Advanced Triage Protocol: The Role of an Automated Lactate Order in Expediting Rapid Identification of Patients at Risk of Sepsis in the Emergency Department.

We undertook a process improvement initiative to expedite rapid identification of potential sepsis patients based on triage chief complaint, vital signs, and initial lactate level. DESIGN: Prospective cohort study. SETTING: Seven hundred-bed tertiary care hospital with ≅65,000 patient visits/yr. PATIENTS: Patients presenting to emergency department (ED) triage who met the following criteria: greater than or equal to two of the three systemic inflammatory response syndrome criteria assessable in triage, a chief complaint suggestive of infection, emergency severity index 2 or 3, and ambulatory to ED. INTERVENTIONS: A computer-generated lactate order was created, staff education and resources increased, and point-of-care lactate testing was introduced. MEASUREMENTS AND MAIN RESULTS: Primary endpoints include the following: percent of patients having a lactate level drawn, percent of lactate samples resulting before room placement, and time intervals from triage to lactate blood draw and to lactate result. Secondary endpoints were percentage of patients admitted to the hospital, percentage admitted to the ICU, and in-hospital mortality. Six thousand nine hundred six patients were included: 226 historic controls (HCs) and 6,680 intervention group patients. The mean serum lactate level was 1.77 ± 1.18 mmol/L. The percentage of patients having a lactate resulted increased from 27.4% in the HC period to 79.6%. The percentage of these lactate results available while the patient was still in the waiting room increased from 0.4% during the HC period to 33.7% during Phase 5 (p < 0.0001). In the intervention period, time from triage to lactate result decreased (78.1-63.4 min; p < 0.0001) and time to treatment room decreased (59.3-39.6 min; p < 0.0001). CONCLUSIONS: Implementation of a computerized lactate order using readily available data obtained during ED triage, combined with point-of-care lactate testing, improves time to lactate blood draw and lactate result in patients at risk for severe sepsis. Initial lactate levels correlated with admission to the hospital, admission to the ICU, and in-hospital mortality.

Posttraumatic Symptoms, Quality of Life, and Survival among Lung Cancer Patients.

PURPOSE: This longitudinal study characterized psychological adjustment in a sample of lung cancer patients by examining the occurrence of posttraumatic stress and growth and their relationships with mental and physical health quality of life and survival over time. METHODS: Two waves of consecutive cohort samples, totaling 115 participants diagnosed with lung cancer, were identified from outpatient oncology clinics. Of these, 93 consented and completed the first of three assessments, and 57 completed the study. Prevalence of posttraumatic stress symptoms (PTSD Checklist) and posttraumatic growth (Posttraumatic Growth Inventory) were assessed and used to predict physical and mental health components of quality of life (Short Form 36) and survival. RESULTS: Patients reported both negative and positive psychological sequelae, with prevalence of estimated PTSD ranging from 5-16% at each assessment as determined by symptom and cut-off methods. Posttraumatic stress and growth were positively related, but were differentially associated with outcomes. More posttraumatic stress predicted lower mental health quality of life, whereas more posttraumatic growth predicted better physical health quality of life and longer survival. These relationships persisted after accounting for disease variables and attrition due to death or illness. CONCLUSIONS: These findings highlight the importance of using longitudinal designs to identify relationships between stress and resilience factors in predicting outcomes.

Randomized psychosocial interventions for breast cancer: impact on life purpose.

OBJECTIVE: The present study sought to identify mediators underlying the effects of an education and a peer support intervention for women with breast cancer and to determine if the efficacy of a peer support intervention is moderated by cancer severity. METHODS: Participants included 180 patients with early stage (I or II) and 65 patients with late stage (IV) breast cancer. The study was originally planned as a 2 (early stage, late stage) × 3 (education intervention, peer support intervention, control condition) design; however, the education condition for the late stage cancer group was dropped, because of slow recruitment. Participants completed measures of well-being prior to being randomized (Time 1), then again 2 weeks after the group meetings ended (Time 2), and 6 months later (Time 3). RESULTS: Among the participants who had attended at least one group meeting, the education intervention predicted more life purpose and marginally predicted more perceived physical health at Time 2. The peer support intervention predicted more life purpose and less depressive symptoms at Time 2. Cancer severity did not moderate these effects. The effect of the peer support intervention on depressive symptoms was mediated by life purpose. None of the intervention effects were evident at Time 3. CONCLUSIONS: Peer support interventions have positive short-term effects on well-being, among women with late and early stage breast cancer, and these effects are partially mediated by changes in life purpose. Education interventions have positive short-term effects on well-being among women with early stage breast cancer. Copyright © 2015 John Wiley & Sons, Ltd.

