Development of a Scale to Examine Responses to Bodily Sensations

OBJECTIVE

Individual differences in the perception of bodily sensations is known to be associated with affective symptomatology. However, the way people psychologically respond to everyday bodily sensations has not been examined in a systematic and balanced way. Thus, we developed the Bodily Sensations Response Scale (BSRS) to evaluate participants' self-reported cognitive, emotional, and behavioral responses to their bodily sensations. We investigated the scale's factor structure and its psychometric properties in two studies.

METHOD

In Study 1, 297 participants completed the 50-item BSRS and exploratory factor analysis (EFA) was performed on the responses. In Study 2 (N = 284), confirmatory factor analysis (CFA) was used to confirm the factor structure of the 32-item BSRS identified in Study 1.

RESULTS

In Study 1, the EFA identified a 32-item three-factor solution as the best fit for the data. Factor 1 described a defeat response to bodily sensations, Factor 2 described an acceptance response, and Factor 3 described a sensitization response. In Study 2, the three-factor solution was shown not to be parsimonious. Rather, CFA identified that the 27-item BSRS had two interpretable factors (Defeat and Acceptance) that explained participants' psychological responses to bodily sensations. The Defeat subscale was moderately to strongly correlated with awareness of bodily sensations (i.e., Body Perception Questionnaire-Short Form scores) and depression, anxiety, and stress symptom severity (i.e., Depression Anxiety Stress Scales-21 scores), whereas the Acceptance subscale was unrelated or only slightly negatively correlated to awareness of bodily sensations and depression, anxiety, and stress symptoms.

CONCLUSION

The 27-item BSRS provides a psychometrically robust assessment of the way in which people psychologically respond to everyday bodily sensations. The measure can assist researchers to better understand how people psychologically process their salient bodily sensations and how this is linked to psychopathology.

Can the relationship between overweight/obesity and sleep quality be explained by affect and behaviour?

PURPOSE

Sleep impairment is reported to be a consequence of overweight and obesity. However, the weight-sleep relationship can alternately be explained by demographics (e.g. age) and covariates (i.e. mood/affect and behaviour in overweight/obese people; e.g. night-eating). Thus, we examined the weight-sleep quality relationship after controlling for the effects of affect and common behaviour (i.e. night-eating, insufficient exercise, alcohol and electronic device use).

METHODS

Online questionnaires asked 161 overweight, obese or normal-weight participants about their sleep quality, night-eating, physical activity, alcohol use, electronic device use and anxiety and depression at T0 (baseline) and T1 (3 months later). Height and weight and waist and hip circumference were objectively measured at T0 and T1, and physical activity was assessed over 24 h (using actigraphy) at T0 and T1. Hierarchical multiple regression analyses evaluated whether the weight measures (i.e. body-mass-index [BMI], waist-to-hip ratio [WHR] and obesity category [overweight/obese vs. normal-weight]) predicted sleep quality and its components at T0 and T1, after controlling demographics (at step 1) and covariates (affective distress and behaviour) at step 2, and entering weight measures at step 3; maximum 8 variables in the analyses.

RESULTS

High BMI predicted several aspects of sleep quality after taking into account co-existing behaviour, affect and demographics: sleep disturbances at T0 and lower sleep efficiency at T1. WHR and obesity category did not predict any aspects of sleep quality. Several co-existing behaviour were related to or predicted sleep quality score and aspects of sleep quality including night-eating, alcohol use and electronic device use and affective symptoms (i.e. anxiety, depression).

CONCLUSION

Results suggest that a person's weight may impact on their sleep quality above and beyond the effects of their co-existing behaviour and affect, although their co-existing behaviour and affect may also adversely impact on sleep quality.

LEVEL OF EVIDENCE

Level III, evidence obtained from well-designed cohort.

The psychological benefits of neuropsychological assessment feedback as a psycho-educational therapeutic intervention: A randomized-controlled trial with cross-over in multiple sclerosis

ABSTRACTEvidence supporting the direct therapeutic benefits of neuropsychological assessment (NPA) feedback relies mostly upon post-feedback consumer surveys. This randomized-controlled trial with cross-over investigated the benefits of NPA feedback in multiple sclerosis (MS). Seventy-one participants were randomly allocated to NPA with feedback or a "delayed-treatment" control group. The primary hypotheses were that NPA feedback would lead to improved knowledge of cognitive functioning and improved coping. Outcome instruments were administered by a research assistant blinded to group allocation. At 1-week post-NPA feedback there were no significant group-by-time interaction effects, indicating no improvement. But nor was there any significant deterioration in psychological wellbeing, despite most participants receiving "bad news" confirming cognitive impairment. At 1-month follow-up, within-subjects' analyses not only found no evidence of any delayed deterioration, but showed clinically significant improvement (small-medium effects) in perceived everyday cognitive functioning, MS self-efficacy, stress and depression. Despite lack of improvement in the RCT component at 1-week post-NPA feedback, the absence of deterioration at this time, in addition to significant improvements in perceived cognitive functioning, self-efficacy and mood at follow-up, together with high satisfaction ratings, all support NPA feedback as a safe psycho-educational intervention that is followed by improved psychological wellbeing over time.Trial registration: Uniform Trial Number identifier: U1111-1127-1585.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12612000161820.

Quality of life and fear of cancer recurrence in patients and survivors of non-Hodgkin lymphoma

Non-Hodgkin lymphoma (NHL) is a common haematological cancer that is comprised of approximately 30 subtypes, of which Waldenström Macroglobulinemia (WM) is a rare incurable form. It is typically managed using a watch-and-wait strategy that can contribute to illness uncertainty which may result in fear of cancer recurrence (FCR) and poor health-related quality of life (QOL). However, few studies have examined the correlates of FCR and QOL in NHL patients, including WM patients. One-hundred males and 92 females with a mean age of 62.7 years who were an average of 6.8 years from diagnosis completed the online questionnaire which asked about demographics, medical history, QOL, FCR, stress, anxiety and depression. Few NHL patients reported significant stress or affective distress, most had moderate-high QOL and 41% experienced recent FCR, relative to published cut-off scores. Poorer QOL was related to depression symptoms, FCR, higher illness burden (i.e. comorbidity) and fewer personal resources (i.e. unemployed), whereas FCR was related to shorter time since diagnosis and more depressive symptoms. Results suggest that FCR and depressive symptoms may adversely impact QOL, whereas a recent cancer diagnosis and depression-related pessimism may contribute to FCR.

Temperature-Dose Relationships with Aflatoxin on the Brine Shrimp, Artemia salina

Temperature-dose relationships with aflatoxin B1 were studied, using the brine shrimp, Artemia salina. Increase in temperature resulted in increased sensitivity by the brine shrimp to aflatoxin. Optimum sensitivity occurred at 37.5°C. Positive results were obtained at 0.5 μg aflatoxin B1/ml artificial sea water with a mortality of over 60%. Greater than 90% mortality occurred at dose levels of 1.0 μ/ml and above. The test can be conducted in 24 hours, and highly trained personnel are unnecessary.

