Psychiatric presentations of cancer

Cancers that most frequently present with psychiatric symptoms include brain tumors, pancreatic carcinoma, tumors of endocrine organs, and hormone-producing tumors. Symptom complexes that should alert physicians to possible underlying carcinoma are depression with weight loss greater than 20 pounds, no past or family history of depression, and an atypical age at onset.     

Conversion of nonfusing mumps virus infections to fusing infections by selective proteolysis of the HN glycoprotein

Mumps virus strains differ in their ability to induce cell fusion following an infection: strains with activeneuraminidase (NANase) fail to cause cell fusion, while strains with less active NANases cause cell fusion. When chymotrypsin is added to infected cells, cell fusion is amplified in a concentration-dependent manner for all mumps virus strains. Virions produced in such infections do not express HN glycoprotein-associated activities. Chymotrypsin treatment of purified mumps virus in vitro results in sequential cleavage into two glycopolypeptides, HNc1 (32K) and HNc2′ (41K), with concomitant loss of hemagglutinating and NANase activities, and infectivity. Further incubation with chymotrypsin causes complete degradation of HNc1 and digestion of HNc2′ to HNc2 (13K–19K). Both HNc2′ and HNc2 contain the [³H]palmitic acid label found in the HN polypeptide, which suggests that these fragments are associated with the viral membrane. Analyses of infected cells and released virions indicate that chymotrypsin acts similarly on HN exposed at the cell surface. Exogenous NAnase does not abolish the protease-augmented cell fusion though it does reduce cell fusion of untreated fusing strain infections. These results confirm that mumps virus HN glycoprotein is critically linked to cell fusion cytopathology and show that cyrptic cell fusion activity in nonfusing strain infections can be unmasked by the proteolytic removal of the HN glycoprotein.     

Twenty-four-hour rhythm in the bronchial hyperreactivity to house dust in asthmatics

Four subjects, 2 males (17 and 35 yr of age) and 2 females (24 and 47 yr of age) suffering from allergic asthma were studied for 10 days in allergen-shielded rooms and without medication. synchronization of subjects to activity was by light on at 7 a.m., and sleep by light off at midnight. A single bronchial challenge to the threshold concentration of house dust, predetermined for each subject, was presented every other day at designated clock hours such that during a 10-day study span tests were presented at the following times: 8 a.m., 3 p.m., 7 p.m. and 11 p.m. The effect upon bronchial patency determined by FEV_1.0 15 min after house dust inhalation resulted in greatest effect at 11 p.m., while that at 8 a.m. resulted in least effect. The differences were statistically significant (p < 0.025). Peak expiratory flow (PEF), self-measured at 3-hr intervals throughout the 10-day span, revealed practically no persistence of effect for inhalation of the house dust preparation at 8 a.m.; on the other hand, considerable persistence of effect on airway patency occurred from tests carried out at 11 p.m. The differences between the 24-hr rhythm-adjusted means (mesors) in the PEF for the (24-hr) spans following house dust inhalation at 8 a.m. and 11 p.m. were statistically significant (p < 0.025) as well.     

Chronic pain: the psychiatrist's role

The psychiatrist's task when treating chronic pain patients is to aid in diagnosing the primary source of pain; secure an understanding of what the pain means to the patient; recommend a pain management program to the referring physician; implement techniques for reducing the contribution made by psychologic factors to pain perception; and undertake psychotherapy to improve the patient's ability to handle personal problems and interpersonal relationships. Our experience has shown that any attempt to cure pain through psychotherapy alone will be unsuccessful. The goal must be rehabilitation, not cure.     

Differential diagnosis of somatopsychic disorders

A substantial number of patients who present with psychiatric symptoms are suffering from underlying or unrecognized medical illnesses. Only by an awareness of differential diagnostic factors and a high index of suspicion can the clinician avoid misdiagnosis and inappropriate treatment of these somatically ill patients. The authors discuss some of the general characteristics that can help differentiate medical illness from primary psychiatric illness, and outline the psychiatric findings commonly associated with a number of physical illnesses.     

Psychiatric aspects of cancer

The authors review the psychiatric symptoms that may precede, accompany, and follow the onset of cancer. Difficulty in expressing anxiety, depression, or anger and low scores on these parameters in psychological testing along with depression and feelings of hopelessness are linked with the emergence of malignant tumors. Cancers of the brain, pancreas, and other endocrine organs, and hormone-secreting tumors frequently develop following the appearance of psychiatric symptoms. The psychological adjustment of cancer patients and the more common psychiatric sequelae of malignancy and its treatment are examined. The authors emphasize the need for careful assessment and attention to the biologic, psychological, and social factors critical to the patient's response and adjustment to the disease.     

