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The activity can be a pharmacological response wellbutrin 300mg with mastercard depression symptoms nightmares, binding discount 300 mg wellbutrin amex mood disorder with psychotic features code, toxicity or any other quantiﬁable event order online wellbutrin anxiety meditation. These essential functional groups for the pharmacological activities are called pharmacophores. A number of approved drugs have also been forced to be withdrawn from the market beacuse of toxicities. For example, in 2004, Merck’s arthritis drug Vioxx was withdrawn owing to severe cardiovascular side-effects, and the Parke-Davis and Warner-Lambert antidiabetic drug troglitazone (Rezulin) was withdrawn from the market in 2000 after it was found to cause severe liver toxicity. The drug industries expend considerable time and effort trying to avoid or minimize toxic effects by identifying and altering the functional groups responsible for toxic effects. A change in functional groups leading to toxicty can be demonstrated by paracetamol toxicity. The sulpha drugs and the penicillin group of antibacterial agents can be the ideal examples for demonstrating the importance of functional groups in drug actions and effectiveness. In Chapter 6, you will also see how a small change in the functional group(s) of steroidal molecules can render remarkable changes in their pharmacological and hormonal functions. In addition, the following structural features have to be present in sulpha drugs for the optimum antibacterial activity. As result, it does not have any in vitro antibacterial activity, but in vivo Prontosil is converted via reduction of the ÀÀNÀÀÀÀNÀÀ linkage to its active metabolite sulphanilamide. They are generally more water soluble, and thus better absorbed and retained better, i. Penicillin G, the parent of all these antibiotics, was ﬁrst isolated from a fungal species, Penicillium notatum. Since the discovery of this antibiotic, several modiﬁcations have been introduced to the parent structure in order to enhance the activity, increase the acid resistance, facilitate bioavailability 4. Penicillin G is rather a complex molecule, and possesses various types of functional group, e. All penicillins are susceptible to attack in acidic solution via intramole- cular attack of the amide carbonyl oxygen on the b-lactam carbonyl, leading to the complete destruction of the b-lactam ring, and thus the antibacterial activity. Similarly, penicillins are unstable in basic solution because of b- lactam ring opening by free basic nucleophiles. Thus, for the antibacterial activity, the stability of the b-lactam functional group in penicillins is of paramount importance. For example, the amino group of amoxicillin and ampicillin makes these molecules acid stable. For example, the amino group in amoxicillin gives the molecule polarity, and makes it effective against both Gram-positive and Gram-negative bacteria. A bulky group directly adjacent to the amide carbonyl will prevent the penicillin from entering the active site of penicillin-destroying enzymes, e. For example, methicillin has a bulky group directly adjacent to the amide carbonyl, and is b-lactamase resistance. For example, the enzymatic breakdown of the analgesic acet- aminophen (paracetamol), where the aromatic nature and the hydroxyl functionality in paracetamol are lost, yields N-acetyl-p-benzoquinone imine, a hepatotoxic agent. Paracetamol can cause liver damage and even liver failure, especially when combined with alcohol. Similarly, many drug molecules are susceptible to oxidation because of certain oxidizable func- tional groups, e. Like any other proteins in the gastrointestinal tract, insulin is reduced to its amino acid components, and the activity is totally lost. Many drugs having oleﬁnic double bonds exhibit trans–cis isomerism in the presence of light. Similarly, because of the presence of certain functional groups or the chemical structure, a drug can be sensitive to heat. Addition reactions Addition means two systems Alkenes, alkynes, aldehydes combine to a single entity. Elimination reactions Elimination refers to the loss Alcohols, alkyl halides and of water, hydrogen halide or alkyl dihalides. Substitution reactions Substitution implies that one Alkyl halides, alcohols, group replaces the other. Alkene, alkyne, aldehydes, ketones, alkyl halides, nitriles, carboxylic acid and its derivatives, and benzene and its derivatives. Pericyclic reactions Concerted reaction that takes Conjugated dienes and place as a result of a cyclic a,b-unsaturated carbonyl rearrangement of electrons. So their chemistry is very different from the chemistry of even-electron and electron-deﬁcient species, e. A radical behaves like an electrophile, as it requires only a single electron to complete its octet. All chain reactions have three steps: chain initiation, chain propagation and chain termination. Usually, this method gives mixtures of halogenated compounds containing mono-, di-, tri- and tetra-halides. How- ever, this reaction is an important reaction of alkanes as it is the only way to convert inert alkanes to reactive alkyl halides. The simplest example is the reaction of methane with Cl2 to yield a mixture of