Can body temperature dysregulation explain the co-occurrence between overweight/obesity, sleep impairment, late-night eating, and a sedentary lifestyle?

PURPOSE

Overweight/obesity, sleep disturbance, night eating, and a sedentary lifestyle are common co-occurring problems. There is a tendency for them to co-occur together more often than they occur alone. In some cases, there is clarity as to the time course and evolution of the phenomena. However, specific mechanism(s) that are proposed to explain a single co-occurrence cannot fully explain the more generalized tendency to develop concurrent symptoms and/or disorders after developing one of the phenomena. Nor is there a clinical theory with any utility in explaining the development of co-occurring symptoms, disorders and behaviour and the mechanism(s) by which they occur. Thus, we propose a specific mechanism-dysregulation of core body temperature (CBT) that interferes with sleep onset-to explain the development of the concurrences.

METHODS

A detailed review of the literature related to CBT and the phenomena that can alter CBT or are altered by CBT is provided.

RESULTS

Overweight/obesity, sleep disturbance and certain behaviour (e.g. late-night eating, sedentarism) were linked to elevated CBT, especially an elevated nocturnal CBT. A number of existing therapies including drugs (e.g. antidepressants), behavioural therapies (e.g. sleep restriction therapy) and bright light therapy can also reduce CBT.

CONCLUSIONS

An elevation in nocturnal CBT that interferes with sleep onset can parsimoniously explain the development and perpetuation of common co-occurring symptoms, disorders and behaviour including overweight/obesity, sleep disturbance, late-night eating, and sedentarism. Nonetheless, a significant correlation between CBT and the above symptoms, disorders and behaviour does not necessarily imply causation. Thus, statistical and methodological issues of relevance to this enquiry are discussed including the likely presence of autocorrelation.

LEVEL OF EVIDENCE

Level V, narrative review.

Autism spectrum disorder and interoception: Abnormalities in global integration?

Research over the past three decades has seen a revived interest in the way the human body—and the way in which it is perceived—interacts with aspects of our experience. Consequently, interoception (i.e. the perception of physiological feedback from the body) has recently been shown to be associated with a wide range of cognitive, emotional, and affective functions, making it broadly relevant to the study of autism spectrum disorder. Although limited qualitative accounts and empirical studies suggest that individuals with autism spectrum disorder encounter abnormalities when perceiving and integrating physiological feedback from their bodies, other studies have suggested that people with/without autism spectrum disorder do not differ in interoceptive ability after accounting for alexithymia. In this article, we discuss the newly recognized importance of interoception in autism spectrum disorder with a focus on how deficits in the perception of bodily feedback might relate to the core features and co-occuring psychopathology of autism spectrum disorder. Finally, a new integrated theory is advanced which posits that people with autism spectrum disorder may experience a reduced capacity to integrate interoceptive information that may result in a narrow attentional bodily focus and reduced motivational and behavioral drives.

African-American patients with cancer Talking About Clinical Trials (TACT) with oncologists during consultations: evaluating the efficacy of tailored health messages in a randomised controlled trial-the TACT study protocol

INTRODUCTION

Low rates of accrual of African-American (AA) patients with cancer to therapeutic clinical trials (CTs) represent a serious and modifiable racial disparity in healthcare that impedes the development of promising cancer therapies. Suboptimal physician-patient consultation communication is a barrier to the accrual of patients with cancer of any race, but communication difficulties are compounded with AA patients. Providing tailored health messages (THM) to AA patients and their physician about CTs has the potential to improve communication, lower barriers to accrual and ameliorate health disparities.

OBJECTIVE

(1) Demonstrate the efficacy of THM to increase patient activation as measured by direct observation. (2) Demonstrate the efficacy of THM to improve patient outcomes associated with barriers to AA participation. (3) Explore associations among preconsultation levels of: (A) trust in medical researchers, (B) knowledge and attitudes towards CTs, (C) patient-family member congruence in decision-making, and (D) involvement/information preferences, and group assignment.

METHODS AND ANALYSIS

First, using established methods, we will develop THM materials. Second, the efficacy of the intervention is determined in a 2 by 2 factorial randomised controlled trial to test the effectiveness of (1) providing 357 AA patients with cancer with THM with 2 different 'depths' of tailoring and (2) either providing feedback to oncologists about the patients' trial THM or not. The primary analysis compares patient engaged communication in 4 groups preconsultation and postconsultation.

ETHICS AND DISSEMINATION

This study was approved by the Virginia Commonwealth University Institutional Review Board. To facilitate use of the THM intervention in diverse settings, we will convene 'user groups' at 3 major US cancer centres. To facilitate dissemination, we will post all materials and the implementation guide in publicly available locations.

TRIAL REGISTRATION NUMBER

NCT02356549.

Inhalation Toxicity of a Smoke Containing Solvent Yellow 33, Disperse Red 9 and Solvent Green 3 in Laboratory Animals

The repeated-dose inhalation toxicity of a smoke containing a mixture of three dyes was tested in female mice, rats and guinea pigs. The green component dye (Solvent Green 3) was retained in the lungs. Particularly in the rats marked collections of alveolar macrophages were found. In the same species several other adverse findings were noted: these included adenocarcinomas of the breast in the high-dose group and a dose-related incidence of biliary hyperplasia. Fatty change was noted in the livers of the test-group mice. A large proportion of the high-dose guinea pigs died during the exposure period, for which reason exposure was stopped early in that group, otherwise the guinea pigs were little affected. However, all test groups of all species showed reductions in growth during the exposure period.

A review of stress-relapse interactions in multiple sclerosis: important features and stress-mediating and -moderating variables

Studies do not provide a consensus opinion of the relationship between stress and relapse in relapsing=remitting multiple sclerosis (RRMS). Few studies have defined the critical features of these stressful situations, or examined the role of stress-mediating and -moderating variables. Available evidence indicates that the relationship between life stress and relapse is complex, and is likely to depend on factors such as stressor chronicity, frequency, severity and type, and individual patient characteristics such as depression, health locus of control and coping strategy use. Little is known about how these factors, individually or in combination, are related to MS disease activity. Viral infections are also likely to precipitate relapse in MS, and significant life-stress may further enhance this relationship. The nature and strength of these interrelationships have strong clinical implications. MS patients are particularly vulnerable to a deteriorating cycle of stressful life events, illness episodes and disability. Timely multidisciplinary care interventions aimed at both minimizing psychological distress and physical symptoms may halt this downward reciprocal cycle. Little is known of the pathogenesis of these putative stress-induced changes in disease activity, and almost all stressor studies suffer from some biases or limitations.

Relationship between stress and relapse in multiple sclerosis: part I. Important features

Objective The aim of this two-year prospective study was to examine the relationship between multiple aspects of life-event stress and relapse in multiple sclerosis (MS) patients.

