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PubMed1998

Expressed emotion and psychiatric relapse: a meta-analysis.

BACKGROUND: Expressed emotion (EE) is a measure of the family environment that has been demonstrated to be a reliable psychosocial predictor of relapse in schizophrenia. However, in recent years some prominent nonreplications of the EE-relapse relationship have been published. To more fully address the question of the predictive validity of EE, we conducted a meta-analysis of all available EE and outcome studies in schizophrenia. We also examined the predictive validity of the EE construct for mood disorders and eating disorders. METHODS: An extensive literature search revealed 27 studies of the EE-outcome relationship in schizophrenia. Using meta-analytic procedures, we combined the findings of these investigations to provide an estimate of the effect size associated with the EE-relapse relationship. We also used meta-analysis to provide estimates of the effect sizes associated with EE for mood and eating disorders. RESULTS: The results confirmed that EE is a significant and robust predictor of relapse in schizophrenia. Additional analyses demonstrated that the EE-relapse relationship was strongest for patients with more chronic schizophrenic illness. Interestingly, although the EE construct is most closely associated with research in schizophrenia, the mean effect sizes for EE for both mood disorders and eating disorders were significantly higher than the mean effect size for schizophrenia. CONCLUSION: These findings highlight the importance of EE in the understanding and prevention of relapse in a broad range of psychopathological conditions.

Expressed Emotion↗

PubMed2003

Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind, placebo-controlled study.

BACKGROUND: Naltrexone and acamprosate have been shown to be effective in relapse prevention of alcoholism via different pharmacologic mechanisms. Since it remains uncertain whether both substances are equally efficient and whether a combination of both drugs potentiates the efficacy, we conducted the first published controlled study comparing and combining both compounds. METHODS: After detoxification, 160 patients with alcoholism participated in a randomized, double-blind, placebo-controlled protocol. Patients received naltrexone, acamprosate, naltrexone plus acamprosate, or placebo for 12 weeks. Patients were assessed weekly by interview, self-report, questionnaires, and laboratory screening. Time to first drink, time to relapse, and the cumulative abstinence time were the primary outcome measures. RESULTS: Naltrexone, acamprosate, and the combined medication were significantly more effective than placebo. Comparing the course of nonrelapse rates between naltrexone and acamprosate, the naltrexone group showed a tendency for a better outcome regarding time to first drink and time to relapse. The combined medication was most effective with significantly lower relapse rates than placebo and acamprosate but not naltrexone. CONCLUSIONS: The results of this study support the efficacy of pharmacotherapeutic strategies in the relapse prevention of alcoholism. Naltrexone and acamprosate, especially in combination, considerably enhance the potential of relapse prevention.

Acamprosate↗

PubMed2006

Cognitive reactivity to sad mood provocation and the prediction of depressive relapse.

CONTEXT: Episode remission in unipolar major depression, while distinguished by minimal symptom burden, can also be a period of marked sensitivity to emotional stress as well as an increased risk of relapse. OBJECTIVE: To examine whether mood-linked changes in dysfunctional thinking predict relapse in recovered patients who were depressed. DESIGN: In phase 1 of this study, patients with major depressive disorder were randomly assigned to receive either antidepressant medication or cognitive behavior therapy. In phase 2, patients who achieved clinical remission underwent sad mood provocation and were then observed with regular clinical assessments for 18 months. SETTING: Outpatient psychiatric clinics at the Centre for Addiction and Mental Health, Toronto, Ontario. PARTICIPANTS: A total of 301 outpatients with major depressive disorder, aged 18 to 65 years, participated in phase 1 of this study and 99 outpatients with major depressive disorder in remission, aged 18 to 65 years, participated in phase 2. MAIN OUTCOME MEASURE: Occurrence of a relapse meeting DSM-IV criteria for a major depressive episode as assessed by the longitudinal interval follow-up evaluation and a Hamilton Depression Rating Scale score of 16 or greater. RESULTS: Patients who recovered through antidepressant medication showed greater cognitive reactivity following the mood provocation than those who received cognitive behavior therapy. Regardless of type of prior treatment, the magnitude of mood-linked cognitive reactivity was a significant predictor of relapse over the subsequent 18 months. Patients whose mood-linked endorsement of dysfunctional attitudes increased by a minimum of 8 points had a significantly shorter time to relapse than those whose scores were not as elevated. CONCLUSIONS: The vulnerability of remitted depressed patients for illness relapse may be related to the (re)activation of depressive thinking styles triggered by temporary dysphoric states. This is the first study to link such differences to prognosis following successful treatment for depression. Further understanding of factors predisposing to relapse/recurrence in recovered patients may help to shorten the potentially lifelong course of depression.

