Different Prevalence of Alarm, Dyspeptic and Reflux Symptoms in Patients with Cardia and Non-cardia Gastric Cancer

Background and Aims: Symptoms of patients with gastric cancer (GC) are often unspecific and differences in symptoms between patients with cardia and non-cardia GC have been poorly investigated. We aimed to characterize symptoms of patients with cardia and non-cardia GC. Methods: Patients with cardia (Siewert type II and III) and non-cardia GC were recruited in the German multicenter cohort of the Gastric Cancer Research (staR) study between 2013 and 2017. Alarm, dyspeptic and reflux symptoms at the time of presentation were documented using a self-administered questionnaire. Results: A completed self-administered questionnaire was available for 568/759 recruited patients (132 cardia GC, 436 non-cardia GC, male 61%, mean age 64 years). Dyspeptic symptoms were more common in patients with non-cardia GC (69.0 vs. 54.5%, p=0.0024). Cardia GC patients reported more frequently alarm symptoms (69.7 vs. 44.7%, p<0.0001), and were more likely to have Union for International Cancer Control (UICC) stage III-IV (54.1vs. 38.9%, p=0.0034). Especially, dysphagia and weight loss were more common in patients with cardia GC (49.2 vs. 6.4 %, p<0.0001 and 37.1 vs. 25.7%, p=0.02, respectively). No differences between the two groups were observed with respect to reflux symptoms. Patients with alarm symptoms were more likely to have UICC stage III-IV at presentation (69.4 vs. 42.9%, p<0.0001). Conclusions: In clinical practice the symptom pattern at presentation may serve as a hint for tumor localization. Despite the fact that they are common in the general population, dyspeptic symptoms offer a chance for earlier GC detection. Thus, in patients with dyspeptic symptoms who fail empiric approaches, endoscopy should not be delayed.

Blood eosinophils in managing preschool wheeze: lessons learnt from a proof-of-concept trial

Background: Management of preschool wheeze is based predominantly on symptom pattern. Objective: To determine whether personalising therapy using blood eosinophils or airway bacterial infection results in fewer attacks compared to standard care. Methods: A proof-of-concept, randomised trial to investigate whether prescription of inhaled corticosteroids (ICS) guided by blood eosinophils, or targeted antibiotics for airway bacterial infection, results in fewer unscheduled healthcare visits (UHCV) compared to standard care. Children aged 1-5 years with >2 wheeze attacks in the previous year were categorised as episodic viral wheeze (EVW), or multiple trigger wheeze (MTW). The intervention group were prescribed ICS if blood eosinophils >3%, or targeted antibiotics if positive culture on induced sputum/cough swab. The control group received standard care. Primary outcome: UHCV at 4 months. Results: 60 children, median age 36.5 (range 14-61) months were randomised. Median blood eosinophils were 5.2 (range 0-21)%, 27/60 (45%) children were atopic and 8/60 (13%) had airway bacterial infection. There was no relationship between EVW, MTW and either blood eosinophils, atopic status, or infection. 67% in each group were prescribed ICS. 15/30 control subjects and 16/30 intervention group had UHCV over 4 months, p=0.8. Time to first UHCV was similar. 50% returned adherence monitors, in those, median ICS adherence was 67%. There were no differences in any parameter between those that did and did not have an UHCV. Conclusion: Clinical phenotype was unrelated to allergen sensitisation or blood eosinophils. ICS treatment determined by blood eosinophils did not impact UHCV, but ICS adherence was poor.

Burnout: modeling, measuring, and managing

Objective: As burnout has been neglected in medical and psychiatric education, we seek to provide a summary overview. Methods: We extract salient findings from the published literature and offer some challenges. Results: We critique the current principal model of burnout, argue for broadening the symptom constructs and for a diathesis-stress model where a perfectionistic personality style is a key predisposing factor, and observe that burnout is not limited by those in formal work. We argue that burnout is not synonymous with depression, overview biological underpinnings, and summarise a three-fold management model. Conclusion: As many burnout patients are referred to psychiatrists, awareness of its symptom pattern and management nuances is of key importance.

