Ψυχοκοινωνικοί παράγοντες που σχετίζονται με την εμφάνιση του καρκίνου του μαστού

Ο καρκίνος του μαστού, παρά την ραγδαία εξέλιξη των διαγνωστικών μεθόδων και των καινοτόμων παρεμβάσεων, εξακολουθεί να αποτελεί μία από τις κύριες αιτίες νοσηρότητας από καρκίνο και πρόωρης θνητότητας των γυναικών σε παγκόσμιο επίπεδο. Τα τελευταία χρόνια γίνεται ιδιαίτερος λόγος για τη διερεύνηση όχι μόνο των βιολογικών και περιβαλλοντικών, αλλά και των ψυχοκοινωνικών παραγόντων που ενδεχομένως σχετίζονται με την έκλυση ή/και την πορεία της νόσου. Σκοπός της παρούσας έρευνας αποτελεί, η διερεύνηση της πιθανής σχέσης ψυχολογικών παραγόντων και κοινωνικών συνθήκων με τον καρκίνο του μαστού. Συγκεκριμένα, διερευνάται εάν τα ψυχοπιεστικά γεγονότα ζωής και το αντιλαμβανόμενο στρες συμβάλουν στην αυξημένη ευαλωτότητα, εάν η ψυχική ανθεκτικότητα λειτουργεί προστατευτικά καθώς και εάν η νόσος συνοδεύεται από αυξημένη συμπτωματολογία άγχους και κατάθλιψης. Μία ομάδα γυναικών υπό θεραπεία για κακοήθεια μαστού σε Νοσοκομειακές μονάδες των Αθηνών (Ν=109) συγκρίθηκε με μια ομάδα ελέγχου χωρίς κακοήθεια (Ν=98). Οι συμμετέχουσες συμπλήρωσαν ερωτηματολόγιο που περιλάμβανε α) την κλίμακα βαθμολόγησης Στρεσσογόνων Γεγονότων (Social Readjustment Rating Scale των Holmes & Rahe), για την τελευταία πενταετία β) την κλίμακα Αντιλαμβανόμενου Στρες (PSS-14) για το πόσο αισθάνονταν στρες στη ζωή τους τα τελευταία πέντε χρόνια γ) την κλίμακα ψυχικής Ανθεκτικότητας (Connor-Davidson Resilience Scale, CD-RISC) δ) την κλίμακα τρέχουσας συμπτωματολογίας Άγχους και Κατάθλιψης (Hospital Anxiety and Depression Scale, HADS) ε) κλειστές ερωτήσεις αναφορικά με παράγοντες κινδύνου σχετιζόμενους με καρκίνο μαστού καθώς κοινωνικό-δημογραφικά χαρακτηριστικά. Στις γυναίκες με καρκίνο του μαστού βρέθηκε ότι το αντιλαμβανόμενο στρες, σε βάθος πενταετίας ήταν σε υψηλότερα επίπεδα συγκριτικά με την ομάδα ελέγχου ενώ τα στρεσσογόνα γεγονότα ζωής δεν διέφεραν μεταξύ των δύο ομάδων. Επίσης τα στρεσσογόνα γεγονότα ζωής παρουσίαζαν ασθενή συσχέτιση με το αντιλαμβανόμενο στρες. Η ψυχική ανθεκτικότητα των ασθενών δεν διέφερε από αυτήν της ομάδας ελέγχου αλλά όσο χαμηλότερη ήταν η ανθεκτικότητα τόσο υψηλότερο ήταν το αντιλαμβανόμενο στρες. Τέλος η συμπτωματολογία άγχους και κατάθλιψης δεν βρέθηκε, στατιστικά σημαντικά, αυξημένη στις γυναίκες με καρκίνο του μαστού παρότι το αντιλαμβανόμενο στρες είχε τη μεγαλύτερη προβλεπτική ισχύ για τα επίπεδα τόσο του άγχους όσο και της κατάθλιψης. Επισημαίνεται ότι οι δύο ομάδες δεν διέφεραν σε στατιστικά σημαντικό βαθμό ως προς τους παράγοντες κινδύνου από το ιατρικό τους ιστορικό, επομένως το αντιλαμβανόμενο μακροχρόνιο στρες βρέθηκε να αποτελεί πρόσθετο παράγοντα κινδύνου. Τα ευρήματα υπογραμμίζουν την αναγκαιότητα σχεδιασμού προγραμμάτων ψυχοκοινωνικής υποστήριξης των γυναικών με καρκίνο του μαστού αλλά και προγραμμάτων πρόληψης σε εθνικό επίπεδο, με