Acoustic Stimulation↗

PubMed1999

Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized controlled trial.

CONTEXT: Relapses of acute asthma following emergency department (ED) discharge can be reduced with systemic corticosteroid treatment. However, whether inhaled corticosteroids (ICSs) provide additional benefit is not known. Objective To determine whether the addition of ICSs to oral corticosteroid treatment would reduce relapses in patients with acute asthma discharged from the ED. DESIGN AND SETTING: Placebo-controlled, double-blind, randomized clinical trial conducted in a community teaching hospital ED in Canada between November 1995 and September 1997, with a 21-day follow-up. PARTICIPANTS: A total of 1006 consecutive patients aged 16 to 60 years presented to the ED with acute asthma; after excluding those using oral and/or inhaled corticosteroids as well as those meeting other exclusion criteria, 188 were included in the study. INTERVENTIONS: Patients were discharged with a nontapering course of oral prednisone (50 mg/d) for 7 days. In a double-blind fashion, patients were randomly assigned to 1600 microg/d of inhaled budesonide (n = 94) or identical placebo (n = 94) for 21 days. MAIN OUTCOME MEASURES: Incidence of relapse, defined as an unscheduled visit for worsening asthma symptoms, in budesonide vs placebo groups. Secondary outcomes included response to the Asthma Quality of Life Questionnaire, beta2-agonist use, symptom score, global asthma improvement assessment, and pulmonary function. RESULTS: Five patients in the budesonide group and 3 in the placebo group either dropped out or were lost to follow-up but were included in primary analyses. After 21 days, 12 (12.8%) of 94 patients in the budesonide group experienced a relapse compared with 23 (24.5%) of 94 in the placebo group, a 48% relapse reduction (P=.049). Asthma Quality of Life Questionnaire scores were higher (better quality) in the budesonide group (P=.001), as well as for all domain scores (P=.001 to .01). Fewer beta2-agonist activations were used at the end of the trial by patients receiving budesonide (2.4/d vs 4.2/d; P=.01). Symptom scores (P=.001 to .004) and self-assessed asthma improvement scores (based on a 7-point Likert scale) (6.2 vs 5.2; P<.001) were higher (indicating fewer symptoms) for budesonide vs placebo. There were no differences in pulmonary function between the groups (peak expiratory flow rate: budesonide, 437 vs placebo, 453 L/min; P= .39) at 21 days. Using this approach, as few as 9 patients would require budesonide to prevent 1 relapse. CONCLUSIONS: Patients discharged from the ED following treatment for acute asthma benefit from added treatment with high-dose inhaled budesonide for 21 days compared with oral corticosteroids alone.

Acute Disease↗

PubMed1998

Chronic relapsing thrombotic thrombocytopenic purpura: role of therapy with cyclosporine.

Relapsing thrombotic thrombocytopenic purpura (TTP) is a rare disorder with most individuals experiencing 1 to 5 relapses. We report a patient with 18 episodes of thrombotic thrombocytopenic purpura (TTP), the highest number of relapses thus far described. The last 11 episodes were treated with regimens containing cyclosporine. The patient's medical record was reviewed for pertinent clinical, laboratory, and treatment data. We summarized various parameters for each episode and compared characteristics of relapses treated with vs. without cyclosporine. The initial episode of TTP was unusual in that it failed to respond to plasmapheresis, glucocorticoids, and fresh frozen plasma (FFP). It remitted only following splenectomy. Episodes 2-7 responded to FFP plus prednisone. Episode 8 failed to respond to prednisone plus FFP but remitted promptly with cyclosporine plus prednisone. Subsequently, 2 relapses responded to cyclosporine alone, 2 to cyclosporine plus FFP, 4 to cyclosporine plus prednisone +/- FFP, and 2 to cyclosporine, FFP, prednisone, and plasma exchange. There was no difference in remission duration, or in severity or duration of relapses treated with vs. without cyclosporine. Use of cyclosporine, however, significantly decreased the requirement for prednisone and the length of maintenance therapy; thus it is effective mainly as an adjunctive therapy for TTP.

