Showing papers by "David Spiegel published in 2004"

Repression and high anxiety are associated with aberrant diurnal cortisol rhythms in women with metastatic breast cancer.

Abstract: Previous research has provided evidence of autonomic, endocrine, and immunological dysregulation in repressors and a possible association with cancer incidence and progression. Recently published data from the authors’ laboratory demonstrated that flatter diurnal cortisol slopes were a risk factor for early mortality in women with metastatic breast cancer. In the current analysis of this same sample (N 91), the authors tested differences at baseline between groups scored using the Weinberger Adjustment Inventory on diurnal cortisol slope and mean cortisol levels. When compared with self-assured and nonextreme groups, the repressor and high-anxious groups had a significantly flatter diurnal slope. Diurnal slope was similar for repressors and high-anxious groups. Groups did not differ on mean cortisol levels, nor did they differ on intercept (morning) values.

Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report

Abstract: As medical care for cancer has become more specialized in diagnosis, treatment has become more technical and fragmented. In order to help cancer patients and their families, we developed a coordinated program called the Stanford Cancer Supportive Care Program (SCSCP) at the Center for Integrative Medicine at Stanford Hospital and Clinics. The Stanford Cancer Supportive Care Program was initiated in 1999 to provide support for cancer patients, addressing the need for improved physical and emotional well-being and quality of life. This paper is a program evaluation report. The number of patient visits grew from 421 in 1999 to 6319 in 2002. This paper describes the utilization of the SCSCP program as assessed by 398 patient visit evaluations during a 9-week period, January 2002 to March 2002. During this time we collected attendance records with demographic data and anonymous questionnaires evaluating each program. Patients were asked to evaluate how the program helped them regarding increase of energy, reduction in stress, restful sleep, pain reduction, sense of hopefulness, and empowerment. Over 90% of the patients using the SCSCP felt there was benefit to the program. Programs were chosen based on a needs assessment by oncologists, nurse managers, social workers, and patients. Massage, yoga, and qigong classes had the highest number of participants. Qualitative data showed benefit for each program offered. This evaluation of a free cancer supportive care program initiated in a hospital outpatient setting provides initial evidence of patient satisfaction and improvement in quality of life.

The assessment of intraobserver and interobserver error in the measurement of noncongenital scoliosis in children ≤ 10 years of age

Abstract: STUDY DESIGN: Retrospective review of scoliosis radiographs. OBJECTIVES: To determine measurement variability in children < or = 10 years of age with noncongenital scoliosis. SUMMARY OF BACKGROUND DATA: Measurement variability in congenital and adolescent idiopathic scoliosis has been studied. There is no study of measurement variability in young children with noncongenital scoliosis. METHODS: A retrospective review of children < or = 10 years of age followed for noncongenital scoliosis was performed. End vertebrae were identified on radiographs, and the curves were measured (Cobb method) twice by each of six observers. The same soft lead pencil and goniometer was used. Intraobserver and interobserver variability for continuous data was determined. RESULTS: There were 64 children. The diagnosis was infantile/juvenile idiopathic scoliosis in 42, neuromuscular scoliosis in 7, scoliosis associated with mesenchymal disorders or other syndromes in 12, and unknown in 3 children. The curve was thoracic in 54, thoracolumbar in 8, and lumbar in 2. There were 19 left and 45 right curves. The average age was 6.6 +/- 2.6 years. There were a total of 768 Cobb angle measurements with an average Cobb angle of 38 +/- 22 degrees (range, 10 degrees -115 degrees ). Intraobserver variability was +/- 6 degrees; interobserver variability was +/- 7 degrees. CONCLUSION: In children < or =10 years of age with noncongenital scoliosis, intraobserver measurement variability in Cobb angle measurement is +/- 6 degrees and interobserver variability is +/-7 degrees. To be certain that there is a significant difference between Cobb angle measurements in children with noncongenital scoliosis and < or = 10 years of age there must be a change of at least +/-7 degrees.

False and Recovered Memories in the Laboratory and Clinic: A Review of Experimental and Clinical Evidence

Abstract: We review the clinical and laboratory evidence for recovered and false memories. Available data suggest that, at least under certain circumstances, both false and recovered memories may occur. We suggest that the critical questions are: (a) how common is each type of memory phenomenon, (b) what factors lead to the occurrence of each (including under what conditions are each possible and/or likely to occur), and perhaps most importantly, (c) can these two types of memories be distinguished from each other? We describe laboratory analogues for both types of experiences and describe an empirical research protocol that can not only demonstrate both phenomena but also compare the two. Such comparisons can help to determine the causes of these phenomena, discover factors that influence the two, and hopefully reveal signature variables that could pro

Cytotoxic T lymphocyte count and survival time in women with metastatic breast cancer.