έμφαση στο αντιλαμβανόμενο στρες και την προαγωγή της ψυχικής ανθεκτικότητας.Breast cancer, despite the rapid development of diagnostic methods and innovative interventions, is still one of the main causes of cancer morbidity and early death in women. Scientific discourse and research, for the last several years, has been studying not only the biological and environmental aspects but also the psycho-social factors that are associated with the onset and the course of the disease. The aim of the present study was to investigate the role of stress and resilience as well as depressive and anxiety symptomatology in breast cancer. Specifically it was examined whether objective and subjective stress contribute in higher vulnerability for breast cancer, whether psychological resilience is a protective factor and whether women with breast cancer have increased levels of depressive and anxiety symptoms, associated with psychological vulnerability. A group of women, who were or had been treated for breast cancer, in hospital units of Athens (Ν=109) was compared to a control group of women without the disease (Ν=98). All participants completed a self-administered questionnaire which included: a) the Social Readjustment Rating Scale (Holmes & Rahe SRRS) measuring stressful life events during the last five years b) The Perceived Stress Scale (PSS-14) measuring subjective stress during the last five years c) the Connor-Davidson Resilience Scale (CD-RISC) d) the Hospital Anxiety and Depression Scale (HADS) and e) a number of closed questions regarding demographic characteristics, information about lifestyle habits considered as risk factors and information from the medical record of women concerning risks for breast cancer. Results indicated that perceived stress was higher in breast cancer patients while the more objective measure of stress was not. Resilience among cases was not significantly different from controls, but the lower the resilience the higher the perceived stress, in both groups. Finally, current depressive and anxiety symptomatology was not higher in women with breast cancer, although the main predictor for both anxiety and depression symptoms among breast cancer patients was perceived stress. The two groups were balanced with respect to all other possible confounders, except for psychiatric treatment but even after adjustment for this effect, the only psychological factor found to be linked with breast cancer was perceived stress. Findings underline the importance of perceived stress in the onset and course of breast cancer, thus providing a key objective for effective psychological interventions. Programs for the psychological support of women with breast cancer as well as health promoting programs aiming at prevention of breast cancer, should put the emphasis on building resilience and manage perceptions of stress

