Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2017-08-30T12:54:55Z No. of bitstreams: 1 Andréa Chiarella.pdf: 1007685 bytes, checksum: 4d0982ec3090d33009e0f68b976de79f (MD5) / Made available in DSpace on 2017-08-30T12:54:55Z (GMT). No. of bitstreams: 1 Andréa Chiarella.pdf: 1007685 bytes, checksum: 4d0982ec3090d33009e0f68b976de79f (MD5) Previous issue date: 2017-08-25 / Pontifícia Universidade Católica de São Paulo - PUCSP / Somatic manifestations and the processes involved are increasingly present in the psychoanalytic clinic. In this way, the body becomes a place of flow for emotions and affections that could not be elaborated psychically. Always in search of a better understanding of what happens with cancer patients, especially those affected by leukemia, I propose in this work a reflection about the possible relation between initial environment, early trauma and the outbreak of cancer in adult life. Through the study of the clinical case of a patient affected by acute leukemia, I seek to gather clinical experience, research and theory, according to the model postulated by Freud, to think of more comprehensive models of clinical management in the treatment of these cases / As manifestações somáticas e os processos nela envolvidos estão cada vez mais presentes na clínica psicanalítica. Desta maneira, o corpo se torna um lugar de vazão para emoções e afetos que não puderam ser elaborados psiquicamente. Sempre em busca de uma maior compreensão do que ocorre com os indivíduos com câncer, especialmente aqueles acometidos pela leucemia, proponho neste trabalho uma reflexão acerca da possível relação entre ambiente inicial, traumas precoces e a eclosão da doença na vida adulta. Através do estudo do caso clínico de um paciente acometido por leucemia do tipo aguda, busco reunir experiência clínica, pesquisa e teoria, conforme postulado por Freud, para pensar em modelos mais abrangentes de conduta clínica nos tratamentos destes casos

Currently, there are an estimated 2.8 million breast cancer survivors in the United States. Due to modern screening practices and raised awareness, the majority of these cases will be diagnosed in the early stages of disease where highly effective treatment options are available, leading a large proportion of these patients to fail from causes other than breast cancer. The primary cause of death in the United States today is cardiovascular disease, which can be delayed or prevented with interventions such as lifestyle modifications or medications. In order to identify individuals who may be at high risk for a cardiovascular event or cardiovascular mortality, a number of prognostic models have been developed. The majority of these models were developed on populations free of comorbid conditions, utilizing statistical methods that did not account for the competing risks of death from other causes, therefore it is unclear whether they will be generalizable to a cancer population remaining at an increased risk of death from cancer and other causes. Consequently, the purpose of this work is multi-fold. We will first summarize the major statistical methods available for analyzing competing risk data and include a simulation study comparing them. This will be used to inform the interpretation of the real data analysis, which will be conducted on a large, contemporary cohort of breast cancer survivors. For these women, we will categorize the major causes of death, hypothesizing that it will include cardiovascular failure. Next, we will evaluate the existing cardiovascular disease risk models in our population of cancer survivors, and then propose a new model to simultaneously predict a survivor's risk of death due to her breast cancer or due to cardiovascular disease, while accounting for additional competing causes of death. Lastly, model predicted outcomes will be calculated for the cohort, and evaluation methods will be applied to determine the clinical utility of such a model.

