Hugo J. Duivenvoorden

PSYCHOLOGICAL SEQUELAE OF CANCER DIAGNOSIS : A META-ANALYTICAL REVIEW OF 58 STUDIES AFTER 1980

Objective In a review of the literature from 1980 to 1994 on psychological and psychiatric problems in patients with cancer, the prevalence, severity, and the course of these problems (ie, depression, anxiety, and general psychological distress) were studied with the help of meta-analyses and qualitative analyses. Apart from this, qualitative analyses were also applied with respect to other relevant variables. Method: A literature search in MEDLINE was conducted and cross-references of articles identified via MEDLINE. Meta-analysis was applied when possible. Results: There seemed to be a wide variation across studies in psychological and psychiatric problems. Meta-analysis showed no significant differences between cancer patients and the normal population with respect to anxiety and psychological distress. However, cancer patients seemed to be significantly more depressed than normals. Compared with psychiatric patients, cancer patients were significantly less depressed, anxious, or distressed. Compared with a sample of other medical patients, cancer patients showed significantly less anxiety. With respect to course, a significant decrease was found in the meta-analysis for anxiety, but not for depression. Further meta-analyses showed significant differences among groups of cancer patients with regard to tumor site, sex, age, design of the study, and year of publication. From the qualitative analyses, it seemed that medical, sociodemographic, and psychological variables were related inconsistently to psychological and psychiatric problems. Conclusion: With the exception of depression, the amount of psychological and psychiatric problems in patients with cancer does not differ from the normal population. The amount of psychological and psychiatric problems is significantly less in cancer patients than in psychiatric patients. The amount of anxiety is significantly less in cancer patients than in other groups of medical patients with mixed diagnoses, whereas depression is not. Future studies should aim at exploring possible causes for the sometimes impressive differences in psychological or psychiatric problems among patients with cancer.

The reliability and validity of the COMFORT scale as a postoperative pain instrument in 0 to 3-year-old infants.

Abstract The aim of this study was to test the reliability and validity of the COMFORT scale as a postoperative pain instrument for children aged 0–3 years. Subjects were 158 neonates and toddlers after major abdominal or thoracic surgery. Trained nurses rated the childrens pain at 3, 6 and 9 h postoperative on the Pediatric Surgical Intensive Care Unit using the COMFORT and a VAS for pain. Interrater reliability of the COMFORT items proved to be good (Kappa 0.63–0.93) for all items with the exception of the item ‘Respiratory response’, which was moderate (Kappa 0.54). LISREL analyses showed that the structure of the COMFORT data was best represented by three latent variables: COMFORT ‘behaviour’ with loadings from the behavioural items (Alertness, Calmness, Respiratory response/Crying, Physical movement, Muscle tone and Facial tension) and separate latent variables for ‘Heart rate baseline’ (HR) and ‘Mean arterial blood pressure baseline’ (MAP). Factor loadings of the items were invariant across time, indicating stability of the structure. The latent variables COMFORT ‘behaviour’ and VAS pain were highly interrelated indicating congruent validity. Stability of COMFORT ‘behaviour’ and VAS pain was moderate which might be due to varying painful episodes in this sample. HR and MAP, although stable across time, were weakly related to VAS pain and COMFORT ‘behaviour’. These findings support the use of the COMFORT ‘behaviour’ scale to assess postoperative pain in neonates and infants.

Long-Term Psychological Impact of Carrying a BRCA1/2 Mutation and Prophylactic Surgery: A 5-Year Follow-Up Study

PURPOSE To explore long-term psychosocial consequences of carrying a BRCA1/2 mutation and to identify possible risk factors for long-term psychological distress. PATIENTS AND METHODS Five years after genetic test disclosure, 65 female participants (23 carriers, 42 noncarriers) of our psychological follow-up study completed a questionnaire and 51 participants were interviewed. We assessed general and hereditary cancer-related distress, risk perception, openness to discuss the test result with relatives, body image and sexual functioning. RESULTS Carriers did not differ from noncarriers on several distress measures and both groups showed a significant increase in anxiety and depression from 1 to 5 years follow-up. Carriers having undergone prophylactic surgery (21 of 23 carriers) had a less favorable body image than noncarriers and 70% reported changes in the sexual relationship. A major psychological benefit of prophylactic surgery was a reduction in the fear of developing cancer. Predictors of long-term distress were hereditary cancer-related distress at blood sampling, having young children, and having lost a relative to breast/ovarian cancer. Long-term distress was also associated with less open communication about the test result within the family, changes in relationships with relatives, doubting about the validity of the test result, and higher risk perception. CONCLUSION Our findings support the emerging consensus that genetic predisposition testing for BRCA1/2 does not pose major mental health risks, but our findings also show that the impact of prophylactic surgery on aspects such as body image and sexuality should not be underestimated, and that some women are at risk for high distress, and as a result, need more attentive care.