Background Few studies have defined the critical features of this life-event stress; for example, stressor duration, frequency, severity, disease-dependency, valency, or stressor constructs, such as the propensity to cause emotional distress/threat or the frustration of life goals.

Methods 101 consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. Stressful life events were assessed at study-entry and at three-monthly intervals for two years. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

Results Acute events, but not chronic difficulties (CDs), predicted relapse occurrence: acute stressor frequency counts predicted greater relapse risk, along with low disability score (EDSS) and being male. We also confirmed the bi-directional stress-illness hypothesis: stressors predicted relapse, and relapse separately predicted stressors.

Conclusions Life-event stress impacts to a small degree on MS relapse. The number and not the severity of acute stressors are most important; chronic stressors do not predict later relapse. Males and those with early stage disease are also at greater risk of relapse. MS patients should be encouraged to reduce acute stressors during times of high stress, and feel reassured that disease-related chronic stressors do not increase their relapse risk.

Cannabis use and anxiety: is stress the missing piece of the puzzle?

OBJECTIVE

Comorbidity between anxiety and cannabis use is common yet the nature of the association between these conditions is not clear. Four theories were assessed, and a fifth hypothesis tested to determine if the misattribution of stress symptomology plays a role in the association between state-anxiety and cannabis.

METHODS

Three-hundred-sixteen participants ranging in age from 18 to 71 years completed a short online questionnaire asking about their history of cannabis use and symptoms of stress and anxiety.

RESULTS

Past and current cannabis users reported higher incidence of lifetime anxiety than participants who had never used cannabis; however, these groups did not differ in state-anxiety, stress, or age of onset of anxiety. State-anxiety and stress were not associated with frequency of cannabis use, but reported use to self-medicate for anxiety was positively associated with all three. Path analyses indicated two different associations between anxiety and cannabis use, pre-existing and high state-anxiety was associated with (i) higher average levels of intoxication and, in turn, acute anxiety responses to cannabis use; (ii) frequency of cannabis use via the mediating effects of stress and self-medication.

CONCLUSION

None of the theories was fully supported by the findings. However, as cannabis users reporting self-medication for anxiety were found to be self-medicating stress symptomology, there was some support for the stress-misattribution hypothesis. With reported self-medication for anxiety being the strongest predictor of frequency of use, it is suggested that researchers, clinicians, and cannabis users pay greater attention to the overlap between stress and anxiety symptomology and the possible misinterpretation of these related but distinct conditions.

Tango programme for individuals with age-related macular degeneration

Recent research shows that tango dance is an absorbing and effective strategy to reduce levels of depression, while also increasing well-being. This study investigates the feasibility, acceptability, and adherence to a tango programme for individuals with age-related macular degeneration (ARMD). Depression is closely intertwined with the ARMD diagnosis, since the loss of central vision has a profoundly negative impact on the person’s quality of life. Seventeen participants were randomised to tango dance (1.5 h, 2 times/week for 4 weeks) or wait-list control condition. Demographic questions and Visual Function Questionnaire were taken at pre-test. Self-rated symptoms of depression, self-esteem, and satisfaction-with-life were assessed at pre-test and post-test. Tango group participants showed significant reductions in depression and significantly increased satisfaction-with-life and self-esteem at post-test relative to the controls, and reported physical improvement, including increased balance. Tango dance was demonstrated to be a feasible and positive activity for this population.

Development of the Tinnitus response scales: factor analyses, subscale reliability and validity analyses

OBJECTIVE

Patients suffering with tinnitus are often advised to accept the noise, but few studies have examined what tinnitus acceptance entails. The present project developed and tested a new instrument to assess the mindfulnessbased constructs of acceptance, control, and defeat, in relation to the experience of chronic tinnitus.

METHOD

Initial scale development involved an expert panel. Participants were recruited from the general population and tinnitus support organizations and complete the first version of the Tinnitus Response Scales (TRS) and measures of tinnitus coping, severity and distress, general distress, illness cognitions, and tinnitus and health characteristics.

RESULTS

Three interpretable TRS factors were found: acceptance, control and defeat (an Internet sample, N = 273) and confirmed using another sample (hard-copy sample, N = 278). Factors were shown to have high internal consistency and testretest reliabilities and differed in terms of their related cognitions, behaviour, and emotional responses to tinnitus, and their tinnitus characteristics.

CONCLUSION

The TRS factors provide an alternative conceptualisation of tinnitus responding. TRS is a brief psychometrically valid measure of tinnitus responding that appears to distinguish between adaptive and non-adaptive responses to tinnitus noise, and should prove useful as a clinical measure.

Argentine tango dance compared to mindfulness meditation and a waiting-list control: a randomised trial for treating depression

OBJECTIVES

To determine whether tango dancing is as effective as mindfulness meditation in reducing symptoms of psychological stress, anxiety and depression, and in promoting well-being.

DESIGN

This study employed analysis of covariance (ANCOVA) and multiple regression analysis.

PARTICIPANTS

Ninety-seven people with self-declared depression were randomised into tango dance or mindfulness meditation classes, or to control/waiting-list.

SETTING

classes were conducted in a venue suitable for both activities in the metropolitan area of Sydney, Australia.

INTERVENTIONS

Participants completed six-week programmes (1½h/week of tango or meditation). The outcome measures were assessed at pre-test and post-test.

MAIN OUTCOME MEASURES

Depression, Anxiety and Stress Scale; The Self Esteem Scale; Satisfaction with Life Scale, and Mindful Attention Awareness Scale.

RESULTS

Sixty-six participants completed the program and were included in the statistical analysis. Depression levels were significantly reduced in the tango (effect size d=0.50, p=.010), and meditation groups (effect size d=0.54, p=.025), relative to waiting-list controls. Stress levels were significantly reduced only in the tango group (effect size d=0.45, p=.022). Attending tango classes was a significant predictor for the increased levels of mindfulness R(2)=.10, adjusted R(2)=.07, F (2,59)=3.42, p=.039.

CONCLUSION

Mindfulness-meditation and tango dance could be effective complementary adjuncts for the treatment of depression and/or inclusion in stress management programmes. Subsequent trials are called to explore the therapeutic mechanisms involved.

Control cognitions and causal attributions as predictors of fatigue severity in a community sample

Control cognitions and causal attributions of fatigue were examined in relation to Weiner's Causal Attribution theory in a community sample. Participants were 97 females and 43 males, aged 18-83 years. Weiner's dimensions of stability and uncontrollability and physical and psychosocial attributions of fatigue were related to fatigue severity. Escape-avoidance coping mediated between psychosocial causal attributions of fatigue to fatigue; whereas planful problem-solving and exercise moderated between stability cognitions to fatigue and psychosocial attributions of fatigue to fatigue, respectively. This, the cause(s) of fatigue were perceived as stable, uncontrollable, and involving physical and psychosocial factors, participants reported worse fatigue. Taken together, the results suggest that fatigue treatments may be most effective when they are tailored or matched to the belief systems of the individuals with fatigue.

