Habit formation in context: Context-specific and context-free measures for tracking fruit consumption habit formation and behaviour

Objectives

Interventions promoting habitual fruit consumption have the potential to bring about long-term behaviour change. Assessing the effectiveness of such interventions requires adequate habit and behaviour measures. Habits are based on learned context-behaviour associations, so measures that incorporate context should be more sensitive to expected habit and behaviour changes than context-free measures. This study compared context-specific and context-free measures of fruit consumption habit and behaviour following a 3-week habit formation intervention.

Design

Prospective online study (n = 58).

Methods

Behaviour frequency was assessed across five timepoints, retrospectively (Time 1 [T1], T5) or via daily diary data (uploaded weekly at T2, T3 and T4). Habit strength was assessed before (T1) and immediately after the intervention (T4), and again 2 weeks later (T5). Analyses of variance were run, with time and context specificity as within-subject factors, and habit and behaviour frequency as dependent measures.

Results

An interaction between time and context specificity was found in both analyses (habit: F(2,114) = 12.848, p < .001, part.η² = .184; behaviour: F(2,114) = 6.714, p = .002, part.η² = .105). Expected habit formation patterns 5 weeks post-baseline were only detected by the context-specific habit measure. Likewise, increased behaviour frequency was only found when the target context was specified (p's < .001).

Conclusions

Assessments of purposeful dietary habit and behaviour change attempts should incorporate context-specific measurement.     

Motivational and self-efficacy reciprocal effects during a 12-month' weight regain prevention program

Objective

Weight regain prevention is a critical public health challenge. Digital behaviour change interventions provide a scalable platform for applying and testing behaviour change theories in this challenging context. This study's goal was to analyse reciprocal effects between psychosocial variables (i.e., needs satisfaction, eating regulation, self-efficacy) and weight over 12 months using data from a large sample of participants engaged in a weight regain prevention trial.

Methods

The NoHoW study is a three-centre, large-scale weight regain prevention trial. Adults who lost >5% of their weight in the past year (N = 1627, 68.7% female, 44.10 ± 11.86 years, 84.47 ± 17.03 kg) participated in a 12-month' digital behaviour change-based intervention. Weight and validated measures of basic psychological needs satisfaction, eating regulation and self-efficacy were collected at baseline, six- and 12 months. Correlational, latent growth models and cross-lagged analysis were used to identify potential reciprocal effects.

Results

Baseline higher scores of needs satisfaction and self-efficacy were associated with six- and 12-month' weight loss. Baseline weight was linked to all psychosocial variables at six months, and six-months weight was associated with needs satisfaction and self-efficacy at 12 months. During the 12 months, increases in eating regulation, needs satisfaction and self-efficacy were associated with weight loss over the same period, and reciprocal effects were observed between the variables, suggesting the existence of Weight Management Cycles.

Conclusions

While further studies are needed, during long-term weight regain prevention, weight decrease, needs satisfaction and self-efficacy may lead to Weight Management Cycles, which, if recurrent, may provide sustained prevention of weight regain.     

An experimental COVID-19 messaging study in a representative sample of the Scottish population: Increasing physical distancing intentions through self-efficacy

Objectives

Self-efficacy is important for adherence to transmission-reducing behaviours (e.g., physical distancing) as also shown in the CHARIS project. We aimed to show that a theory-based short message can increase physical distancing self-efficacy and intentions to keep physical distance.

Design

Structured telephone surveys with a randomly selected nationally representative sample of adults in Scotland (N = 497).

Methods

Participants were randomly assigned to one of two experimental conditions: message condition (short message to increase self-efficacy via vicarious experiences, verbal persuasion and emotional arousal) or control condition (no message). Followed by measures for self-efficacy and intention for physical distancing on 4-point scales. Adherence to physical distancing was assessed on a 5-point frequency scale (never – always).

