Andrew L. Brickman

Quality of Life: Radical Prostatectomy Versus Radiation Therapy for Prostate Cancer

PURPOSE The impact of radical prostatectomy and external beam radiotherapy on the quality of life of patients was compared. MATERIALS AND METHODS A total of 136 patients underwent radical prostatectomy and 60 underwent external beam radiotherapy for clinically localized prostate cancer. Patients were asked to complete a questionnaire containing The Functional Living Index: Cancer, the Profile of Moods States, and a series of questions evaluating bladder, bowel and sexual function. RESULTS The radical prostatectomy group had worse sexual function and urinary incontinence, while the external beam radiotherapy group had worse bowel function. Of the patients 90% from both groups stated that they would undergo the treatment again. CONCLUSIONS Radical prostatectomy and external beam radiotherapy have comparable impact upon quality of life.

What is chronic fatigue syndrome? Heterogeneity within an international multicentre study

Objective: We sought to compare the characteristics of patients presenting with chronic fatigue (CF) and related syndromes in eight international centres and to subclassify these subjects based on symptom profiles. The validity of the subclasses was then tested against clinical data. Method: Subjects with a clinical diagnosis of CF completed a 119-item self-report questionnaire to provide clinical symptom data and other information such as illness course and functional impairment. Subclasses were generated using a principal components-like analysis followed by latent profile analysis (LPA). Results: 744 subjects returned complete data sets (mean age 40.8 years, mean length of illness 7.9 years, female to male ratio 3:1). Overall, the subjects had a high rate of reporting typical CF symptoms (fatigue, neuropsychological dysfunction, sleep disturbance). Using LPA, two subclasses were generated. Class one (68% sample) was characterized by: younger age, lower female to male ratio; shorter episode duration; less premorbid, current and familial psychiatric morbidity; and, less functional disability. Class two subjects (32%) had features more consistent with a somatoform illness. There was substantial variation in subclass prevalences between the study centres (Class two range 6–48%). Conclusions: Criteria-based approaches to the diagnosis of CF and related syndromes do not select a homogeneous patient group. While substratification of patients is essential for further aetiological and treatment research, the basis for allocating such subcategories remains controversial.

Sexual risk behaviors in late middle age and older HIV seropositive adults.

Little is known about the sexual behaviors of older adults, although the prevalence of HIV/AIDS is rapidly increasing in this population. As part of a larger multi-site study examining secondary HIV prevention, we recruited from an HIV primary care clinic 210 sexually active HIV positive individuals aged 45 and over (125 men, 85 women) who had engaged in vaginal or anal sex within the past six months. Twenty percent of the participants reported inconsistent use of condoms and 33% had multiple sexual partners during the previous six months. Negative mood and perceived HIV stigma were associated with inconsistent condom use. In addition, multiple sex partners and higher level of education were related to inconsistent condom use during sex with partners of negative or unknown serostatus. These findings indicate that contrary to current beliefs, sexually active older adults, similar to younger ones, may be engaging in high risk transmission behaviors.

Bupropion treatment of fluoxetine-resistant chronic fatigue syndrome

Chronic fatigue syndrome (CFS) includes many symptoms of major depression. For this reason, many antidepressants have been used to treat the symptoms of this disorder. Among the more recently released antidepressants are fluoxetine and bupropion. In this open study, nine CFS patients who either could not tolerate or did not respond to fluoxetine showed significant response when administered 300 mg/day of bupropion for an 8-week period in both rating of HDRS (t = 4.80, p < 0.01) and BDI (t = 2.48, p < 0.05). Furthermore, bupropion improvement in Hamilton Depression Rating Scale correlated significantly with change in plasma homovanillic acid (HVA) (r = 0.96, p < 0.01). Plasma total methylhydroxyphenolglycol (MHPG) also increased significantly during bupropion treatment (t = 2.37, p = 0.05). Measures of T1 microsomal antibodies also decreased over treatment time; increases in natural killer cell numbers correlated inversely with change in plasma levels of free MHPG (r = -0.88, p < 0.05). Bupropion responders were more likely to have trough blood levels above 30 ng/ml (chi 2 = 3.6, p = 0.05).