Background: Advanced breast cancer (ABC) is affecting substantial number of Chinese women in Hong Kong. Understanding their unmet supportive care needs (SCNs) is important for health care system to precisely allocate resources to areas demanded for help the most and for patients to achieve better quality of life. Objectives: (1) To validate Chinese version of Supportive Care Needs Survey Questionnaire (SCNS-SF34), (2) to address the prevalence of unmet SCNs at baseline (newly diagnosis of ABC) and explore relevant factors associating with baseline unmet SCNs, (3) to identify the trajectories of unmet SCNs from baseline, 6-week, 12-week, 18-week to one-year post-diagnosis of ABC among Hong Kong Chinese women and identify the predictors related to individual resources. Methods: The study consisted of two phases. In Phase I, breast cancer (BC) patients were recruited from six public hospitals and the SCNS-SF34 (which covers five domains of needs) was administered concurrently with measures of psychological distress CHQ-12 (Chinese Health Questionnaire-12), HADS (Hospital Anxiety and Depression Scale), symptom distress (MSAS-SF), and patient satisfaction (ChPSQ-9) to explore factor structure by using Exploratory Factor Analysis (EFA) and to examine internal consistency, and convergent, divergent and discriminant validities of the identified factor structure. In phase II, women newly diagnosed with ABC were recruited and followed up to assess their unmet SCN trajectories one year after diagnosis. Prevalence of initial baseline SCNs and associated demographic, medical and psychological factors were identified. Linear Mixed Modeling (LMM) was performed to assess trajectories for each SCNs domain. Hypothesized variables reflecting personal and social resources (optimism, trait hope, social support, psychological distress and patient satisfaction) were examined for association with the changes of unmet SCNs after adjusting for demographic and medical characteristics. Results: Instead of five-factor structure identified in the original SCNS-SF34, a four-factor structure with 33 items was identified, comprising: 1) Health system, information and patient support needs (HSIPS), 2) Psychological needs (PSYC), 3) Physical and daily living needs (PDL) and 4) Sexuality needs (SEX). The SCNS-SF33-C demonstrated moderate-to-good internal consistency (Cronbach’s alphas=0.75-0.92) across all domains. Acceptable convergent and divergent validity were demonstrated. Discriminant validity was demonstrated in the SCNS-SF33-C’s ability to differentiate between clinically distinct patient groups (ABC vs. localized BC and active treatment vs. no active treatment). Of the top 15 unmet SCNs, all belonged to the HSIPS domain. There were significant linear declines in unmet HSIPS and PSYC needs over the year after diagnosis, but not in PDL and SEX. After adjusting for demographic and medical factors, LMM identified symptom distress, patient satisfaction and patient satisfaction x time are predictors of HSIP. Total symptom distress, optimism, anxiety and anxiety x time predicted PSYC. Total symptom distress was predictor of PDL. Anxiety was predictor of SEX. Conclusions: The SCNS-SF33-C has a suitable factor structure and psychometric properties for the use in assessing unmet psychosocial SCN among Chinese women with BC. Generally, unmet HSIP and PSYC tended to decline, while levels of unmet PDL and SEX tended to persist over time. Specific individual resources predicted the future change of unmet SCNs. / published_or_final_version / Community Medicine / Master / Master of Philosophy

The most common form of childhood cancer is Acute Lymphoblastic Leukemia (ALL). Patients treated for ALL may experience short- and long-term physiological and cognitive effects due to treatment. However, delayed emotional and behavioral effects in pediatric survivors, as well as risk-factors that may make them more susceptible to developing problems with psychological and behavioral functioning are less understood. Studies investigating pediatric survivors have demonstrated that negative emotional and behavioral late effects can and do occur (Hobbie et al., 2000; Buizer et al. 2006; Novakovic et al., 1996; Mulhern, Wasserman, Friedman, & Fairclough, 1989), and it has been purported that survivors experience higher rates of depression, anxiety and low self-esteem (Koocher, O’Malley, Gogan, & Foster, 1980; Kazak, 1994). Anxiety in particular, has been identified as one of the longest lasting psychological sequelae of cancer (Kazak, 1994). Still, the data on long-term psychological sequelae is mixed, with some studies suggesting healthy, long-term, psychological adjustment (Brown et al., 1992; Fritz, Williams & Amylon, 1988; Greenberg, Kazak, & Meadows, 1989). This pilot study attempted to investigate emotional and behavioral late effects of cancer as reported by survivors and their caregivers on the Behavior Assessment System for Children, Second Edition (BASC-2). This study also investigated potential risk factors that made it more likely to develop emotional and behavioral late-effects. This study hypothesized that females, those undergoing high intensity chemotherapy, and those starting chemotherapy at an earlier age, would report significantly more internalizing and externalizing problems. Analysis revealed significant differences in reporting of anxiety, depression, attention and hyperactivity symptoms combined based on the age when treatment started. No other significant findings were uncovered; however, in an effort to provide directions for future research, patterns in the data were examined by comparing overall means on BASC-2 subscales. For example, females reported more hyperactive symptoms than males. In general, individuals who started treatment at younger ages reported more difficulty with emotional and behavioral functioning. Additionally, males and females adaptive behavior fell within normal limits. Overall, no BASC-2 mean scores were in the at-risk or clinically significant range of impairment suggesting adequate emotional, behavioral and adaptive functioning overall. / text