Results

Using mediation analyses with bootstrapping procedures, we first confirmed that self-efficacy was associated indirectly with adherence, via higher intentions in a partial mediation (unstandardized indirect effect .21, 95% CI .18–.25). The message increased self-efficacy; participants receiving the message reported higher self-efficacy (M = 4.23, SD = .80) compared to participants in the control condition (M = 4.08, SD = .77; standardized regression coefficient = .19, p < .05) and self-efficacy affected intention (.48, p < .001). There was a small significant indirect effect of the message on intention via self-efficacy (unstandardized indirect effect .07, CI .01–.14).

Conclusions

Increasing self-efficacy for physical distancing with a short message can successfully increase intention to physical distance via increased self-efficacy. As both self-efficacy and intentions are important predictors of adherence to transmission-reducing behaviours short messages have potential to limit the spread of COVID-19.     

Communicating global cardiovascular risk: Are icon arrays better than numerical estimates in improving understanding,recall and perception of risk?

Objective

Experts recommend that adults have their global cardiovascular risk assessed. We investigated whether icon arrays increase understanding, recall, perception of CVR, and behavioral intent as compared with numerical information.

Methods

Male outpatient veterans, at an intermediate to high cardiovascular risk participated in a randomized controlled trial of a computer tutorial presenting individualized risk. Message format was presented in 3 formats: percentages, frequencies, and frequencies with icon arrays. We assessed understanding immediately (T1) and recall at 20 min (T2) and 2 weeks (T3) after the intervention. We assessed perceptions of importance/seriousness, intent to adhere, and self-efficacy at T1. Self-reported adherence was assessed at T3.

Results

One-hundred and twenty male veterans participated. Age, education, race, health literacy and numeracy were comparable at baseline. There were no differences in understanding at T1 [p = .31] and recall at T3 [p = .10]. Accuracy was inferior with frequencies with icon arrays than percentages or frequencies at T2 [p ≤ .001]. There were no differences in perception of seriousness and importance for heart disease, behavioral intent, self-efficacy, actual adherence and satisfaction.

Conclusion

Icon arrays may impair short-term recall of CVR.

Practice implications

Icon arrays will not necessarily result in better understanding and recall of medical risk in all patients.     

Utility of temporal self-regulation theory in health and social behaviours: A meta-analysis

Purpose

Temporal self-regulation theory was developed to address an observed intention-behaviour gap across behaviours. However, a synthesis of studies has not yet been conducted to investigate the theory's utility to explain behaviour and bridge the intention-behaviour gap. This review aimed to evaluate the predictive ability of temporal self-regulation theory to understanding behaviour and pre-registered at PROSPERO (ID: CRD42021253174).

Method

Forward citation searches on the original theory publication through Google Scholar until May 2021 identified 37 eligible articles, including, 12,555 participants assessing at least two of the three theory constructs. Random-effects meta-analyses assessed the strength of associations between theory constructs on behaviour and random effects meta-regressions assessed moderators of behaviour.

Results

Findings provide support for temporal self-regulation theory to explain behaviour with very weak (self-regulatory capacity r = .039, CI = .00, –.07) to moderate (intention r = .331, CI = .26, .40; behavioural pre-potency r = .379, CI = .32, .44) effect sizes. Further, the strength of associations varied across behaviour types and contexts. However, there was high heterogeneity across studies and some moderating effects could not be assessed due to insufficient numbers of studies assessing interactions.

Conclusions

We urge researchers to assess and report interactions for better understanding of the drivers of behaviour to develop effective interventions for positive behaviour change.     

An Age-Tailored Intervention Sustains Physical Activity Changes in Older Adults: A Randomized Controlled Trial

Background

A randomized controlled trial compared an age-tailored intervention to increase physical activity levels in older adults to an age-neutral intervention.

Purpose

Both interventions communicated activity planning strategies and messages to improve self-efficacy. On top of this, the age-tailored intervention also included two lifespan components that targeted present orientation and emotional focus, and fostered strategies of selection, optimization, and compensation.