Depression and coping in candidates for kidney transplantation: Racial and ethnic differences.

Subjects were 288 adolescents and adults with end-stage renal disease who were candidates for kidney transplantation, a group identified at risk for noncompliance. The purpose was to examine racial and ethnic variations in coping—variables that may underlie noncompliance and impact upon health outcome. Secondarily, the relationship between depression and particular styles of coping was investigated. Race/Ethnicity was divided into three categories: Black/Non-Hispanic, White/Non-Hispanic, and Hispanic. Coping and depression were assessed using the COPE and Beck Depression Inventory, respectively. Results indicated that Hispanic and Black subjects were more likely to use maladaptive styles of coping and less likely to use adaptive coping than were White subjects and that Black subjects reported more physical symptoms of depression. These findings point to possible mechanisms underlying the occurrence of noncompliance and resulting poorer health outcome for individuals of different racial and ethnic groups.

Innovations in Family Therapy Strategies for Overcoming Resistance to Treatment

Regardless of their theoretical orientation or mode and place of practice, every therapist has had the disappointing and frustrating experience of “resistance to therapy” in the form of missed or canceled first appointments. For the family therapist, this becomes an even more common and complex issue because more than one individual needs to be engaged to come to treatment.

Pathogenesis of cognitive complaints in patients on hemodialysis

Memory-concentration complaints are a common symptom among end-stage renal disease patients receiving hemodialysis. However, assuming an organic basis for these complaints might lead to unnecessary and expensive testing. To further explore the etiology of cognitive complaints, this study examined the contribution of demographic, neuropsychological, medical, affective, and personality variables to memory-concentration complaints in 426 hemodialysis patients. Following stepwise multiple regression to identify the best predictor variables within each domain, hierarchical multiple-regression analysis determined the significant predictors of memory-concentration complaints. Education, digit symbol score, and hemoglobin jointly accounted for approximately 7% of the variance. Cognitive (psychological) symptoms of depression explained an additional 9% of variance. Somatic symptoms of depression did not significantly contribute, whereas state anxiety did. Finally, personality variables collectively accounted for another 9% of variance. Overall, the model accounted for 28% of explained variance in memory-concentration complaints. These findings demonstrate that affect and personality factors are more predictive of memory-concentration complaints in hemodialysis patients than are neuropsychological or medical factors. The clinical implication is that the initial response to memory-concentration complaints in these patients should be evaluations of psychological condition.

Noncompliance in end-stage renal disease: A threat to quality of care and cost containment.

Noncompliance to treatment regimen after kidney transplantation is a threat to health outcomes and cost containment. Although there are methodological challenges to obtaining reliable compliance data, the results of noncompliance are increased morbidity and mortality in posttransplant patients. In addition, recent research suggests that patients who incur repeated rejection episodes leading to graft failure have higher levels of medical utilization. Some psychosocial factors related to compliance and medical utilization are potentially modifiable through cognitive-behavioral intervention.

Psychosocial and Biomedical Predictors of Attention and Memory in End-Stage Renal Disease Patients

This study examined the neurocognitive functioning of 554 end-stage renal disease (ESRD) patients to determine the underlying factor structure of tests of attention and memory and to assess the differential impact of psychosocial and biomedical variables on these factors. Analysis revealed three underlying factors: Sustained Attention, Focused Attention, and Memory Recall. Hierarchical regression analyses revealed that psychosocial and biomedical variables were most strongly related to the Focused Attention factor. Education, vocabulary score, age, race, age by creatinine, creatinine, and renal replacement therapy accounted for 30% of variance in Focused Attention; sex, depression, and hypertension were unrelated. After controlling for demographic and medical variables, type of renal replacement therapy was a statistically, but not clinically, significant predictor of Focused Attention, with peritoneal dialysis associated with better attentional performance relative to hemodialysis. The potential relationship between focused attention and compliance is discussed.