Posttraumatic stress disorder symptoms in newly diagnosed patients with head and neck cancer and their partners.

BACKGROUND: Head and neck cancer is a life-threatening illness requiring aversive treatments. Despite clear potential for posttraumatic stress disorder (PTSD) symptoms in both patients and their partners, research is scant. METHODS: Newly diagnosed patients and partners (number of dyads = 42) completed questionnaires to assess symptoms of PTSD, anxiety, and depression, as well as demographic, medical, and attitudinal variables. RESULTS: Partners had higher average levels of PTSD symptoms than patients (p = .023). More partners (28.6%) met criteria for estimated PTSD caseness than did patients (11.9%). There were no significant differences in levels of other anxiety or depression symptoms. Perceived threat of disease appeared to be a stronger correlate of PTSD symptom levels than medical variables in patients and partners. CONCLUSION: A diagnosis of head and neck cancer elicits significant levels of PTSD symptoms in patients, and even higher levels among partners. Identified correlates of distress, including perceived threat of disease, are potential intervention targets.

Chronic exposure to stress hormones promotes transformation and tumorigenicity of 3T3 mouse fibroblasts.

Epinephrine and norepinephrine are produced during psychological stress and can directly bind to cells to induce DNA damage. These effects may have more long-lasting consequences such as DNA mutations resulting in an increased potential for cellular transformation and/or tumor progression. This study examined the molecular effects of a chronic (24 h) in vitro exposure to these stress hormones on murine 3T3 cells. Long exposures (24 h) in dose-response experiments with norepinephrine or epinephrine induced significant increases in DNA damage in treated cells compared to that of untreated controls as measured by the alkaline comet assay. Pre-treatment with a blocking agent (the ß-adrenergic receptor antagonist propranolol) eliminated this increase in damage. In addition, both norepinephrine and epinephrine increased cellular transformation, as assessed by growth in soft agar, and 3T3 cells pre-treated with either norepinephrine or epinephrine induced a more rapid onset of tumors and more aggressive tumor growth in nude mice. In summary, incubation of 3T3 cells with catecholamines results in long-term DNA damage as measured by increased transformed phenotypes and tumor progression, indicating that they are important mediators of stress effects on genomic instability and vulnerability to tumor formation.

Emergency department patients' preferences for technology-based behavioral interventions.

STUDY OBJECTIVE: To assess emergency department (ED) patients' preferences for technology-based behavioral interventions, and the demographic factors associated with these preferences. METHODS: A cross-sectional survey of a random sample of urban ED patients (≥13 years) from a representative sample of shifts, with oversampling of adolescents/young adults (aged 13 to 24 years). Participants self-administered the survey about baseline technology use, concerns about technology-based interventions, and preferred intervention format for 7 behavioral health topics. We performed descriptive statistics and multivariate logistic regression (controlling for demographics and then additionally for baseline technology use) to identify factors differentially associated with technology preference for each behavioral topic. RESULTS: Of patients presenting during research assistant shifts, 1,429 (≈59%) were screened and 664 (68.2% of eligible) consented to participate. Mean age was 31 years (SD 0.69); 54.5% were female, 64.1% were white, 23.2% were Hispanic, and 46.6% reported low income. Baseline use of computers (91.2%), Internet (70.7%), social networking (66.9%), mobile phones (95.0%), and text messaging (73.8%) was high. Participants reported interest in receiving interventions on each behavioral topic. Ninety percent preferred a technology-based intervention for at least 1 topic. Patients expressed greatest concerns about Internet (51.5%) and social networking (57.6%), particularly about confidentiality. Adjusting for sex, race, ethnicity, and income, younger age associated with preference for technology-based interventions for unintentional injuries (odds ratio 0.63 for technology preference if adult versus youth; 95% confidence interval 0.45 to 0.89) and peer violence (odds ratio 0.63 if adult; 95% confidence interval 0.43 to 0.92). Additionally adjusting for baseline technology usage, only baseline usage was associated with preference for technology-based interventions. CONCLUSION: ED patients reported high baseline technology use, high interest in behavioral health interventions, and varying preferences for technology-based interventions. Future studies should address actual feasibility and acceptability of technology-based interventions in a more generalized population and ways to alleviate concerns about these interventions.

