[Symptom validation: an overview]

When assessing mental disorders, there may appear different distortions of symptoms. Often patients exaggerate their complaints in order to achieve certain aims (e. g. retirement). Special symptom validity tests are therefore demanded as standard methods. These tests aim to verify the plausibility of the patient's symptoms, described at the assessment. This paper will give an overview of international and national research on symptom validation, manipulation of the test results, and coaching of patients.

The Andersen Model of Total Patient Delay: a systematic review of its application in cancer diagnosis

Objective

Patient pathways to presentation to health care professionals and initial management in primary care are key determinants of outcomes in cancer. Reducing diagnostic delays may result in improved prognosis and increase the proportion of early stage cancers identified. Investigating diagnostic delay could be facilitated by use of a robust theoretical framework. We systematically reviewed the literature reporting the application of Andersen's Model of Total Patient Delay (delay stages: appraisal, illness, behavioural, scheduling, treatment) in studies which assess cancer diagnosis.

Methods

We searched four electronic databases and conducted a narrative synthesis. Inclusion criteria were studies which: reported primary research, focused on cancer diagnosis and explicitly applied one or more stages of the Andersen Model in the collection or analysis of data.

Results

The vast majority of studies of diagnostic delay in cancer have not applied a theoretical model to inform data collection or reporting. Ten papers (reporting eight studies) met our inclusion criteria: three studied several cancers. The studies were heterogeneous in their methods and quality. The review confirmed that there are clearly identifiable stages between the recognition of a symptom, first presentation to a health care professional, subsequent diagnosis and initiation of treatment. There was strong evidence to support the existence and importance of appraisal and treatment delay as defined in the Andersen Model, although treatment delay requires expansion. There was some evidence to support scheduling delay which may be contributed to by both patient and the health service. Illness delay was often difficult to distinguish from appraisal delay. It was less clear whether behavioural delay exists as a separate significant stage.

Conclusions

Greater consistency is required in the conduct and reporting of studies of diagnostic delay in cancer. We propose refinements to the Andersen Model which could be used to increase its validity and improve the consistency of reporting in future studies.

Pharmacological pre- and post-conditioning with the sphingosine-1-phosphate receptor modulator FTY720 after myocardial ischaemia-reperfusion

BACKGROUND AND PURPOSE

Our recent experiments demonstrated that the Sphingosine-1-phosphate (S1P) receptor agonist FTY720 (2-amino-2-[2-(4-octylphenyl)ethyl]-1,3-propanediol hydrochloride) improves recovery of function after myocardial ischaemia-reperfusion ex vivo. Therefore, we tested the hypothesis that pharmacological post-conditioning with FTY720 reduces infarct size after myocardial ischaemia-reperfusion in vivo.

EXPERIMENTAL APPROACH

Myocardial ischaemia was induced in Wistar rats by ligation of the left coronary artery for 45 min. FTY720 (0.5 mg kg(-1)) was applied i.p. either once, before reperfusion, or twice, 24 h before myocardial ischaemia and before reperfusion. After 24 h reperfusion, we determined infarct size by triphenyltetrazolium chloride staining and granulocyte infiltration by immunohistochemistry. Tumour necrosis factor-alpha (TNF)-alpha concentration was determined by elisa. S1P receptor expression was studied by Western blot. Calcium transients were evaluated in Indo-1-loaded cardiomyocytes.

KEY RESULTS

In both groups, FTY720 significantly reduced lymphocyte count in peripheral blood. FTY720 treatment attenuated granulocyte infiltration and TNF-alpha protein expression in reperfused myocardium. However, both treatment regimens were not able to reduce infarct size. FTY720 increased mortality due to induction of fatal ventricular tachyarrhythmias when administered once before reperfusion, but protected against reperfusion arrhythmias when given 24 h prior to ischaemia. Pretreatment selectively down-regulated S1P(1) receptor expression within the myocardium. S1P receptor agonists did not induce calcium deregulation in cardiomyocytes.

CONCLUSIONS AND IMPLICATIONS

FTY720 applied during reperfusion did not reduce infarct size but increased mortality during myocardial ischaemia-reperfusion due to induction of arrhythmias. Pretreatment with FTY720 before ischaemia abrogated the deleterious pro-arrhythmic effects without reducing infarct size.

