Resilience in Lower Grade Glioma Patients

Current data show that resilience is an important factor in cancer patients’ well-being. We aim to explore the resilience of patients with lower grade glioma (LGG) and the potentially influencing factors. We performed a cross-sectional assessment of adult patients with LGG who were enrolled in the LoG-Glio registry. By phone interview, we administered the following measures: Resilience Scale (RS-13), distress thermometer, Montreal Cognitive Assessment Test for visually impaired patients (MoCA-Blind), internalized stigmatization by brain tumor (ISBI), Eastern Cooperative Oncological Group performance status (ECOG), patients’ perspective questionnaire (PPQ) and typical clinical parameters. We calculated correlations and multivariate regression models. Of 74 patients who were assessed, 38% of those showed a low level of resilience. Our results revealed significant correlations of resilience with distress (p < 0.001, −0.49), MOCA (p = 0.003, 0.342), ECOG (p < 0.001, −0.602), stigmatization (p < 0.001, −0.558), pain (p < 0.001, −0.524), and occupation (p = 0.007, 0.329). In multivariate analyses, resilience was negatively associated with elevated ECOG (p = 0.020, β = −0.383) and stigmatization levels (p = 0.008, β = −0.350). Occupation showed a tendency towards a significant association with resilience (p = 0.088, β = −0.254). Overall, low resilience affected more than one third of our cohort. Low functional status is a specific risk factor for low resilience. The relevant influence of stigmatization on resilience is a novel finding for patients suffering from a glioma and should be routinely identified and targeted in clinical routine.

Development of heart failure in long-term survivors of childhood cancer: results from the cvss study

Background

Long-term survivors of childhood cancer (CCS) are at increased risk for cardiovascular sequelae, including heart failure (HF) as the largest non-malignant contributor to excess death. Yet, little is known about the risk factors, mechanisms of cardiac dysfunction and prevalence of different stages of HF in these patients.

Purpose

To investigate the development and prevalence of HF phenotypes in CCS compared to the general population.

Methods

The CVSS study is a prospective single-center cohort study investigating cardiovascular sequelae of CCS. Patients were eligible for the study when they were diagnosed with a neoplasia according to the International Classification of Childhood Cancer (ICCC 3) at an age prior to 15 years between 1980 and 1990, survived more than five years after initial cancer diagnosis and received antineoplastic treatment. Between 2013 and 2016, study individuals underwent a comprehensive, standardized clinical investigation in the CVSS cohort study including echocardiographic examination. HF was categorized as stages A to D according to current HF guidelines of the American Heart Association (AHA). A population-based sample free of cancer (age- and sex matched) serves as control group.

Results

From 1,002 individuals, all CCS with history of chemo- or radiotherapy and no subsequent neoplasia (n=877) were included (mean age 34.2 (±5.5) years, 44.7% (N=392) female). Age at diagnosis was 6.28 years (±4.24) and the mean interval from the date of diagnosis of cancer to the date of completion of baseline examination 28.5±3.2 years. Based on echocardiographic examination, clinical data and biomarker assessment, 26.6% of CCS were diagnosed with HF stage A, 21.1% with HF stage B and 2.1% with symptomatic HF, i.e. HF stage C/D. Importantly, prevalence of different HF stages varied strongly by specific tumor history. Compared to the population, the prevalence ratio (PR) was 1.16 [95% confidence interval 1.02/1.31] for stage A HF and 1.91 [1.63/2.23] for the composite of stage B to D HF in an age- and sex-adjusted Poisson regression model. Multivariable linear regression with the systolic marker left ventricular ejection fraction as dependent variable and adjustment for tumor entities, age, sex, and cardiovascular risk factors (CVRF) revealed a lower EF in patients with history of bone tumors (β −6.0 [−8.1/−3.0]), soft tissue sarcoma (β −2.2 [−4.1/−0.35]), leukemia (β −0.84 [−1.8/0.08]) and renal tumors (β −1.8 [−4.0/0.27]) compared to the population. In contrast, the same model for the diastolic marker E/E', showed an association only with CVRF, but not with tumor entities.

Conclusion

The prevalence of stage B to D HF was significantly higher among long-term CCS in the 3rd to 5th age decade compared to the population and varied strongly by tumor entity. Systolic dysfunction was primarily associated with history of tumor entities, whereas diastolic dysfunction was associated with the higher burden of CVRF in CCS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study is funded by the Deutsche Forschungsgemeinschaft (DFG) (SP 1381/2-1&2, FA 1038/2-1&2, WI 3881/2-1&2)

Prevalence and outcome of cardiac amyloidosis in an all-comer population of patients with non-ischaemic heart failure

Background

Cardiac amyloidosis (CA) is increasingly recognized as an underlying cause of heart failure with preserved ejection fraction (HFpEF), associated with high morbidity and mortality. However, most studies, solely investigated the prevalence of CA in special subgroups including HFpEF and severe aortic valve disease.