Diabetic patients and the impact of renal transplantation

A series of diabetic patients being evaluated for renal transplantation or having already had the procedure were referred for psychiatric evaluation and treatment. The authors note the disparity between the expectations of patients before transplantation and their subsequent level of functioning. The development of depression and behavioral problems is discussed with particular attention to the relationship between the severity of diabetic complications and the presence of depressive symptoms. Treatment may include behavioral approaches for negativistic patients and administration of tricyclic antidepressants for depressed patients.     

Prazosin, an alpha1-adrenoceptor antagonist, partially inhibits exercise-induced asthma

The effect of prazosin, a potent and specific alpha 1-adrenoceptor antagonist given by inhalation (total nebulized 2 mg) was compared with placebo in a double-blind randomized study of 10 atopic asthmatic children. Prazosin significantly (p less than 0.01) reduced the severity of post-exercise bronchoconstriction (maximum fall in peak expiratory flow after exercise 21.4% +/- SEM 6.3% after prazosin compared with 42.5% +/- 7.3% after placebo). This protective action of prazosin suggests that activation of alpha 1-adrenoceptor may be involved in the pathogenesis of exercise-induced asthma either by facilitation of mast-cell mediator release or by direct contraction of bronchial smooth muscle. Prazosin did not significantly change resting bronchomotor tone or histamine-induced bronchoconstriction, suggesting no effect on bronchial smooth muscle contractility.     

Growth, pulmonary, and endocrine function in chronic asthma patients on daily and alternate-day adrenocorticosteroid therapy.

Growth, pulmonary, and adrenal-pituitary function were assessed in 20 steroid-dependent asthmatic children and adolescents while they were on daily prednisone therapy. The patients were then switched to equivalent daily methylprednisolone or twice equivalent alternate-day methylprednisolone for a 3-mo period, after which time studies were repeated. The steroid regimens were then crossed so that those patients taking daily methylprednisolone were switched to alternate-day therapy and the alternate-day therapy patients were switched to daily medication for another 3-mo interval, after which studies were repeated again. Abnormal growth, bone maturation, and cataracts were identified. Mean symptom scores at each evaluation were similar. Pulmonary function tests and shunt studies showed little difference between methylprednisolone and prednisone. Endocrine function tests showed a high incidence of disturbed pituitary and adrenal function. A 3-mo period of alternate-day therapy did not alter this.     

Clinical evaluation of intranasal topical flunisolide therapy in allergic rhinitis.

A double-blind, vehicle control, parallel clinical trial evaluated the effectiveness and safety of the local application of flunisolide, a potent new topical steroid, in the treatment of ragweed hay fever. Fifty patients with well-defined, poorly controlled ragweed allergy were studied during the 1974 ragweed season. Analysis of the data showed that the active drug group had a significant decrease in individual symptoms of sneezing, nasal stuffiness, and nasal secretions, compared with the placebo group. Antihistamine usage was statistically decreased in the active drug over placebo group. There was no evidence of adrenal suppression. This study indicates that intranasal administration of flunisolide in adult patients is both efficacious and safe in the treatment of seasonal allergic rhinitis.     

Clinical and immunologic evaluation of glutaraldehyde-modified, tyrosine-adsorbed short ragweed extract: a double-blind, placebo-controlled trial

Glutaraldehyde-modified, tyrosine-adsorbed ragweed extract (GTR) is a modification of allergen extract to reduce allergenicity but retain immunogenicity. We evaluated the clinical efficacy and immunologic changes associated with the administration of GTR (16,350 protein nitrogen units) or placebo to a group of 100 atopic subjects with ragweed hay fever. The study was carried out in a double-blind, placebo-controlled fashion. Clinical response was measured by daily symptom diaries. physician evaluations, and patient responses. Changes in ragweed-specific IgE and IgG antibody were evaluated with an amplified enzyme-linked immunosorbent assay (alpha-ELISA) and were compared with measurements by RAST and a protein A-binding assay for IgG antibody. Treatment with GTR resulted in a sixfold increase in blocking IgG antibody and a small increase in IgE-specific antibody. No changes occurred in the placebo treated group. Mild immediate local reactions occurred after 74% of injections, and late-onset local reactions occurred after 62% of injections in the treated group. The placebo-treated group experienced immediate or late local reaction after only 12% of injections. There were two mild late-onset urticarial reactions of a generalized nature in the treatment group. The treatment group experienced significantly fewer symptoms than the placebo group throughout the season (p less than 0.02), although the difference was not dramatic. The results showed that GTR could be safely given in five preseasonal injections, with retained immunogenicity but less potential for generalized reactions. GTR is an improved method of allergy immunotherapy with the potential for clinical benefit when used in a brief preseasonal treatment regimen.     