Chronic Disease↗

PubMed1999

Molecular cytogenetic studies of a serially transplanted primary prostatic carcinoma xenograft (CWR22) and four relapsed tumors.

BACKGROUND: Established cell lines or xenografts from prostatic carcinoma have been infrequently studied cytogenetically. CWR22 and CWR22-R are xenografts that are unique in offering one strongly androgen-dependent and several relapsed strains of a human prostate cancer that can be investigated in the laboratory. We report on the cytogenetic characterization of the hormone-dependent CWR22, and the relapsed CWR22-R serially transplanted xenografts, in our laboratory. METHODS: We utilized a suspension harvest of the xenograft tissue to optimize our yield for metaphase chromosome studies and analyzed the hormone-dependent CWR22 and four relapsed CWR22-R xenografts. These studies were accomplished using standard G-banded analysis and fluorescence in situ hybridization (FISH). A variety of DNA probes including alpha-satellite DNA probes, and chromosomal libraries, were utilized for the FISH analysis. RESULTS: Utilizing both standard cytogenetic analysis and FISH studies we have more precisely defined the CWR22 xenograft: 49,XY,+i(1)(q10),-2, der(4)t(2;4)(p21;q33), +7,+8,+12[7]/50,XY,idem, +der(2)t(2;4)(p21;q33)del(2)(q13q33)[13]. Four relapsed xenografts, CWR22R-2152, CWR22R-2524, CWR22R-2274, and CWR22R-2272 were also studied. Each of these lines demonstrated a different karyotype. CONCLUSIONS: The CWR22 karyotype offers the simplest reported karyotype for a prostate cancer tissue culture cell line or xenograft; this makes CWR22 an attractive candidate for studies of genetic changes associated with the relapse of prostate cancer treated with androgen withdrawal. Four separate, serially transplanted, relapsed CWR22-R xenografts were detected, each with a separate karyotype.

Androgens↗

PubMed1999

Smoking withdrawal and relapse in head and neck cancer patients.

BACKGROUND: Smoking withdrawal and relapse were characterized among newly diagnosed head and neck cancer patients participating in a physician-delivered smoking cessation intervention. METHODS: Patients completed questionnaires at baseline, 1, 6, and 12 months following intervention delivery. RESULTS: Significant baseline predictors of smoking relapse included medical treatment (XRT versus surgical treatment), stage of change/readiness to quit (precontemplators), age of initiation (younger), and greater addiction (smoking </=30 minutes after waking). Relapsers were significantly more likely to quit using gradual reduction versus cold turkey and had less confidence in remaining quit. Relapsers experienced significantly higher levels of anxiety and craving during withdrawal. Relapse was temporally delayed compared with healthy populations. CONCLUSION: Assistance with cessation efforts should be ongoing for one year and should include nicotine replacement therapy and psychotropic medications to address significant relapse triggers.

Affect↗

PubMed1998

Frequency of relapses in patients with polymyositis and dermatomyositis.

The frequency of clinical and biochemical relapses was determined in a group of 50 patients with polymyositis (PM), dermatomyositis (DM), or overlap syndromes who were followed for periods of up to 13 years. Relapses occurred in 30 of the 50 patients (60%) during the period of follow-up. The annual relapse rate was not significantly different in the three groups of patients. Subclinical relapses occurred in each group but were less frequent in the DM than in the PM and overlap groups. Relapses could occur at any time but were more frequent during periods of stable maintenance therapy. There was no correlation between relapses and initial disease severity, delay to diagnosis and commencement of treatment, or any class I or II histocompatibility locus antigen.

Anti-Inflammatory Agents↗

PubMed2000

Factors predicting the relapse of depression in old age.