Purpose

With the present study we sought to investigate prevalence of different phenotypes of CA in an all comer-population of patients with non-ischaemic heart failure (HF) and to analyze the impact of CA on all-cause mortality.

Methods

The My Biopsy HF-Study (German clinical trials register number: 22178) is a retrospective monocentric study investigating the underlying etiology of HF in an all-comer population of patients with HF of unknown etiology. Patients presenting with symptoms of HF at the University Medical Centre between 14/10/2012 and 01/03/2021, who underwent endomyocardial biopsy (EMB) were enrolled in the present study. Ischaemic HF and valvular HF were ruled out prior to EMB. Specimens were sent for further examination to a specialized laboratory approved by the Food and Drug Administration

Results

Between October 2012 and March 2021, 767 patients (71.6% men) with HF of unknown etiology were included. Mean age at the time of presentation was 55.4 years (±14.4). Altogether, 72.5% of the patients presented with HF with reduced ejection fraction (HFrEF), 7.1% were diagnosed with HF with mid-range ejection fraction (HFmrEF) and 20.4% with HFpEF. Based on histological examination and genotyping, CA was diagnosed in 44 (5.7%) patients (immunglobulin light chain [AL] CA: 15 patients; variant transthyretin [ATTRv] CA: 6 patients; wild type transthyretin [ATTRwt] CA: 21 patients; de novo CA: 2 patients). Patients with CA were older compared with patients without CA (69.4±11.4 vs. 54.1±14.5; p&lt;0.0001), had a higher prevalence of arterial hypertension (68.2% vs. 50.9%; p=0.045) and showed a better left ventricular ejection fraction based on echocardiographic examination (47.5% vs. 32.6%; p&lt;0.0001). With respect to biomarker expression, levels of both brain natriuretic peptide and high-sensitive troponin I were significantly higher in patients without CA (BNP: 914.1 vs 612; p=0.01; troponin I: 812.8 vs. 171.7; p=0.006). In univariate logistic regression analysis CA was associated with a significant all-cause mortality (hazard ratio [HR] per unit increase [ui], 5.17, 95% CI, 2.93–9.08; p&lt;0.0001), even after adjustment for classical cardiovascular risk factors (HRperui 3.12, 95% CI, 1.11–8.76; p=0.03) and comorbidities like chronic obstructive pulmonary disease, chronic kidney disease and stroke (HRperui 2.93, 95% CI, 1.2–7.15; p=0.018).

Conclusions

Among patients presenting with HF of unknown etiology, including patients with HFpEF, HFmrEF and HFrEF, cardiac amyloidosis is the underlying cause of HF in 5.7% of patients and is independently associated with all-cause mortality.

Funding Acknowledgement

Type of funding sources: None.

Impact of cardiac amyloidosis on outcomes of patients hospitalized with heart failure in Germany

Background

Amyloidosis is a multi-systemic disease resulting from deposition of misfolded proteins as insoluble fibrils in the interstitium of affected organs including the heart, subsequently leading to organ failure. Cardiac involvement is predominantly observed in light chain (AL) amyloidosis and wild-type transthyretin (ATTRwt) amyloidosis.

Purpose

We aimed to investigate prevalence and prognostic implications of cardiac amyloidosis of any etiology on outcomes of hospitalized patients with heart failure (HF) in Germany.

Methods

We analyzed data of the German nationwide inpatient sample (2005–2018) of patients hospitalized for HF (including myocarditis with HF and heart transplantation with HF). HF patients with amyloidosis (defined as cardiac amyloidosis [CA]) were compared with those HF patients without amyloidosis and impact of CA on outcomes was assessed (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations).

Results

During this fourteen-year observational period 5,478,835 hospitalizations of HF patients were analyzed. Amyloidosis was coded in 5,407 hospitalizations of HF patients (0.1%). Prevalence of CA was 1.87 hospitalizations per 100,000 German population. CA patients were younger (75.0 [IQR 67.0/80.0] vs. 79.0 [72.0–85.0] years, p&lt;0.001), predominantly male (68.9%) and had a higher prevalence of cancer (14.8% vs. 3.6%, P&lt;0.001) compared with HF without amyloidosis. Although patients without amyloidosis had a pronounced cardiovascular risk profile -especially arterial hypertension (45.4% vs. 35.6%; p&lt;0.001) and diabetes mellitus (38.9% vs. 18.5%; p&lt;0.001)- and a higher prevalence of concomitant coronary artery disease (40.5% vs. 34.5%; p&lt;0.001) and chronic obstructive pulmonary disease (17.1% vs. 9.4%; p&lt;0.001), adverse in-hospital events including necessity of transfusions of blood constituents (7.1% vs. 5.4%, p&lt;0.001) and cardio-pulmonary resuscitation (CPR, 2.7% vs. 1.4%; p&lt;0.001) were more frequent in CA. CA was independently associated with acute kidney failure (OR 1.40 [95% CI 1.28–1.52], p&lt;0.001), CPR (OR 1.58 [95% CI 1.34–1.86], p&lt;0.001), intracerebral bleeding (OR 3.13 [95% CI 1.68–5.83], p&lt;0.001) and in-hospital mortality in the 6th and 8th decade of life (6thdecade: OR 1.40 [95% CI 1.01–1.94], p=0.042; 8thdecade: OR 1.18 [95% CI 1.03–1.35], p=0.02).