chlorinated methane derivatives. For example, when a large excess of methane is used, the product is almost completely methyl chloride (chloromethane). Cl Cl Cl o Cl 250 C + + Cl2 + Chloro 1,2-Dichloro Cl cyclopentane cyclopentane 1,3-Dichloro cyclopentane A free radical chain reaction is also called a radical substitution reaction, because radicals are involved as intermediates, and the end result is the substitution of a halogen atom for one of the hydrogen atoms of alkane. In the homolytic bond cleavage, one electron of the covalent bond goes to each atom. The chlorine molecule (Cl2) dissociates into two chlorine radicals in the ﬁrst step, known as the initiation step, leading to the substitution reaction of chlorine atoms for hydrogen atoms in methane. A chlorine atom is highly reactive because of the presence of an unpaired electron in its valence shell. In this step, the intermediate reacts with a stable molecule to produce another reactive intermediate and a product molecule. The propagation step yields a new electrophilic species, the methyl radical, which has an unpaired electron. In a second propagation step, the methyl radical abstracts a chlorine atom from a chloromethane molecule, and generates a chlorine radical. Various reactions between the possible pairs of radicals allow for the formation of ethane, Cl2 or the methyl chloride. Thus, the chlorine radical is much less selective than the bromine radical, and it is a useful reaction when there is only one kind of hydrogen in the molecule. If a radical substitution reaction yields a product with a chiral centre, the major product is a racemic mixture. For example, radical chlorination of n-butane produces a 71% racemic mixture of 2-chlorobutane, and bromination of n-butane produces a 98% racemic mixture of 2-bromobutane.
Treatment with erythropoietin and iron should be stopped purchase 300 mg wellbutrin anxiety no more, and her blood pressure monitored over 8–12 weeks order generic wellbutrin on line bipolar depression vs depression. If hypertension is solely related to the erythropoi- etin therapy wellbutrin 300 mg fast delivery anxiety or heart attack, her blood pressure should normalize and no further treatment will be required. In retrospect it may have been prudent to have more closely monitored her ery- thropoietic therapy and once her Hb 12g/dL stopped it as this may have avoided her neurological event. The antibody consists mainly of The introduction of a foreign antigen into the body may pro- IgG. Immune responses are of two types, namely humoral (via This is mediated by sensitized T lymphocytes which recognize B lymphocytes, plasma cells and antibody) or cellular (via T and bind the antigen and subsequently release a cascade of lymphocytes). The effector arm of cellular immu- However, it may be defective, disorganized or overactive. By the same token, these are the very drugs that are used clinically as immunosuppressants when it is necessary to damp down an inappropriate immune response. There is a small and short-lived rise in age to the tissue; this is known as hypersensitivity. There are antibody titre which consists largely of IgM; four types of hypersensitivity. These mediators include common and require prompt treatment with appropriate histamine, leukotrienes C4, D4 and E4, eosinophil chemotac- antibiotics. Viral infections may be more severe This can cause anaphylaxis, bronchospasm, hay fever or than usual and include the common herpes infection, but urticaria. These reactions occur when antibody combines with antigenic Protozoal infections (e. This is because although most drugs are low molecular Teratogenicity This is less common than might be anticipated. Men should wait 12 weeks (the time required to clear tion is haemolytic disease of the newborn, when antibodies abnormal sperm) after stopping treatment. Such reactions may be mediated by IgM or increased incidence of malignant disease. Serum Glucocorticosteroids are used in each of the four kinds of sickness is an example of this type of response. Clinically two-edged sword and before considering individual agents it they are used to prevent acute graft rejection and improve is worth considering some of their general adverse effects. A high dose of ciclosporin is given 4–12 hours E-selectin and vascortin – leading to reduced before transplantation and then various oral maintenance vascular permeability; dose regimens are used. Therapeutic drug monitoring is used – reduces synthesis of arachidonic acid metabolites to optimize therapy. This impairs access to the nucleus of the cytosolic Key points component of the transcription promoter nuclear factor of Calcineurin inhibitors (e. It undergoes variable presystemic metabolism by gastro-intestinal Uses cytochrome P450 3A4. It may also be used to treat certain ciclosporin clearance, but caution is needed because of its autoimmune diseases (e. Dose reduction is required in patients with rheumatoid arthritis, inflammatory bowel disease, chronic active hepatic impairment. Owing to its potential toxicity, it is usually reserved for patients in whom glu- Therapeutic drug monitoring cocorticosteroids alone are inadequate. Effective immunosuppression occurs at trough concentrations of Key points 100–300μg/L. Phenytoin • Sirolimus, which also synergizes with calcineurin and rifampicin increase hepatic clearance, thus reducing inhibitors, is an alternative. Concomitant use of nephrotoxic agents such as aminoglycosides, vancomycin and amphotericin increases nephrotoxicity. The side effect and drug–drug interac- Mycophenolate mofetil is an ester of a product of the Penicillium tion profile of tacrolimus is similar to that of ciclosporin, but mould. The major effect is probably to pre- vent antigen from accessing the antigen-recognition site on Mechanism of action the T-helper cells. It is given intravenously for acute organ In vivo the active entity, mycophenolic acid, inhibits inosine transplant rejection. Adverse effects include anaphylaxis and monophosphate dehydrogenase (a pivotal enzyme in purine serum sickness. In addition, mycophenolic acid inhibits the production of pro-inflammatory cytokines. They are IgG2a antibodies produced • bone marrow suppression, especially leukopenia and from murine hybridoma cells and are given intravenously. For novel anti-proliferative agents, such as sirolimus and Adverse effects everolimus – see Table 50. Their contribution to most vas- • Natalizumab (an anti-alpha-4 beta-3 integrin monoclonal cular responses is minor, but some (e. In certain circumstances, injection of an antigen is followed by the production of reaginic IgE antibodies. Clinically, the patient presents a picture of shock and collapse with hypotension, bronchospasm and Several important therapeutic drugs block the release or action oropharyngeal-laryngeal oedema, often accompanied by of mediators of immune reactions. Asimilar so-called ‘anaphylactoid reac- tion’ may occur after the non-IgE-mediated release of media- tors by x-ray contrast media. It is concentrated in Anaphylaxis and anaphylactoid reactions mast-cell and basophil granules. The highest concentrations • Anaphylaxis: are found in the lung, nasal mucous membrane, skin, stomach – is IgE-mediated hypersensitivity (type-1) that occurs and duodenum (i. Histamine is liberated by several basic – its pathophysiology is major cardiovascular and drugs (usually when these are given in large quantities intra- respiratory dysfunction due to vasoactive mediator venously), including tubocurarine, morphine, codeine, van- release from mast cells; – common causes are penicillins, cephalosporins and comycin and suramin. Histamine controls some local vascular many other drugs, insect stings and food allergies responses, is a neurotransmitter in the brain, releases gastric (e. There • Anaphylactoid reactions: are two main types of histamine receptors, H1 and H2. Histamine induces vascular endothelium to release nitric oxide, which causes vasodilatation and lowers systemic blood pressure. Histamine propensity to develop local allergic reactions if exposed to appro- contributes to the triple response to mechanical stimulation priate antigens, causing hay fever, allergic asthma or urticaria. Common agents used to treat hay fever • Stop the offending drug or blood/blood product infusion. The adverse effects of all these preparations are similar, • Administer adrenaline (epinephrine) 0. They are produced by mediators include the following: also effective in preventing hay fever and its symptoms. Cromoglicate is used as nasal or eye drops for allergic rhinitis • inhibition of their biosynthesis; and conjunctivitis. Local adverse effects include occasional • blockade of their release; nasal irritation or transient stinging in the eye.
Of conducting clinical research primary importance to the investigator is the ratio- nale for use of the drug and the expected safety Investigator meeting proﬁle buy wellbutrin 300 mg free shipping mood disorder treatment centers. Much can be inferred from the investiga- tor’s preparation and questions about the investiga- Sponsors now try to conduct many initiation activ- tional drug wellbutrin 300mg cheap depression symptoms high blood pressure. Such meetings including the requirements for the patient popula- (which may be in person or utilize videoconferen- tion purchase wellbutrin with visa depression existential crisis, the study design and a description of the safety cing or internet technology) can be used to orient and efﬁcacy variables. The nature and form of provide an opportunity to ensure common under- informed consent are reviewed. In these discus- standing of issues, subjective grading systems and sions, the sponsor’s representative is attempting so on. However, investigator meetings tend not to to identify aspects of the study that present difﬁ- be attended by all the staff who will be involved in culties or problems for the investigator. Inevitably, investigators usually have clear understanding this means that the sponsor’s representative has to and strategy for the above activities. Examples of conduct study initiation activities at the institution the questions that require answering during pre- with some key staff. Some objective measure of the availability of the correct patient population is important during a Conducting study initiation pre-study visit. The sponsor’s representative can often best accomplish this through a chart or hos- The study initiation visit is sometimes confused pital census review. The