[Close cooperation between the physician and the psychotherapist in the personality disorders treatment department]

Two authors--the doctor and the psychologist describe the practical aspects of cooperation between the psychiatrist and psychotherapist who take part in the treatment of personality disorder patients. The first part of the paper presents a brief description of the Personality Disorder Treatment Department of Józef Babiński Hospital in Kraków. The next part of the paper presents three cases of patients who were treated in that department. The case of Mr. A shows what kind of meaning can be ascribed to the medications. The next two cases show how the doctors and the process of treatment itself, can be overused by the patients. Mrs. B takes the treatment up mainly to be recognised as a sick and disabled person. She appears as a person who does not want to be cured. Withthe case of Mrs. C, the authors show how different somatic problems may protect a person against going through difficult emotions. In the summary, the authors point out the importance of the very close cooperation between all professionals who are involved in the treatment of patients with mental disorders. Such cooperation helps to gain a better understanding of these patients and it could give better results of psychotherapy as well as pharmacotherapy.

[New international staging system and classification of risk groups in neuroblastoma]

Combinations of many different prognostic factors are used for correct qualification of neuroblastoma patients to the risk group and optimal choice of therapy. However, factors selected worldwide for this qualification are not uniform. The International Neuroblastoma Risk Group (INRG) was established to evaluate and select the most important prognostic factors in different forms of NBL as well as to create a system that allows evaluation of stage and risk group on the basis of pre-surgical imaging only, not requiring surgical resection and histopathological evaluation of lymph nodes, like in the International Neuroblastoma Staging System (INSS). Presurgical definition of risk groups facilitates the comparison of the results of studies let in different centers, also in patients observed without surgery and let further development of multicentre international studies. In the paper, the criteria of international classification to the risk groups depending on the presence of established risk factors are presented. Therapy should be individually selected for each specified group. The classification will be probably modified when the new prognostic criteria are discovered.

[Occurrence and prognostic impact of selected factors in neuroblastoma in children]

Neuroblastoma (NBL) accounts for 6-10% of neoplastic diseases of childhood. The clinical course of NBL is very variable and depends on the presence of prognostic factors. The aim of the study is retrospective evaluation of occurrence of known prognostic factors and disease markers in patients treated in 1991-2005 in our institution. Sixty of 100 treated patients were included to the study, in whom tumor embedded in paraffin was available. In all patients, who had no genetic evaluation at diagnosis, especially MYCN amplification, FISH study was performed. In analyzed group, 29 patients died, 23 of them from NBL. Disease progression (n = 12) or relapse (n = 19) was observed in 31 patients. In the whole analyzed group, age had statistically significant influence on deaths caused by NBL (p = 0.01) and therapy failures (p = 0.00008). The statistically significant increase of NBL death incidence (p = 0.00001) and therapy failures (p = 0.00004) was found in stage 4 patients in comparison with other stages. Presence of MYCN amplification statistically significant decreases overall survival (OS) (p = 0.01) and disease free survival (DFS) (p = 0.047) for the whole analyzed group. However, presence of MYCN amplification had no statistically significant influence on OS and DFS in patients over 1 year of age. Multiple Cox analysis showed independent statistically significant influence of stage and MYCN amplification on prognosis. Employment of new treatment modalities, with treatment intensity adjusted to the risk group, but also with the specificity adapted to tumor characteristics (cytogenetic and molecular) as well as further development of supportive therapy improvement may lead to improvement of treatment results, especially in high risk group and to reduction of therapy complications and improvement of quality of life in all children with this tumor.

[Significance of application of immunocytochemical detection of GD2 antigen in bone marrow in neuroblastoma patients]

The presence of disseminated neuroblastoma cells in bone marrow in children over 1 year old is important for clinical staging and risk assessment at diagnosis and for therapy monitoring. Reliable detection of single tumor cells in bone marrow may be a factor of great prognostic significance. Currently disseminated NBL cells are detected by conventional cytomorphological examination of bone marrow smears but this method is not sensitive enough to detect single tumor cells. The development of more sensitive methods of evaluation bone marrow is needed. For this purpose Neuroblastoma Bone Marrow Committee developed standard immunocytochemical assay based on detection of the neuroblastoma-specific antigen. Disialoganglioside GD2 is a surface antigen expressed on neuroblastoma cells but not detectable on the surface of normal bone marrow cells. This article describes significance of immunoctochemical method of identification neuroblastoma cells in bone marrow.