Conclusions

CA was identified as an independent risk factor for complications and in-hospital mortality in HF patients. Physicians should be aware of this issue concerning treatments and monitoring of CA-patients.

Funding Acknowledgement

Type of funding sources: None.

Depression prevalence using the HADS-D compared to SCID major depression classification: An individual participant data meta-analysis

OBJECTIVES

Validated diagnostic interviews are required to classify depression status and estimate prevalence of disorder, but screening tools are often used instead. We used individual participant data meta-analysis to compare prevalence based on standard Hospital Anxiety and Depression Scale - depression subscale (HADS-D) cutoffs of ≥8 and ≥11 versus Structured Clinical Interview for DSM (SCID) major depression and determined if an alternative HADS-D cutoff could more accurately estimate prevalence.

METHODS

We searched Medline, Medline In-Process & Other Non-Indexed Citations via Ovid, PsycINFO, and Web of Science (inception-July 11, 2016) for studies comparing HADS-D scores to SCID major depression status. Pooled prevalence and pooled differences in prevalence for HADS-D cutoffs versus SCID major depression were estimated.

RESULTS

6005 participants (689 SCID major depression cases) from 41 primary studies were included. Pooled prevalence was 24.5% (95% Confidence Interval (CI): 20.5%, 29.0%) for HADS-D ≥8, 10.7% (95% CI: 8.3%, 13.8%) for HADS-D ≥11, and 11.6% (95% CI: 9.2%, 14.6%) for SCID major depression. HADS-D ≥11 was closest to SCID major depression prevalence, but the 95% prediction interval for the difference that could be expected for HADS-D ≥11 versus SCID in a new study was -21.1% to 19.5%.

CONCLUSIONS

HADS-D ≥8 substantially overestimates depression prevalence. Of all possible cutoff thresholds, HADS-D ≥11 was closest to the SCID, but there was substantial heterogeneity in the difference between HADS-D ≥11 and SCID-based estimates. HADS-D should not be used as a substitute for a validated diagnostic interview.

Temporal trends, sex-differences and outcomes of patients hospitalized for heart failure in Germany

Background

Despite remarkable improvements in treatment of cardiovascular disease, heart failure (HF) is still characterized by a high mortality rate. Sex-specific differences in HF have been described, but underlying reasons are widely unexplored. Thus, we aimed to investigate sex differences of patients hospitalized for HF in a nationwide cohort.

Methods

The nationwide German inpatient sample (2005–2016) was used for this sex-specific analyses. Temporal trends on hospitalizations, mortality, and treatments were analyzed and independent predictors of adverse outcomes identified.

Results

The present analysis comprises 4,538,977 hospitalizations due to HF (52.0%women) in Germany (2005–2016). Although women were older (median 82 (IQR75–87) vs. 76 (69–82), P&lt;0.001), coronary artery disease (CAD, 50.3% vs. 30.7%, P&lt;0.001) was more prevalent in men, who were more often treated with PCI (3.4% vs. 1.4%, P&lt;0.001) and implantable cardioverter-defibrillator (2.2% vs. 0.5%, P&lt;0.001). In-hospital mortality was significantly lower in men than in women (8.9% vs. 10.2, P=0.001) and was reduced in patients who received PCI or implantation of an ICD.

While total numbers of hospitalizations between 2005 and 2016 increased in both men (β-estimate 7185.71 (95% CI 6502.23 to 7869.18), P&lt;0.001) and women (β-estimate 5297.60 (95% CI 4557.37 to 6037.83), P&lt;0.001) as well as almost all comorbid co-conditions, in-hospital mortality rate decreased more distinctly in women (β-estimate −0.41 (95% CI: −0.42 to −0.39), P&lt;0.001) compared to men (β-estimate −0.29 (95% CI: −0.30 to −0.27), P&lt;0.001).

Conclusions

Interventional treatments of HF were associated with improved outcomes and equally beneficial for both sexes. However, they were more often used in male HF patients, in which CAD is significantly more frequent than in female HF patients. This may explain the higher case fatality rate of HF in females.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research (BMBF)

Global longitudinal strain predicts outcome in chronic heart failure across American Heart Association stages: results from the MyoVasc study

Background

Global longitudinal strain (GLS) demonstrated a superior prognostic value over left ventricular ejection fraction (LVEF) in acute heart failure (HF). Its prognostic value across American Heart Association (AHA) stages of HF – especially under considering of conventional echocardiographic measures of systolic and diastolic function – has not yet been comprehensively evaluated.