The Multiple Sclerosis Work Difficulties Questionnaire

Background: A better understanding of the workplace difficulties experienced by people with multiple sclerosis (PwMS) may be critical to developing appropriate vocational and rehabilitative programs.

Objective: We aimed to assess the factor structure, internal consistency and validity of the new Multiple Sclerosis Work Difficulties Questionnaire (MSWDQ).

Methods: Work difficulty items were developed and reviewed by a panel of experts. Using the MSWDQ, cross-sectional self-report data of work difficulties were obtained in addition to employment status and MS disease information, in a community-based sample of 189 PwMS.

Results: Exploratory Maximum Likelihood Factor Analysis on the draft questionnaire yielded 50 items measuring 12 factors. Subscale internal consistencies ranged from 0.74 to 0.92, indicating adequate to excellent internal consistency reliability. The MSWDQ explained 40% of the variance in reduced work hours since diagnosis, 40% of the variance in expectations about withdrawing from work, 34% of the variance in expectations about reducing work hours, and 39% of the variance in expectations about changing type of work due to MS.

Conclusion: The MSWDQ is a valid and internally reliable measure of workplace difficulties in PwMS. Physical difficulties, as well as cognitive and psychological difficulties were important predictors of workplace outcomes and expectations about future employment.

Stress, depression, workplace and social supports and burnout in intellectual disability support staff

BACKGROUND

Staff providing support to people with intellectual disabilities are exposed to stressful work environments which may put them at an increased risk of burnout. A small prior literature has examined predictors of burnout in disability support staff, but there is little consensus. In this study, we examined direct and indirect associations between work stressors (i.e. challenging client behaviour), staff emotional response to the behaviour (i.e. perceived stress, anxiety, depression), social and organisational support resources, and staff burnout.

METHODS

A short survey examined client behaviour, staff psychological stress, anxiety, depression, social support (number, satisfaction), organisational support and burnout in 80 disability support staff in a community setting.

RESULTS

Burnout levels were similar to or slightly lower than normed values for human services staff. Cross-sectional regression analyses indicated that depression symptoms and organisational support were related to worse emotional exhaustion and depersonalisation, whereas less social support was related to less personal accomplishment. Social support satisfaction (but not social support number or organisational support) moderated between high psychological stress to less emotional exhaustion.

CONCLUSIONS

Taken together, these results suggest that depression symptoms and low organisational support were frequently concurrent with burnout symptoms. Furthermore, worker's personal and organisational supports may have helped bolster their sense of personal accomplishment, and buffered against the potential for emotional exhaustion.

The 'grass ceiling': limitations in the literature hinder our understanding of cannabis use and its consequences

AIM

To illustrate how limitations in the cannabis literature undermine our ability to understand cannabis-related harms and problems experienced by users and identify users at increased risk of experiencing adverse outcomes of use.

METHOD AND RESULTS

Limitations have been organized into three overarching themes. The first relates to the classification systems employed by researchers to categorize cannabis users, their cannabis use and the assumptions on which these systems are based. The second theme encompasses methodological and reporting issues, including differences between studies, inadequate statistical control of potential confounders, the under-reporting of effect sizes and the lack of consideration of clinical significance. The final theme covers differing approaches to studying cannabis use, including recruitment methods. Limitations related to the nature of the data collected by researchers are discussed throughout, with a focus on how they affect our understanding of cannabis use and users.

CONCLUSIONS

These limitations must be addressed to facilitate the development of effective and appropriately targeted evidence-based public health campaigns, treatment programmes and preventative, early intervention and harm minimization strategies, and to inform cannabis-related policy and legislation.

Satisfaction of early breast cancer patients with discussions during initial oncology consultations with a medical oncologist

OBJECTIVE

The purpose of this report is to extend the current understanding of patient satisfaction by examining expectations of a sample of breast cancer patients and concordance with their medical oncologists about the content of consultations and the importance of consultation items.

METHODS

Three hundred and ninety-five female early stage breast cancer patients of 56 oncologists participated. Patients and oncologists completed a matched questionnaire measuring (a) met expectations, (b) concordance over content and item importance, and (c) satisfaction.

RESULTS

Overall patient satisfaction was extremely high (x=91/100%) although expectations were not met at the stated level desired. Patients and physicians disagreed over what was conveyed and received. Higher overall satisfaction was predicted by levels of met expectations (unstandardized beta=0.69, p=0.008, SE=0.26) and concordance over (a) content (unstandardized beta=1.09, p=0.002, SE=0.34) and (b) importance (unstandardized beta=-0.78, p=0.006, SE 0.28).

CONCLUSION

Although patient expectations were not well met and physician-patient discord was high about the content of consultations and the importance of consultation items, patients reported high levels of satisfaction. Expectation fulfillment and levels of concordance predicted satisfaction.

Longitudinal assessment of anxiety, depression, and fatigue in people with multiple sclerosis

OBJECTIVES

No longitudinal studies have concurrently evaluated predictors of anxiety, depression, and fatigue in people with multiple sclerosis (PwMS). This study determined factors that best predicted anxiety, depression, and fatigue in MS patients from a large pool of disease, cognitive, life-event stressor (LES), psychosocial, life-style, and demographic factors.

DESIGN

A 2-year prospective longitudinal study evaluated predictors of psychological distress and fatigue in PwMS.

METHODS

One hundred and one consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. LES, anxiety, depression, and fatigue were assessed at baseline and at 3-monthly intervals for 2-years. Disease, cognitive, demographic, psychosocial, and life-style factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

Depression strongly predicted anxiety and fatigue, and anxiety and fatigue strongly predicted later depression. Psychological distress (i.e. anxiety, depression) was also predicted by a combination of unhealthy behaviours (e.g. drug use, smoking, no exercise, or relaxation) and psychological factors (e.g. low optimism, avoidance coping), similar to the results of community-based studies. However, state-anxiety and fatigue were also predicted by immunotherapy status, and fatigue was also predicted by LES and demographics.

CONCLUSIONS

These results suggest that similar factors might underpin psychological distress and fatigue in MS patients and community-well samples, although MS treatment factors may also be important. These results might assist clinicians in determining which MS patients are at greatest risk of developing anxiety, depression, or fatigue.

Stress, psychological distress, psychosocial factors, menopause symptoms and physical health in women

OBJECTIVES

Relatively few studies have evaluated relationships between stress, psychological distress, psychosocial factors and menopause symptoms, and none have evaluated emotional intelligence (EI) in relation to menopause. In this study, direct and indirect relationships were evaluated between stress, psychological distress, psychosocial factors (e.g. social support, coping, EI), menopause symptom severity and physical health in middle-aged women.