Method

A total of 386 German older adults (aged 60–95 years) were randomized to receive either the age-tailored intervention (age-specific strategy training and short-term emotional focus) or the age-neutral intervention. Physical activity was measured by questionnaires at baseline (T1) and at 6-month (T2) and 12-month follow-ups (T3). Latent true change modeling was applied by creating latent change scores (T2???T1 and T3???T2).

Results

After controlling for gender, age, and physical and mental health, allocation to the age-tailored intervention predicted a latent physical activity difference at T3???T2, but not at T2???T1.

Conclusion

Compared to the age-neutral intervention, the age-tailored intervention led to superior maintenance of physical activity within these older adults.     

The development of a complex intervention in China: the ‘Caring for Couples Coping with Cancer “4Cs” Programme’ to support couples coping with cancer

Background

As the primary informal caregiver for cancer patients, spousal caregivers are a population at a high risk of hidden morbidity. The factors impacting couples coping with cancer are complex, and within spousal caregiver-patient dyads the impact is mutual. The aim of this study is to explain the process that led to the development of an acceptable, feasible, and potentially effective ‘Caring for Couples Coping with Cancer “4Cs” Programme’ to support couples coping with cancer as the unit of intervention in China.

Methods

The Medical Research Council’s (MRC) framework for developing and evaluating complex interventions was adopted to develop an intervention for couples coping with cancer. Three steps were taken in the process of developing the 4Cs programme, namely: (1) identifying the evidence base by conducting a series of extensive reviews of the relevant literature and conducting a focus group study; (2) identifying/developing a theory by proposing a preliminary Live with Love Conceptual Framework ‘P-LLCF’ for cancer couple dyads; and (3) modelling the process and outcomes of the 4Cs programme.

Results

The programme that was developed is comprised of six individual sessions to be delivered by the researcher/therapists over 6 weeks. The main contents of the sessions of the 4Cs programme are: primary stressors (section 1); secondary stressors (section 2); dyadic mediator (section 3); dyadic appraisal (section 4); dyadic coping (section 5); and a programme overview (section 6). The emphasis of the programme is on supporting couples coping with cancer. A booklet was developed to provide the participants with easy access to written information about their common concerns in caring for loved ones with cancer.

Conclusions

Guided by the MRC guidelines, a potentially effective, feasible, and acceptable 4Cs programme aimed at supporting couples coping with cancer as a dyad was developed. Future research is needed to pilot and evaluate the feasibility, modelling, and outcomes of this 4Cs programme.

     

Determinants of physical activity promotion by smoking cessation advisors as an aid for quitting: Support for the Transtheoretical Model

Objectives

Physical activity (PA) can reduce cigarette cravings and aid quitting but little is known about its promotion by smoking cessation advisors. This study aimed to: (1) determine the extent to which smoking cessation advisors promote PA; and (2) examine the relationship between PA promotion as a cessation aid and advisor characteristics and cognitions, within the Transtheoretical Model (TM) framework.

Methods

Self-report surveys assessing PA promotion, TM variables, advisors’ own PA levels and demographics were completed by 170 advisors in England and Scotland.

Results

Advisors reported spending 29 min promoting PA over a 6/7-week clinic. Those in later stages of readiness for promoting PA as a cessation aid and those spending more time promoting PA held more positive beliefs regarding pros and cons, self-efficacy, outcome efficacy and importance of PA within smoking cessation. Time spent promoting PA and stage of readiness were strongly associated. There was a trend for the more physically active advisors to promote PA more often.

Conclusions

About half the advisors promoted PA and TM variables predicted this variability.

Practice implications

PA promotion among smoking cessation advisors may be facilitated by enhancing self-efficacy, outcome efficacy and pro- and con-beliefs related to PA promotion.     

Experiences of dialectical behaviour therapy for adolescents: A qualitative analysis

Objectives

To explore how former patients in dialectical behaviour therapy for adolescents (DBT-A) experience their treatment, and specifically if there were aspects of the treatment that they retrospectively identify as particularly meaningful, helpful or unhelpful.