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

This study employed a qualitative hermeneutic methodology to compare and explore the stress faced by families caring for a family member with cancer or HIV/AIDS. Four 'Indian' families, two with a family member with cancer and two with a family member with HIV/AIDS, were purposiveiy sampled through NGOs in Pietermaritzburg and Durban. Generally it appeared that the illnesses brought about a range of stressors in families including fmancial and care-related stressors, role changes, difficulties accessing medical treatment, uncertainty and the psychological responses of family members. The impact of these on families was mediated by the families' abilities, social support, a variety of meaning factors and stigma. It did however, appear that families caring for a family member with HIV/AIDS had to cope with several additional burdens including coping with a more prolonged and variable period of illness, fears of infection, increased difficulties accessing medical treatment, less social support and stigma. / Thesis (M.A.)-University of Natal, Pietermaritzburg, 2002. / Konrad Schrenk

Reviews conflict regarding the effectiveness of psycho-oncological therapies at reducing patient anxiety, depression and general distress, suggesting that unknown factors are moderating trial results. This meta-analysis investigates the moderating impact of a large range of socio-demographic, psychological, medical and therapy factors using published and unpublished data from 146 prospective controlled trials, including non-random designs. Preliminary analyses of trial design quality features exposed 2 moderators: recruit screening for psychological distress or history, and the nature of the control condition. These structured a 2 x 2 matrix used to conduct substantive analyses. Admitting only recruits with established baseline distress was found to predict greater effect size, as was excluding patients with a history of distress. Main effects for patients with baseline distress compared with untreated controls, were medium-strong at g = 0.52 - 0.70. Evidence of varying strengths indicated that patients who were older, of lower income, male, single, or suffering from cancer sited elsewhere than breast produced higher effect sizes. Data also highlighted particular stages in the cancer journey: re-entry to normal life at the end of medical treatment, recurrence, and distant disease spread. Findings suggest that risk and distress screening should be employed by both clinicians and researchers. Researchers should also re-direct attention away from unscreened middle class early stage breast cancer patients, towards more vulnerable socio-demographic and medical groups. The potential of using survivors and indirect therapies to effectively and efficiently reach vulnerable groups deserves exploration. Reviewers need to take into account the 2 trial design moderators discovered, and should include non-random controlled trials which may have more access to particularly vulnerable groups because some past conclusions were confounded by the co-variation of study design with sampling characteristics.