METHODS

One hundred and sixteen women aged 45-55 years were recruited through women's health centres and community organizations. They completed a short questionnaire asking about stress, psychological distress (i.e. anxiety, depression), EI, attitude to menopause, menopause symptoms and physical health.

RESULTS

Low emotional intelligence was found to be related to worse menopause symptoms and physical health, and these associations were partly mediated by high stress, anxiety and depression, a negative attitude to menopause and low proactive coping.

CONCLUSIONS

Women with high EI appear to hold more positive attitudes to menopause and experience less severe stress, psychological distress and menopause symptoms and better physical health. These results suggest that women who expect menopause to be a negative experience or are highly stressed or distressed may be more likely to experience a more negative menopause.

Immunological disturbance and infectious disease in anorexia nervosa: a review

OBJECTIVE

Severely malnourished patients with anorexia nervosa (AN) are reported to show fewer symptomatic viral infections and a poorer response to bacterial infection than controls. They are also reported to show mild immune system changes, although the relevance of these to altered infection disease presentation in AN and AN pathophysiology is unknown. Thus, in this paper, we suggest a range of immune system changes that might underpin these altered responses to common pathogens, and review a number of recent infectious disease findings for their utility in explaining the pathophysiology of AN.

METHODS

A systematic review of the literature pertaining to immunity and infectious disease in AN was performed.

RESULTS

AN is associated with leucopenia, and the increased spontaneous and stimulated levels of proinflammatory cytokines [i.e. interleukin (IL)-1β, IL-6 and tumour necrosis factor α). A range of less consistent findings are also reviewed. Most of these data were not controlled for length of illness, degree of malnutrition, micronutrient or vitamin deficiencies or recent refeeding and starvation.

CONCLUSION

Cytokine disturbances have been suggested to be causally related to AN symptomatology and pathophysiology of AN, although the evidence supporting this assertion is lacking. Immune and cytokine changes in AN do, however, occur in association with a decreased incidence of symptomatic viral infection, decreased clinical response to bacterial infection leading to delayed diagnosis and increased morbidity and mortality associated with the infections.

An examination of the initial cancer consultation of medical and radiation oncologists using the Cancode interaction analysis system

This study provides an analysis of the structure of the initial cancer consultation, the consultation styles of medical and radiation oncologists, and their effect on patient outcomes. One hundred and fifty-five cancer patients attending their first consultation with either a medical or radiation oncologist were audiotaped and the transcripts were analysed using the Cancode computer interaction analysis system. Findings revealed that medical oncologists allowed patients and their families more input into the consultation and were rated as warmer and more patient-centred compared with radiation oncologists. However, radiation oncologists spent a longer period discussing, and were more likely to bring up, social support issues with patients. Both medical and radiation oncologists varied their consultation style according to the patient's gender, age, anxiety levels, prognosis, and education. Patients seeing an oncologist who was rated as warmer and discussed a greater number of psychosocial issues had better psychological adjustment and reduced anxiety after consultation. These findings provide current evidence that may be used to inform improvements of communication skills training for oncologists and highlight the need for future communication research to separately consider oncologists from different disciplines.

Efficacy of an Emotion-Focused Treatment for Prolonged Fatigue

Previous research findings have suggested a relationship between less adaptive emotional functioning and fatigue. The present study used a research design involving multiple baselines across participants to evaluate the efficacy of a new emotion-focused treatment for prolonged fatigue delivered in a cognitive behavioral therapy framework. The 13 adults participating in the study met the criteria for prolonged fatigue and provided fatigue baselines of 2, 5, or 8 weeks. The results indicated that the treatment was effective, with fatigue severity levels after the initiation of treatment significantly lower than that predicted by baseline patterns, as determined by the split median method of trend estimation. At 3—4 months after treatment, 8 of 11 clients who completed the treatment no longer met the criteria for prolonged fatigue.

The Impact of a Self-Efficacy Intervention on Short-Term Breast-Feeding Outcomes

Maternal self-efficacy for breast-feeding may contribute to success in breast-feeding. This study aimed to increase breast-feeding self-efficacy and actual breast-feeding through an intervention based on Bandura's self-efficacy theory. A total of 90 pregnant women participated in the study. The women who were assigned to a breast-feeding self-efficacy intervention showed significantly greater increases in breast-feeding self-efficacy than did the women in the control group. Furthermore, at 4 weeks postpartum, women in the intervention group showed a trend toward breast-feeding their infants longer and more exclusively than did those in the control group. Greater increases in breast-feeding self-efficacy were associated with a significantly higher level of breast-feeding. Replicating previous research, breast-feeding self-efficacy was significantly related to concurrent breast-feeding behavior, and high antenatal breast-feeding self-efficacy predicted a higher level of later breast-feeding in control-group women. These findings have implications for breast-feeding support programs and for the potential general utility of self-efficacy-based interventions in health education.

Seeking informed consent to cancer clinical trials; evaluating the efficacy of doctor communication skills training

INTRODUCTION

Clinical trials have come to be regarded as the gold standard for treatment evaluation. However, many doctors and their patients experience difficulties when discussing trial participation, leading to poor accrual to trials and questionable quality of informed consent. We have previously developed a communication skills training program based on a typology for ethical communication about Phase II and III clinical trials within four categories. The training program consisted of a 1 day experiential workshop that included didactic teaching, exemplary video and role play. The aim of this study was to evaluate the effectiveness of the communication skills training workshop.

METHOD

Oncologists were recruited from three major teaching hospitals conducting oncology outpatient clinics in three Australian capital cities. Ten oncologists and 90 of their adult cancer patients who were eligible for a Phase II or III clinical trial participated. Ninety informed consent consultations were audiotaped before (n = 59) and after (n = 31) training, and fully transcribed. The presence or absence of each domain component was coded and these were summed within categories. A coding manual was produced which enabled standardization of the coding procedure. Patients completed questionnaires before and after the consultation, and doctors completed a short measure of satisfaction after the consultation.

RESULTS

Doctors increased their use of some aspects of shared decision-making behavior (t(87) = -1.945, p = 0.05) and described some aspects of essential ethical/clinical information more commonly. In addition they used less coercive behaviors (z = -1.976, p = 0.048). However, they did not provide more clinical information or structure their consultations in the recommended fashion. Patients in the post-training cohort reported more positive attitudes to clinical trials, but other outcomes were not affected by the intervention.

CONCLUSIONS

This short training programme demonstrated limited success in improving the oncologist's communication skills when gaining informed consent. A larger randomized controlled trial of extended training is now underway.

Relationship between stress and relapse in multiple sclerosis: Part II. Direct and indirect relationships

OBJECTIVE

The aim of this two-year prospective study was to determine which factors were: (i) directly related and/or (ii) indirectly related to multiple sclerosis (MS) relapse. These factors included life-event stressors, disease, demographic, psychosocial and lifestyle factors.