Posttraumatic growth in women one year after diagnosis for gynecologic cancer or benign conditions.

The authors sought to examine levels and predictors of posttraumatic growth over one year after surgery in women diagnosed with gynecologic cancer or benign conditions necessitating surgical intervention. Women with advanced-stage cancer (n = 16), early-stage cancer (n = 18), benign gynecologic disease (n = 21), and no disease (n = 14; postannual pelvic exam) completed questionnaires (Perceived Threat, PTSD Checklist [PCL]) 1 week prior to surgery and completed the Posttraumatic Growth Inventory (PTGI) 16 months postsurgery. The four groups' scores varied significantly on the PTGI. The three disease groups reported higher levels of posttraumatic growth than the no disease group. Higher PCL score presurgery and greater disease severity were positively related to posttraumatic growth, and higher income level was negatively related to posttraumatic growth. Women with gynecologic cancer, regardless of stage, and women with benign gynecologic conditions experience posttraumatic growth.

Worse than sticks and stones? Bullying is associated with altered HPA axis functioning and poorer health.

Adolescents (N=107; M=12.23 years, SD=1.09 months) participated in a two-part study examining peer victimization, neuroendocrine functioning, and physical health. In phase 1, adolescents completed questionnaires assessing peer victimization and health. They returned for phase 2 which consisted of two sessions. In session 1, adolescents learned to collect salivary cortisol samples; they collected four samples over 2 non-sports school days. In session 2, adolescents completed the Trier Social Stress Test (TSST) in which they prepared and delivered a speech while cortisol was collected. Peer victimization predicted poor health outcomes and a flattened cortisol awakening response (CAR); this CAR was linked with health problems. During the TSST, victims reported more stress and exhibited altered cortisol levels. Higher cortisol immediately after the stressor and lower cortisol 30 min after the stressor were associated with more health problems. This study provides evidence that the relationship between peer victimization and poor physical health may be explained by differences in neuroendocrine functioning.

Perceived threat and PTSD symptoms in women undergoing surgery for gynecologic cancer or benign conditions.

OBJECTIVE: We sought to examine levels of perceived threat and traumatic stress symptoms both before and in the short- and long-term period after surgery and associated care in women diagnosed with gynecologic cancer or benign conditions. METHODS: Women with advanced-stage cancer (n=22), early-stage cancer (n=31), benign gynecologic disease (n=33), and no disease (n=25; post-annual pelvic examination) completed questionnaires (Perceived Threat, Impact of Event Scale (IES), and Post-Traumatic Stress Disorder (PTSD Checklist (PCL)) on three occasions: 1 week before surgery (Time 1), 7 weeks after surgery or comparable time (Time 2), and 16 months after surgery (Time 3). RESULTS: Perceived threat did not differ across disease groups at Time 1, but there were differences at both later times (F(2, 93.1)=11.83; p<0.001; group × time interaction); women with advanced cancer reported the highest levels. IES scores were consistently higher for the disease groups compared with the no-disease group (F(3,104.2)=11.19; p<0.001), but were not significantly different from one another. IES scores declined over time, most markedly for the three disease groups (group × time interaction (F(6,163.8)=2.60; p=0.02). Survival analysis indicated significant differences across the groups in risk of estimated PTSD [Wilcoxon χ(2) (3, N=96)=7.83, p=0.050] with 34% of advanced cancer, 16% of early cancer, and 15% of benign disease groups reaching estimated PTSD criteria. CONCLUSIONS: Women with gynecologic cancer, regardless of stage, and women with benign conditions experience heightened traumatic stress at the time of diagnosis, and some continue to be distressed many months afterwards. Broad-based screening and intervention for traumatic stress symptoms may be warranted.

A urinary marker of oxidative stress covaries positively with hostility among midlife community volunteers.

OBJECTIVE: Although not all findings are consistent, growing evidence suggests that individuals high in dispositional hostility are at elevated risk for cardiovascular disease and all-cause mortality; however, the mechanisms of these associations remain unclear. One possibility is that hostility is associated with oxidative stress. Here, we explore relationships between hostility and a measure of systemic oxidative stress among a mid-life sample. METHODS: In a community sample of 223 adults aged 30 to 54 years (86% white, 50% female), oxidative stress was measured as the 24-hour urinary excretion of 8-hydroxy-2'-deoxyguanosine (8-OHdG). An abbreviated Cook Medley Hostility Scale was used to measure dimensions of hostility. RESULTS: Regression analyses controlling for demographic characteristics and cardiovascular risk factors showed a positive relationship of 8-OHdG with total hostility (beta = 0.003, p = .03) and hostile affect (beta = 0.018, p < .001). CONCLUSIONS: These findings provide evidence that dispositional hostility, and in particular, hostile affect, covary positively with systemic oxidative stress, raising the possibility that oxidative stress contributes to the pathogenicity of hostile attributes.