Design

From a larger sample of 75 former DBT-A patients 19 were selected for a qualitative semi-structured interview study.

Methods

Young adults (N = 19; 18 females, one male), who as adolescents had been enrolled in DBT-A due to self-harming behaviours and features of borderline personality disorder, were interviewed up to 8 years (median 6.0; min 1.3; max 8.2) after end of treatment, at mean age 23 years (SD 2.5). Reflexive thematic analysis was implemented.

Results

Six key themes were revealed; (1) The need to be seen, listened to and believed in, (2) the importance of teamwork between patient and therapist, (3) the value of group and structure, (4) therapy as lifesaving and life-changing, (5) the risks of feeling misplaced and (6) the risks of abrupt endings.

Conclusion

A trusting relationship with the therapist promoted commitment and motivation for treatment. This relationship was facilitated by the therapist showing explicit care and belief in the patient's own competence in changing their destructive behaviours. Meeting peers in group skill training offered a salient form of validation and was reported to be of particular value. The format of meeting peers and the importance of the dialectical therapeutic stance need to be studied further. Not all youth experienced DBT-A as suitable and the need for sufficient treatment dose was emphasized.     

Mother–child adrenocortical synchrony: Roles of maternal overcontrol and child developmental phase

An increasing amount of empirical attention is focused on adrenocortical synchrony as an index of biobehavioral co-regulation between parent and child in the context of early child development. Working with an ethnically diverse community sample of children (N = 99, 50.5% male, ages 9–12), we collected saliva samples from mother–child dyads prior to and after a laboratory-based performance challenge task, and tested whether maternal overcontrol and child age moderated dyadic synchrony in cortisol. Results revealed that cortisol levels between mothers and children were significantly positively correlated at pretask for dyads with mean age and older children only, at 25-min post-task for all dyads, and at 45-min post-task for all dyads. Higher overcontrol/older child dyads exhibited a unique pattern of cortisol synchrony wherein at pretask, mother–child levels had the strongest positive correlation, whereas at 25 and 45 min, mother–child cortisol levels were significantly inversely correlated. These findings contribute to theory and research on parent–child relationships by examining parenting behavior, developmental stage, and adrenocortical synchrony in tandem.     

Long-term effect of communication training on the relationship between physicians’ self-efficacy and performance

Objective

To examine the long term impact of a communication skills intervention on physicians’ communication self-efficacy and the relationship between reported self-efficacy and actual performance.

Methods

62 hospital physicians were exposed to a 20-h communication skills course according to the Four Habits patient-centered approach in a crossover randomized trial. Encounters with real patients before and after the intervention (mean 154 days) were videotaped, for evaluation of performance using the Four Habits Coding Scheme. Participants completed a questionnaire about communication skills self-efficacy before the course, immediately after the course, and at 3 years follow-up. Change in self-efficacy and the correlations between performance and self-efficacy at baseline and follow-up were assessed.

Results

Communication skills self-efficacy was not correlated to performance at baseline (r = −0.16; p = 0.22). The association changed significantly (p = 0.01) and was positive at follow-up (r = 0.336, p = 0.042). The self-efficacy increased significantly (effect size d = 0.27). High performance after the course and low self-efficacy before the course were associated with larger increase in communication skills self-efficacy.

Conclusion

A communication skills course led to improved communication skills self-efficacy more than 3 years later, and introduced a positive association between communication skills self-efficacy and performance not present at baseline.

Practice implications

Communication skills training enhances physicians’ insight in own performance.     