[Treatment results of children with neuroblastoma: report of Polish Pediatric Solid Tumor Group]

Approximately 60 children aged 0-18 years are diagnosed of NBL each year in Poland. About 60% of all patients suffering from NBL have a chance for durable cure. Unfortunately the prognosis for patients within the high-risk group accounting for more than 50% of all NBL patients remains poor despite the introduction of more intensive chemotherapy regimens with radical surgery procedures and megachemotherapy with subsequent stem cell transplantation. Only one third of patients in this group can be cured. To improve the treatment results of the high-risk patient group and to decrease the rate of therapy related side effects current European treatment protocols have been introduced systematically in Poland. In February 2009 information about 389 patients (age 0.1-16.5 years) diagnosed between 2001 and 2008 were obtained. Results of therapy of 319 patients who started treatment from 2001 to 2007 were analyzed. Between 104 infants and 215 children over 1 year of age, stage 4 of disease was found in 25% and 54.5%, respectively. In this period additionally to European treatment protocols, two another protocols were used. Satisfactory treatment results were obtained in 104 infants (5-year event free survival /EFS/=82.6%), irrespective of the type of treatment protocol. Over 5-year EFS for children over 1 year of age in 1, 2 and 3 stage of disease was: 100%, 86.3% and 64.5%, respectively. On the contrary, 107 patients with 4 stage of disease achieved the 5-year EFS of 27% only. Treatment results obtained in patients treated according to the European HR-NBL-1/ESIOP protocol were better than for patients treated according to other treatment protocols (5-year EFS: 31.1% and 16.4%, respectively), but difference between these groups was not significant. Between 2001 and 2007 data reporting increased to 81% from 19% noted earlier. Unfortunately, results of treatment for children over 1 year of age remain still unsatisfactory. That is why there is a need of improvement of modern, unified treatment realization as well as better data reporting. For realization of these aims adequate financial support is essential.

[Central nervous system involvement at diagnosis and at relapse in children with neuroblastoma]

Central nervous system (CNS) involvement in the course of neuroblastoma (NBL) in children is relatively rare. However, it seems to become serious clinical problem in the group of patients from high risk group. They presently achieve longer time of survival caused by employment of more intensive treatment modalities. The aim of the study was clinical evaluation of the patients over 1 year of age with stage 4 NBL with CNS involvement, both at diagnosis and at relapse. From 1997 to 2007, 117 patients (age 0.2-13.5 years) started NBL treatment. In 58 children over 1 year, stage 4 of disease was diagnosed. In 4 (6.9%) cases the CNS involvement was found at diagnosis. In 5 patients (8.6%) the isolated relapse in brain was diagnosed. The clinical symptoms caused by increased intracranial pressure were observed in all patients at relapse. In the case of initial involvement no neurological symptoms were observed. All 5 children with CNS involvement as isolated relapse did not present with infiltration of skull bones, whereas at initial diagnosis the brain lesions were continuous with bone metastases. Among 5 patients with isolated relapse 4 died because of NBL progression. Among 4 children with initial CNS involvement 1 died due to haemorrhage to CNS. Probably brain involvement at initial NBL diagnosis is not an additional negative prognostic factor. Because of extremely poor prognosis in patients with CNS relapse it should be advised to consider possible implementation of preventive treatment. It is also necessary to invent new more effective treatment methods.

[Expression of c-kit and PDGFR and possibility of tyrosine kinase inhibitor employment in treatment of neuroblastoma in children]

Because of unsatisfactory treatment results in high risk neuroblastoma, it is necessary to find new, effective and safe, treatment options. Tyrosine kinase inhibitors, including imatinib, are one of the most profoundly examinated drugs. Its employment in neuroblastoma treatment is potentially possible because of expression of c-kit and PDGFR, which are cellular targets of imatinib. It was shown that this drug inhibits growth of neuroblastoma cell lines both in vivo and in vitro. The prognostic meaning of receptors expression is still not clear and depends on the method used for evaluation. The only found phase II study did not reveal the satisfactory response for imanitinib in treatment of resistant neuroblastoma, but the presence of receptors expression was not inclusion criteria. However, it seems that assuming the correct patient's eligibility criteria and proper dosage schedule, possible in combination with chemotherapy, imatinib may become safe and effective treatment modality.

