OXTR polymorphism predicts social relationships through its effects on social temperament

Humans have a fundamental need for strong interpersonal bonds, yet individuals differ appreciably in their degree of social integration. That these differences are also substantially heritable has spurred interest in biological mechanisms underlying the quality and quantity of individuals’ social relationships. We propose that polymorphic variation in the oxytocin receptor gene (OXTR) associates with complex social behaviors and social network composition through intermediate effects on negative affectivity and the psychological processing of socially relevant information. We tested a hypothesized social cascade from the molecular level (OXTR variation) to the social environment, through negative affectivity and inhibited sociality, in a sample of 1295 men and women of European American (N = 1081) and African American (N = 214) ancestry. Compared to European Americans having any T allele of rs1042778, individuals homozygous for the alternate G allele reported significantly lower levels of negative affectivity and inhibited sociality, which in turn predicted significantly higher levels of social support and a larger/more diverse social network. Moreover, the effect of rs1042778 variation on social support was fully accounted for by associated differences in negative affectivity and inhibited sociality. Results replicated in the African American sample. Findings suggest that OXTR variation modulates levels of social support via proximal impacts on individual temperament.     

Interpersonal distress is associated with sleep and arousal in insomnia and good sleepers

Objective

The interpersonal environment is strongly linked to sleep. However, little is known about interpersonal distress and its association with sleep. We examined the associations among interpersonal distress, objective and subjective sleep in people with and without insomnia.

Methods

Participants in this cross-sectional observational study included men and women with insomnia (n = 28) and good sleeper controls (n = 38). Interpersonal distress was measured with the Inventory of Interpersonal Problems. Sleep parameters included insomnia severity, self-reported presleep arousal, and sleep quality; and polysomnographically-assessed sleep latency (SL), total sleep time (TST), wake after sleep onset (WASO), percent delta (stage 3 + 4 NREM), percent REM, and EEG beta power. Hierarchical linear regression was used to assess the relationship between distress from interpersonal problems and sleep and the extent to which relationships differed among insomnia patients and controls.

Results

More interpersonal distress was associated with more self-reported arousal and higher percentage of REM. More interpersonal distress was associated with greater insomnia severity and more cognitive presleep arousal for individuals with insomnia, but not for controls. Contrary to expectations, interpersonal distress was associated with shorter sleep latency in the insomnia group. Results were attenuated, but still significant, after adjusting for depression symptoms.

Conclusion

Distress from interpersonal problems is associated with greater self-reported arousal and higher percent REM. Individuals with insomnia who report more distress from interpersonal problems have greater insomnia severity and cognitive presleep arousal, perhaps due to rumination. These findings extend our knowledge of the association between interpersonal stressors and sleep. Assessment and consideration of interpersonal distress could provide a novel target for insomnia treatment.     

Risk of myocardial infarction associated with chronic hepatitis C virus infection: a population-based cohort study

Hepatitis C virus (HCV) infection is associated with systemic inflammation and metabolic complications that might predispose patients to atherosclerosis. However, it remains unclear if HCV infection increases the risk of acute myocardial infarction (MI). To determine whether HCV infection is an independent risk factor for acute MI among adults followed in general practices in the United Kingdom (UK), a retrospective cohort study was conducted in The Health Improvement Network, from 1996 through 2008. Patients ≥18 years of age with at least 6 months of follow-up and without a prior history of MI were eligible for study inclusion. HCV-infected individuals, identified with previously validated HCV diagnostic codes (n = 4809), were matched on age, sex and practice with up to 15 randomly selected patients without HCV (n = 71 668). Rates of incident MI among patients with and without a diagnosis of HCV infection were calculated. Adjusted hazard ratios were estimated using Cox proportional hazards regression, controlling for established cardiovascular risk factors. During a median follow-up of 3.2 years, there was no difference in the incidence rates of MI between HCV-infected and -uninfected patients (1.02 vs 0.92 events per 1000 person-years; P = 0.7). HCV infection was not associated with an increased risk of incident MI (adjusted HR, 1.10; 95% confidence interval [CI], 0.67-1.83). Sensitivity analyses including the exploration of a composite outcome of acute MI and coronary interventions yielded similar results (adjusted HR, 1.16; 95% CI, 0.77-1.74). In conclusion, HCV infection was not associated with an increased risk of incident MI.     

A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania

Introduction

Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates.

Methods

We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018.

Results

During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05).

Conclusion and recommendations

Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania’s National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

     

Phase II trial of sequential high-dose chemotherapy with paclitaxel,melphalan and cyclophosphamide,thiotepa and carboplatin with peripheral blood progenitor support in women with responding metastatic breast cancer

A single high-dose cycle of chemotherapy can produce response rates in excess of 50%. However, disease-free survival (DFS) is 15-20% at 5 years. The single most important predictor of prolonged DFS is achieving a complete response (CR). Increasing the proportion of patients who achieve a complete response may improve disease-free survival. Women with metastatic breast cancer and at least a partial response (PR) to induction chemotherapy received three separate high-dose cycles of chemotherapy with peripheral blood progenitor support and G-CSF. The first intensification was paclitaxel (825 mg/m(2)), the second melphalan (180 mg/m(2)) and the third consisted of cyclophosphamide 6000 mg/m(2) (1500 mg/m(2)/day x 4), thiotepa 500 mg/m(2) (125 mg/m(2)/day x 4) and carboplatin 800 mg/m(2) (200 mg/m(2)/day x 4) (CTCb). Sixty-one women were enrolled and 60 completed all three cycles. Following the paclitaxel infusion most patients developed a reversible, predominantly sensory polyneuropathy. Of the 30 patients with measurable disease, 12 converted to CR, nine converted to a PR*, and five had a further PR, giving an overall response rate of 87%. The toxic death rate was 5%. No patient progressed on study. Thirty percent are progression-free with a median follow-up of 31 months (range 1-43 months) and overall survival is 61%. Three sequential high-dose cycles of chemotherapy are feasible and resulted in a high response rate. The challenge continues to be maintenance of response and provides the opportunity to evaluate strategies for eliminating minimal residual disease.     