BACKGROUND: Studies in mixed-aged populations show differences between the predictors of a relapse and those of a long-term course of depression, supporting the hypothesis about similar differences among the aged. AIM: The aim was to identify the factors predicting or related to a relapse of depression among the Finnish elderly having recovered from depression during treatment. MATERIAL AND METHODS: The population consisted of 70 depressed (DSM-III criteria) elderly (60 yr-) Finns having recovered from depression during treatment as determined 15 months after baseline. By the 4-year follow-up after the recovery, 20 patients had relapsed and 50 persons were non-depressed. RESULTS: The logistic regression model showed major depression and psychomotor retardation to be independent predictors. Relapses were not related to stressors in life or physical illnesses occurring during the follow-up. CONCLUSIONS: Major depressive elderly patients have a high risk for relapses without the occurrence of the stressors or physical illnesses. In clinical practice, major depressive elderly patients should be followed up in order to detect and treat potential relapses as early as possible. Cooperation between psychiatrists and general practitioners is needed in the follow-up. Theoretically, the results suggest the assumption of a biochemical aetiology of major depression.

Aged↗

PubMed1978

Patterns of relapse and survival following radical mastectomy. Analysis of 716 consecutive patients.

The records of 716 consecutive patients with breast cancer randomized from January 1964 to January 1968 between radical and extended radical mastectomy not followed by postoperative radiation therapy were reviewed. Relapse and survival rates were related to different patterns with the intent to define, on clinical basis, the high-risk groups in whom systemic adjuvant treatment can be attempted. The 10-year relapse rate was 52.9% for the whole series. In patients with negative axillary nodes (N-) this finding was 27.9% compared to 75.5% for patients with positive nodes (N+ 1-3: 66.5%, N+ greater than 3: 83.6%). The relapse rate was also affected by concomitant involvement of internal mammary nodes (IMN): N- IMN+: 60%, N+ IMN+: 96.7%. The corresponding 10-year survival rates were as follows: 59.7% (total), 81.9% (N-), 39.6% (N+), 53.7% (1-3), 25.6% (greater than 3), 45.8% (N- IMN+), 20.5% (N+ IMN+). In N+ patients relapse and survival rates were directly proportional to the size of primary tumor, while this trend was not present in N- patients. Location of primary tumor as well as menopausal status showed no direct effect on relapse and survival. In both nodal groups the sites of first relapse were documented to occur preferentially in distant organs and tissues.

Adult↗

PubMed1980

The histology of the initial relapse of Hodgkin's disease.

The histology of relapsing Hodgkin's disease was compared with that of the original diagnostic biopsy in 56 patients. A criterion for inclusion in this study was relapse in an untreated site, thereby excluding all patients initially treated with chemotherapy. THose patients selected for study were initially treated with local radiotherapy, and relapsed outside the initial radiation fields. There was an impressive maintenance of the histologic appearance in the relapse biopsies: a change in histology was seen only in a small percentage of cases. The histologic relationship of so-called "cellular phase" of nodular sclerosing Hodgkin's disease to classical nodular sclerosing Hodgkin's disease was confirmed. Those patients with a relapse-free interval greater than one year more often had an epithelioid cell reaction (granulomatous reaction) in their biopsy material in contrast to those who relapsed in less than one year.

Eosinophils↗

PubMed1981

Ovarian tumor as manifestation of relapse in acute lymphoblastic leukemia.

Acute lymphoblastic leukemia (ALL) was initially diagnosed in a 12-year-old girl. Maintenance chemotherapy was discontinued after 32 months of continuous remission. Relapse of ALL occurred ten months after cessation of chemotherapy. Twenty-one months after relapse, she presented with a large ovarian tumor due to leukemic infiltration while her bone marrow and central nervous system (CNS) were still in remission. She remained in bone marrow and CNS remission when disseminated leukemic infiltration of the peritoneum was found seven months later. She died of bone marrow relapse 11 months after ovarian relapse, six years and two months after the initial diagnosis. In contrast to testicular relapse, ovarian relapses in acute lymphoblastic leukemia are rarely reported.

Child↗

PubMed1982

Multifocal relapse after concurrent chemotherapy and radiotherapy of small cell lung cancer.

