinuation yielded a significant decrease in anxiety sensitivity and state anxiety in these long-term users. 3. Several likely explanations for the findings are discussed. 4. In the short term, treatment of panic disorder with benzodiazepines may lower anxiety symptoms. However, in the long run, it may decrease the individual tolerance to anxiety and discomfort.