The Shared Pleasure Paradigm: A study in an observational birth cohort in South Africa

Mother–infant dyads in low- and middle-income countries (LMICs) may be exposed to a range of factors associated with suboptimal development. Optimal infant development is likely supported by synchronicity in the early mother–infant relationship, but limited corroborative research is available in LMICs. The Drakenstein Child Health Study (DCHS) provided an opportunity to study this synchronicity and its associations in South Africa. A South African birth cohort study investigating early-life determinants of child health in a LMIC context provided participants. The Shared Pleasure (SP) paradigm helped assess early mother–infant synchronicity in videos of a sub-set of 291 mother–infant dyads at their 14-week well baby visit. General linear regression models investigated the relationship between selected maternal and infant characteristics and the presence of Shared Pleasure moments. Out of a possible 291 dyads, 82% (n = 239) yielded Shared Pleasure moments. The mean age of mothers was 27 years, while infant sex distribution comprised 54% females and 46% males. The shortest single Shared Pleasure moment lasted at least 0.5 s and the longest 28 s. Shared Pleasure moments were associated with higher gestation age at delivery (p = 0.008) and higher infant birth weight (p = 0.006), but were not related to mother's mental health and infant health outcomes at 14 weeks. The high frequency of positive Shared Pleasure moments in reciprocal dyadic interactions in this sample suggests that significant disruption in shared pleasure may be present only in extreme cases (e.g. mothers with severe mental disorders). Further work is needed to investigate the mechanisms underlying the associations between early mother–infant synchronicity and better outcomes noted here, and to assess whether SP may serve as a culturally appropriate screen for assessing connectedness.

     

Self-efficacy for temptations is a better predictor of weight loss than motivation and global self-efficacy: Evidence from two prospective studies among overweight/obese women at high risk of breast cancer

Objectives

Identifying predictors of weight loss could help to triage people who will benefit most from programs and identify those who require additional support. The present research was designed to address statistical, conceptual and operational difficulties associated with the role of self-efficacy in predicting weight loss.

Methods

In Study 1, 115 dieting overweight/obese women at high risk of breast cancer were weighed and completed questionnaires assessing motivation, global self-efficacy and self-efficacy for temptations. The main outcome measure was weight, measured 3-months post-baseline. Study 2 was identical (n = 107), except changes in psychological variables were computed, and used to predict weight 6-months post-baseline.

Results

In Study 1, self-efficacy for temptations was a significant predictor of weight loss at 3-month follow-up. In Study 2, improved self-efficacy for temptations between baseline and four-weeks was predictive of lower weight at 6 months.

Conclusion

The key finding was that self-efficacy for temptations, as opposed to motivation and global self-efficacy, was predictive of subsequent weight loss.

Practice implications

The implication is that augmenting dieters’ capability for dealing with temptations might boost the impact of weight loss programs.     

A Digital Smoking Cessation Program Delivered Through Internet and Cell Phone Without Nicotine Replacement (Happy Ending): Randomized Controlled Trial

Background

Happy Ending (HE) is an intense 1-year smoking cessation program delivered via the Internet and cell phone. HE consists of more than 400 contacts by email, Web pages, interactive voice response, and short message service technology. HE includes a craving helpline and a relapse prevention system, providing just-in-time therapy. All the components of the program are fully automated.

Objective

The objectives were to describe the rationale for the design of HE, to assess the 12-month efficacy of HE in a sample of smokers willing to attempt to quit without the use of nicotine replacement therapy, and to explore the potential effect of HE on coping planning and self-efficacy (prior to quitting) and whether coping planning and self-efficacy mediate treatment effect.

Methods

A two-arm randomized controlled trial was used. Subjects were recruited via Internet advertisements and randomly assigned to condition. Inclusion criteria were willingness to quit on a prescribed day without using nicotine replacement and being aged 18 years or older. The intervention group received HE, and the control group received a 44-page self-help booklet. Abstinence was defined as “not even a puff of smoke, for the last seven days” and was assessed by means of Internet surveys or telephone interviews 1, 3, 6, and 12 months postcessation. The main outcome was repeated point abstinence (ie, abstinence at all four time points). Coping planning and self-efficacy were measured at baseline and at the end of the preparation phase (ie, after 2 weeks of treatment, but prior to cessation day).