Systemic antifungal therapy for tinea capitis in children

BACKGROUND: Tinea capitis is a common contagious fungal infection of the scalp in children. Systemic therapy is required for treatment and to prevent spread. This is an update of the original Cochrane review. OBJECTIVES: To assess the effects of systemic antifungal drugs for tinea capitis in children. SEARCH METHODS: We updated our searches of the following databases to November 2015: the Cochrane Skin Group Specialised Register, CENTRAL (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), and CINAHL (from 1981). We searched five trial registers and checked the reference lists of studies for references to relevant randomised controlled trials (RCTs). We obtained unpublished, ongoing trials and grey literature via correspondence with experts in the field and from pharmaceutical companies. SELECTION CRITERIA: RCTs of systemic antifungal therapy in children with normal immunity under the age of 18 with tinea capitis confirmed by microscopy, growth of fungi (dermatophytes) in culture or both. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 25 studies (N = 4449); 4 studies (N = 2637) were new to this update. Terbinafine for four weeks and griseofulvin for eight weeks showed similar efficacy for the primary outcome of complete (i.e. clinical and mycological) cure in three studies involving 328 participants with Trichophyton species infections (84.2% versus 79.0%; risk ratio (RR) 1.06, 95% confidence interval (CI) 0.98 to 1.15; low quality evidence). Complete cure with itraconazole (two to six weeks) and griseofulvin (six weeks) was similar in two studies (83.6% versus 91.0%; RR 0.92, 95% CI 0.81 to 1.05; N = 134; very low quality evidence). In two studies, there was no difference between itraconazole and terbinafine for two to three weeks treatment (73.8% versus 78.8%; RR 0.93, 95% CI 0.72 to 1.19; N = 160; low quality evidence). In three studies, there was a similar proportion achieving complete cured with two to four weeks of fluconazole or six weeks of griseofulvin (41.4% versus 52.7%; RR 0.92, 95% CI 0.81 to 1.05; N = 615; moderate quality evidence). Current evidence for ketoconazole versus griseofulvin was limited. One study favoured griseofulvin (12 weeks) because ketoconazole (12 weeks) appeared less effective for complete cure (RR 0.76, 95% CI 0.62 to 0.94; low quality evidence). However, their effects appeared to be similar when the treatment lasted 26 weeks (RR 0.95, 95% CI 0.83 to 1.07; low quality evidence). Another study indicated that complete cure was similar for ketoconazole (12 weeks) and griseofulvin (12 weeks) (RR 0.89, 95% CI 0.57 to 1.39; low quality evidence). For one trial, there was no significant difference for complete cure between fluconazole (for two to three weeks) and terbinafine (for two to three weeks) (82.0% versus 94.0%; RR 0.87, 95% CI 0.75 to 1.01; N = 100; low quality evidence). For complete cure, we did not find a significant difference between fluconazole (for two to three weeks) and itraconazole (for two to three weeks) (82.0% versus 82.0%; RR 1.00, 95% CI 0.83 to 1.20; low quality evidence). This update provides new data: in children with Microsporum infections, a meta‐analysis of two studies found that the complete cure was lower for terbinafine (6 weeks) than for griseofulvin (6‐12 weeks) (34.7% versus 50.9%; RR 0.68, 95% CI 0.53 to 0.86; N = 334; moderate quality evidence). In the original review, there was no significant difference in complete cure between terbinafine (four weeks) and griseofulvin (eight weeks) in children with Microsporum infections in one small study (27.2% versus 60.0%; RR 0.45, 95% CI 0.15 to 1.35; N = 21; low quality evidence). One study provides new evidence that terbinafine and griseofulvin for six weeks show similar efficacy (49.5% versus 37.8%; RR 1.18, 95% CI 0.74 to 1.88; N = 1006; low quality evidence). However, in children infected with T. tonsurans, terbinafine was better than griseofulvin (52.1% versus 35.4%; RR 1.47, 95% CI 1.22 to 1.77; moderate quality evidence). For children infected with T. violaceum, these two regimens have similar effects (41.3% versus 45.1%; RR 0.91, 95% CI 0.68 to 1.24; low quality evidence). Additionally, three weeks of fluconazole was similar to six weeks of fluconazole in one study in 491 participants infected with T. tonsurans and M. canis (30.2% versus 34.1%; RR 0.88, 95% CI 0.68 to 1.14; low quality evidence). The frequency of adverse events attributed to the study drugs was similar for terbinafine and griseofulvin (9.2% versus 8.3%; RR 1.11, 95% CI 0.79 to 1.57; moderate quality evidence), and severe adverse events were rare (0.6% versus 0.6%; RR 0.97, 95% CI 0.24 to 3.88; moderate quality evidence). Adverse events for terbinafine, griseofulvin, itraconazole, ketoconazole, and fluconazole were all mild and reversible. All of the included studies were at either high or unclear risk of bias in at least one domain. Using GRADE to rate the overall quality of the evidence, lower quality evidence resulted in lower confidence in the estimate of effect. AUTHORS' CONCLUSIONS: Newer treatments including terbinafine, itraconazole and fluconazole are at least similar to griseofulvin in children with tinea capitis caused by Trichophyton species. Limited evidence suggests that terbinafine, itraconazole and fluconazole have similar effects, whereas ketoconazole may be less effective than griseofulvin in children infected with Trichophyton. With some interventions the proportion achieving complete clinical cure was in excess of 90% (e.g. one study of terbinafine or griseofulvin for Trichophyton infections), but in many of the comparisons tested, the proportion cured was much lower. New evidence from this update suggests that terbinafine is more effective than griseofulvin in children with T. tonsurans infection. However, in children with Microsporum infections, new evidence suggests that the effect of griseofulvin is better than terbinafine. We did not find any evidence to support a difference in terms of adherence between four weeks of terbinafine versus eight weeks of griseofulvin. Not all treatments for tinea capitis are available in paediatric formulations but all have reasonable safety profiles

Predicting the Risk of Rheumatoid Arthritis and Its Age of Onset through Modelling Genetic Risk Variants with Smoking