Light and immunofluorescent study of the Arthus reaction in the rabbit lung

A localized Arthus reaction was produced in the lung of sensitized rabbits by delivery of antigen into a lower lobe bronchus using a method of selective bronchial catheterization under fluoroscopy. The rabbits were sensitized with bovine immunoglobulin G (B-IgG) in incomplete Freund's adjuvant (IFA) to produce precipitating antibody without classic delayed hypersensitivity. Pulmonary histopathology was studied at intervals following antigen challenge, using light and immunofluorescent microscopy. Gross lesions peripheral to the lower lobe bronchus receiving antigen were found within 12 hr. Subsequent necrosis resulted in a dense scar by 6 wk. Microscopically, early lesions were typified by localized bronchitis, bronchiolitis, alveolitis, and vasculitis with exuberant exudates containing predominantly polymorphonuclear leukocytes. Extensive focal necrosis was present by 72 hr. Immunofluorescent studies revealed the presence of B-IgG, rabbit IgG, and complement (C3) in and around bronchi, bronchioles, alveoli, and vessels. No granulomatous lesions were found, and proliferation of alveolar lining cells was not detected in these studies. Thus, the lung can participate in an acute Arthus reaction following local antigen challenge in systemically sensitized animals. The pathology more closely resembles a necrotizing bacterial pneumonia than an interstitial or hypersensitivity pneumonitis under the conditions of this experimental system. Implications for human disease are speculative.     

Alteration of T cell function in healthy persons with a history of thymic x-irradiation.

The possible late effects of x-irradiation to the infantile thymus were investigated by studying immune functions in 12 healthy persons with a history of thymic x-irradiation and healthy control subjects. No differences were found in serum immunoglobulin values, humoral antibody levels, lymphocyte counts, and lymphocyte reactivity to phytochemagglutinin, vaccinia virus, purified protein derivative (PPD), and allogeneic cells. The irradiation group exhibited cellular hyperresponsiveness to streptoskinase-streptodornase (SK-SD). In contrast, mean skin and in vitro lymphocyte responses to Candida albicans were depressed in the patients with thymic irradiation. A dissociation of these two Candida responses was found in only 1 of 14 healthy control subjects but in 7 of 12 irradiated individuals. While thymic irradiation did not result in impaired immunologic defenses leading to clinical disease, it caused alterations in T cell responses similar to those reported in patients with chronic mucocutaneous candidiasis.     

Maxillary sinusitis and bronchial asthma: correlation of roentgenograms, cultures, and thermograms

Autologous renal tubular epithelial antigen was demonstrated together with immunoglobulins and β₁c along the glomerular capillary walls in 4 out of 9 patients with idiopathic membranous glomerulonephritis, and the existence of the clinical entity of glomerulonephritis mediated by tubular epithelial antigen-antibody complexes was suggested. Although no differences in laboratory data were noted between tubular antigen-positive and -negative groups, clinical remission occurred only in the negative group. The fact that no remission was observed in the tubular antigen-positive group may be explained by the continuous supply of the antigen from endogenous sources that maintained the production of immune complexes and subsequent glomerular injury.     

Risk factors for developing asthma and allergic rhinitis: A 7-year follow-up study of college students

Nine hundred three former college freshmen were followed 7 yr after entering college by means of a detailed allergy questionnaire. Original data collected from the students as freshmen, including a history of atopy and allergy skin test results, were evaluated in relation to the frequency of developing new allergies. During the 7-yr follow-up period, new cases of hay fever occurred in 12.6%, nonseasonal allergic rhinitis in 4.8%, and new asthma in 2.5% The risks of developing asthma and allergic rhinitis are both significantly associated with a prior positive allergy skin test. The risk of developing asthma, not hay fever, is significantly associated with a prior history of atopy. The association of positive allergy skin tests with the development of new cases of allergy remains significant throughout the 7-yr follow-up period. However, individuals who had all negative skin tests developed significantly fewer new cases of clinical allergy during the first 3 yr of follow-up; in the next 4 yr of the 7-yr follow-up, increased numbers of individuals with negative scratch tests developed new cases of allergy. Thus, negative skin tests proved of less prognostic value during the last 4-yr period of this 7-yr study, although significant differences still are apparent between the positive and negative reactor groups.     