Purpose

To evaluate the prognostic value of GLS for HF-specific outcome across AHA HF stages A to D.

Methods

Data from the MyoVasc-Study (n=3,289) were analysed. Comprehensive clinical phenotyping was performed during a five-hour investigation in a dedicated study centre. GLS was measured offline utilizing QLab 9.0.1 (PHILIPS, Germany) in participants presenting with sinus rhythm during echocardiography. Worsening of HF (comprising transition from asymptomatic to symptomatic HF, HF hospitalization, and cardiac death) was assessed during a structured follow-up with subsequent validation and adjudication of endpoints. AHA stages were defined according to current guidelines.

Results

Complete information on GLS was available in 2,400 participants of whom 2,186 categorized to AHA stage A to D were available for analysis. Overall, 434 individuals were classified as AHA stage A, 629 as stage B and 1,123 as stage C/D. Mean GLS increased across AHA stages of HF: it was lowest in stage A (−19.44±3.15%), −18.01±3.46% in stage B and highest in AHA stage C/D (−15.52±4.64%, P for trend &lt;0.0001). During a follow-up period of 3.0 [1.3/4.0] years, GLS denoted an increased risk for worsening of HF after adjustment for age and sex (hazard ratio, HRGLS [per standard deviation (SD)] 1.97 [95% confidence interval 1.73/2.23], P&lt;0.0001) in multivariable Cox regression analysis. After additional adjustment for cardiovascular risk factors, clinical profile, LVEF and E/E' ratio, GLS was the strongest echocardiographic predictor of worsening of HF (HRGLS [per SD] 1.47 [1.20/1.80], P=0.0002) in comparison to LVEF (HRLVEF [per SD] 1.23 [1.02/1.48], P=0.031) and E/E' ratio (HRE/E' [per SD] 1.12 [0.99/1.26], P=0.083). Interestingly, when stratifying for AHA stages, GLS denoted a similar increased risk for worsening of HF in individuals classified as AHA stage A/B (HRGLS [per SD] 1.63 [1.02/2.61], P=0.039) and in those classified as AHA stage C/D (HRGLS [per SD] 1.95 [1.65/2.29], P&lt;0.0001) after adjustment for age and sex. For further evaluation, Cox regression models with interaction analysis indicated no significant interaction for (i) AHA stage A/B vs C/D (P=0.83) and (ii) NYHA functional class &lt;II vs ≥II in individuals classified as AHA stage C/D (P=0.12).

Conclusions

GLS demonstrated a higher predictive value for worsening of HF than conventional echocardiographic measures of systolic and diastolic function. Interestingly, GLS indicated an increased risk for worsening of HF across AHA stages highlighting its potential value to advance risk prediction in chronic HF.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Center for Cardiovascular Research (DZHK), Center for Translational Vascular Biology (CTVB) of the University Medical Center of the Johannes Gutenberg-University Mainz

Towards the targeted assessment of relevant problems: Optimization of the distress Thermometer for adult neuro-oncological patients

OBJECTIVE

Generic psychosocial screening tools may not reflect the unique symptom profile of brain tumour patients (BTPs). The aim was to adapt the problem list of the distress thermometer (DT) for BTPs.

METHODS

First, items of low relevance for BTPs were identified on basis of retrospective analyses. Second, relevant yet missing problems were identified via an extensive literature search, qualitative interviews with BTPs and experts, as well as an online expert survey. The resulting raw version of the adapted problem list in BTPs was subsequently pretested.

RESULTS

In the first part, data of n = 657 BTPs were analysed. Twelve items (20%) were excluded in this step as they proved to be less relevant for BTPs (i.e., items were endorsed by less than 10% and without significant correlations to patients' DT score). In the second part, qualitative interviews and the online survey with 102 professionals led to the addition of 21 new and the modification and condensation of 17 relevant problems specific for BTPs. This adapted list was than successfully pretested in n = 19 patients, leading to the 'distress thermometer brain tumour problem list' (DT-BT), consisting of 42 relevant problems.

CONCLUSION

The adapted problem list for the DT particularly reflects the neurological and psychosocial burden of an intracranial tumour and allows for the targeted assessment of the specific burdens and needs of BTPs. Our revised version of the DTs problem list (DT-BT) should in the next step be widely validated in multinational samples.

Fear of disease progression and relevant correlates in acute leukemia patients prior to allogeneic hematopoietic stem cell transplantation

OBJECTIVE

Prior to hematopoietic stem cell transplantation (HSCT), and despite the high objective risks associated with HSCT, fear of progression (FoP) has only sparsely been studied in patients with acute leukemia until now. The aim of this study was the assessment of the prevalence of FoP, and any relevant correlates and typical concerns.

METHODS

We included 59 adult patients with acute leukemia who were tested prior to their first HSCT during an in-patient stay. Patients completed self-report measures assessing FoP (Fear of Progression Questionnaire-Short Form, FoP-Q-SF) and relevant correlates of FoP (eg, patients' physical state, depression, psychosocial distress, or social support).