purpose of the study initiation visit is to orient the study staff (sub- investigators, study coordinators, etc. At the point of the How will the protocol speciﬁcally operate at the study initiation visit, the study site should be fully prospective center? All study staff who will have direct involvement How many studies is the investigator conducting in the trial should participate in the study initiation currently? In addition, a monitor needs to have excel- presentation, participants may raise important lent interpersonal communication and problem- medical or logistical issues that have or have not solving skills. It is Clinical monitoring requires clinical, interpretive important to note these concerns and communicate and administrative skills. Quality monitoring will always include tent in the basic medical and scientiﬁc issues of and conﬁrm the following activities: the investigational product and protocol, know the target disease or symptoms, be able to train the properly obtained informed consent; investigative staff on the conduct of the study, conﬁrm facility capabilities, conduct the site initia- adherence to the protocol procedures and inclu- tion meeting, describe adverse event reporting sion/exclusion criteria; requirements and be able to resolve protocol issues during and after meeting. Monitoring permits an supplies; in-process assessment of the quality of the data being collected. The frequency of clinical monitoring depends on Monitoring clinical studies involves the act of the actual accrual rate of the subjects. Monitors studies may need to be visited more frequently ensure that the study is conducted, recorded and depending on the accrual rate of subjects, the 3. The monitors should anticipate sufﬁ- Local language Route of administration cient time for good monitoring practices. Name of investigator Dosage Following a monitoring visit, the monitor will Study number Dosage form prepare a monitoring report for sponsor records Bottle number Quantity or volume and follow up correspondence to the trial site. Lot number Storage precautions The monitor may need to plan intervention and Drug name or code Directions for use possible replacement of nonperforming or non- Manufacturer name Note: ‘For Clinical Trial’ compliant trial centers. Manufacturer address Caution statement Local afﬁliate name Expiry date Managing drug accountability identical within multicenter trials. Regulatory The sponsor is responsible for providing the investi- documents required for investigational drug use gator with investigational product. Both the sponsor in the core countries must be anticipated and and investigator have a role in drug accountability. Once the study is underway, the investigator’s The monitor reconciles investigational product staff must account for the use of the investigational shipped, dispensed and returned, arranges for ship- drug. Subjects should return unused medication ment of investigational product to core country or and empty containers to the investigator. The investigative sites, checks investigational product amount of drug dispensed and the amount used supplies at site against enrollment and withdra- by the patients are compared for discrepancies. Monitors must also check that inventory problems, implements tracking system drug supplies are being kept under the required for investigational product management on a study storage conditions. Failure to do so can result product supplies and ensures ﬁnal reconciliation in some of the data having to be discarded during of investigational product supplies. This issue can prove to be Good clinical practices require sponsors to be problematic when a single site is studying patients able to account for the drug supplies prepared and at different locations. Finally, the double-blind shipped to the investigator, the investigator’s use of code must not be broken except when essential those supplies and the return and destruction of for the management of adverse events. Planning drug supplies ing of treatment codes can make that patient’s data is a detailed and complex activity. Safety concerns are present throughout the drug Drug packaging should follow as consistent a development process. To be successful, monitors need to be com- Management of safety is a principal responsi- petent in bility of the sponsor monitor. The monitor has responsibility for informing the investigator basic medicine and therapeutics; about the safety requirements of the study. This will include a discussion of expected and unex- recognizing clinical signs and symptoms; pected adverse events, how to report adverse events should they occur and how to characterize interpretation of laboratory ﬁndings; the adverse events in terms of project-speciﬁc deﬁnitions. In source documents, safety issues The sponsor needs to provide ongoing review of may be uncovered in the progress notes of hospital safety data for investigational products. Monitors must be alert to exaggerated changes from baseline with expected pharmacolo- Closing down a study is important because it may gical effects, acute and chronic effects and multiple represent the sponsor’s last best chance to obtain drug treatment reactions. The study closedown Monitors are often the ﬁrst company