Association of enjoyable leisure activities with psychological and physical well-being.

OBJECTIVE: To examine whether engaging in multiple enjoyable activities was associated with better psychological and physiological functioning. Few studies have examined the health benefits of the enjoyable activities that individuals participate in voluntarily in their free time. METHOD: Participants from four different studies (n = 1399 total, 74% female, age = 19-89 years) completed a self-report measure (Pittsburgh Enjoyable Activities Test (PEAT)) assessing their participation in ten different types of leisure activities as well as measures assessing positive and negative psychosocial states. Resting blood pressure, cortisol (over 2 days), body mass index, waist circumference, and perceived physiological functioning were assessed. RESULTS: Higher PEAT scores were associated with lower blood pressure, total cortisol, waist circumference, and body mass index, and perceptions of better physical function. These associations withstood controlling for demographic measures. The PEAT was correlated with higher levels of positive psychosocial states and lower levels of depression and negative affect. CONCLUSION: Enjoyable leisure activities, taken in the aggregate, are associated with psychosocial and physical measures relevant for health and well-being. Future studies should determine the extent that these behaviors in the aggregate are useful predictors of disease and other health outcomes.

Cancer genetics service interest in women with a limited family history of breast cancer.

Women with a limited family history of breast cancer may be interested in cancer genetics information although their objective risk of breast cancer may not indicate routine referral to cancer genetics services. This study examined factors related to interest and use of cancer genetics services in a community sample of women with a limited family history of breast cancer (N = 187) who had no previous contact with cancer genetics services. Participants provided demographic information and ratings of perceived risk, cancer distress, attitudes, and intentions to initiate cancer genetics services. Participants were given information about a cancer genetics clinic that served women having concerns about their breast cancer risk. Women were contacted within 6 weeks and 8 months following their study appointment. Six weeks following their study appointment, 25% of women had initiated cancer genetics services. Eight months following their study appointment, 18% of women reported having completed a cancer genetics service appointment. Baseline intentions independently predicted both initiation at 6 weeks and appointment at 8 months. Cancer distress was positively associated with cancer genetics service initiation and appointment. Results suggest that some women with a limited family history of breast cancer are interested in seeking out cancer genetics information. Women with a limited family history of breast cancer may benefit from the availability of cancer genetics information provided through primary healthcare settings.

Coping with genetic testing for breast cancer susceptibility.

OBJECTIVE: To examine how women cope with genetic testing for heightened susceptibility to breast cancer. METHODS: Participants were 126 White women (age = 44 +/- 9 years) who were participants in a larger study of genetic testing for risk of different chronic diseases. All women were at higher-than-average risk for breast cancer due to a personal and/or family history and were considering genetic testing. Distress (Symptom Checklist-90-Revised, Impact of Event Scale, Perceived Stress Scale, Spielberger State-Trait Anxiety Inventory, and the Center for Epidemiological Studies Depression Scale) was assessed at four assessments; one before and three after the decision to have genetic testing. The majority of women (n = 100) had testing. The follow-up assessments occurred at 1 week after receiving results (or 3-4 months after baseline if testing was not elected), and then at 3 and 6 months after the second assessment. Coping (Brief COPE) was measured at the first and third assessments. RESULTS: Coping was relatively stable over time and did not vary as a function of genetic test results. Active coping strategies were used more often by women with a personal cancer history than by women without cancer. Use of avoidant coping was reliably and positively associated with distress over time independent of cancer history and test result. CONCLUSIONS: The identification of specific coping styles that were associated with more or less distress is useful as a means of identifying and targeting coping interventions and predicting which participants may be at risk for distress.

Guiding research in family care: a new approach to oncology caregiving.