RESULTS

About one third of the patients (35.6%; n = 21) had high FoP. Higher FoP was associated with previous cancer diagnosis, as well as depression, anxiety, reduced physical functioning, lower mental health-related quality of life, and lower positive social support. The greatest fears reported by these patients reflected common fears of cancer patients (eg, fear about leaving their families behind), but also specific fears related to the current situation (eg, fear of severe medical treatments during the course of the illness).

CONCLUSIONS

This was the first study providing an extensive analysis of FoP in leukemia patients prior to the extreme situation of HSCT. FoP is frequent and of major clinical importance for these patients. Hence, we recommend that patients undergo routine screening for FoP, to identify highly distressed patients at an early stage, and to offer targeted support.

Probability of major depression diagnostic classification based on the SCID, CIDI and MINI diagnostic interviews controlling for Hospital Anxiety and Depression Scale - Depression subscale scores: An individual participant data meta-analysis of 73 primary studies

OBJECTIVE

Two previous individual participant data meta-analyses (IPDMAs) found that different diagnostic interviews classify different proportions of people as having major depression overall or by symptom levels. We compared the odds of major depression classification across diagnostic interviews among studies that administered the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D).

METHODS

Data accrued for an IPDMA on HADS-D diagnostic accuracy were analysed. We fit binomial generalized linear mixed models to compare odds of major depression classification for the Structured Clinical Interview for DSM (SCID), Composite International Diagnostic Interview (CIDI), and Mini International Neuropsychiatric Interview (MINI), controlling for HADS-D scores and participant characteristics with and without an interaction term between interview and HADS-D scores.

RESULTS

There were 15,856 participants (1942 [12%] with major depression) from 73 studies, including 15,335 (97%) non-psychiatric medical patients, 164 (1%) partners of medical patients, and 357 (2%) healthy adults. The MINI (27 studies, 7345 participants, 1066 major depression cases) classified participants as having major depression more often than the CIDI (10 studies, 3023 participants, 269 cases) (adjusted odds ratio [aOR] = 1.70 (0.84, 3.43)) and the semi-structured SCID (36 studies, 5488 participants, 607 cases) (aOR = 1.52 (1.01, 2.30)). The odds ratio for major depression classification with the CIDI was less likely to increase as HADS-D scores increased than for the SCID (interaction aOR = 0.92 (0.88, 0.96)).

CONCLUSION

Compared to the SCID, the MINI may diagnose more participants as having major depression, and the CIDI may be less responsive to symptom severity.

Disclosure of Grief Questionnaire (DGQ): Entwicklung und Validierung eines Fragebogens zur Erfassung von Kommunikationsmustern nach Trauerfällen

Zusammenfassung. Für die Verarbeitung belastender Ereignisse ist das Offenlegen der persönlichen Erfahrungen gegenüber dem sozialen Umfeld von zentraler Bedeutung. Allerdings gibt es bislang keine geeigneten Instrumente zur Erfassung der Kommunikationsmuster nach Trauerfällen. Ziel der aktuellen Studie war daher, den Fragebogen zum Offenlegen von traumatischen Erfahrungen (FOT; Müller, Beauducel, Raschka & Maercker, 2000 ) für Trauerprozesse zu adaptieren und seine psychometrische Qualität über eine Online-Befragung von 302 Personen, die mindestens einen Trauerfall erlebt hatten, zu überprüfen. In einer Hauptkomponentenanalyse ergab sich eine 2-Faktoren-Lösung mit den beiden Faktoren „Verschwiegenheit“ und „Mitteilungsbedürfnis“. Die psychometrischen Kennwerte der Skalen sind mit Cronbachs α-Werten zwischen .82 – .88 als zufriedenstellend bis gut einzuordnen. Ebenso kann die Konstruktvalidität vor dem Hintergrund signifikanter Korrelationen mit verwandten Maßen als gegeben angesehen werden. Der „Disclosure of Grief Questionnaire“ (DGQ) ist somit ein reliables und valides Instrument zur Erfassung der individuellen Kommunikationsmuster nach einem Trauerfall.

OS3.2 Relevant topics for brain tumor patients in the Distress Thermometer, first results of the HEAT study

BACKGROUND

Patient-centered assessments and disease-adjusted patient-reported outcome measures (PROMs) are crucial in neuro-oncology. The Distress Thermometer (DT) is a well-accepted screening tool for cancer patients including a numerical rating scale (1–10, cut-offs indicating relevant distress ≥4–6) and 40 items describing possible problem categories (emotional, social, physical, practical and spiritual). The aims of the first part of the “Adaption of the Distress Thermometer in patients with intracranial tumors” (HEAT) study were to evaluate the importance and relevance of items for brain tumor patients (BTP).