Thesis (MNutr (Interdisciplinary Health Sciences. Human Nutrition))--Stellenbosch University, 2008. / Background This study aimed to define the prevalence of side-effects and the change in weight and BMI during radical radiotherapy for head and neck malignancies (HNM) at Tygerberg Academic Hospital (TBH), Western Cape, South Africa. Acute side-effects may delay or prevent the delivery of a complete curative radiotherapy dose. Weight loss has been shown to significantly worsen prognosis and increase prevalence of treatment complications. However, weight maintenance may lead to beneficial outcomes. Assessing the impact of radical radiotherapy on patients with HNM is therefore critical and can promote development and implementation of medical and nutritional interventions. Methods Patients were weighed before and weekly during radiotherapy. Blood was drawn before, during and at the end of radiotherapy so that the Prognostic Inflammatory and Nutritional Index (PINI) could be calculated. Selected clinical data, clinical grades of mucositis and the diagnosis of a fungal infection of the oral cavity were extracted from clinical records. The McMaster Head and Neck Radiotherapy Questionnaire and a Lifestyle and Dietary Questionnaire were administered weekly. Descriptive statistics and the following were used: ANOVA, Repeated Measures ANOVA and McNemar Chi-square tests. Results Thirty-eight patients were recruited and 21 completed the study. Follow-up occurred over a maximum of nine weeks. A decrease in the weight (p = 0.01) and BMI (p = 0.01) and increase in the PINI (p = 0.04) occurred during radiotherapy. The mean absolute weight loss was 3.2kg (4.8), the mean percentage weight loss was 4.5% (6.7) and the mean decrease in BMI was 1.2kg/m2 (1.8). There was an increase in the prevalence of malnutrition (p = 0.02), as defined in this study. Oral mucositis occurred in all participants from Week 4; the majority developing Grade II or III Mucositis. Fungal infection of the oral cavity was prevalent throughout radiotherapy, with the highest prevalence (30%) in Week 4. Increases in severity of symptoms related to the mouth (p = 0.0000), throat (p = 0.05) and skin domains (p = 0.0000) occurred. Fifty-nine percent of inpatients and 45% of outpatients were prescribed supplementation drinks and most participants reported that a dietitian had not consulted them, in each week of radiotherapy. Discussion Severe side-effects in the mouth, throat and skin were experienced and a decline in nutritional status was observed. The poor nutritional status prior to commencing and weight loss during radiotherapy could have increased the severity of side-effects. The induction of the acute phase response indicated that this could have contributed to the decline in nutritional status observed. In addition, the infrequent nutritional support is likely to have further contributed to the lack of weight maintenance. Conclusion This first study conducted in South Africa has demonstrated the prevalence of significant side-effects and change in weight and BMI in this patient population. It is recommended that more effective analgesic medication is prescribed and that measures are taken to improve oral hygiene of participants to prevent fungal infection of the oral cavity. Improved nutritional support in terms of regular dietetic follow-up of all patients and more frequent prescription of supplementation drinks during radiotherapy is also recommended.

M.A. (Social Work) / Cancer is a common condition and is becoming an important issue in South Africa. During their lifetime people may develop different forms of cancer such as lung -, throat -, skin -, colon -, and breast cancer. Cancer affects people of different age groups from small children up to older people. It cuts across different racial groups and different socio economic levels. The patient with cancer faces one of the greatest stress situations known to man. Cancer is frequently a chronic disease. Acute periods of illness or intensive therapy may interrupt periods of normality for months or years. Treatment may necessitate major alterations in lifestyle or normal body functions. The diagnosis of cancer is seen by many as synonymous with death. (Kellogg & Sullivan : 1978) Kellogg (1978) believes that the fear of loss of self determination, of being dependent and non - productive, can be more stressful than the prospect of death itself. The patient may also fear that the disease, the results of treatment, or the changes he presumes will result, will cause others to isolate or abandon him...

This study utilized ethnographic methodology to describe the communicative interactional patterns in families with a member who has breast cancer. Three breast cancer patients whose families were between the adolescent and launching of children developmental lifestage (McGoldrick & Carter, 1982) were chosen for the study. Data were collected from a series of three interview sessions over a period of four weeks with a two week time lapse between each of the interview sessions. Interview sessions were conducted in the families' homes by the researcher. All interviews were video and audio tape recorded for the purpose of preserving data for transcribing and coding. Research questions examined individual perception of meaning in regard to the disease, the structure and organization of the family in relation to the illness, and the effects of family communicative interaction on the course and management of the disease. Findings indicated that family members' responses to the diagnosis of "breast cancer were influenced by multi-generational "beliefs. All three families formulated a collective belief which supported the mother's belief about the disease. Each of the three families were mother-centered, and each mother seemed to use a metacommunicative approach to mediating family transactions. Each of the three fathers were reported as having been isolated and withdrawn within the family at various times. However, each father appeared to play a protective role in deflecting tension and stress away from the mother. All three couples appeared to have constructed an egalitarian relationship with an implicit agreement as to who was more skilled to hold the power within a particular context. In all three families, the generational boundaries were clearly defined. Conflict and affect were most generally expressed in an indirect manner through wit and sarcasm. However, because each of these three families were structured to allow for personal autonomous functioning of each individual member, patients were supported in seeking a modality outside of the family system to express more ambivalent feelings.