John E. Schmidt

Use of a Case Definition Approach to Identify Cancer-Related Fatigue in Women Undergoing Adjuvant Therapy for Breast Cancer

PURPOSE Use a proposed case-definition approach to identify the prevalence of cancer-related fatigue (CRF), demographic, clinical and psychosocial predictors of subsequent CRF, and psychosocial factors associated with concurrent CRF. PATIENTS AND METHODS Women (n = 288) undergoing adjuvant therapy for early-stage breast cancer were recruited from two outpatient clinics. Women completed a baseline assessment before adjuvant therapy and a post-treatment assessment at the conclusion of an initial course of adjuvant chemotherapy or radiotherapy. At both assessments, women completed a clinical interview and measures of fatigue, distress, coping, and quality of life (QOL). The clinical interview consisted of modules from the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and a diagnostic interview to identify cases of CRF. RESULTS CRF prevalence at the baseline and post-treatment assessments was 10% and 26%, respectively. Multivariate analyses identified factors prospectively associated with greater risk for CRF at the post-treatment assessment, including receipt of adjuvant chemotherapy and a tendency to catastrophize in response to fatigue. Patients with and without CRF differed on a host of concurrent measures of fatigue, depression, functioning, and QOL with mean effect sizes in the range of 1.0 standard deviation. CONCLUSION CRF is a clinical syndrome experienced before and during adjuvant therapy for breast cancer. Results suggest CRF has a multifactorial etiology and support use of the proposed case definition approach to defining CRF. Future research is necessary to determine the scientific value of these criteria for understanding the etiology and management of fatigue in the oncology setting.

The role of social and dispositional variables associated with emotional processing in adjustment to breast cancer: an internet-based study.

Cognitive and emotional processing is seen as critical to successful adjustment to traumatic experiences, such as breast cancer. Cognitive and emotional processing can be facilitated by dispositional and social environmental factors. Emotional intelligence is a dispositional characteristic defined as the ability to understand, accurately perceive, express, and regulate emotions (J. D. Mayer & P. Salovey. 1997). This study investigated psychological adjustment as a function of emotional intelligence, social support, and social constraints in 210 patients recruited via postings to Internet-based breast cancer support groups. Regression analyses indicated high social constraints and low emotional intelligence were associated with greater distress. Evidence suggested high emotional intelligence could buffer against the negative impact of a toxic social environment. Results support a social-cognitive processing model of adaptation to traumatic events and suggest consideration of emotional intelligence may broaden this model.

Traumatic Stressors and Post-Traumatic Stress Disorder Symptoms in Headache Patients

Objective.—The aim of this study was to assess the prevalence of significant traumatic stressors and post‐traumatic stress disorder (PTSD) symptoms in a headache population.

Psychological and sleep quality differences between chronic daily headache and temporomandibular disorders patients

The aim of this study was to investigate whether chronic daily headache (CDH) and temporomandibular disorders (TMD) patients present with different psychological and sleep quality characteristics. Sixty-seven patients diagnosed with CDH, according to classification criteria from Silberstein et al., were matched by age and sex with 67 patients who had a primary diagnosis of myofascial pain (MP) and 67 patients with a primary diagnosis of TMJ intracapsular pain (IC) according to the Research Diagnostic Criteria for TMD. The CDH group was comprised of three mutually exclusive diagnostic groups: chronic migraine (n = 35); chronic tension-type headache (n = 26); ‘other CDH’ (n = 6). All patients completed a battery of psychological and sleep quality questionnaires. All CDH subgroups showed similar psychological and sleep quality profiles. Pain intensity and duration were controlled in the multivariate analyses (MANCOVA) by treating them as covariates. The CDH and MP groups revealed higher levels of psychological distress than the IC group on most psychological domains. The MP group also revealed numerically higher levels of psychological distress in most psychological domains than the CDH group, although these differences were generally not significant. We did not find significant differences between the three groups on post traumatic stress symptoms either. Sleep quality was significantly worse in the MP group than in the CDH and IC groups. These results are discussed in the context of multimodal patient evaluation and treatments that are often necessary for successful clinical management.