MATERIAL AND METHODS

The multicenter study included three University hospitals. After given informed consent patients were prospectively evaluated either during their hospital stay or in the outpatient setting using DT as well as the 40 item problem list. Clinical and demographic data were recorded. We performed an analysis regarding frequency of indicated topics and evaluated their relevance for patients’ psychosocial well-beings via Pearson correlations with the DT score.

RESULTS

Data of n = 670 patients were analyzed. Mean age was 52 years (SD = 14, range 18–81), most of the patients harbored WHO°I tumors (37%) and WHO°IV tumors (28%). Male to female ratio was 1:1, 17% were assessed preoperatively, 40% postoperatively and 43% during adjuvant therapy or follow-up. 14% of the patients faced a tumor recurrence at assessment. Mean score of DT was 5.23 (SD = 2.9, range 0–10). Applying a cut-off score ≥ 4, 61% reported distress (≥ 5: 46% and ≥ 6: 37%). Regarding the relevance of the problem list for BTP, emotional problems (e. g., anxiety, depression) were most frequently reported. A total of 14/40 (35 %) of items were endorsed by less than 10% of patients. With exception of emotional problems all areas were reflected: practical problems (e. g., problems with child care or insurance), social problems (e. g., problems with children), spiritual concerns (e. g., loss of faith), and physical problems (e. g., breathing, fever). However, some of these rarely reported problems were of relevance for patients’ psychosocial well-being as indicated by significant correlations between the respective item and the DT score. This was, for example, the case for problems with childcare (r = .106; p < .01) or breathing (r = .125; p = .001).

CONCLUSION

Tools developed for cancer patients do not yet perfectly reflect all needs of BTP. Based on our data, we suggest further adjustments of available tools. Yet, it should be taken into account that subgroups of BTP may require different problem lists in the DT, as we observed some topics (e.g. breathing) probably be related to BTP under chemotherapy or steroids only. Moreover, our data require cross-cultural validation as especially results regarding practical problems and insurance might differ in cultures with different social security systems.

The importance of social relationships for brain tumor patients' quality of life: A case for the inclusion of the concept of disclosure in psycho-oncological care

Purpose: Interpersonal factors are of major importance for cancer patients' physical and mental health. Brain tumor patients rank amongst those cancer patients with the highest psychosocial burden. Changes in language, cognition, and personality pose specific risk factors for impeding interpersonal functioning in this patient group. Despite this, role and relevance of social support including both supportive (e.g., emotional support) and detrimental interactions causing distress (e.g., critical remarks) are not well understood. Aims of this study were thus (1) to investigate the association of social support and patients' Health Related Quality of Life (HRQoL) and (2) to assess whether this relationship is mediated by the patients' disclosure behavior.Methods: Seventy-four ambulatory brain tumor patients (mean age 54 years; 58% women) completed the following self-report questionnaires: Illness-specific Social Support Scale (SSUK) for assessment of positive support and detrimental interactions, the Disclosure of Trauma Questionnaire (DTQ) for assessment of patients' disclosure behavior, and the Short-Form Health Survey (SF-8) for assessment of QoL.Findings: Detrimental social interactions were significantly related to patients' mental and physical well-being while positive support was not. Our results support a model in which patients perceiving detrimental social interactions show more difficulties in talking about illness-specific contents in a functional manner. This, in turn, was associated with a lower physical and mental HRQoL.Conclusions: This was the first study in which the close associations of detrimental social interactions, brain tumor patients' dysfunctional disclosure behavior and patients' mental as well as physical well-being were empiricially validated. Thus, dysfunctional disclosure behavior might pose a relevant therapeutic target when offering psycho-oncological support for brain tumor patients and their families.

Plasma total prion protein as a potential biomarker for neurodegenerative dementia: diagnostic accuracy in the spectrum of prion diseases

AIMS

In the search for blood-based biomarkers of neurodegenerative diseases, we characterized the concentration of total prion protein (t-PrP) in the plasma of neurodegenerative dementias. We aimed to assess its accuracy in this differential diagnostic context.

METHODS

Plasma t-PrP was measured in 520 individuals including healthy controls (HC) and patients diagnosed with neurological disease control (ND), Alzheimer's disease (AD), sporadic Creutzfeldt-Jakob disease (sCJD), frontotemporal dementia (FTD), Lewy body dementia (LBD) and vascular dementia (VaD). Additionally, t-PrP was quantified in genetic prion diseases and iatrogenic CJD. The accuracy of t-PrP discriminating the diagnostic groups was evaluated and correlated with demographic, genetic and clinical data in prion diseases. Markers of blood-brain barrier impairment were investigated in sCJD brains.

RESULTS

Compared to HC and ND, elevated plasma t-PrP concentrations were detected in sCJD, followed by FTD, AD, VaD and LBD. In sCJD, t-PrP was associated neither with age nor sex, but with codon 129 PRNP genotype. Plasma t-PrP concentrations correlated with cerebrospinal fluid (CSF) markers of neuro-axonal damage, but not with CSF t-PrP. In genetic prion diseases, plasma t-PrP was elevated in all type of mutations investigated. In sCJD brain tissue, extravasation of immunoglobulin G and the presence of swollen astrocytic end-feet around the vessels suggested leakage of blood-brain barrier as a potential source of increased plasma t-PrP.