ORGAN WORK AND ORGAN WEIGHT

1. The ratios between the rates of growth of the body and of the heart, kidneys, and liver are approximately uniform between 40 gm. body weight and the body weight at maturity in the albino rat. The male and female hearts grow at 0.75 times the rate of growth of the body, the male kidneys at 0.717 times, the female kidneys at 0.648 times, and the liver at 0.838 times the rate of growth of the body as a whole. 2. Formulas for the prediction of organ weight from body weight were derived from the data on 1591 albino rats kept under constant conditions. 3. A series of experiments in which dietetic and metabolic variables were introduced into otherwise constant conditions showed that the heart weight was not affected by diet, and that both kidney weight and weight of liver protein (used as a measure of effective liver size) varied in the direction of change in the protein content of the diet. Decrease in rate of metabolism induced by thyroidectomy and increase in metabolism following the administration of thyroxin led to a corresponding fall and rise of heart, kidney, and liver protein weight. These results were confirmed in experiments on fasted rats with the exception that under these conditions thyroidectomy did not appreciably decrease liver protein weight relatively to fasted controls. Increase in organ metabolism due to dinitrophenol had no effect on organ weight. 4. When experimental changes alter the composition of the body with respect to fat or water, the comparison of experimental and control organ weights in terms of any one function of body weight is fallacious. 5. Conditions that change kidney weight usually change liver protein weight in the same direction and roughly to the same degree. The possible meaning of two exceptions to this rule is discussed. 6. The observations made are regarded as supporting the hypothesis that, after weaning, change in the weight of the heart, kidney, and liver protein is determined mainly by change in the amount of work done by these organs.

"Medication career" or "moral career"? The two sides of managing antidepressants: a meta-ethnography of patients' experience of antidepressants

The UK National Institute for Clinical Excellence (NICE) Clinical Guidelines recommend routine prescription of antidepressants for moderate to severe depression. While many patients accept a prescription, one in three do not complete treatment. We carried out a meta-ethnography of published qualitative papers since 1990 whose focus is patients' experience of antidepressant use for depression, in order to understand barriers and facilitators to concordance and inform a larger qualitative study investigating antidepressant use over time. A systematic search of five databases was carried out, supported by hand searches of key journals, writing to first authors and examining reference lists. After piloting three critical appraisal tools, a modified version of the CASP (Critical Appraisal Skills Programme) checklist was used to appraise potentially relevant and qualitative papers. We carried out a synthesis using techniques of meta-ethnography involving translation and re-interpretation. Sixteen papers were included in the meta-ethnography. The papers fall into two related groups: (1) Papers whose focus is the decision-making relationship and the ways patients manage their use of antidepressants, and (2) Papers whose focus is antidepressants' effect on self-concept, ideas of stigma and its management. We found that patients' experience of antidepressants is characterised by the decision-making process and the meaning-making process, conceptualised here as the 'medication career' and 'moral career'. Our synthesis indicates ways in which general practitioners (GPs) can facilitate concordant relationships with patients regarding antidepressant use. First, GPs can enhance the potential for shared decision-making by reviewing patients' changing preferences for involvement in decision-making regularly throughout the patient's 'medication career'. Second, if GPs familiarise themselves with the competing demands that patients may experience at each decision-making juncture, they will be better placed to explore their patients' preferences and concerns--i.e. their 'moral career' of medication use. This may lead to valuable discussion of what taking antidepressants means for patients' sense of self and how their treatment decisions may be influenced by a felt sense of stigma.

Psychological impact of genetic counseling for familial cancer: a systematic review and meta-analysis

BACKGROUND

Identification of a genetic basis underlying certain types of cancer has led to an increase in demand for genetic counseling about individual risks of the disease. We conducted a systematic review of the literature to determine the quality and strength of evidence relating to psychological outcomes of genetic counseling for familial cancer.

METHODS

Six electronic databases were searched to identify controlled trials and prospective studies that examined the effect of genetic counseling on risk perception, knowledge, anxiety, cancer-specific worry, depression, and cancer surveillance. Twenty-one studies from 25 papers met inclusion criteria, including five controlled trials and 16 prospective studies. Analysis of each outcome was stratified by short-term (</=1 month) and long-term (>/=3 months) follow-up. Trial evidence was assessed with standardized differences of the means at follow-up between intervention and comparison groups, and these data were pooled by use of random-effects meta-analysis.

RESULTS

Meta-analysis of controlled trials showed that genetic counseling improved knowledge of cancer genetics (pooled short-term difference=0.70 U, 95% confidence interval (CI)=0.15 to 1.26 U) but did not alter the level of perceived risk (pooled short-term difference=-0.10 U, 95% CI=-0.23-0.04 U). Prospective studies reported improvements in the accuracy of perceived risk. No effect was observed in controlled trials on general anxiety (pooled long-term effect=0.05 U, 95% CI=-0.21-0.31 U) or cancer-specific worry (pooled long-term difference=-0.14 U, 95% CI=-0.35-0.06 U), although several prospective studies demonstrated short-term reductions in these outcomes. Few studies examined cancer surveillance behaviors, and no studies attempted to measure informed choice.