BACKGROUND

Relatively little attention has been paid to the role of non-clinical relapse predictors (other than stressful life-events) in MS, or factors that indirectly impact on the stress-relapse relationship.

METHODS

A total of 101 consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. Stressful life-events, depression, anxiety and fatigue were assessed at study-entry and at three-monthly intervals for two years. Disease, demographic, psychosocial and lifestyle factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

MS relapse was predicted by acute stressor frequency counts, coping responses that utilized social support, and being born in Australia, but not by chronic stressors, disease, demographic, psychosocial or lifestyle factors. No factors were found to indirectly impact on the stress relapse relationship.

CONCLUSIONS

The number rather than severity of stressors was most important in relation to MS relapse risk, along with coping responses that utilized social support, suggesting that MS patients should avoid situations that are likely to generate multiple stressors or which provide few avenues for social support.

Direct and indirect relationships between emotional intelligence and subjective fatigue in university students

OBJECTIVE

The aim of this study was to examine the direct and indirect relationships between emotional intelligence and subjective fatigue.

METHODS

One hundred sixty seven university students completed questionnaires assessing subjective fatigue, emotional intelligence, and a range of other psychosocial factors. A series of regression analyses were used to examine the direct and indirect relationships between subjective fatigue and psychosocial factors.

RESULTS

Higher emotional intelligence was associated with less fatigue. The psychosocial variables depression, anxiety, optimism, internal health locus of control, amount of social support, and satisfaction with social support each partially mediated between emotional intelligence and fatigue. Additionally, sleep quality partially mediated between emotional intelligence and fatigue.

CONCLUSION

These findings regarding the association between subjective fatigue, emotional intelligence, and other psychosocial factors may facilitate an understanding of the aetiology of fatigue and contribute to future research examining interventions aimed at helping individuals cope with fatigue.

Bacterial infections in anorexia nervosa: delayed recognition increases complications

OBJECTIVE

We compared the natural history of bacterial infection in patients with anorexia nervosa (AN) with controls, and assessed which of a range of patient characteristics were associated with infection, fever response, and the rate of infectious complications in AN patients.

METHOD

The charts of 311 consecutive hospital admissions of AN patients were reviewed. Patients who had a bacterial infection while in the hospital were compared with the AN patients who did not have an infection, with respect to a range of demographic and disease variables. Fever response and infection complication rate also were evaluated in AN patients with a bacterial infection and in nonanorectic control subjects admitted with a bacterial infection.

RESULTS

AN patients with a bacterial infection showed a reduced fever response, were often difficult to diagnose because of fewer signs and symptoms, and infection became more frequent with increasing patient age.

DISCUSSION

A reduction in fever response and the signs and symptoms of infection significantly delayed diagnosis in AN patients and increased the complication rate from bacterial infection. We recommend that an increased index of suspicion and an early complete blood count and bacteriologic cultures be adopted for the investigation of bacterial infection in AN patients.

Education and role modelling for clinical decisions with female cancer patients

BACKGROUND

Patients vary widely in their preferences and capacity for participating in treatment decision-making. There are few interventions targeting patient understanding of how doctors make decisions and shared decision-making. This randomized trial investigates the effects of providing cancer patients with a package designed to facilitate shared decision-making prior to seeing their oncologist.

PATIENTS AND METHODS

Sixty-five female cancer patients were randomized to receive either the package (booklet and 15-min video) or a booklet on living with cancer, before their initial consultation. Participants completed questionnaires prior to the intervention, immediately after the oncology consultation, and 2 weeks and 6 months later. The first consultation with the oncologist was audio-taped and transcribed.

RESULTS

Patients receiving the package were more likely than controls to declare their information and treatment preferences in the consultation, and their perspectives on the costs, side-effects and benefits of treatment. Doctors introduced considerably more new themes in the consultations with intervention subjects than they did with controls; no other differences in doctor behaviour were noted.

CONCLUSIONS

This short intervention successfully shifted patient and doctor behaviour closer to the shared decision-making model, although it did not alter patients' preferences for information or involvement.

Seeking informed consent to cancer clinical trials:

Clinical trials have come to be regarded as the gold standard for treatment evaluation. However, many doctors and their patients experience difficulties when discussing trials, leading to poor accrual to trials and questionable quality of informed consent. We have previously developed a typology for ethical communication about Phase II and III clinical trials within four domains: (a) shared decision making, (b) sequencing information, (c) type and clarity of information, and (d) disclosure/coercion. The aim of this study was to compare current clinical practice when seeking informed consent with this typology. Fifty-nine consultations in which 10 participating oncologists sought informed consent were audiotaped. Verbatim transcripts were analysed using a coding system to (a) identify the presence or absence of aspects of the four domains and (b) rate the quality of aspects of two domains: (i) shared decision-making and (ii) type and clarity of information. Oncologists rarely addressed aspects of shared decision-making, other than offering to delay a treatment decision (78%). Moreover, many of these discussions scored poorly with respect to ideal content. The oncologists were rarely consistent with the sequence of information provision. A general rationale for randomising was only described in 46% of consultations. In almost one third of the consultations (28.8%) doctors made implicit statements favouring one option over another, either standard or clinical trial treatment. Doctors complied with some but not other aspects of a standard procedure for discussing clinical trials. This reflects the difficulty inherent in seeking ethical informed consent and the need for communication skills training for oncologists.

Developing ethical strategies to assist oncologists in seeking informed consent to cancer clinical trials

Randomised clinical trials have come to be regarded as the gold standard in treatment evaluation. However, many doctors see the discussion of a clinical trial as an intrusion into the doctor-patient relationship and find these discussions difficult to initiate. Detailed informed consent is now a requirement of patient participation in trials; however, it is known that patients commonly fail to understand and recall the information conveyed. These difficulties for doctors and patients raise questions about the ethical integrity of the informed consent process. In this study, we have developed a set of communication strategies underpinned by ethical, linguistic and psychological theory, designed to assist doctors in this difficult task. Initially, audiotape transcripts of 26 consultations in which 10 medical oncologists invited patients to participate in clinical trials were analysed by expert ethicists, linguists, oncologists and psychologists, using rigorous qualitative methodology. A subset of seven of these was subjected to detailed linguistic analysis. A strategies document was developed to address themes which emerged from these analyses. This document was presented to relevant expert stakeholders. Their feedback was incorporated into the final document. Four themes emerged from the analysis; (a) shared decision-making, (b) the sequence of moves in the consultation, (c) the type and clarity of the information provided and (d) disclosure of controversial information and coercion. Detailed strategies were developed to assist doctors to communicate in these areas. We have developed a set of ethical strategies which may assist health professionals in this difficult area. A training package based on these strategies is currently being evaluated in a multi-centre randomised controlled trial.