CONCLUSIONS

Plasma t-PrP is elevated in prion diseases regardless of aetiology. This pilot study opens the possibility to consider plasma t-PrP as a promising blood-based biomarker in the diagnostic of prion disease.

PTSD severity among emergency personnel: An investigation based on the Ehlers and Clark cognitive model

OBJECTIVE

The relevance of both cognitive and interpersonal processes in predicting adjustment to potentially traumatic events has been highlighted in the literature. The aim of the present study was to investigate whether dysfunctional disclosure mediates the relationship between excessive negative appraisals and posttraumatic stress disorder (PTSD) symptomatology that is proposed in the cognitive PTSD model of Ehlers and Clark (2000).

METHOD

A sample of 134 emergency service workers was interviewed to gain in-depth information regarding their experience of potentially traumatic events, and the following social interactions. Additionally, participants responded to the Disclosure of Trauma Questionnaire, the Posttraumatic Cognitions Inventory, and the Impact of Event Scale-Revised.

RESULTS

Bootstrap mediation analyses revealed that the effect of negative trauma related appraisals on PTSD symptoms is partly mediated by dysfunctional disclosure. In particular, the two aspects of dysfunctional disclosure "reluctance to talk" and "excessive emotional reactions during disclosure" were of relevance in this model. The results remained stable even when controlling for potentially relevant sociodemographic and situational characteristics.

CONCLUSIONS

Our results stress the importance of not only cognitive factors, but also interpersonal behavior in the development and maintenance of PTSD symptoms because we identified interpersonal risk factors (i.e., dysfunctional communicative strategies) to be relevant for PTSD elevation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Fear of disease progression in adult ambulatory patients with brain cancer: prevalence and clinical correlates

BACKGROUND

Fear of progression (FoP) is frequent in patients with cancer and of high clinical relevance. Despite the often devastating prognosis of brain cancer, FoP has not yet been assessed in neurooncological patients.

OBJECTIVE

The aim of this study was thus the assessment of FoP and its clinical correlates.

METHODS

In an ambulatory setting, 42 patients with a primary brain tumour completed the Fear of Progression questionnaire FoP-Q-12. Clinical correlates of FoP were assessed via a variety of measures, including patients' physical state (Karnofsky Performance Status, KPS), cancer-related psychosocial distress (Distress Thermometer, DT), anxiety (General Anxiety Disorder Scale, GAD-7), depression (Patient Health Questionnaire, PHQ-9), Quality of Life (Short Form Health Survey, SF-8), and unmet supportive care needs (Supportive Care Needs Survey, SCNS).

RESULTS

Eighteen patients (42%) suffered from high FoP (i.e. scored ≥ 34 in the FoP-Q-12). According to the 12 items of the FoP-Q-12, the greatest fears were worrying about what would happen to their family and being afraid of severe medical treatments. No sociodemographic variables (e.g. age, gender) or medical tumour characteristics (e.g. tumour malignancy, first or recurrent tumour) were related to FoP. Patients with more severe physical symptoms reported higher FoP. Patients with higher FoP were more anxious, more depressed, reported lower Quality of Life, and suffered from more unmet supportive care needs.

CONCLUSION

Our results demonstrate that FoP is frequent and of high clinical relevance for neurooncological patients. Its assessment is not sufficiently covered by instruments for assessment of other areas of psychological morbidity (e.g. general anxiety). Moreover, FoP cannot be predicted by objective characteristics of the patients and disease. Thus, the routine screening for FoP is recommended in neurooncological patients. Clinicians should bear in mind that patients with high FoP are likely to suffer from high emotional distress and unmet supportive care needs and initiate treatment accordingly.

A missing piece? Neuropsychiatric functioning in untreated patients with tumors within the cerebellopontine angle

PURPOSE

To date, little is known about neuropsychiatric symptoms in patients with tumors within the cerebellopontine angle (CPA). These, however, might be of clinical relevance. Aim of this study was thus to assess possible impairment in cognition, elevation in mood symptoms, and fatigue in this specific patient group.

METHODS

Forty-five patients with an untreated CPA tumor (27 vestibularis schwannoma, 18 meningioma) were tested within a cross-sectional observational study in a single institution prior to neurosurgical treatment. Patients were administered a multifaceted battery comprising of widely-used tests for assessment of neuropsychiatric functioning.

RESULTS

The majority of the included patients (69%) showed neurocognitive impairment, most frequently in the areas of attention and visuo-motor speed (e.g., alertness) (62%) as well as visuo-construction (44%). Impaired structural integrity of the brain stem was accompanied by more serious neurocognitive deficits. About one-third of the sample reported clinically relevant depression and/or anxiety and an even higher proportion (48%) described high levels of fatigue. Cognitive and affective symptoms as well as fatigue contributed significantly to patients' Quality of Life, indicating the clinical relevance of neuropsychiatric symptoms in patients with CPA tumors.