CONCLUSIONS

Genetic counseling for familial cancer is associated with improvement in knowledge but does not have an adverse effect on affective outcomes. We urge further investigation of these findings through well-designed, well-reported, randomized controlled trials with suitable comparison groups and additional outcome measures [J Natl Cancer Inst 2004; 96:122-33].

Psychological impact of genetic counseling for familial cancer: a systematic review and meta-analysis

BACKGROUND

Identification of a genetic basis underlying certain types of cancer has led to an increase in demand for genetic counseling about individual risks of the disease. We conducted a systematic review of the literature to determine the quality and strength of evidence relating to psychological outcomes of genetic counseling for familial cancer.

METHODS

Six electronic databases were searched to identify controlled trials and prospective studies that examined the effect of genetic counseling on risk perception, knowledge, anxiety, cancer-specific worry, depression, and cancer surveillance. Twenty-one studies from 25 papers met inclusion criteria, including five controlled trials and 16 prospective studies. Analysis of each outcome was stratified by short-term (< or =1 month) and long-term (> or = 3 months) follow-up. Trial evidence was assessed with standardized differences of the means at follow-up between intervention and comparison groups, and these data were pooled by use of random-effects meta-analysis.

RESULTS

Meta-analysis of controlled trials showed that genetic counseling improved knowledge of cancer genetics (pooled short-term difference = 0.70 U, 95% confidence interval [CI] = 0.15 to 1.26 U) but did not alter the level of perceived risk (pooled short-term difference = -0.10 U, 95% CI = -0.23 to 0.04 U). Prospective studies reported improvements in the accuracy of perceived risk. No effect was observed in controlled trials on general anxiety (pooled long-term effect = 0.05 U, 95% CI = -0.21 to 0.31 U) or cancer-specific worry (pooled long-term difference = -0.14 U, 95% CI = -0.35 to 0.06 U), although several prospective studies demonstrated short-term reductions in these outcomes. Few studies examined cancer surveillance behaviors, and no studies attempted to measure informed choice.

CONCLUSIONS

Genetic counseling for familial cancer is associated with improvement in knowledge but does not have an adverse effect on affective outcomes. We urge further investigation of these findings through well-designed, well-reported, randomized controlled trials with suitable comparison groups and additional outcome measures.

Allergen-loaded biodegradable poly(d,l-lactic-co-glycolic) acid nanoparticles down-regulate an ongoing Th2 response in the BALB/c mouse model

BACKGROUND AND OBJECTIVE

Biocompatible and biodegradable microparticles have gained interest as antigen delivery systems during the recent years. We investigated whether biodegradable poly(d,l-lactic-co-glycolic) acid (PLGA) nanospheres could be used as allergen vehicles for few-shot therapy of type I allergy.

METHODS

The major birch pollen allergen Bet v 1 was encapsulated in PLGA nanospheres (PLGA-Bet v 1). We examined the antigenicity and the immune response to PLGA-Bet v 1 in a BALB/c mouse model.

RESULTS

The antigenicity of Bet v 1 was largely unaffected by PLGA entrapment. When BALB/c mice were immunized subcutaneously with PLGA-Bet v 1, they formed allergen-specific IgG antibodies, but did not develop hypersensitivity to Bet v 1, as shown by type I skin tests. To evaluate their therapeutic potential, PLGA-Bet v 1 with or without Al(OH)3 or non-entrapped Bet v 1 with Al(OH)3 were used for single-shot treatment of sensitized mice. Both groups treated with PLGA-Bet v 1 developed high levels of Bet v 1-specific IgG2a antibodies (P<0.01), whereas IgG1 levels decreased significantly (P<0.01). Moreover, T cells from mice treated with PLGA-Bet v 1 showed IFN-gamma and IL-10 production. The synthesis of these cytokines was enhanced in the groups where Al(OH)3 had been added to the vaccine formulation.

CONCLUSION

Allergen-loaded PLGA nanoparticles modulate an ongoing Th2 response in the BALB/c mouse model, as demonstrated by down-regulation of IgG1 and production of IFN-gamma and IL-10. Our data strongly suggest that PLGA nanospheres can advantageously be used for formulations of allergen extracts or allergen derivatives for the few-shot treatment of type I allergy.