HPA axis activation and neurochemical responses to bacterial translocation from the gastrointestinal tract

Stress can cause migration of indigenous bacterial flora from the gut to the peritoneum, a phenomenon known as bacterial translocation. Destruction of the cell walls of gram-negative bacteria can result in the production of endotoxin (lipopolysaccharide, LPS), which is the likely cause of sepsis. Exogenously administered LPS can activate the hypothalamo-pituitary-adrenal (HPA) axis as well as brain noradrenergic and indoleaminergic systems. Thus, it is possible that activations of these systems associated with laboratory stressors in rats and mice could be attributed to bacterial translocation and LPS production. To test this hypothesis we conducted experiments on the time course of bacterial translocation in response to restraint in mice, while measuring HPA and neurochemical responses. These experiments failed to show good correlations between the occurrence of bacterial translocation and HPA and neurochemical activations, suggesting that the later responses were not linked to bacterial translocation. This conclusion was supported by the observation of normal neurochemical responses to restraint in germ-free mice. In further experiments, translocation of Salmonella typhimurium, a bacterium that readily translocates in unstressed animals, was associated with HPA activation and noradrenergic and indoleaminergic responses, indicating that bacterial translocation can indeed activate the HPA axis and brain amines. However, the above experiments suggest that this is not the mechanism by which restraint activates these systems.

Responding to the active and passive patient: flexibility is the key

BACKGROUND

Patients vary widely in their preferences and capacity for participation in medical decision-making. This study aimed to document oncologist responses to more extreme presentations and identify helpful and unhelpful strategies for clinicians.

PATIENTS AND METHODS

A trained actor played the role of a patient with early stage breast cancer who was attending her first consultation with a medical oncologist. She adopted in random order two different consultation participation styles: that of a very anxious, active patient, and that of a depressed, passive patient. Medical consultations between the actor and 16 medical oncologists were videotaped and then analysed qualitatively by two trained raters.

RESULTS

Strategies that facilitated shared decision-making with both patient types and were positively endorsed by the actor/patient included explicit agenda-setting, active listening, checking understanding, endorsing question-asking, offering decisional delay, and non-verbal behaviours conveying empathy and warmth. Oncologists successfully negotiated with the active patient to share control of the consultation, and responded to emotional cues from the passive patient. Unhelpful strategies were also identified.

CONCLUSIONS

Few clinicians receive training in responding to differing communication styles in their patients that could potentially cause conflict and hinder optimal treatment decision-making. This study suggests some useful strategies for oncologists to consider, to widen their behavioural repertoire in the cancer consultation.

Lay constructions of decision-making in cancer

In recent years there has been increased emphasis on involving people in decision-making about their medical care. However, few studies have addressed the questions of why women with cancer want information, and what they believe to be the important factors influencing their decision-making. In order to examine these questions 20 women with cancer were interviewed via telephone 2 weeks after their first consultation with one of 6 medical oncologists. Recruitment continued until informational redundancy was achieved. While women cited the risk of recurrence, life expectancy, side-effects, and quality of life as influencing their decisions, they placed at least as much emphasis on their personal relationship with the specialist. These 'personal' factors included: feeling that the doctor cared for, understood and respected them; that they could trust and have confidence in the doctor; that the doctor would give them enough time; that they would be listened to; and that the doctor would be open and honest. If these factors were felt to be present, many women were happy to accept the doctor's recommendation, confident that they would receive the optimum treatment. However, many women felt there was no decision to be made: further treatment must be undertaken to reduce risk, and minor variations in the treatment protocol were of little significance. These results underline the importance of establishing patient priorities and concerns before embarking on discussions about treatment.

Oncologists' reactions to cancer patients' verbal cues

The diagnosis and treatment of cancer cause considerable psychological distress and morbidity. Consequently, cancer patients have high needs for informational and emotional support and doctors vary in their ability to recognise and address these needs. This study investigated patients' attempts to gain informational and emotional support through the use of verbal cues. The sample consisted of 298 patients with heterogeneous cancers, seeing one of five medical and four radiation oncologists for the first time. Sociodemographic variables and patient anxiety and satisfaction ratings were obtained. Transcripts of the audiotaped consultations were analysed and question-asking, use of indirect cues, cue type (informational or emotional), content categories in which questions and cues occurred and doctor response (responded to or not responded to), were recorded. Patients asked a median of 11 questions and gave two cues per consultation, usually during treatment discussions. Patients gave, and doctors responded to, more informational than emotional cues. Patients gave significantly more informational cues during longer consultations. Younger and female patients gave more cues for emotional support and asked questions. No demographic variables were associated with the doctors' response to emotional and informational cues; however, consultations in which more informational cues were responded to were shorter, even when controlling for the number of cues given. Satisfaction with the consultation and patient anxiety were unaffected by doctors' responses to cues. Overall, results showed that doctors effectively identify and respond to the majority of informational cues; however, they are less observant of and able to address cues for emotional support. Cues can be addressed without lengthening the consultation or increasing patient anxiety.

Promoting patient participation and shortening cancer consultations: a randomised trial

Patient participation in medical consultations has been demonstrated to benefit their subsequent psychological well being. Question asking is one way in which patients can be active. We investigated 2 means of promoting cancer patient question asking. One was the provision of a question prompt sheet to patients prior to their initial consultation with their oncologist. The second was the active endorsement and systematic review of the question prompt sheet by their oncologist. 318 patients with heterogeneous cancers, seeing one of 5 medical and 4 radiation oncologists for the first time, were randomised to either receive or not receive a question prompt sheet. Doctors were randomised to either proactively address or passively respond to the question prompt sheet in the subsequent consultation. Anxiety was assessed prior to the consultation. Consultations were audiotaped and content analysed. Anxiety was assessed again immediately following the consultation. Within the next 10 days patients completed questionnaires assessing information needs, anxiety and satisfaction and were given a structured telephone interview assessing information recall. Patients provided with a question prompt sheet asked more questions about prognosis compared with controls and oncologists gave significantly more prognostic information to these patients. Provision of the question prompt sheet prolonged consultations and increased patient anxiety; however, when oncologists specifically addressed the prompt sheet, anxiety levels were significantly reduced, consultation duration was decreased and recall was significantly improved. A patient question prompt sheet, used proactively by the doctor, is a powerful addition to the oncology consultation.

Use of infliximab in pediatric patients with inflammatory bowel disease

BACKGROUND

The concentration of tumor necrosis factor, a proinflammatory cytokine, is increased in the gastrointestinal mucosa of patents with active Crohn's disease (CD) and ulcerative colitis (UC). Neutralization of tumor necrosis factor decreases the mucosal inflammatory response of adults with CD. Little information is available on the use of monoclonal antibody to tumor necrosis factor (infliximab) in children and adolescents with CD or UC.

OBJECTIVE

To evaluate the clinical response and side effects of patients to infliximab.

METHODS

A retrospective review of data regarding 18 pediatric and adolescent patients with active CD (n = 15) and UC (n = 3) poorly controlled with conventional therapy. All patients received one to six intravenous infusions of infliximab 5 mg/kg, while receiving their usual medications.