Abstract: While prognostic factors in early stage breast cancer are well documented, few studies have examined predictors of the rate of metastatic progression. The purpose of this study was to examine cytotoxic T-cell lymphocyte (CTL) count as a marker of disease status in women with metastatic breast cancer. This study examined CTL subset counts as predictors of subsequent survival in 113 women with metastatic or recurrent breast cancer. Samples were measured by flow cytometry using monoclonal antibodies for cell surface antigens for percentages and absolute numbers of CTLs (CD3/CD8), total lymphocytes, T cells (CD3), helper T cells (CD3/CD4), and total white blood cell (TWC) count. Higher CTL counts emerged as a significant predictor of longer survival up to 7 years later (Wald = 7.40, p = 0.007; Cox regression model). The relationship of higher CTL count with enhanced survival was independent of the effects of medical treatment. CTLs were significantly associated with TWC count ( r = 0.42, p < 0.001). However, TWC count was not associated with subsequent survival time. Higher CTL count was associated with Karnofsky performance status ( r = 0.27, p = 0.004). However, after adjustment for the Karnofsky score, the CTL count/survival relationship remained significant (Wald = 4.33, p = 0.038). In conclusion, there is a robust relationship between CTL count and survival that is independent of the effects of medical treatments, TWC count, and Karnofsky performance status. Moreover, a reduced CTL count may be a mediator or marker of more rapid disease progression in metastatic breast cancer. �

Placebos in practice

Abstract: Placebo comes from the Latin for “I will please.” Pleasing a patient would seem to be a good thing to do. Yet considerable controversy exists about the use of a biologically inert or irrelevant substance with therapeutic intent. Nitsan and Lichtenberg show in this issue (p 944) that placebos are often used in modern medicine.1 Their survey of 89 doctors and nurses providing hospital based and ambulatory care in Israel found that 60% used placebos in their practice, most often (43%) to fend off an “unjustified” demand for medication, to calm a patient (38%), as an analgesic (38%), or, more problematically, as a diagnostic tool (28%). The paper makes it clear that the placebo pleases modern doctors. Should it? If the placebo effect is real, is it right to use it? Most of medicine used placebos at one time. Medicine in the 20th century was supposed to end this. We would use only scientifically proved active pharmacological and surgical interventions. Yet only about half of medical treatments are supported by evidence.2 A conference held at the National Institutes of Health in the United States in 2002 reviewed the evidence and concluded that we needed more science, not fewer placebos.3 It called for research on brain and body pathways that mediate placebo effects, and for optimising the use of the placebo phenomenon while attending to ethical and practical concerns about it. The response to placebos varies widely across different cultures, but the myth that placebo responders are uneducated, unintelligent, free of serious medical illness, or histrionic was not supported by current research.w1 The conference also noted the importance of the nocebo effect—negative expectations can produce negative results.w2 In the 19th century, for example, tomatoes were believed to be poisonous, and many people were treated in hospitals for symptoms of tomato poisoning.w3 Doubts have been raised about the usefulness of the placebo in conditions other than pain. A recent meta-analysis and related Cochrane report found little evidence that using a placebo improved symptoms, with the exception of pain relief.4,5 This meta-analysis had numerous problems.6 It lumped together 40 heterogeneous outcome assessments and further restricted the power to detect an effect by dichotomising them as improved or not, rather than treating these outcomes as continuous variables. The one analysis that did treat outcome continuously found a significant effect—reduction in pain. What this meta-analysis really showed is not that the placebo doesn't cure anything, but rather that it does not cure everything. Despite such scientific scepticism, the placebo phenomenon seems to influence the behaviour of patients and doctors. The growth of patients' interest in integrative or holistic medicine in the past decade is perhaps a reaction to the growth of evidence based medicine.7,8 Most placebos are relatively harmless. Modern medicine involves treatments, such as surgery, chemotherapy, and bone marrow transplantation, that are effective but also toxic. Many patients may choose integrative medicine as a kinder and gentler treatment that harnesses rather than eschews the placebo effect and engages them as participants in their care, especially in the treatment of chronic problems such as anxiety and pain that are often not well managed in medicine.w4 That an idea, feeling, or relationship can have a real effect on the body is now established. Scientific domains such as psychoneuroimmunology and psychoneuroendocrinology are helping us to understand mechanisms whereby belief in benefit might affect resistance to disease, for example as a form of stress reduction with physiological consequences. Considerable evidence indicates that depression, for example, affects outcome in heart disease and cancer.9,10 In the survey by Nitsan and Lichtenberg, few doctors (15%) used placebos without deception.1 However, deception is not a necessary component of the placebo response. Many have justifiable ethical concerns about deliberately deceiving patients regarding the nature of their treatment. But perhaps therapeutic intent and expectation are sufficient to mobilise healing in patients.w5 The use of the placebo as a diagnostic tool by 28% of respondents is more troubling, as the authors note. That a patient gets pain relief from a placebo does not imply that the pain is not real or organic in origin. Ample evidence shows that psychological interventions such as hypnosis can alter the perception of pain dramatically. Beecher noted that grievously wounded soldiers on the Anzio beachhead required less analgesia than less seriously injured patients in Boston.11 Their intense desire to survive overrode their focus on the pain of their injuries. Psychological factors such as redirected attention, distraction, and changes in perceived meaning of real pain can alter its intensity. Thus the use of the placebo for “diagnosis” of whether or not pain is real is misguided. The placebo effect, thought of as the result of the inert pill, can be better understood as an effect of the relationship between doctor and patient.12 Adding the doctor's caring to medical care affects the patient's experience of treatment, reduces pain, and may affect outcome. This survey makes it clear that doctors continue to use placebos, and most think they help. We cannot afford to dispense with any treatment that works, even if we are not certain how it does.