Effects of smoking status on immediate treatment outcomes of multidisciplinary pain rehabilitation

OBJECTIVE The primary aim of this study was to determine the effects of smoking on treatment outcomes following multidisciplinary pain rehabilitation. A secondary aim was to assess the tobacco use characteristics of smokers with chronic pain. DESIGN A prospective, nonrandomized, repeated measures design. SETTING Multidisciplinary pain rehabilitation center at a tertiary referral medical center. PATIENTS All patients (N = 193) consecutively admitted from August 2005 through February 2006. INTERVENTIONS A 3-week outpatient multidisciplinary pain rehabilitation program. OUTCOME MEASURES The Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Center for Epidemiologic Studies-Depression scale (CES-D), Pain Anxiety Symptom Scale (PASS-20) and Pain Catastrophizing Scale (PCS) were administered at admission and dismissal. RESULTS The study involved 49 (83% women) smokers and 144 (83% women) nonsmokers. The mean number of cigarettes smoked daily was 17.5 (SD 11.1) and the mean duration of smoking was 21.5 years (SD 12.1). After adjusting for demographic differences, repeated measures of analysis of covariance showed a main effect of smoking status for MPI affective distress (P = 0.008), CES-D (P = 0.001) and PCS (P = 0.011). An interaction of smoking status and time was found for the PASS-20 (P = 0.028), MPI affective distress (P = 0.033), MPI life control (P = 0.003) and SF-36 role-emotional (P = 0.004) subscale. While the majority of smokers were ready to consider smoking abstinence, 43% declined a brief smoking cessation intervention. CONCLUSIONS In this series of patients undergoing multidisciplinary treatment for chronic pain, immediate treatment effects for a variety of outcome measures were similar or significantly better in smokers compared with nonsmokers.

Changes in heart rate variability associated with acute alcohol consumption: Current knowledge and implications for practice and research

Alcohol consumption is associated with a broad array of physiologic and behavioral effects including changes in heart rate. However, the physiologic mechanisms of alcohol effects and the reasons for individual differences in the cardiac response remain unknown. Measuring changes in resting heart rate (measured as beats/min) has not been found to be as sensitive to alcohols effects as changes in heart rate variability (HRV). HRV is defined as fluctuations in interbeat interval length which reflect the hearts response to extracardiac factors that affect heart rate. HRV allows simultaneous assessment of both sympathetic and parasympathetic activity and the interplay between them. Increased HRV has been associated with exercise and aerobic fitness, while decreased HRV has been associated with aging, chronic stress, and a wide variety of medical and psychiatric disorders. Decreased HRV has predictive value for mortality in general population samples and patients with myocardial infarction and used as an indicator of altered autonomic function. A significant inverse correlation was found between HRV and both the severity of depression and the duration of the depressive episode. HRV analysis provides insights into mechanisms of autonomic regulation and is extensively used to clarify relationships between depression and cardiovascular disease. This article will review the methodology of HRV measurements and contemporary knowledge about effects of acute alcohol consumption on HRV. Potential implications of this research include HRV response to alcohol that could serve as a marker for susceptibility to alcoholism. At present however there is almost no research data supporting this hypothesis.

Withdrawal of analgesic medication for chronic low-back pain patients: improvement in outcomes of multidisciplinary rehabilitation regardless of surgical history.

Crisostomo RA, Schmidt JE, Hooten WM, Kerkvliet JL, Townsend CO, Bruce BK: Withdrawal of analgesic medication for chronic low-back pain patients: improvement in outcomes of multidisciplinary rehabilitation regardless of surgical history. Am J Phys Med Rehabil 2008;87:527–536. Objective:To determine the posttreatment outcomes of multidisciplinary pain rehabilitation that incorporates analgesic medication withdrawal for chronic low-back pain patients on the basis of lumbar spine surgical history. Design:This is a retrospective analysis of 383 consecutive chronic low-back pain patients participating in a 3-wk, outpatient, intensive, multidisciplinary pain rehabilitation program. The study sample was divided into three groups based on history of spine surgery: 196 patients without previous lumbar spine surgery, 125 with history of lumbar fusion, and 62 with history of nonfusion lumbar spine surgery. Patients were assessed at admission and dismissal for medication use, pain severity and affective characteristics, physical functioning, depression, and pain catastrophizing. Results:At admission, patients in both the fusion and nonfusion surgery groups were using more opioids compared with the no-surgery group. Reported pain severity and duration was highest in the fusion group compared with the other groups. Admission to dismissal comparisons showed significant and nearly equal improvements for all groups in health and medication measures. Conclusions:Study results demonstrate that multidisciplinary pain rehabilitation treatment incorporating analgesic medication withdrawal is associated with significant clinical improvements in physical and emotional functioning, regardless of lumbar spine surgical history.