Anosmia but Not Ageusia as a COVID-19-Related Symptom among Cancer Patients—First Results from the PAPESCO-19 Cohort Study

Background: Cancer patients may fail to distinguish COVID-19 symptoms such as anosmia, dysgeusia/ageusia, anorexia, headache, and fatigue, which are frequent after cancer treatments. We aimed to identify symptoms associated with COVID-19 and to assess the strength of their association in cancer and cancer-free populations. Methods: The multicenter cohort study PAPESCO-19 included 878 cancer patients and 940 healthcare workers (HCWs). At baseline and quarterly thereafter, they reported the presence or absence of 13 COVID-19 symptoms observed over 3 months and the results of routine screening RT-PCR, and they were systematically tested for SARS-CoV-2-specific antibodies. We identified the symptom combinations significantly associated with COVID-19. Results: Eight percent of cancer patients were COVID-19 positive, and 32% were symptomatic. Among the HCWs, these proportions were 9.5 and 52%, respectively. Anosmia, anorexia, fever, headache, and rhinorrhea together accurately discriminated (c-statistic = 0.7027) COVID-19 cases from cancer patients. Anosmia, dysgeusia/ageusia, muscle pain, intense fatigue, headache, and chest pain better discriminated (c-statistic = 0.8830) COVID-19 cases among the HCWs. Anosmia had the strongest association in both the cancer patients (OR = 7.48, 95% CI: 2.96–18.89) and HCWs (OR = 5.71, 95% CI: 2.21–14.75). Conclusions: COVID-19 symptoms and their diagnostic performance differ in the cancer patients and HCWs. Anosmia is associated with COVID-19 in cancer patients, while dysgeusia/ageusia is not. Cancer patients deserve tailored preventive measures due to their particular COVID-19 symptom pattern.

Prevalence and Course of Depression During the First Year After Mild to Moderate Stroke

Background This study examined the prevalence and longitudinal course of depression during the first year after mild to moderate stroke. Methods and Results We identified patients with mild to moderate ischemic stroke or intracerebral hemorrhage (National Institutes of Health Stroke Scale score <16) and at least 1 depression assessment at 3, 6, or 12 months after stroke (n=648, 542, and 533, respectively) from the Brain Attack Surveillance in Corpus Christi project (2014–2016). Latent transition analysis was used to examine temporal profiles of depressive symptoms assessed by the 8‐item Patient Health Questionnaire between 3 and 12 months after stroke. Mean age was 65.6 years, 49.4% were women, and 56.7% were Mexican Americans. The prevalence of depression after stroke was 35.3% at 3 months, decreased to 24.9% at 6 months, and remained stable at 25.7% at 12 months. Approximately half of the participants classified as having depression at 3 or 6 months showed clinical improvement at the next assessment. Subgroups with distinct patterns of depressive symptoms were identified, including mild/no symptoms, predominant sleep disturbance and fatigue symptoms, affective symptoms, and severe/all symptoms. A majority of participants with mild/no symptoms retained this symptom pattern over time. The probability of transitioning to mild/no symptoms was higher before 6 months compared with the later period, and severe symptoms were more likely to persist after 6 months compared with the earlier period. Conclusions The observed dynamics of depressive symptoms suggest that depression after stroke tends to persist after 6 months among patients with mild to moderate stroke and should be continually monitored and appropriately managed.

Heterogeneity in Symptoms in Depression - A replication study in a Digital Mental Health Intervention using the PHQ-9 Questionnaire (Preprint)