New method for quantitative analysis of GD2 ganglioside in plasma of neuroblastoma patients

Neuroblastoma, the most common extracranial solid tumour of childhood, is a malignancy of unknown origin and non-specific symptoms. One of the markers of the disease is GD2 ganglioside (disialoganglioside), which is abundantly expressed on the surface of neuroblastoma cells. Gangliosides are known to be shed by tumour cells and this phenomenon can be significant in cancer progression as they inhibit a number of immune responses both in vitro and in vivo. In search for novel markers useful in monitoring and prognosis of neuroblastoma, we developed and validated a new quantitative method of GD2 ganglioside analysis in human blood plasma. We evaluated the level of gangliosides in blood serum of 34 neuroblastoma patients using high-performance liquid chromatography. The technique was used to detect fluorescently labelled oligosaccharides derived from serum glycosphingolipids by enzymatic digestion with ceramide glycanase. The developed method allowed determination of GD2 concentrations at the picomole level and required only 40 microl of plasma, which should be particularly useful when the quantity of clinical material is limiting. Moreover, this method can be applied to study concentration of other gangliosides, as shown for GD3 ganglioside. Analysis of plasma samples from the 34 neuroblastoma patients did not reveal any correlations between the concentration of GD2 ganglioside and clinical parameters, including the results of therapy; it showed, however, that the concentration of GD2 ganglioside in the plasma of neuroblastoma patients decreased substantially in the course of treatment.

New method for quantitative analysis of GD2 ganglioside in plasma of neuroblastoma patients

Neuroblastoma, the most common extracranial solid tumour of childhood, is a malignancy of unknown origin and non-specific symptoms. One of the markers of the disease is GD2 ganglioside (disialoganglioside), which is abundantly expressed on the surface of neuroblastoma cells. Gangliosides are known to be shed by tumour cells and this phenomenon can be significant in cancer progression as they inhibit a number of immune responses both in vitro and in vivo. In search for novel markers useful in monitoring and prognosis of neuroblastoma, we developed and validated a new quantitative method of GD2 ganglioside analysis in human blood plasma. We evaluated the level of gangliosides in blood serum of 34 neuroblastoma patients using high-performance liquid chromatography. The technique was used to detect fluorescently labelled oligosaccharides derived from serum glycosphingolipids by enzymatic digestion with ceramide glycanase. The developed method allowed determination of GD2 concentrations at the picomole level and required only 40 microl of plasma, which should be particularly useful when the quantity of clinical material is limiting. Moreover, this method can be applied to study concentration of other gangliosides, as shown for GD3 ganglioside. Analysis of plasma samples from the 34 neuroblastoma patients did not reveal any correlations between the concentration of GD2 ganglioside and clinical parameters, including the results of therapy; it showed, however, that the concentration of GD2 ganglioside in the plasma of neuroblastoma patients decreased substantially in the course of treatment.

The role of surrogate endpoints in the evaluation of efficacy and safety of therapeutic interventions in diabetes mellitus

In this paper, we examine the concept of surrogate endpoints (i.e. substitute outcome measures) and review their use in clinical trials involving therapies for diabetes mellitus using the example of metformin. Trials such as DCCT and UKPDS, in which patient-important endpoints were evaluated, are relatively rare in diabetology. Clinical decisions, therefore, are often based on evidence obtained using surrogate outcomes, usually fasting or postprandial glycemia or glycated hemoglobin level. In contrast to patient-important endpoints, surrogates do not describe direct clinical benefit to the patient. However, a proven association between a surrogate and patient-important endpoint is essential to draw appropriate therapeutic conclusions. In the process of new drug development, the duration of follow-up, sample size and methodology of the studies initially available are often inadequate to demonstrate the effect of the intervention on patient-important endpoints. Evidence concerning the effect of an intervention on surrogate outcomes usually comes first, followed only later by reports describing its influence on patient-important endpoints. Metformin may serve as an example in several ways. The first publications reported beneficial effects on glycemic control and body weight. Outcomes from the subsequent UKPDS study suggested the patient-important efficacy of metformin measured as a reduction in mortality and a decrease in the incidence of diabetic complications, including myocardial infarction. This reasoning process worked for some but not all strategies. It is particularly questionable whether a change in surrogate endpoint was associated with a potential deterioration in patient-important outcomes. Defining the general relationship between surrogates widely used as measures of metabolic control and patient-important endpoints remains an important challenge in contemporary diabetology.