What happens next? Evaluation of a scheme to support primary care practitioners with a fledgling interest in research

INTRODUCTION

Various initiatives have been implemented in recent years to support primary care practitioners new to research. We describe the evaluation of one particular scheme, the NHS Eastern Region Primary Care R&D Enterprise Award Scheme, and discuss the implications of the results for future policy.

METHODS

Representatives from both the funders (NHS R&D) and the award holders were involved in the design of an evaluation questionnaire and in the interpretation of the results.

RESULTS

and Discussion. The evaluation demonstrated value in relation to traditional research outcomes and also, notably, in relation to professional contribution. Future policies may need to address: the indicators used in measuring the success of such schemes; the relationship between what individuals choose to do and its context within national policy on research and development; and the sustainability of involvement in research.

[Postoperative pain therapy with tilidin and tilidin retard as an oral patient-controlled analgesia after uncomplicated myocardial revascularization]

OBJECTIVE

The purpose of this study was to evaluate whether or not the combination of tilidin and tilidin retard as oral patient-controlled analgesia provide a suitable pain management in patients after uncomplicated myocardial revascularization.

METHODS

We conducted a randomised phase IV study to evaluate the effectiveness of postoperative analgesia with tilidin and tilidin retard. Patients with a baseline tilidin retard and tilidin liquid demand medication (group B, 42 patients) were compared with a base line paracetamol and tramadol-HCl liquid demand medication (group A, 44 patients). All patients received the first dose of study medication at the second postoperative day after evaluation of the individual pain score using NRS (numeric rating scale).

RESULTS

Pain relief in group B was significantly better only at the second postoperative day (NRS 1,8 compared to 3,3 in group A), associated with tolerable side effects and comfortable handling.

CONCLUSION

The combination of sustained release with immediate release drugs as a patient controlled analgesia provides suitable and comfortable analgesia after myocardial bypass surgery.

Breast cell proliferation in postmenopausal women during HRT evaluated through fine needle aspiration cytology

The basis of breast cancer risk associated with hormonal therapies may lie in the regulation of cell proliferation. In a prospective, double-blind, randomized study postmenopausal women were given continuous combined hormone replacement therapy (HRT) either as estradiol valerate 2 mg/dienogest 2 mg, (E2V/DNG) or estradiol 2 mg/noretisterone acetate 1 mg (E2/NETA) for 6 months. Fine needle aspiration (FNA) biopsies were used for immunocytochemical analysis of breast cell proliferation before and during treatment. From 45 women completing the study 135 biopsies were obtained. In the total material there was a more than 4-fold increase in proliferation between baseline and 3 months (p < 0.001). The mean percentage of MIB-1 positive breast cells increased from 2.2 to 9.1%. In some individual women values were as high as 25%. No further increase was recorded at 6 months. While numerical values were somewhat lower in the E2V/DNG group, there were no significant differences between treatments. There was a positive correlation between breast cell proliferation (MIB-1%) and circulating levels of both estradiol (r(s) = 0.54, p < 0.01) and estrone (r(s) = 0.53, p < 0.01) after 3 and 6 months of treatment. No correlations with other endogenous hormones, proteins or with the two exogenous progestogens dienogest and norethisterone were observed. Increased breast cell proliferation should probably be regarded as an unwanted side-effect during HRT. Means to identify those women with the most pronounced proliferative response should be developed. The FNA biopsy technique may be a useful tool to monitor and evaluate the proliferative response to HRT in the normal breasts of postmenopausal women.

Indirect lymph node lymphangiography using an iodine-based contrast medium and projection radiography following submucosal injection in a rabbit model

BACKGROUND

This study investigated the possibility of local lymph node detection and lymphatic mapping following submucosal injection of an iodine-based contrast medium.

METHODS AND MATERIALS

We established a contrast medium (oil/water emulsion on iodine basis) with a particle size of mainly 1.7+/-0.1 micro m. Ten rabbits received rectal submucosal injections of the contrast medium and underwent repeated projection radiography.

RESULTS

Passage of the contrast medium into lymphatic vessels and storage in lymph nodes was seen in all ten animals. The best contrast was achieved within 24 and 48 h after injection. Lymph nodes were still seen in eight cases with the final radiograph on day 14. There were no clinical side effects observed. Injection sites showed mild signs of inflammation in histological examinations. Pathological signs were not detectable in lymph nodes containing the contrast media.

CONCLUSIONS

This method appears useful when investigating local lymph nodes following submucosal injection due to its passage into lymphatic vessels and storage in lymph nodes.