Preoperative Anxiety in Patients with Pancreatic Cancer: What Contributes to Anxiety Levels in Patients Waiting for Surgical Intervention.

Pancreatic cancer is one of the most lethal malignancies. Currently, the only treatment is surgical resection, which contributes to significant preoperative anxiety, reducing quality of life and worsening surgical outcomes. To date, no standard preventive or therapeutic methods have been established for preoperative anxiety in pancreatic patients. This observational study aims to identify which patients' socio-demographic, clinical and psychological characteristics contribute more to preoperative anxiety and to identify which are their preoperative concerns. Preoperative anxiety was assessed the day before surgery in 104 selected cancer patients undergoing similar pancreatic major surgery, by administering the STAI-S (State-Trait Anxiety Inventory Form) and the APAIS (Amsterdam Preoperative Anxiety and Information Scale). Our data suggest that patients with high STAI-S showed higher levels of APAIS and that major concerns were related to surgical aspects. Among psychological characteristics, depressive symptoms and trait anxiety appeared as risk factors for the development of preoperative anxiety. Findings support the utility of planning a specific psychological screening to identify patients who need more help, with the aim of offering support and preventing the development of state anxiety and surgery worries in the preoperative phase. This highlights also the importance of good communication by the surgeon on specific aspects related to the operation.

Prevalence of depression in a cohort of 400 patients with pancreatic neoplasm attending day hospital for major surgery: Role on depression of psychosocial functioning and clinical factors.

OBJECTIVE: (1) To determine the prevalence and type of depressive symptoms at day-hospital clinical evaluation, before undergoing major surgery in patients diagnosed with pancreatic neoplasm. (2) To analyze the association between depression and sociodemographic, clinical, and psychosocial variables. (3) To understand how coping strategies, perceived social support, and self-efficacy might affect depressive symptoms in this cohort of patients. METHODS: Secondary data analysis collected during the baseline phase of a randomized controlled trial performed at the Pancreas Institute of the University Hospital of Verona, Italy, between June 2017 and June 2018. RESULTS: 18.5% of pancreatic patients had a PHQ-9 score ≥10 (cut-off). Depressed patients were basically more often female (p = 0.07), younger (p = 0.06), and married/with a partner (p = 0.02). Depression was associated to high trait anxiety (p < 0.01), the use of anxiolytics (p < 0.01), sleep-inducing drugs (p < 0.01), and painkillers (p < 0.01). Among psychosocial variables, depressed patients showed lower perceived self-efficacy (p < 0.01) and family and friends' social support (p < 0.01) and used significantly more often dysfunctional coping strategies (p < 0.01), compared to nondepressed. A logistic multivariate model using psychosocial variables as explanatory and depression as dependent was calculated and post hoc analyses were conducted to describe the contribution of each psychosocial variable on depression. CONCLUSIONS: Our study advocates the need for screening for distress and depression in cancer surgery units and recommends to strengthen patients' adaptive coping, social support, and sense of effectiveness in facing the challenges related to the medical condition and treatment process.

PREPARE: PreoPerative Anxiety REduction. One-Year Feasibility RCT on a Brief Psychological Intervention for Pancreatic Cancer Patients Prior to Major Surgery.

INTRODUCTION: The aim of the present paper is to establish feasibility and required power of a one-session psychological intervention devoted to increasing patient's self-efficacy and awareness in dealing with anxiety symptoms before major pancreatic cancer surgery. METHODS: Parallel assignment RCT. All consenting patients listed for pancreatic major surgery during day-hospital visits (T0) between June 2017-June 2018 were assigned randomly in blocks of ten to a psychological intervention vs usual care group to be held the day before surgery (T1). The psychological intervention provided the patient the opportunity to increase self-efficacy in dealing with anxiety by talking with a psychologist about personal concerns and learning mindfulness based techniques to cope with anxiety. RESULTS: 400 patients were randomized into the experimental vs. usual care group. 49 and 65, respectively, completed baseline and post-intervention measures. The dropout rate between day-hospital (T0) and pre-surgery intervention (T1) was high (74.5%) due to several management and organization pitfalls. The main outcome, perceived self-efficacy in managing anxiety, showed a significant increase in the intervention group compared to the control group (p < 0.001), and was related to a reduction in state anxiety (p < 0.001). The intervention group perceived also lower emotional pain (p = 0.03). A power analysis was performed to define the appropriate sample size in a definitive RCT. CONCLUSION: Beneath the complexity in retaining patients along their trajectory in pancreatic surgery department, when they had the opportunity to follow a brief psychological intervention, most of them adhered, showing a significant reduction in preoperative emotional distress and less emotional pain perception after surgery. Even if results need caution because of the high attrition rate, we can infer that our psychological intervention has the potential to be proposed in surgical setting, being short, easy to learn and applicable to a wide range of patients. CLINICAL TRIAL REGISTRATION: The trial was registered on ClinicalTrials.gov (identifier: NCT03408002). The full protocol is available from the last author.