OBJECTIVE: Much research has documented both negative emotional and physical health conditions that may result from providing care to a family member with an illness. However, little has been done in family caregiving, particularly in oncology, to evaluate pathways in which biological and behavioral responses to stress may interact. The purpose of this article is to describe how a mind-body (biobehavioral) model can be adapted to study family caregivers of persons with a brain tumor. METHOD: A systematic literature review was performed on caregiving literature in the area of dementia and oncology to provide support for proposed relationships in the model. RESULTS: Prior research supports the application of a biobehavioral model to family caregiving in neuro-oncology and suggests ways in which emotional reactions to caregiving may be manifested as changes in physical health. CONCLUSION: Suggestions for conducting biobehavioral research in oncology caregiving and alternative variables for future research are presented.

Psychological distress and quality of life associated with genetic testing for breast cancer risk.

This study investigated short- and long-term psychological outcomes associated with BRCA1/2 genetic testing in women with a personal or family history of breast cancer. Participants included 126 women considering genetic testing. Questionnaires were administered prior to testing, one week, three and six months after result disclosure. Results indicated no systematic effects of testing based on personal cancer history. Mutation carriers and women who elected not to be tested reported greater perceived risk and intrusive and avoidant thoughts at follow-up time points than did women who received negative (uninformative) or variant results. Mutation carriers reported more distress at the three-month follow-up but by six months the effects of test result on distress dissipated and groups were comparable. Cluster analyses identified two groups of individuals based on distress at baseline; these groups were used to predict psychological outcomes after testing. Distress remained constant in both groups: those who were high at baseline remained high and those who were low remained low. Test results did not moderate this effect. Results suggest that genetic testing for BRCA1/2 does not increase distress or have deleterious effects on quality of life over the long term. However, sub-groups of women may report more distress over time. These data indicate the need for more targeted counseling to individuals who report high levels of distress when considering genetic testing.

Induction of DNA damage, alteration of DNA repair and transcriptional activation by stress hormones.

Stress is associated with increased production of sympathetic and other adrenal hormones. Epinephrine (E), norepinephrine (NE) and cortisol are produced during psychological stress and may affect many cells directly. These effects may be transient (e.g. heart rate, immune cell trafficking) or they can have more long-lasting consequences, such as permanent DNA damage which may result in increased cell transformation and/or tumorigenicity. Here, the molecular effects of short term in vitro exposure of these stress hormones were analyzed on murine 3T3 cells by measuring effects on DNA damage and repair, cell transformation and changes in mRNA expression of genes specifically involved in DNA damage signaling pathways. Short-term exposure (<30 min) to physiological concentrations of either cortisol, NE or E induced at least five-fold increases in DNA damage in treated cells compared to untreated controls. Pre-treatment with blocking agents such as the glucocorticoid receptor antagonist RU486, or the beta-adrenergic receptor antagonist propranolol, eliminated this increase in damage. Both cortisol and NE interfered with repair of DNA damage in cells exposed to UV and resulted in an increase in the transformed phenotype. In contrast, E had none of these effects on 3T3 cells. Stress hormones had no significant effects on cell cycle regulation. Targeted gene arrays showed that cortisol, NE and E modulated the transcription of 21, 14 and 18 genes, respectively. These genes were directly related to DNA damage signaling pathways, and included up-regulation of DNA damage sensors Chk1 and Chk2, and the proto-oncogene CDC25A, which is involved in cell cycle delay following DNA damage. Taken together, these data show that stress hormones can increase DNA damage and transformation and alter transcriptional regulation of the cell cycle.

Increased cortisol in women with intimate partner violence-related posttraumatic stress disorder.

Intimate partner violence (IPV) is a chronic and recurrent traumatic stressor associated with PTSD; however, its biological correlates are not well understood. This study examined diurnal salivary cortisol and platelet catecholamines in women with lifetime IPV-related PTSD and in women exposed to IPV who did not develop PTSD. Cortisol was elevated in women with lifetime PTSD compared to controls. No differences were found for platelet catecholamines.

Stress and quality of life in African American cancer survivors.

The quality of life (QOL) of cancer survivors must be investigated as we learn about the risks and protective factors associated with cancer survival. Little research has included African American cancer survivors, and this group could be more or less vulnerable to the added stress of cancer. By virtue of the greater stress burden imposed by minority status, lower socioeconomic status, and other social/ cultural factors, African Americans may be at increased risk for poor QOL and poor health outcomes. Alternatively, they may be protected from some of these negative outcomes. We propose a model to better understand the unique sociocultural features that influence QOL for certain cancer sites where racial disparities are well established. A comprehensive knowledge of QOL among these survivors will guide future research and facilitate the development of interventions to improve QOL, possibly reducing observed health disparities.