representa- (closeout) visit usually occurs after the last subject tives to learn about an adverse event. The timeliness has completed the trial including any posttreatment of reporting the event to sponsor safety group is follow-up visits. Drug supplies should be recon- important in satisfying regulatory reporting require- ciled, and the integrity of the double-blind treat- ments. Failure to adhere to the reporting timelines clinical study report is available, it should be given required for regulatory authorities is evidence of to the investigator for signature. The sponsor trials, a single lead investigator may sign a pooled monitor is responsible for assuring adherence to study report. The cases must be While the goal of monitoring is to provide ‘clean’ followed to completion. Computerized checking programs including the intent-to-treat analysis population and edit checks make the process more value- and the safety data listings. Each module satisﬁes a speciﬁc drafting of assigned study report sections documentation need. The modules are generally according to the clinical study report prototype; organized as follows: interpretation of adverse events; Module I: Includes a basic summary of the study not unlike a publication. The clin- not just a summary but also a critical assessment of ical representative should be able to interpret clin- the clinical evaluation of the drug. The ability to report provides an independent assessment of the understand computer-generated clinical output and risk-to-beneﬁt ratio of the drug and its use. Quite apart from established in-house training Most vendors advertise widely in the trade programs, there is a wide selection of vendors journals, and many of their courses are tailored offering competency-based training.
Healthcare professionals should monitor a patient’s plasma protein and albumin levels and the protein-binding percentage of all drugs before administering drugs to the patient generic 300mg wellbutrin with amex depression what to do. Bloodflow There must be adequate bloodflow to target areas of the body; otherwise generic wellbutrin 300mg amex anxiety zone pancreatic cancer, insuf- ficient drug particles will reach affected parts of the body buy cheap wellbutrin 300mg line depression test diagnosis. Drugs that accumulate in fat are called lipid soluble and remain for about three hours because there is low blood flow in fat tissue. Competing Drugs Two drugs administered simultaneously might compete for the same binding sites making some drug particles unable to find a binding site. Two drugs that are highly protein bound—such as Coumadin (warfarin) and Inderal (propra- nolol)—will compete for the protein sites. This can cause serious problems and can result in toxic levels of one or both of the drugs when increased amounts of free drug become available. Abscesses, exudates, body glands, and tumors hinder the distribution of drugs in the body. The placenta metabolizes some drugs making then inactive and thereby protecting the fetus from drugs given to the mother. However, steroids, nar- cotics, anesthetics, and some antibiotics can penetrate the placental barrier and cause adverse effects to the fetus. This metabolism—called biotransformation—occurs in the liver where enzymes inactivate a drug by changing it into more water-soluble compounds that can be excreted from the body. Elimination occurs mainly through the kidneys, although some drugs are also eliminated in bile, feces, lungs, sweat, and breast milk. Patients suffering from liver diseases are prone to drug toxicity because the diseased liver no longer metabolizes the drug sufficiently to allow elimination through the kidneys. The result is a buildup of the drug, which can eventually lead to a toxic effect on the body. The amount of time for half of the drug concentration to be eliminated from the body is called the drug’s half-life and is a crucial measurement used to deter- mine how often to administer a drug. Some drugs have a short half-life (less than 8 hours) while other drugs have a longer half-life (24 hours). This means it takes 5 to 7 days before there is a steady state of Digoxin in the serum. This is referred to as the steady state serum concentration and is the time it takes for the drug to have a therapeutic effect. This can result in toxicity should additional doses be given before the previ- ous does is eliminated from the body. Free drugs, water-soluble drugs, and unchanged drugs are filtered by the kidneys and eliminated through urine. Protein-bound drugs do not filter through the kidneys until the drug is released from the protein. The quantity of drugs that can be excreted by the kidneys is influenced by the pH of the urine, which normally is between 4. For example, urine can be made more alkaline by giving the patient sodium bicarbonate or made more acidic by giving the patient high doses of vitamin C or ammonium chloride. The results of the creatinine clearance test vary with age and whenever there is decreased muscle mass. In some situations, it is important to reduce the excretion of a drug to prolong the drug’s therapeutic effect, such as with penicillin. Giving the patient another drug, such as Probenecid, blocks excretion of penicillin. Drugs can be