Factors related to the expression of emotions by early-stage breast cancer patients.

OBJECTIVE: (1) To report the number and type of emotional expressions (cues/concerns) raised by breast cancer patients; (2) to identify the influence of setting, patient characteristics, and doctor-patient interaction on emotional expression. METHODS: 308 Italian-speaking female patients were recruited at their first breast cancer consultation. The visits were audio-recorded and analysed for number and type of emotional expressions (VR-CoDES). Oncologists' interaction skills were rated by the VR-COPE. Socio-demographic, clinical and personality variables were gathered before the consultation. Clinical variables and oncologists' evaluations of the patient were collected after. RESULTS: Breast cancer patients raised emotional issues mainly as cues. The setting (centre where the consultations took place), the oncologist's attribution of anxiety, regardless of anxiety test screening (STAI-X1) score before the consultation, and the oncologist's ability to pick up on patient's worries, handle emotional needs or understand psychosocial condition were all positively related with the number of emotional expressions. More tightly structured consultations had fewer emotional expressions. CONCLUSION: Both contextual and interactional aspects have an impact on patient emotional expressions. PRACTICE IMPLICATIONS: Oncologists need to be trained to manage both the content and the process of medical consultation. Work organization of the consultation setting needs to be taken into account.

Autophagy pathways in drug abusers after forensic autopsy: LC3B, ph-mTOR and p70S6K analysis.

INTRODUCTION: Autophagy plays a role in various central nervous system diseases. Little is known about its molecular activation in drug addiction. Our aim was to investigate the signalling pathways of autophagy in brain tissues from drug abusers. METHODS: Twenty-five drug abusers with acute lethal intoxication and 10 controls were medico-legally autopsied. Brain-tissue samples from the parietal cortex and cerebellum were obtained. Expression of LC3B, phospho-mTOR (ph-mTOR) and phospho70S6 Kinase (p70S6K) was identified in tissue microarrays, with three tissue spots per case. Blood, urine or vitreous humour were tested in all cases to identify the acute intoxication. Hair analysis was performed in 14 cases to confirm chronic intoxication; the remaining cases had a documented medical history of chronic abuse. RESULTS: The autophagy marker LC3B was always positive on both the cortex and the cerebellum, stratified as strongly in 18 (72%) cases and weakly positive in seven (28%) cases. ph-mTOR was negative in all cases. The p70S6K molecule showed positivity in 14 (56%) cases on cortex tissue. The cerebellum was always negative, except for Purkinje cells. Drug abusers had statistically more double positive cases (LC3B-p70S6K) than controls ( p=0.0094). CONCLUSION: Autophagy pathways were activated in our series, and 56% of drug abusers showed simultaneous LC3B-p70S6K immunoexpression on tissue from the parietal cortex and cerebellum. This may be of value in autopsy practice as an indicator of brain damage due to drug abuse and could serve as alternative or additional double sensitive diagnostic method to detect drug-related deaths using a tissue-based rationale.

Virtual Autopsy as a Screening Test Before Traditional Autopsy: The Verona Experience on 25 Cases.

BACKGROUND: Interest has grown into the use of multidetector computed tomography (CT) and magnetic resonance imaging as an adjunct or alternative to the invasive autopsy. We sought to investigate these possibilities in postmortem CT scan using an innovative virtual autopsy approach. METHODS: Twenty-five postmortem cases were scanned with the Philips Brilliance CT-64 and then underwent traditional autopsy. The images were interpreted by two blinded forensic pathologists assisted by a radiologist with the INFOPSY® Digital Autopsy Software System which provides three-dimensional images in Digital Imaging and Communications in Medicine format. Diagnostic validity of virtual autopsy (accuracy rate, sensitivity, specificity, and predictive values) and concordance between the two forensic pathologists (kappa intraobserver coefficients) were determined. RESULTS: The causes of death at traditional autopsies were hemorrhage due to traumatic injuries (n = 8), respiratory failure (5), asphyxia due to drowning (4), asphyxia due to hanging or strangulation (2), heart failure (2), nontraumatic hemorrhage (1), and severe burns (1). In two cases, the cause of death could not be ascertained. In 15/23 (65%) cases, the cause of death diagnosed after virtual autopsy matched the diagnosis reported after traditional autopsy. In 8/23 cases (35%), traditional autopsy was necessary to establish the cause of death. Digital data provided relevant information for inferring both cause and manner of death in nine traumatic cases. The validity of virtual autopsy as a diagnostic tool was higher for traumatic deaths than other causes of death (accuracy 84%, sensitivity 82%, and specificity 86%). The concordance between the two forensic pathologists was almost perfect (>0.80). CONCLUSIONS: Our experience supports the use of virtual autopsy in postmortem investigations as an alternative diagnostic practice and does suggest a potential role as a screening test among traumatic deaths.