Results

A total of 290 participants received either the HE intervention (n=144) or the control booklet (n=146). Using intent-to-treat analysis, participants in the intervention group reported clinically and statistically significantly higher repeated point abstinence rates than control participants (20% versus 7%, odds ratio [OR] = 3.43, 95% CI = 1.60-7.34, P = .002). Although no differences were observed at baseline, by the end of the preparation phase, significantly higher levels of coping planning (t ₂₆₁ = 3.07, P = .002) and precessation self-efficacy (t ₂₆₁ = 2.63, P = .01) were observed in the intervention group compared with the control group. However, neither coping planning nor self-efficacy mediated long-term treatment effect. For point abstinence 1 month after quitting, however, coping planning and self-efficacy showed a partial mediation of the treatment effect.

Conclusions

This 12-month trial documents a long-term treatment effect of a fully automated smoking cessation intervention without the use of nicotine replacement therapy. The study adds to the promise of using digital media in supporting behavior change.     

Patient age: a neglected factor when considering disease management in adults with type 2 diabetes

Objective

The average age at diagnosis for type 2 diabetes is decreasing. However, because age is most often controlled for in clinical research, little is known regarding how adult age is associated with diabetes disease-related variables.

Methods

In a community based study with type 2 diabetes patients (N = 506), after adjusting for potentially confounding variables, we examined associations between patients’ age and: stress, depression, diabetes-related distress, self-efficacy, diet, exercise, and glycemic control. We then explored to what extent age interacts with these variables in their association with glycemic control.

Results

Younger age was independently associated with: greater chronic stress and negative life events, higher levels of diabetes-related distress, higher depressed affect, eating healthier foods and exercising less frequently, lower diabetes self-efficacy, and higher HbA1c. Interactions showed that younger patients with high stress and/or low self-efficacy were more likely to have higher HbA1c levels than older patients.

Conclusions

Results suggest younger adult patients with type 2 diabetes represent a unique patient subgroup with specific needs and health risks based on their developmental stage and life context.

Practice implications

Treatment programs need to target younger adult patients and may need to utilize different media or modalities (e.g., social media) to reach this group.     

Implication of the Pro12Ala polymorphism of the <Emphasis Type="Italic">PPAR-gamma 2</Emphasis>gene in type 2 diabetes and obesity in the French population

Background  

The Pro12Ala Single Nucleotide Polymorphism (SNP) of the Peroxisome Proliferator-Activated Receptor gamma 2 (PPAR-gamma 2) has been associated with insulin resistance and type 2 diabetes (T2D) and also inconsistently with obesity. The aim of this study was to evaluate the impact of this SNP with regards to T2D and childhood and adult obesity in the French Caucasian population.     

Personality and mentalization: A latent profile analysis of mentalizing problematics in adult patients

Background

The aim of this study was to investigate the relationship between patients' mentalizing problematics and their personality; specifically, it aimed to identify clusters of individuals characterized by specific patterns of mentalizing imbalances and to analyze the relationship between these and diagnosis of personality disorder (PD), nonmentalizing modes, emotion dysregulation, and interpersonal reactivity.

Methods

Four hundred therapeutic dyads were recruited. A part of these (n = 183) only completed clinician-report measures, Mentalization Imbalances Scale, and Modes of Mentalization Scale, while others (n = 217) also completed patients' self-report measures, which were Reflective Functioning Questionnaire, Difficulties in Emotion Regulation Scale, and Interpersonal Reactivity Index.

Results

A latent profile analysis enlightened the presence of four clusters with problematics in the dimensions of mentalization, indicated by cluster names: (1) Affective-self-automatic profile (ASA-P) (with higher percentage of PDs); (2) External profile (E-P) (with lower percentage of PDs); (3) Others-automatic-affective profile (OAA-P); (4) Cognitive-self-automatic profile (CSA-P). Multivariate analysis of variances confirmed that the four clusters differed in relation to the quality of mentalization, emotional dysregulation and interpersonal reactivity, with higher levels of nonmentalization modes, uncertainty about mental states and emotion dysregulation in ASA-P, higher levels of good mentalization in E-P, lower impulsivity in CSA-P, and greater empathic concern in OAA-P.     