excreted artificially through the use of dialysis, which is a com- mon treatment in certain drug overdoses. Drugs that are metabolized by the liver are secreted into bile and then passed through the intestines and eliminated in feces. During this process, the blood- stream might reabsorb fat-soluble drugs and return them to the liver where they are metabolized and eliminated by the kidneys. The lungs eliminate drugs that are intact and not metabolites such as gases and anesthetic drugs. Some drugs, such as ethyl alcohol and paraldehyde, are excreted at multiple sites. A small amount is excreted by the lungs and the rest by the liver and the kidneys. Sweat and salivary glands are not a major route of drug elimination because elimination depends on the diffusion of lipid-soluble drugs through the epithe- lial cells of the glands. However, side effects of drugs, such as rashes and skin reactions, can be seen at these sites. Some intravenously administered drugs are excreted into saliva and cause the patient to taste the drug. Eventually, drugs that are excreted into saliva are swallowed, reabsorbed, and eliminated in urine. Diuretics and barbiturates, which are weak acids, are less concentrated in breast milk. However, even small amounts of drugs can accumulate causing an undesirable effect on an infant receiving breast milk. Some drugs bypass the first pass effect by sublingual administration (under the tongue) or buccal administra- tion (between the gums and the cheek) where they are absorbed directly into the bloodstream from the mouth. These drugs do not enter the stomach where the hydrochloric acid might destroy drug particles. Other drugs go directly to the liver through the portal vein and also bypass the stomach. The drug is then metabo- lized in the liver and much of the drug may be eliminated and not available for a therapeutic effect. Sometimes this effect is so great that none of the drug is available for use if given by mouth. The drug must then be given in very high doses or parenterally (intramuscularly or intravenously) to bypass the liver. Pharmacodynamics Pharmacodynamics is a drug’s effect on the physiology of the cell and the mech- anism that causes the pharmaceutical response. Its secondary effect is to depress the cen- tral nervous system causing drowsiness. The secondary effect is desirable if the patient needs bedrest, but undesirable if the patient is driving a car. A period of time passes after a drug is administered until the pharmaceutical response is realized. The onset time response is the time for the minimum concentration of drug to cause the initial pharmaceutical response.
Taylor (1983) used such strategies to improve patients’ self-worth order wellbutrin without prescription vitale depression definition, their ability to be close to others trusted wellbutrin 300mg anxiety upon waking, and the improvement in the meaningfulness of their lives order discount wellbutrin mood disorder support group long island. Such methods have been suggested to involve self- transcendence and this has again been related to improvement in well-being and decrease in illness-related distresses. Simonton and Simonton (1975) are well known for applying psychosocial factors and interventions for improving the quality of life of cancer patients using a whole-person approach. This involves the following processes: (1) relaxation, which aims to decrease muscle tension and therefore decrease pain; (2) mental imagery, whereby cancer patients are encouraged to focus on something positive (this aims to develop a belief in the ability to recover, therefore decreasing pain, tension and fear); and (3) exercise programmes, which aim to increase the sense of well-being. In 1975, Simonton and Simonton encouraged a positive attitude towards treatment using whole-person approach among 152 cancer patients for 18 months, and argued that this intervention predicted a good response of treatment and reduced side-eﬀects. This involves encouraging cancer patients to examine the personal meaning of their cancer and what they can do to cope with it (see Focus on research 14. Psychological factors in longevity The ﬁnal question about the role of psychology in cancer is its relationship to longevity; do psychosocial factors inﬂuence longevity? Using semi-structured interviews, they deﬁned three types of responders: those with ‘ﬁghting spirit’, those who showed denial of the implications of their disease and those who showed a hopeless/helpless response. The authors reported that the groups who showed either ‘ﬁghting spirit’ or ‘denial’ had a longer disease-free interval than the other group. In addition, at a further 15-year follow-up, both a ﬁghting spirit and denial approach also predicted longevity. At baseline the authors did not measure several important physiological prognostic indicators, such as lymph node involvement, as these measures were not available at the time. These physiological factors may have contributed to both the disease-free interval and the survival of the patients. Clinical data, measures of hopelessness, life changes and measures of aﬀect were collected at baseline from 49 Israeli women diagnosed with breast cancer. The life events and diﬃculties occurring during the disease-free