Affective communication during bad news consultation. Effect on analogue patients' heart rate variability and recall.

OBJECTIVE: The aim of the study was to investigate the effect of physicians' supportive communication on analogue patients' (APs) heart rate variability (HRV) and recall, while watching a video of palliative treatment being explained to a female patient. METHODS: Sixty healthy women, acting as APs, were randomly assigned to watch one of two versions (standard vs. affective) of a scripted video-vignette of a bad news consultation to a female patient. The physician's communication differed only in the delivery of four supportive comments. Empathy, support and engagement perception were assessed by three questions. APs' HR was recorded during video-observation and recall was assessed immediately after. HRV was determined through measures defined in time and frequency domains. RESULTS: Data of 54 APs (27 + 27) were included. The group with supportive communication perceived the physician as more empathic and supportive. Intra- and Inter-group comparisons suggested a greater sense of stress in the standard communication group. Recall did not differ in the two groups. CONCLUSION AND PRACTICE IMPLICATIONS: Findings show that the use of supportive expressions contribute to the perception of the physician as more empathic, potentially buffer patients' arousal after a bad news announcement, but does not confirm a positive impact on general recall.

Cortical Expression of the Polysialylated Isoform of the Neural Cell Adhesion Molecule on Brain Tissue to Recognize Drug-Related Death: An Exploratory Analysis.

The polysialylated isoform of the neural cell adhesion molecule (PSA-NCAM) has been shown to be a key player in neuroplastic changes and is expressed in various disorders. We investigated the PSA-NCAM expression on brain cortical tissue in a cohort of drug-related deaths. Brains from 25 drug abusers and 10 control subjects were removed at autopsy, and 2 samples of the right parietal lobe of each case were obtained. The polysialylated isoform of NCAM was evaluated on formalin-fixed and paraffin-embedded tissues. Eleven patients were polydrug abusers; 14 used a single substance. The mechanisms of death were acute respiratory failure (n = 19), cardiorespiratory failure (n = 4), acute heart failure (n = 1), and brain injury (n = 1). Toxicological analyses of blood were available for all cases, and urine and bile analyses for 19 of 25 cases. The polysialylated isoform of NCAM immunoexpression in the neuronal soma and dendritic spines was observed in 18 (72%) of 25 drug abusers and in 2 (20%) of 10 control subjects. Drug abusers were statistically more positive for PSA-NCAM than control subjects (P = 0.0082). The expression of PSA-NCAM in the parietal cortex could be an indicator of brain damage due to drug abuse, and its availability could allow the forensic pathologists to develop rapid and low-cost additional or alternative method to improve detection of drug-related deaths.

How psychiatrist's communication skills and patient's diagnosis affect emotions disclosure during first diagnostic consultations.

OBJECTIVE: To describe how emotions are disclosed during psychiatric diagnostic consultations and the contribution of the psychiatrists in facilitating their expression. METHODS: Descriptive naturalistic study. Sixteen psychiatrists recorded their first consultations with 104 patients. Emotions and the immediate response given by the psychiatrist were coded with the Verona Coding Definitions of Emotional Sequences. For each disclosed emotion, the potential link to preceding expressions with affective content (cue or concern) was checked and the immediate response given by the psychiatrist was coded. RESULTS: Most emotions were expressions of anxiety in terms of psycho-physiological or cognitive correlates. Concerns were present in 94% of the consultations, 47.6% were not linked to previous cues/concerns. Cues which became concerns and concerns which were further elaborated by the patient were those that had been acknowledged and handled by the psychiatrist by actively providing space to their expression. Compared to all other diagnostic groups, patients with mood disorders talked more explicitly and more often about their feelings. CONCLUSION: The type and frequency of expressed emotions varies with patient diagnosis, suggesting different cognitive processes underlining psychopathology. PRACTICE IMPLICATIONS: Psychiatrist's competence in providing space by using active listening skills is essential to uncover patients emotions.