BACKGROUND Past work has shown massive variation in depressive symptoms between patients, challenging the perception of major depressive disorder (MDD) as being uniform. This appears quite relevant also for digital mental health (DMH) interventions. While individualization is one of the key potentials of these approaches, this is regularly not utilized and the same static depression treatment is offered to all patients. OBJECTIVE This paper aims to replicate the approach from Fried & Nesse (2015), analyzing the variation of depressive symptoms within 1757 participants in a DMH intervention for depression and anxiety. METHODS Participants’ answers to the single items of the Patient Health Questionnaire 9-item scale (PHQ-9) were used to identify distinct patterns out of the 9 core symptoms of the DSM-5. RESULTS Overall, the 1757 participants showed 231 different patterns of symptoms. The most regular pattern occurred for 8% of the patients. 85% of the participants had a symptom pattern that was shared with less than 4% of the whole sample. The number of unique symptom patterns per participant decreased with higher symptom severity, but the 342 patients with overall severe depression symptoms still exhibited 34 different constellations of single symptoms. CONCLUSIONS The large variation in symptoms challenges the assignment of static depression interventions in DMH and calls for more individualized treatment procedures. Luckily, such procedures can be implemented particularly easily in an app-based context, for example by modular program structures.

Clinical Correlations of Posttraumatic Nightmares in Survivors of Motor Vehicle Accidents

Background: We evaluated the severity and clinical correlates of nightmares of persons injured in high impact motor vehicle accidents (MVAs). Method: De-identified data of 80 post-MVA patients (mean age 38.9 years, SD=12.8) were available and included scores on Item 2 of the PCL-5 (severity of repeated, disturbing dreams of the stressful event). Scores were also available on the Brief Pain Inventory (BPI), Morin’s Insomnia Severity Index (ISI), Rivermead Post-concussion Symptoms Questionnaire, Subjective Neuropsychological Symptoms Scale (SNPSS), Whiplash Disability Questionnaire, and on three questionnaire measures of driving anxiety (Steiner’s, Whetstone’s, and DAQ). The patients were assessed, on the average, 49.7 weeks (SD=36.3) after their MVA; all still experienced active post-MVA symptoms requiring therapy. Results: Clinically relevant levels of MVA nightmares were reported by 62.5% of post-MVA patients. Subjectively more aversive levels of MVA nightmares correlated with higher driving anxiety as measured by the Whetstone questionnaire and DAQ, with higher levels of average post-accident pain and insomnia, with post-accident neuropsychological symptoms as measured by the Rivermead and SNPSS, and with higher post-accident levels of depression, anger, and generalized anxiety. Discussion and Conclusions: Almost two-thirds of our post-MVA patients reported MVA nightmares and their level of subjectively aversive impact correlated with most variables within the typical polytraumatic symptom pattern of these patients.

Phantom Brake Phenomenon in Survivors of Car Accidents

Background: Survivors of high impact car accidents, when traveling in cars as passengers, may exhibit the phantom brake reaction. The reaction consists of involuntarily pressing the foot on the floor of the car in a reflexive attempt "to brake", even though there is no brake pedal in front of the passenger seat. This study examines the incidence and correlates of this special phenomenon. Method: De-identified data of 114 survivors (37 men, 77 women; mean age 38.6, SD=12.4) of high impact motor vehicle accidents (MVAs) were available, with their responses to the Brief Pain Inventory, Insomnia Severity Index, Rivermead Post-Concussion Symptoms Questionnaire, Subjective Neuropsychological Symptoms Scale (SNPSS), PTSD Checklist for DSM-5 (PCL-5), ratings of depression and of generalized anxiety, and 3 questionnaire measures of driving anxiety, i.e., Whetstone’s, Steiner’s, and the Driving Anxiety Questionnaire (DAQ). One item of the DAQ assesses the phantom brake phenomenon on a 4-point scale (0=No, 1=Mild, 2=Moderate, 3=Severe): this is the key variable in the present study. Results: Mild to severe forms of the phantom brake reaction were reported by 92.1% of the post-MVA patients. Significant correlations (p<0.05, 2-tailed) were found of the intensity of phantom brake reaction to the intensity of post-MVA pain (rs from 0.20 to 0.33), insomnia (r=0.40), the Rivermead post-concussion scale (r=.29), other post-concussive and whiplash symptoms as measured by the SNPSS (r=0.19), depression (r=0.30), generalized anxiety (r=0.32), and to DAQ (r=0.47) and Whetstone’s (r=0.50) measures of driving anxiety. No significant relationships were found of the phantom brake reaction to age and gender. Discussion and Conclusion: The phantom brake reaction was reported by almost all post-MVA patients and can be considered as a part of their post-MVA polytraumatic symptom pattern.