Prediction of outcome of fetal congenital heart disease using a cardiovascular profile score

OBJECTIVES

Congestive heart failure in fetuses with congenital heart defects (CHD) is associated with high perinatal mortality. The clinical condition can be characterized by five ultrasound markers that comprise the 10-point cardiovascular profile (CVP) score. Our aim was to assess the value of the CVP score in evaluating the condition and in maintaining surveillance of fetuses with CHD.

METHODS

We evaluated retrospectively 131 singleton pregnancies with a diagnosis of fetal CHD, which had been assessed by serial echocardiographic examinations, during which the CVP score was obtained. Fetal and neonatal outcomes, including perinatal mortality and Apgar scores, were assessed.

RESULTS

Fetuses with a final CVP score <or= 7 were statistically significantly more likely to suffer mortality than were fetuses with a final CVP score >or= 8 (87.5% vs. 15.2% mortality; P < 0.0001, chi square = 24.5). Significance was maintained after controlling for birth weight, lag time between the final examination and delivery and the dichotomized 5-min Apgar score (odds ratio, 22.3; P = 0.024). For low Apgar score and mortality, the CVP score had low sensitivity (0.25 and 0.27, respectively) but high specificity (0.98 and 0.99, respectively). The presence of hydrops and severe cardiomegaly were statistically significantly associated with mortality (P < 0.05).

CONCLUSIONS

Fetuses with CHD and a CVP score below 8 are at risk of perinatal death. The CVP score may be used to assess the severity of fetal CHD and to plan perinatal management.

'In vitro' cytokine secretion by peripheral blood and decidual lymphocytes during the third trimester of normal pregnancy

If the 'Th2 phenomenon' is dependent on trophoblastic antigens and cytokines, the profile of cytokines secreted by decidual lymphocytes (DL) should indicate stronger Th2 shift than that of peripheral blood lymphocytes (PBL). We studied spontaneous and mitogen-stimulated 'in vitro' cytokine secretion of cultured lymphocytes isolated from peripheral blood (n = 21) and decidua (n = 11) of third trimester healthy pregnant women not being in labor. The ELISA method was used for estimation of IL-2, IL-4, IL-6, IL-10, IL-12, IFN-gamma and TGF-beta. The results (given in pg/ml) were found to be statistically significant in the Mann-Whitney U-test (p < 0.05). Compared to PBL, DL produced spontaneously decreased concentrations of IL-12, IL-6, IFN-gamma and TGF-beta and upon mitogen stimulation increased quantities of IL-2, IL-4 and IL-10. It demonstrates that DL play an active role in local Th2-like immunoregulation and that their cytokine secretion pattern estimated in 'in vitro' conditions is biased towards Th2 activity more than that of PBL.

A multicentre randomized/controlled trial of a conventional versus modestly accelerated radiotherapy in the laryngeal cancer: influence of a 1 week shortening overall time

BACKGROUND AND PURPOSE

To compare in a phase III study the loco-regional control, disease-free survival and overall survival induced by an accelerated regimen (AF) as compared with conventional regimen (CF) and to analyze the early and late post-radiation morbidity in both arms.

MATERIALS AND METHODS

Patients with age < or = 75, WHO 0-1, suitable for a radical course of radiotherapy T1-T3, N0, M0, stage of glottic and supraglottic laryngeal cancer were randomized to either CF: 66Gy given in 33 fractions over 45 days or AF: 66Gy given in 33 fractions over 38 days (2 fractions every Thursday). A total of 395 patients were included from 05.1995 to 12.1998.

RESULTS

Early toxicity: At the end of radiotherapy patients treated with AF complained for more severe reactions than patients treated with CF. In 8 weeks after treatment completion patients treated with AF complained only for more severe pain on swallowing (P=0.027). In 4 months after treatment completion all types of toxicity except for skin teleangiectasia (P=0.001) were similar in the two groups. Loco-regional control: comparison between CF and AF showed no difference in terms of loco-regional control (P=0.37).

CONCLUSIONS

The improvement in AF in terms of loco-regional control is estimated to be 3-5% in comparison with conventional regimen and is not significant. The intensity of reactions after 4 months was similar in both arms, what suggests the possibility of further shortening of the overall time by few days or enhancing the total dose within the limits of acceptable morbidity.