interval were recorded in 50 women who had developed their ﬁrst recurrence of breast cancer and 50 women who were in remission. The two subject groups were matched for the main physical and pathological factors believed to be associated with prognosis and for the socio-demographic variables believed to be related to life events and diﬃculties. The results showed that life events rated as severe were related to ﬁrst recurrence of breast cancer. However, the study was cross-sectional in nature, which has implications for determining causality. Background Evidence suggests that a substantial minority of cancer patients show psychological ill-health, particularly in terms of depression and anxiety. As a result, a number of psycho- therapeutic procedures have been developed to improve cancer patients’ emotional well- being. However, evaluating the eﬀectiveness of such procedures raises several ethical and methodological problems, and these are addressed by Greer et al. These are: (1) the ethical considerations of having a control group (can patients suﬀering from psychological distress not be given therapy? Altogether, 153 subjects completed the baseline and eight-week measures and 137 completed all measures. Measures Subjects completed the following measures at baseline (before randomiza- tion), at eight weeks and four months follow-up: s The Hospital Anxiety and Depression scale. Therapy involved approximately eight one-hour weekly sessions with individual patients and their spouses (if appropriate). However, many patients in the present study did not attend all these sessions and several received additional sessions throughout the four months. The therapy focused on the personal meaning of the cancer for the patient, examined their coping strategies and emphasized the current problems deﬁned jointly by the therapist and the patient. Personality/coping style and longevity In 1991, Eysenck and Grossarth-Maticek reported a study whereby they selected ‘at- risk’ individuals who were healthy (the controls) and another group of individuals (the experimental group) who showed conﬂict-avoiding and emotion-suppression type per- sonality (a type C/cancer-prone personality). The experimental group received cognitive behavioural therapy in an attempt to change how they dealt with stress. At follow-up, the authors reported that this group showed a decrease in mortality rate compared with the controls who did not receive the cognitive behavioural therapy. In a further study by Temoshok and Fox (1984), the results from a 15-year follow-up of women with breast cancer indicated that poor outcome was associated with a passive, helplessness coping style. However, it has been questioned as to whether the personality styles predicted to be associated with diﬀerent illnesses are distinct (Amelang and Schmidt- Rathjens 1996). There is no relationship between psychological factors and longevity However, not all research has pointed to an association between psychological factors and longevity. However, the results showed no relationship between these outcomes and the psycho- social factors measured at baseline. These results caused debate in the light of earlier studies and it has been suggested that the absence of a relationship between life events and outcome may be due to the older age of the women in Barraclough and co-workers’ study, the short follow-up period used, and the unreported use of chemotherapy (Ramirez et al. Think about how psychological factors such as behaviour, beliefs and coping inﬂuenced their state of health. By examining the role of psychology in illness, it is implicitly assumed that psychology and illness (the body) are separate. This promotes a model of an individual who has a physical and a mental world which interact but are separate. Although this interaction is an attempt at a holistic approach to health and illness, it is still intrinsically dualistic. Many of the research studies carried out in health psychology are cross-sectional (i. However, it is quite possible that the relationship between these variables is either causal in the opposite direction (e. Prospective studies are used as an attempt to solve this problem, but even prospective studies only examine the correlation between variables – it is still diﬃcult to talk about causality. This book provides a useful review of the literature on the role of psychology in cancer aetiology and disease-free intervals. It ﬁrst examines the deﬁnitions of obesity, its prevalence and potential consequences. It then examines the role of physiological factors and behaviour in causing obesity. The chapter then explores obesity treatment raising the question ‘should obesity be treated at all? It describes what it is and how it is deﬁned and then looks at the role of psychology in its etiology. The potential role of psychological factors in obesity is illustrated in Figure 15. Obesity can be deﬁned in a number of ways, including the use of population means and in terms of body mass index. Using population means involves exploring mean weights given a speciﬁc population and deciding whether someone is below average weight, average or above average in terms of percentage overweight.
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