EFFICACY OF NIJMEGEN QUESTIONNAIRE IN RECOGNITION OF THE HYPERVENTILATION SYNDROME

The pattern of complaints of patients with the hyperventilation syndrome (HVS) was studied on the basis of the Nijmegen HVS Questionnaire (van Doorn, Colla, Folgering). This list was completed by 75 patients with the clinical diagnosis HVS. Non-metric principal components analysis (NMPCA) showed that the structure was three-dimensional, the dimensions being labelled: Shortness of breath (HVS-1), Peripheral tetany (HVS-II), Central tetany (HVS-III). The questionnaires differentiating ability was investigated by comparing HVS patients with non-HVS persons (80 persons employed in health care). All three components had an unequivocally high ability to differentiate between HVS and non-HVS. Application of linear analysis of discriminance to HVS-I, HVS-II and HVS-III together yielded 93% correct classifications. Statistical double cross-validation resulted in 90 and 94% correct classifications. The sensitivity of the Nijmegen Questionnaire in relation to the clinical diagnosis was 91% and the specificity 95%. It is concluded that the questionnaire is suitable as a screening instrument for early detection of HVS, and also as an aid in diagnosis and therapy planning.

Screening and Diagnosis for the Fragile X Syndrome among the Mentally Retarded: An Epidemiological and Psychological Survey

The fragile X syndrome is an X-linked mental retardation disorder caused by an expanded CGG repeat in the first exon of the fragile X mental retardation (FMR1) gene. Its frequency, X-linked inheritance, and consequences for relatives all prompt for diagnosis of this disorder on a large scale in all affected individuals. A screening for the fragile X syndrome has been conducted in a representative sample of 3,352 individuals in schools and institutes for the mentally retarded in the southwestern Netherlands, by use of a brief physical examination and the DNA test. The attitudes and reactions of (non)consenting parents/guardians were studied by (pre- and posttest) questionnaires. A total of 2,189 individuals (65%) were eligible for testing, since they had no valid diagnosis, cerebral palsy, or a previous test for the FMR1 gene mutation. Seventy percent (1,531/2,189) of the parents/guardians consented to testing. Besides 32 previously diagnosed fragile X patients, 11 new patients (9 males and 2 females) were diagnosed. Scoring of physical features was effective in preselection, especially for males (sensitivity .91 and specificity .92). Major motives to participate in the screening were the wish to obtain a diagnosis (82%), the hereditary implications (80%), and the support of research into mental retardation (81%). Thirty-four percent of the parents/guardians will seek additional diagnostic workup after exclusion of the fragile X syndrome. The prevalence of the fragile X syndrome was estimated at 1/ 6,045 for males (95% confidence interval 1/9,981-1/ 3,851). On the basis of the actual number of diagnosed cases in the Netherlands, it is estimated that >50% of the fragile X cases are undiagnosed at present.

Does neonatal surgery lead to increased pain sensitivity in later childhood

&NA; Does pain or tissue damage in early life lead to hyperalgesia persisting into childhood? We performed a cross‐sectional study in 164 infants to investigate whether major surgery within the first 3 months of life increases pain sensitivity to subsequent surgery and to elucidate whether subsequent surgery in the same dermatome or in a different dermatome leads to differences in pain sensitivity. All infants received standard intraoperative and postoperative pain management, with rescue analgesia guided by a treatment algorithm. Differences in pain sensitivity during surgery were assessed by the intraoperative fentanyl intake and by (nor)epinephrine plasma concentrations. Differences in postoperative pain sensitivity were assessed by the observational pain measures COMFORT and VAS, and by morphine intake and (nor)epinephrine plasma concentrations. Infants previously operated upon in the same dermatome needed more intraoperative fentanyl, had higher COMFORT and VAS scores, had greater (nor)epinephrine plasma concentrations, and needed also more morphine than did infants with no prior surgery. In contrast, infants who previously underwent surgery in another dermatome had only significant higher postoperative analgesic requirements and norepinephrine plasma concentrations in comparison with infants with no prior surgery. These preliminary differences may indicate the occurrence of spinal and supraspinal changes following neonatal surgery. We conclude that the long‐term consequences of surgery in early infancy are greater in areas of prior tissue damage and that these effects may portend limited clinical but important neurobiological differences.