The improved characterisation of risk factors for rheumatoid arthritis (RA) suggests they could be combined to identify individuals at increased disease risks in whom preventive strategies may be evaluated. We aimed to develop an RA prediction model capable of generating clinically relevant predictive data and to determine if it better predicted younger onset RA (YORA). Our novel modelling approach combined odds ratios for 15 four-digit/10 two-digit HLA-DRB1 alleles, 31 single nucleotide polymorphisms (SNPs) and ever-smoking status in males to determine risk using computer simulation and confidence interval based risk categorisation. Only males were evaluated in our models incorporating smoking as ever-smoking is a significant risk factor for RA in men but not women. We developed multiple models to evaluate each risk factor's impact on prediction. Each model's ability to discriminate anti-citrullinated protein antibody (ACPA)-positive RA from controls was evaluated in two cohorts: Wellcome Trust Case Control Consortium (WTCCC: 1,516 cases; 1,647 controls); UK RA Genetics Group Consortium (UKRAGG: 2,623 cases; 1,500 controls). HLA and smoking provided strongest prediction with good discrimination evidenced by an HLA-smoking model area under the curve (AUC) value of 0.813 in both WTCCC and UKRAGG. SNPs provided minimal prediction (AUC 0.660 WTCCC/0.617 UKRAGG). Whilst high individual risks were identified, with some cases having estimated lifetime risks of 86%, only a minority overall had substantially increased odds for RA. High risks from the HLA model were associated with YORA (P<0.0001); ever-smoking associated with older onset disease. This latter finding suggests smoking's impact on RA risk manifests later in life. Our modelling demonstrates that combining risk factors provides clinically informative RA prediction; additionally HLA and smoking status can be used to predict the risk of younger and older onset RA, respectively

Treatment of Mycobacterium marinum cutaneous infections

Mycobacterium marinum is a non-tuberculous Mycobacterium found in non-chlorinated water, with worldwide prevalence. It is the most common atypical Mycobacterium that causes opportunistic infection in humans. It presents as a solitary, red-to-violaceous plaque or nodule with an overlying crust or verrucous surface, or as inflammatory nodules or abscesses, usually in a sporotrichotic type of distribution. Deep infections may also occur. Although diagnosis is confirmed by isolation and identification of the organism in practice diagnosis remains largely presumptive based on clinicohistological features and the response to treatment. Polymerase chain reaction allows the routine early detection of the organism from a biopsy specimen. In the near future, it seems possible that histopathological examination might be greatly assisted by the rapidly improving possibilities with in vivo imaging. There have been many therapeutic modalities used effectively in the treatment of M. marinum infections. Spontaneous remission has also been reported in untreated infections and in immunocompetent hosts. However, there is no proven treatment of choice because M. marinum is naturally multi-drug resistant species and treatment is based primarily on the personal experience and preference of individual investigators, without the benefit of large studies. In superficial cutaneous infections minocycline, clarithromycin, doxycycline and trimethoprim-sulfamethoxazole as monotherapy are effective treatment options, but drug resistance varies and thereby combination therapy usually of two drugs may be required. Ciprofloxacin has shown considerable effectiveness. In cases of severe infections, including those with a sporotrichoid distribution pattern, a combination of rifampicin and ethambutol seems to be the recommended regimen. The use of isoniazid, streptomycin and pyrazinamide as empirical treatment options should be avoided. Surgical treatment is not usually recommended and must be cautiously applied. Cryotherapy, X-ray therapy, electrodesiccation, photodynamic therapy and local hyperthermic therapy have been reported as effective therapeutic alternatives. M. marinum infection should always be included in the differential diagnosis of all cases with poor-healing wounds in upper extremities and a history of exposure to aquariums. © 2007 Informa UK Ltd

Pimecrolimus induced tinea incognito masquerading as intertriginous psoriasis

A 58-year-old, obese, male, army officer was presented with tinea incognito of the groin masking intertriginous psoriasis. According to his history, he had pruritic, symmetrical erythematous eruption of the groin of 2-month duration that he treated himself by using topical pimecrolimus 1%. This medication had been prescribed for his 8-year son&apos;s atopic dermatitis by the paediatrician. Direct examination with potassium hydroxide preparation showed fungal hyphae and Trichophyton rubrum was isolated in culture. This is the second case of topical pimecrolimus induced tinea incognito. We also review the cutaneous disorders that tinea incognito may mimic. © 2007 The Authors