RESULTS

All patients experienced clinical improvement, including decrease in the frequency of stooling and resolution of extraintestinal symptoms such as arthropathy, malaise, and skin manifestations after treatment with infliximab. All but one patient had a documented decrease in the erythrocyte sedimentation rate. Prednisone dosage was tapered in all but two patients, and discontinued in seven patients. Intravenous infusion of infliximab was well tolerated. One patient developed a rash several days after the infusion. A patient who received six infliximab infusions developed recurrent Staphylococcus aureus infections, as well as septic arthritis and chronic osteomyelitis during the follow-up period, raising the issue of the long-term safety of infliximab.

CONCLUSIONS

Treatment of our patients with refractory CD and UC with infliximab was associated with remarkable clinical improvement. Although the drug may have an important role in their management, further assessment of long-term safety and efficacy is needed.

Bacterial translocation can increase plasma corticosterone and brain catecholamine and indoleamine metabolism

The potential contribution of stress-induced bacterial translocation to the activation of the hypothalamo-pituitary-adrenocortical (HPA) axis and brain biogenic amines was assessed. Mice were restrained for various periods, and brain concentrations of tryptophan, catecholamines, serotonin, and their metabolites, plasma corticosterone, and the translocation of viable bacteria from the gastrointestinal tract to the mesenteric lymph nodes, spleen, and liver were measured. Restraint induced the translocation of indigenous gram-positive bacteria in only a small proportion of animals, but translocation of gram-negative bacteria did not occur. Restraint induced short-lived increases in plasma corticosterone and brain amine metabolism, whereas bacterial translocation was slower and persisted long after the HPA axis and neurochemical responses had dissipated. When mice were infected with Salmonella typhimurium, spontaneous translocation occurred and plasma corticosterone, interleukin-6 concentrations, and brain catecholamine and indoleamine metabolism were elevated. These findings indicate that the translocation of indigenous gastrointestinal bacteria did not contribute to the HPA axis and neurochemical changes induced by restraint. However, translocation of nonindigenous S. typhimurium with or without restraint did induce HPA and neurochemical responses.

Coping with metastatic melanoma: the last year of life

BACKGROUND

Few longitudinal studies have concurrently investigated cognitive appraisal, coping and psychological adjustment in patients with terminal cancer. This study aimed to (i) consider patterns of change in these variables during the last year of life and (ii) consider covariates associated with patients' psychological adjustment.

METHODS AND PATIENTS

Questionnaires were sent to a cohort of stage IV melanoma patients seen at the Sydney Melanoma Unit between 1991 and 1996, approximately every 3 months, for up to 2 years. A sub-sample of 110 patients completed at least one questionnaire in the last year of life. Repeated measures linear regression was used to model cognitive appraisal, coping and psychological adjustment.

RESULTS

In the last year of life, patients' cognitive appraisal of their disease remained relatively stable, whereas their use of active coping strategies increased (p=0. 04). There was some deterioration in psychological adjustment, particularly in patients' ability to minimize the impact of cancer on daily life (p=0.03), but this effect did not remain significant when patients' level of tiredness was included in the model. Cognitive appraisal, coping style and quality of life indicators were all associated with psychological adjustment.

CONCLUSION

These findings suggest that while patients work hard to actively cope with their disease, they experience increasing levels of tiredness, and deterioration in their mood and ability to function in their daily lives.

Non-invasive quantification of skin injury resulting from exposure to sulphur mustard and Lewisite vapours

The severity and progression of skin lesions resulting from exposure to the chemical warfare agents Lewisite (L) and sulphur mustard (SM) have been investigated using the non-invasive biophysical methods of evaporimetry and reflectance spectroscopy in large white pigs in vivo. Erythema (redness) expressed immediately after exposure to L or SM vapours appeared to be related to the lesion severity as demonstrated by histopathological analysis. Skin brightness correlated well with scab formation whereas blueness (cyanosis) did not appreciably alter throughout the study. Rates of transepidermal water loss (TEWL) changed both with occlusion (during vapour exposure) and also mirrored the progression of macroscopic skin injury after 12 h. Whilst no single parameter could be used in isolation to ascertain the severity and subsequent progression of the skin lesions, measurement of erythema, skin brightness and TEWL could provide quantitative, non-invasive methods for determining the efficacy of antidotes or therapies to prevent the toxic effects of chemical warfare agents. However, neither colourimetry or TEWL provided a clinical evaluation of such lesions that were comparable with the prognostic capabilities of laser Doppler imaging.

Dermabrasion--a novel concept in the surgical management of sulphur mustard injuries

Since its first use on the battlefields of Northern France during the First World War (1914-1918), sulphur mustard has remained a significant chemical threat to military forces around the world. Progress towards an effective treatment for these injuries has been slow due to the lack of suitable animal models upon which to study the toxicology and pathology. However, porcine and human skin are similar in structure and exposures to sulphur mustard vapour have been performed on porcine models to define the development and subsequent resolution of mustard-induced skin injuries. Yucatan miniature (n = 12) and large white (n = 6) pig models were used to assess the usefulness of mechanical dermabrasion in accelerating the naturally slow rate of healing of sulphur mustard vapour-induced injuries to the skin. Burn injuries underwent debridement at 4 days post-exposure and the resulting lesions were assessed at various time points up to 8 weeks post-abrasion. Rates of re-epithelialisation were accelerated in the dermabrasion (treated) vs the control (untreated) group by up to a factor of three (ANOVA: p = .0196, Yucatan; p = 0.165, large white pig). It was concluded that dermabrasion of sulphur mustard burns is a valuable procedure in the surgical management of these injuries.

Bacterial lipopolysaccharide induces a conduction block in the sciatic nerves of rats

A single injection of Escherichia coli lipopolysaccharide (LPS; intraperitoneally [i.p.] and intravenously [i.v.]) reliably induces peripheral nerve disturbances in the hindlimbs of inbred Australian albino Wistar (AaW) rats. In the series of experiments presented here, we aimed to characterize this syndrome by examining electrophysiologic, immunologic, and immunochemical features. The LPS-induced neurologic sequelae in AaW rats were transient, at least partly reversible by drug treatment, and were not associated with any detectable neuropathologic findings by light microscopy. Neurologic sequelae were prevented by administration of dexamethasone and by pretreatment with the macrophage inhibitor gadolinium chloride, suggesting that they were caused by LPS-induced activation of peripheral macrophages. Sequelae were associated with early decreases in compound muscle-action potential amplitudes, indicating impaired functioning of either proximal sciatic nerve axons and/or neuromuscular synapses. Spinal somatosensory-evoked potential latencies also were increased, indicating impaired somatosensory function at the sciatic nerve, dorsal roots, spinal cord, and/or postsynaptic interneurons, although the precise location of impairment could not be delineated. Similarities between this syndrome and immune-mediated polyneuropathies in humans are discussed.