Behavioural and emotional problems in children and adolescents with congenital heart disease

Behavioural/emotional problems were assessed at least nine years after surgical correction for congenital heart disease (ConHD) in childhood. Parents of 144 10-15-year-old ConHD-children completed the Child Behavior Checklist (CBCL) and 179, 11-17-year-old, ConHD-adolescents completed the Youth Self-Report (YSR). On the CBCL and YSR ConHD-children and adolescents obtained significantly higher problem scores than same-aged peers from normative reference groups. No significant differences were found between problem scores for different cardiac diagnostic groups. A negative correlation was found between CBCL total problem scores and IQ-scores of ConHD-children; for YSR total problem scores no such relationship was found.

Caregiver Burden, Health-Related Quality of Life and Coping in Dementia Caregivers: A Comparison of Frontotemporal Dementia and Alzheimer’s Disease

Frontotemporal dementia (FTD) is the second most prevalent dementia after Alzheimer’s disease (AD). We compared 29 FTD and 90 AD caregivers with respect to burden, health-related quality of life (HQoL) and coping. FTD caregivers were more burdened than AD caregivers, and caregivers of patients who were demented for shorter duration had lower HQoL. We furthermore compared the 29 FTD caregivers with 34 caregivers of institutionalized FTD patients to understand their specific caregiver issues. Caregivers of FTD patients institutionalized after shorter dementia duration were most burdened and affected in their HQoL. Overall, passive coping strategies were associated with increased burden and decreased HQoL. We recommend that FTD caregivers be offered more support than AD caregivers. Furthermore, we suggest that interventions target passive coping strategies.

Three-year follow-up after presymptomatic testing for Huntington's disease in tested individuals and partners.

The 3-year psychological effects of presymptomatic DNA diagnosis for Huntingtons disease are described in 20 identified carriers of the Huntingtons disease gene (mean age = 31 years), 29 noncarriers (mean age = 32 years), and 37 partners. The Intrusion and Avoidance subscales of the Impact of Event Scale (M. J. Horowitz, N. Wilner, & W. Alvarez, 1979) and the Beck Hopelessness Scale (A. T. Beck, 1986; A. T. Beck, A. Weissman, D. Lester, & L. Trexler, 1974) measured psychological distress at 4 time points: baseline (before disclosure of test results) and 1 week, 6 months, and 3 years after testing. Multivariate testing on course of distress revealed similar patterns of intrusive thoughts about Huntingtons disease over the 3-year follow-up in carriers and noncarriers but showed opposite patterns of avoidance at the 6-month assessment. One week after disclosure, carriers had increased and noncarriers had decreased levels of hopelessness. These effects disappeared after 6 months and did not recur. Carrier partners followed the same course of distress as carriers. Carrier partners with children were significantly more distressed than those without offspring. Noncarrier partners were significantly less distressed than noncarriers after 3 years.

Long-term effects of routine morphine infusion in mechanically ventilated neonates on children’s functioning: Five-year follow-up of a randomized controlled trial

&NA; Newborns on ventilatory support often receive morphine to induce analgesia. Animal experiments suggest that this may impair subsequent cognitive and behavioral development. There are sparse human data on long‐term effects of neonatal morphine. We aimed to investigate the effects of continuous morphine administered in the neonatal period on the child’s functioning. We conducted a follow‐up study among 5‐year‐olds who, as mechanically ventilated neonates, had participated in a placebo‐controlled trial on effects of morphine administration on pain and neurologic outcome. They were now tested on intelligence, visual motor integration, behavior, chronic pain, and health‐related quality of life. Univariate analyses showed significantly lower overall intelligence quotient (IQ) scores for children who earlier had received morphine, that is, mean 94 (SD 14.5) versus 100 (SD 12.9) for those who received placebo (P = 0.049). Other between‐group differences in outcomes were not found. The statistical difference disappeared after correction for treatment condition, open‐label morphine consumption over the first 28 days, and a propensity score for clinically relevant co‐variables in multiple regression analyses. However, scores on one IQ subtest, “visual analysis,” were significantly negatively related to having received morphine and to open‐label morphine consumption the first 28 days. The finding of a significant effect of morphine on the “visual analysis” IQ subtest calls for follow‐up at a later age focusing on the higher‐order neurocognitive functions. Morphine received in the neonatal period has negative effects on the child’s cognitive functioning at the age of 5 years which warrants follow‐up at a later age.