Cromolyn in extrinsic and intrinsic asthma

Cromolyn sodium was evaluated in 30 patients with intrinsic bronchial asthma and in 29 patients with extrinsic bronchial asthma using a double-blind crossover method. Each patient was studied during a base line, placebo, and cromolyn period. Daily evaluation was performed with regard to upper respiratory tract symptoms, lower respiratory tract symptoms, oral medication scores, use of sympathomimetic agents by aerosolization and peak expiratory flow rates measured 5 times a day. Weekly evaluation consisted of a physician's evaluation and a timed vital capacity. At the end of each test period spirometry, airway resistance and an exercise tolerance test were performed. Evaluation of the intrinsic asthmatic patients revealed significant improvement during the cromolyn period as compared to the placebo and base line periods with regard to the daily recorded variables and the physician's evaluation. Study of the other parameters showed no significant trend. Evaluation of the use of cromolyn in extrinsic bronchial asthma revealed no general trends for any of the parameters measured.     

Serum IgG, IgA, IgM, and IgE levels and allergy in Filipino children in the United States

The serum levels of IgE, IgG, IgA, and IgM of 27 American-born Filipino children 5 to 17 years of age were measured and found to be significantly higher than those of a control group of 24 Caucasian children of similar age distribution and attending the same general pediatric clinics. The geometric mean of serum IgE of the Filipinos was 227 U. per milliliter and of the Caucasians, 69 U. per milliliter (p < 0.01). The geometric means of other serum immunoglobulin levels of the Filipinos by comparison with the Caucasians were: IgG, 1,303 and 1,010 mg. per 100 ml. (p < 0.01); IgA, 195 and 120 mg. per 100 ml. (p < 0.001); and IgM, 141 and 92 mg. per 100 ml. (p < 0.02), respectively. The incidence of atopic disease was higher in the Filipino study group (48 per cent) than in the Caucasian control group (25 per cent); eczema was especially prevalent in the Filipino group. Elevated serum IgE levels were associated with atopic disease in both racial groups; however, there was no correlation between serum level of IgG, IgA, or IgM and atopy.     

Occupational asthma in poultry workers

Sixteen poultry workers with poultry house--related rhinitis and/or asthma underwent clinical and laboratory evaluation that included history and physical examination, skin tests with common inhalant and PAg, total- and specific-IgE levels, and pulmonary-function studies. Sixteen age- and sex-matched atopic subjects who were not occupationally exposed to poultry and 12 asymptomatic veterinarians with occupational exposure to poultry served as controls. Rhinitis and asthma developed only in symptomatic poultry workers after exposure to poultry; only in these individuals could immediate wheal-and-flare reactions to poultry antigens be detected (p less than 0.001). The elapsed time between the initial poultry exposure and the onset of poultry house--related symptoms averaged 10 yr. In the symptomatic poultry workers, immediate skin test reactivity and RAST reactions were most frequently associated with NFM. The association between respiratory symptoms temporally related to poultry house exposure and the demonstrable IgE antibody-mediated reaction suggests a relationship between the two.     

Effect of a β-adrenergic agonist,fenoterol, on nasal sensitivity to allergen

Fenoterol hydrobromide, 1 mg/ml, was given by nasal spray in doses between 204 and 576 μg in an attempt to reduce nasal sensitivity to Lolium perenne allergen in a nasal provocation test during a 2-hr period following the drug. In a randomized double-blind comparison between fenoterol and placebo in 11 patients, reduction of nasal sensitivity by fenoterol was small but significant in a one-tailed test (p = 0.03). In the 15 min following the fenoterol spray the increase in the average nasal airway resistance (NAR) was significantly higher than the increase in NAR after placebo (p = 0.026), suggesting that fenoterol may also act as a vasodilator in the nose. This effect is consistent with findings by other investigators who showed that isoproterenol also increased nasal airways resistance.