Reliability,validity and responsiveness to change of the Patient Report of Extent of Psoriasis Involvement (PREPI) for measuring body surface area affected by psoriasis

Background The development of a simple, reliable, valid and responsive method for measuring the extent of skin involvement in psoriasis is important for use in epidemiological studies. Objectives We sought to investigate the psychometric characteristics of the Patient Report of Extent of Psoriasis Involvement (PREPI), a single‐question method for measuring body surface area affected by psoriasis. Methods This was a cross‐sectional study of 140 patients with psoriasis, with an exploratory prospective longitudinal cohort component. Reliability was measured via a test‐retest approach and criterion validity was investigated by comparing the PREPI with an assessment of body surface area of involvement by a dermatologist. We additionally compared Skindex‐29 scores with the PREPI. To demonstrate responsiveness and establish a minimally important difference in the PREPI, we created receiver operating characteristic curves for the PREPI instrument. Results The test‐retest reliability of the PREPI was nearly perfect [intraclass correlation coefficient (ICC) = 0·99, 95% confidence interval (CI) 0·97–0·99], and there was substantial agreement between patient and physician assessments (ICC = 0·82, 95% CI 0·75–0·87). The PREPI showed significant correlations with all Skindex‐29 domains. We found the PREPI to be responsive to change and identified changes in the PREPI score that have good discrimination between patients with and without a minimally important clinical difference. Conclusions Our study suggests that the PREPI is a reliable, valid and responsive measure of body surface area affected by psoriasis that may be useful for future epidemiological research.     

Cutting cost and increasing access to colorectal cancer screening: another approach to following the guidelines.

CONTEXT: Through medical decision making, physicians in the U.S. influence the spending of >$1.3 trillion or 15% of the gross domestic product. U.S. physicians are challenged to identify areas of clinical practice to improve while cutting cost and increasing access. Primary screening for colorectal cancer is a good example to illustrate this point.OBJECTIVE: To apply a population-based method of medical decision making in the area of primary screening for colorectal cancer in order to illustrate a reduction in health care costs while increasing access and maintaining quality of care.DESIGN: We used a combination of (a) census population data, (b) National Cancer Institute Survey data on screening rates, and (c) charge data to estimate the current costs of colorectal cancer screening. We also estimated cost and capacity increases that would occur under various other screening scenarios. These included all currently screened subjects receiving annual fecal occult blood testing (FOBT), all currently unscreened individuals undergoing either colonoscopy every decade or annual FOBT, and all eligible subjects undergoing annual FOBT.Main outcome measures: Cost and access differences between current screening activity and other potential scenarios compliant with guidelines.RESULTS: Screening for colorectal cancer with yearly, six-window, rehydrated FOBT for all normal-risk individuals over the age of 50 has the potential to screen 3,813,095 more Americans for colon cancer yearly than are currently being screened, while costing $8.7 billion less per decade than what is currently being spent on screening a fraction of the population. Looking into the future, it is possible to increase screening rates from 50% to 100%, while saving almost $10 billion per decade by using FOBT for all eligible Americans. In practice, some proportion of these benefits would be realized as the calculations assume a 100% patient compliance rate.CONCLUSIONS: Considering a population-based approach and the balance among quality, accessibility, and cost parameters, we recommend primary screening for colorectal cancer to be based on yearly six-window, rehydrated FOBT. Colonoscopy due to cost and access issues should be relegated to secondary screening and case finding.     

Hand-assisted laparoscopic approach to renal harvest for autotransplantation

PURPOSE: To describe a laparoscopic hand-assisted approach to renal autotransplantation that allows both harvest and transplant through the same incision. PATIENTS AND METHODS: Three patients underwent renal autotransplantation from May 2003 to April 2004, two for loin pain-hematuria syndrome and one for severe ureteral-stricture disease. Two patients underwent autotransplantation on the left and one on the right. Hand-assisted laparoscopy was planned such that inferomedial extension of the hand-port incision would provide adequate exposure of the iliac vessels for autotransplantation. RESULTS: The average operative time was 240 minutes, the warm ischemia time was 2 minutes 43 seconds, and the hospital stay was 3 days. All three patients had successful graft function by postoperative renal scan with a mean follow-up of 7.1 months. CONCLUSION: Hand-assisted laparoscopic renal harvest for autotransplantation can be completed with placement of the hand port such that transplantation can be accomplished through the same incision. As many of these patients have had multiple prior retroperitoneal operations, the intracorporeal hand can greatly facilitate these potentially difficult dissections with no added morbidity.     

Error in surgical pathology

A total of 272 surgical pathology claims reported to The Doctors Company from 1998 through 2003 were reviewed. They were analyzed and repetitive patterns involving both specimen type and category of diagnostic error were identified. These patterns were then compared with those uncovered in a prior review of 218 surgical pathology claims reported from 1995 through 1997 to identify trends and see if new patterns of diagnostic error had emerged.