Cyclooxygenase inhibition abolishes age-related differences in cerebral vasodilator responses to hypercapnia.

Blood flow and vasodilatory responses are altered by age in a number of vascular beds, including the cerebral circulation. To test the role of prostaglandins as regulators of cerebral vascular function, we examined cerebral vasodilator responses to CO(2) (cerebrovascular reactivity) in young (26 ± 5 yr; 6 males/6 females) and older (65 ± 6 yr, 5 males/5 females) healthy humans before and after cyclooxygenase inhibition (using indomethacin). Middle cerebral artery velocity (MCAv) responses to stepped hypercapnia were measured before and 90 min after indomethacin. Changes in MCAv during the recovery from hypercapnia (vasoconstrictor responses) were also evaluated before and after indomethacin. Cerebrovascular reactivity was calculated using linear regression between MCAv and end-tidal CO(2). Young adults demonstrated greater MCAv (55 ± 6 vs. 39 ± 5 cm/s: P < 0.05) and MCAv reactivity (1.67 ± 0.20 vs. 1.09 ± 0.19 cm·s(-1)·mmHg(-1); P < 0.05) to hypercapnia compared with older adults (P < 0.05). In both groups MCAv and MCAv reactivity decreased between control and indomethacin. Furthermore, the age-related differences in these cerebrovascular variables were abolished by indomethacin. During the recovery from hypercapnia, there were no age-related differences in MCAv reactivity; however, indomethacin significantly reduced the MCAv reactivity in both groups. Taken together, these results suggest that cerebral blood flow velocity and cerebrovascular reactivity are attenuated in aging humans, and may be due to a loss of prostaglandin-mediated vasodilation.

Emotional expression and emotional recognition in breast cancer survivors: A controlled comparison

The role of emotional expression (EE) in the onset and progression of cancer remains equivocal. The purpose of this study was to compare breast cancer patients (n = 25) and matched healthy controls (n = 25) on self-report and behavioral measures of EE and emotional recognition. Based upon Pennebakers paradigm, participants completed a verbal positive or negative EE behavioral task. Transcripts of participants’ responses were analyzed using the Linguistic Inquiry and Word Count and were coded for emotional valence and intensity by trained raters blind to experimental condition. Breast cancer patients and healthy controls did not differ on self-report, dispositional measures of EE nor on a behavioral measure of emotional recognition. During the behavioral EE task, patients used significantly less inhibition words than controls and were rated as expressing more intense emotion. Results provide some support for the view that cancer diagnosis and treatment can alter emotionally expressive behavior.

Evaluation of a Biofeedback-Assisted Meditation Program as a Stress Management Tool for Hospital Nurses: A Pilot Study

OBJECTIVE To assess whether a self-directed, computer-guided meditation training program is useful for stress reduction in hospital nurses. DESIGN We prospectively evaluated participants before and after a month-long meditation program. The meditation program consisted of 15 computer sessions that used biofeedback to reinforce training. Participants were instructed to practice the intervention for 30 minutes per session, four times a week, for four weeks. Visual analogue scales were used to measure stress, anxiety, and quality of life (assessments were performed using Linear Analogue Self-Assessment [LASA], State Trait Anxiety Inventory [STAI], and Short-Form 36 [SF-36] questionnaires). Differences in scores from baseline to the studys end were compared using the paired t test. RESULTS Eleven registered nurses not previously engaged in meditation were enrolled; eight completed the study. Intent-to-treat analysis showed significant improvement in stress management, as measured by SF-36 vitality subscale (P = .04), STAI (P = .03), LASA stress (P = .01), and LASA anxiety (P = .01). Nurses were highly satisfied with the meditation program, rating it 8.6 out of 10. CONCLUSIONS The results of this pilot study suggest the feasibility and efficacy of a biofeedback-assisted, self-directed, meditation training program to help hospital nurses reduce their stress and anxiety. Optimal frequency of use of the program, as well as the duration of effects, should be addressed in future studies.