CT60 genotype does not affect CTLA-4 isoform expression despite association to T1D and AITD in northern Sweden

Background  

Polymorphisms in and around the CTLA-4 gene have previously been associated to T1D and AITD in several populations. One such single nucleotide polymorphism (SNP), CT60, has been reported to affect the expression level ratio of the soluble (sCTLA-4) to full length CTLA-4 (flCTLA-4) isoforms. The aims of our study were to replicate the association previously published by Ueda et al. of polymorphisms in the CTLA-4 region to T1D and AITD and to determine whether the CT60 polymorphism affects the expression level ratio of sCTLA-4/flCTLA-4 in our population.     

Evaluation of artificial sweat in athletes with spinal cord injuries

Athletes with spinal cord injury often experience high heat storage due to reduced sweating capacity below the spinal injury. Spray bottle (SB) maybe used to apply mist for evaporative cooling during breaks in competitions. This study examined the efficacy of SB during rest breaks. Seven participants, four female and three males, (mean ± SD age 24 ± 4.1 year, weight 56.2 ± 7.0 kg, upper-body VO₂ peak 2.4 ± 0.6 l/min) volunteered for the study. Participants were paraplegic athletes (T3–T12/L1) with both complete and incomplete lesions. Participants arm-cranked using a ramp protocol in an environment of 21 ± 1.5°C and 55 ± 3% rh once using a SB during 1-min rest between 7-min stages of increasing intensity and once without the SB (CON). Mean total work was similar (p = 0.86) for the SB and CON (2495.7 ± 914.6 vs. 2407.1 ± 982.3 kJ, respectively). Likewise, the mean work times were similar between trials (27 ± 6 and 26 ± 7 min for SB and CON, respectively). Furthermore, there were no significant differences detected between trials for skin temperature, rectal temperature, esophageal temperature (p > 0.05). There were no statistically significant differences detected between trials for RPE (p > 0.05). In conclusion, the application of artificial sweat via SB was ineffective in attenuating the onset of uncompensable heat strain during high-intensity arm exercise in a comfortable environment.     

Morphological spectrum of renal cell carcinoma,unclassified: an analysis of 136 cases

Aims

Renal cell carcinoma, unclassified (RCCU) is a category that includes a morphologically and biologically heterogeneous group of tumours that are unable to be diagnosed as other well‐defined entities. We aim to describe the morphological findings of tumours within this category and to determine the most frequent morphological features leading to classification difficulty.

Methods and results

One hundred and thirty‐six cases of RCCU were examined. Patients ranged in age from 23 to 87 years. Seventy‐seven patients were men and 59 were women. International Society of Urological Pathology (ISUP) grade was most commonly 3 (n = 66), followed by 2 (n = 42) and 4 (n = 28). Tumour size ranged from 0.6 to 24.9 cm. The American Joint Committee on Cancer (AJCC) pathological T categories included pT1a (n = 50), pT1b (n = 14), pT2a (n = 7), pT2b (n = 4), pT3a (n = 50) and pT4 (n = 9). Forty‐four cases included lymph node(s), 41% of which (n = 18) had metastases. Tumours were assessed for a variety of histological features and assigned to the following morphological groups: predominantly oncocytoma/chromophobe RCC‐like; clear cell RCC‐like; papillary RCC‐like; collecting duct‐like; and pure sarcomatoid differentiation. The majority of the oncocytoma/chromophobe and clear cell RCC‐like phenotypes were low stage (pT1 or pT2). The papillary RCC‐like, collecting duct‐like and pure sarcomatoid phenotypes were mainly high stage (pT3 or pT4).

Conclusions

Renal cell carcinoma, unclassified is a term that encompasses tumours with a variety of morphological features and a wide biological spectrum. The most common source of diagnostic difficulty was tumours composed of predominantly eosinophilic cells.