Electrical cardioversion to assess the association between self-reported symptoms and rhythm status in patients with persistent atrial fibrillation

Funding Acknowledgements Type of funding sources: None. Background. Knowledge about the association between symptoms and rhythm status (symptom-rhythm correlation) has potential clinical implications as it may identify patients with atrial fibrillation (AF) who profit from rhythm control in regard to reduction in symptom burden and improvement in quality of life. However, standardized strategies to assess symptom-rhythm correlation in AF patients are currently not available. Purpose. This study aimed to assess symptom-rhythm correlation in patients with persistent AF using electrical cardioversion (ECV) as a diagnostic probe. Methods. We used ECV to examine symptom-rhythm correlation in 81 patients with persistent AF. The presence of self-reported symptoms before ECV and at the first outpatient AF clinic follow-up visit (within 1-month) was assessed to determine the prevalence of a symptom-rhythm correlation (defined as self-reported symptoms present during AF and absent in sinus rhythm or absent in AF and yet relief during sinus rhythm). The symptom-rhythm correlation was absent in patients with symptoms before ECV who remained symptomatic during sinus or in patients with symptoms prior to ECV and without symptoms in AF after ECV. Asymptomatic patients before ECV with or without symptoms in AF or sinus rhythm afterwards had no symptom-rhythm correlation as well. The symptom-rhythm correlation was unevaluable in patients who were symptomatic in AF before ECV and at the first outpatient AF clinic follow-up visit. In addition, predominant self-reported symptoms (symptoms with highest self-reported symptom burden) were assessed to evaluate the symptom patterns around ECV. Intra-individually variable symptom patterns were defined as changes in predominant self-reported symptoms within patients around ECV. Results. Symptom-rhythm correlation was assessed in all patients. Only in 18 patients (22%), a symptom-rhythm correlation could be documented. Twenty-eight patients (35%) did not show any symptom-rhythm correlation and 35 patients (43%) had an unevaluable symptom-rhythm correlation as these patients were in symptomatic AF both at baseline and at the first outpatient AF clinic follow-up visit. Importantly, self-reported symptom patterns around ECV were intra-individually variable in 10 patients (12%) without symptom-rhythm correlation (of which 9 patients (11%) had AF recurrence) and in 2 patients (2%) with an unevaluable symptom-rhythm correlation. Conclusions. In patients with persistent AF, the prevalence of a symptom-rhythm correlation around ECV is low, but ECV often changes symptom pattern. Further studies are warranted to identify more optimal strategies to assess symptom-rhythm correlation in patients with persistent AF. Abstract Figure. Symptom-rhythm correlation and patterns

Evaluation and Management Outcomes and Burdens in Patients with Refractory Chronic Cough Referred for Behavioral Cough Suppression Therapy

Purpose The purpose of this study was to investigate the typical symptoms and medical management characteristics of adult patients with refractory chronic cough (RCC) who are referred to speech-language pathology (SLP) for behavioral cough suppression therapy (BCST) in order to estimate cost-effectiveness and efficiency of current practice patterns for this population. Methods One hundred sixty-four (164) patients with RCC referred for BCST were surveyed. Patients completed an initial survey at BCST onset related to symptom pattern and prior treatment, including the Leicester Cough Questionnaire (LCQ). Every four to six weeks patients completed follow-up surveys to assess their response to BCST. Results Mean age was 58 years (83.5% women). The majority of patients reported their cough began two or more years prior to BCST. Approximately half (49%) reported seeing four or more physicians (including primary care physicians) and being prescribed four or more medications (57%) prior to BCST. Medications targeting post-nasal drip (72%), reflux (70%), asthma (56%), and allergies (56%) were most commonly prescribed. BCST resulted in a clinically significant improvement in 70.1% of participants. The mean change in LCQ for those who improved with BCST was 6.61. Over half (58%) reported they were quite satisfied to completely satisfied with their treatment response. The average time from enrollment to study completion was 64 days. Conclusion The results of this study suggest early intervention with BCST may be a cost-effective and efficient option for patients with RCC.