Coronary and aortic calcifications in patients new to dialysis.

Abstract: Background: Vascular calcification has been associated with all cause and cardiovascular mortality in patients with end-stage kidney disease (ESRD). Whether vascular calcification is present in persons with advanced chronic kidney disease starting dialysis or develops in patients on dialysis is unknown. The purpose of this study was to examine the prevalence of vascular and coronary calcification in patients new to hemodialysis. Methods: A total of 129 subjects new to dialysis were evaluated using electron beam computed tomography. The primary outcome was the presence and extent of coronary artery, aortic, and valvular calcification. Results: Forty-three percent of subjects had no significant coronary artery calcification (total score ≤ 30) and 27% had no detectable aortic calcification. Thirty-four percent had coronary artery scores that placed them above the 90th percentile for age and sex. Coronary artery calcification was significantly associated with a history of coronary artery disease and atherosclerotic vascular disease (ASVD) whereas aortic calcification was significantly associated with ASVD. Age (p < 0.0001), pulse pressure (p = 0.004), diabetes mellitus (p = 0.009), and a history of smoking (p = 0.026) were independently associated with the extent of coronary artery calcification. Age (p < 0.0001) and pulse pressure (p = 0.0003) were independently associated with the extent of aortic calcification. Conclusions: A large fraction of patients new to hemodialysis had no evidence of coronary artery or aortic calcification. Coupled with the extensive vascular calcification reported by others in prevalent dialysis patients these findings suggest that dialysis-specific factors contribute to calcific vascular disease in ESRD.

Cross-Cultural Aspects of Cancer Care

Abstract: Life and death, emotion and social support, stress and disease are universal human concerns. The diagnosis of cancer induces a human dread that is grounded in our biological being. Nonetheless, the experience of cancer and its treatment is inevitably influenced by cultural, ethnic, economic, and religious differences. In some cultures, the diagnosis of cancer conveys a greater sense of shame than others. Only recently have Japanese cancer patients been willing to make public declarations of their disease status, forming heretofore unheard of support groups such as “Akai Bono Kai.” Cultural concerns about modesty and sexuality, or cultural acceptance of a fatalistic approach to life may inhibit screening activities in certain cultures, such as among Chinese and Latina women. Direct talk about the future that might make an American cancer patient feel respected and involved in treatment could seem to a Chinese cancer patient a self-fulfilling prophesy of doom. De Toqueville described Americans as a “nation of joiners.” We tend to be relatively direct and open, inclined to discuss problems and try to solve them. At the same time, we do not like to admit to having problems, and often lose ourselves in work and other activities when confronted with threats to health. Our desire for openness and shared decision-making in medical care is not entirely consistent with our belief in success, in

Rapid loss of hepatitis B immunity in hemodialysis patients

Abstract: Premise. Hepatitis B remains a concern in chronic hemodialysis units. The Centers for Disease Control guidelines recommend yearly hepatitis B antibody screening once a therapeutic titer of ≥10 mIU/ml has been achieved, and the Centers for Medicare & Medicaid Services reimburse dialysis facilities for this annual screening. We questioned whether yearly testing was adequate surveillance to ensure immunity. Methods. This study was designed to evaluate the rate of loss of hepatitis B antibody titer in patients who achieved a therapeutic titer by vaccination. All patients achieving a hepatitis B antibody titer ≥10 mIU/ml between January 2001 and December 2001 were included in the study, with 36 patients meeting the entrance criteria. The time course from first achieving that titer was then followed. Hepatitis B antibody titers were drawn quarterly. Loss of immunity was defined as a titer 150 mIU/ml. By 6 months, 39% of the patients had lost their immunity and were potentially susceptible to infection. By 12 months, 50% of the patients had a drop in their titer to < 10 mIU/ml. The 18 patients who lost their titer prior to 1 year had a mean peak titer of 54 mIU/ml compared with 94 mIU/ml for the patients who maintained their titer (p = ns). Conclusion. Yearly screening of vaccine responders may not be adequate to ensure that all patients are protected against hepatitis B.