Twenty-one patients with small cell lung cancer (SCLC) were treated with cyclophosphamide (1250 mg/m2), Adriamycin (40 mg/m2), vincristine (2 mg) every three weeks. Thoracic radiotherapy (3000 rad: 10 or 15 fractions) began four weeks after starting chemotherapy. Patients with brain metastases received cranial irradiation. Thirteen of 19 evaluable patients responded to therapy (four complete responses). Sixteen of 19 had significant intrathoracic response (eight complete). Of the three patients without an intrathoracic tumor response, two had simultaneous progression in systemic locations and only one had intrathoracic progression preceding systemic progression. Intrathoracic relapse preceded systemic relapse in two patients, was simultaneous with it in six and followed systemic relapse in four others. Therefore only three patients had intrathoracic tumor progression or relapse preceding systemic progression or recurrence. The more intensive course of radiotherapy was significantly better in preventing intrathoracic tumor progression. Although intrathoracic tumor control is important, primary failure of therapy or relapse appears to be multifocal. Future attention must be directed toward control of multiple potential sites of relapse.

Aged↗

PubMed1983

Patterns of care study: Hodgkin's disease relapse rates and adequacy of portals.

The Patterns of Care Study (PCS) has noted differences in stage adjusted relative relapse rates for Hodgkin's disease in four large facilities; the rates vary from 0% to 11% for infield or marginal recurrence (P = 0.003), and from 10% to 39% for any relapse (P = 0.0006) among these facilities. These differences in outcome were not attributable to variation in patient workup, treatment method, or radiation dose. A resurvey of 181 of these records of patients treated with radiation therapy for cure, in which portal films were available for review, indicates that treatment portal films did not encompass the disease adequately in 66 patients. When this occurred, there was a 50% overall relapse rate with 32% recurrence either infield or marginal. Chemotherapy tended to obscure the effect of inadequate technology, and when the 26 patients receiving chemotherapy as part of their initial treatment were excluded, inadequate margins were followed by even higher rates of relapse. For the subgroup of patients treated with radiation therapy alone, inadequate margins were associated with a 54% overall relapse rate, of which 33% were infield or marginal recurrence. When the portal films for patients treated with radiation therapy only were judged to be adequate, the total rate of any relapse was 14%, with 7% infield or marginal recurrence. PCS data indicate there is a critical need for accurate inclusion of Hodgkin's disease in the treatment portals; that marked facility differences exist in this technical process; and that skilled independent observers can reliably identify inaccurate technical performance.

Evaluation Studies as Topic↗

PubMed1985

Comparison of maintenance treatment regimens for first central nervous system relapse in children with acute lymphocytic leukemia. A Pediatric Oncology Group study.

Eighty-seven children with central nervous system (CNS) leukemia were randomized to receive either induction intrathecal chemotherapy (ITC) and cranial irradiation (CRT) plus maintenance ITC, or induction ITC and craniospinal irradiation (CSpRT) with no maintenance ITC. ITC consisted of six weekly injections of methotrexate, hydrocortisone, and arabinosylcytosine. Also, intensification of systemic induction and maintenance chemotherapy was given. CRT + ITC was given as CRT, 2400 rad in 12 fractions followed by ITC maintenance bimonthly for 2 years. Craniospinal irradiation consisted of CRT + 1400 rad in ten fractions to the spine. Randomization was stratified according to whether CNS leukemia occurred at initial diagnosis of acute lymphocytic leukemia (ALL) (Stratum I, 15 patients), during first bone marrow (BM) remission (Stratum II, 49 patients), simultaneous with first BM relapse (Stratum III, 12 patients), or during second BM remission (Stratum IV, 11 patients). The median follow-up for patients who remain at risk is 15 + months. Eight children (seven on CRT + ITC, one on CSpRT) developed presumed therapy related encephalopathy. In Stratum II, 16 of 29 (55%) patients receiving CRT + ITC experienced adverse events: 3 deaths during continuous complete remission (CCR) and 13 relapses (2 CNS, 1 CNS + BM, 1 BM + testes, and 2 testes) as compared with only 5 relapses in 20 (25%) patients on CSpRT (1 CNS, 1 CNS + BM, 1 BM, and 2 testes). The children on both regimens were comparable for sex, race, age at initial ALL diagnosis, time from ALL diagnosis to first episode of CNS leukemia, systemic therapy both before and after CNS relapse, and number of blasts in the spinal fluid at diagnosis of CNS leukemia. The conclusion is that children with isolated CNS leukemia can achieve prolonged survival with aggressive therapy, and that CSpRT is possibly less toxic and more likely than is CRT + ITC to prevent subsequent BM and testicular relapse (P less than 0.02), but not subsequent CNS relapse (P = 0.7). A possible systemic therapy effect of spinal irradiation is postulated to explain the superiority of CSpRT.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1989

The problem of neck relapse in early stage supraglottic larynx cancer.

We reviewed the records of 104 patients with Stage T1NO or Stage T2NO epidermoid carcinoma of the supraglottic larynx treated between 1965 and 1979. In 79 patients, surgery was the only type of initial treatment. These 79 patients are the subjects of this report. Forty-eight (61%) of these patients were treated by total laryngectomy, whereas 31 (39%) had a partial laryngectomy. An elective unilateral radical neck dissection was performed on 31 patients considered at high risk, but metastatic disease was found in the dissected side of the neck histologically in only 32% (ten of 31) of these patients. The minimum follow-up period was 5 years and the maximum was 20 years. Twenty-nine percent of the patients (23 of 79) experienced a neck relapse. The neck relapse rate was the same whether the patients did or did not have an elective radical neck dissection. Among the patients who experienced a neck relapse, 65% (15 of 32) have died of the cancer. Among those who did not experience a neck relapse, none (zero of 56) have died of the cancer (P less than 0.01). These results indicate that in surgically treated patients with early stage supraglottic larynx cancer, neck relapse was the major cause of failure associated with death from cancer. Strategies for decreasing the relapse rate are discussed.

Adult↗

PubMed1989

Prognostic factors for relapse after complete response in patients with metastatic germ cell tumors.

Among 216 patients with metastatic germ cell tumors who achieved a complete response (CR) to cisplatin-based chemotherapy (CT), 38 have experienced a relapse. Prognostic factors for time to relapse from time of response were considered using the Cox proportional hazards model. Compared with patients who responded to CT and did not require surgery and patients whose surgery showed only either necrotic debris or mature teratoma, those who required surgery for residual tumor after CT were at much higher risk for relapse, although their residual tumor was totally resected. Of the 19 patients who required this surgery, eight have experienced a relapse. Other prognostic factors for relapse included lactate dehydrogenase (LDH) and human chorionic gonadatropin (hCG) at the time of initial CT. Although those who require surgery for residual tumor after CT receive additional CT, there is still a high risk of relapse.

Adult↗

PubMed1989

Central nervous system relapses after bone marrow transplantation for acute lymphoblastic leukemia in remission.

This study defines the risk of central nervous system (CNS) relapse in patients undergoing bone marrow transplantation (BMT) for acute lymphoblastic leukemia (ALL) in remission, with no posttransplant prophylactic CNS therapy. Ninety-two consecutive patients in complete remission received BMT for ALL (n = 82) or high-grade non-Hodgkin's lymphoma with poor prognostic factors at diagnosis (n = 10). Sixty-six patients received allogeneic BMT (Allo-BMT) and 26 patients, without an identical sibling, underwent autologous BMT (Auto-BMT). Fifteen patients had CNS involvement at diagnosis and underwent BMT in first remission. Eight patients experienced CNS relapse after BMT, corresponding to a probability of 11% at 3 years. Apart from a history of prior CNS involvement, no patient characteristic evaluated statistically influenced CNS relapse after BMT. The probability of CNS relapse was 5.5% for the 70 patients without history of CNS involvement and 27.5% for the 22 patients with prior CNS involvement. However, subgroup analysis showed that the increased risk of CNS relapse is mainly observed in Auto-BMT patients with history of prior CNS involvement, particularly in patients undergoing BMT in first remission (three of five Auto-BMT versus one of ten Allo-BMT). Taking into account the multiple factors which influence the occurrence and the treatment of CNS leukemia, the results on this retrospective study suggests that (1) for patients without CNS involvement at diagnosis and for whom BMT is performed in first remission, cranial irradiation before BMT and posttransplant prophylactic CNS therapy can be omitted because of the low probability of CNS relapse after BMT (3.4%), when total-body irradiation (TBI) is included in the conditioning regimen; and (2) the difference observed between Allo-BMT and Auto-BMT patients with previous CNS involvement and undergoing BMT in first remission could indicate that graft-versus-host leukemia acts even in the CNS in Allo-BMT patients.

Adolescent↗