CONCLUSIONS

Although patients with untreated CPA tumors often suffer from devastating and prominent physical symptoms, neuropsychiatric problems are also frequent. Including these aspects in the routine clinical assessment and initiating treatment accordingly might thus improve clinical management of the patients and improve Quality of Life.

Assessment of preoperative anxiety in neurosurgical patients: Comparison of widely used measures and recommendations for clinic and research

OBJECTIVE

Preoperative anxiety is frequent in neurosurgical patients and of high clinical relevance (e. g., associated with anestesiological requirements and surgery outcome). Little however is known about the quality of instruments for assessment of preoperative anxiety in this specific patient group and setting. This paper therefore focused on the psychometric properties of widely used questionnaires. Aim of this study was thus to enable both the clinician and the researcher to select appropriate instruments for assessment of surgery-related anxiety.

PATIENTS AND METHODS

The following instruments for assessment of preoperative anxiety were administered in a pseudo-randomized order one day prior to surgery in sample of 158 neurosurgical patients: The State Trait Operation Anxiety Inventory (STOA) - state scale, the Amsterdam Preoperative Anxiety and Information Scale (APAIS), and the one-item visual analogue scale (VAS). The questionnaires were psychometrically tested according to classical test theory (validity, reliability, diagnostic accuracy).

RESULTS

Construct validity was supported in all applied measures (convergent and divergent validity, known-group comparisons). For the STOA state, we found a one factor scale structure and thus no support for the proposed subscales covering cognitive and affective anxiety. The proposed scale structure of the APAIS, measuring anxiety and information requirement, was replicated. Internal consistency as indicator for reliability of the STOA and the APAIS was excellent (Cronbach's alpha = 0.937/0.868). All instruments showed adequate diagnostic accuracy with the most favourable results of the STOA.

CONCLUSIONS

All instruments included in this study can be recommended for assessment of surgery-related anxiety in neurosurgical patients with regard to their psychometric properties. Each instrument offers distinct advantages. Thus, clinicians and researchers can base their individual choice on specific aims and available resources.

Cross-cultural adaptation and psychometric properties of the SCOPA-Sleep-German version

Aim of the study was the cross-cultural adaptation and validation of the German version of the Scale for Outcomes in Parkinson's disease-Sleep Scale (SCOPA-Sleep) for assessment of night-time sleep problems (NS) and daytime sleepiness (DS). Eighty-three patients with Parkinson's disease completed the SCOPA-Sleep and a multitude of measures for assessment of validity (e.g., PSQI, ESS). Twenty patients completed the SCOPA-Sleep twice within 2 months for assessment of retest reliability. Sixty-four healthy controls were also included for validity estimation. Internal consistency (Cronbach's alpha) was good with coefficients of .801 and .854 for SCOPA-NS and SCOPA-DS, respectively. Test-retest reliability and inter-rater agreement were excellent. Factor analysis revealed two factors, one for each of the subscales NS and DS. Convergent validity was high with correlations of .797 between SCOPA-NS and PSQI, and .679 between SCOPA-DS and ESS. The German version of the SCOPA-Sleep showed good diagnostic accuracy. Optimal cutoff scores were calculated, resulting in an AUC of .908 for NS and of .959 for DS. The German version of the SCOPA-Sleep is a reliable and valid instrument for assessing NS and DS in patients with Parkinson's disease. As diagnostic accuracy is excellent, this scale can be recommended for routine assessment of both NS and DS in PD combined with other standard measures.

Affective state and cognitive functioning in patients with intracranial tumors: validity of the neuropsychological baseline assessment

OBJECTIVES

The aim of this paper is to investigate the relationship between the affective and cognitive states of neurooncological patients prior to the neurosurgical treatment to assess associations between distress levels and neuropsychological test performance in this sample and setting.

METHODS

The prospective study population consists of 172 patients. Patients were studied preoperatively with a comprehensive test battery consisting of a variety of affective and cognitive measures. Psychological instruments included the Hospital Anxiety and Depression Scale, the Amsterdam Preoperative Anxiety and Information Scale, and the Acute Stress Disorder Scale.

RESULTS

Factor analysis revealed two factors representing subjective affective functioning: whereas one reflects the patients' more general emotional state (Hospital Anxiety and Depression Scale, Acute Stress Disorder Scale), the second reflects anxiety specifically related to the neurosurgical procedure (Amsterdam Preoperative Anxiety and Information Scale). After age and education have been accounted for via linear regression analyses, affect did not contribute to cognitive performance in any of the cognitive domains in the whole patient sample. However, in patients with extreme levels of psychiatric morbidity, there was evidence for distinct cognitive morbidity consistent with previous research.

CONCLUSIONS

Our results suggest that, for a large variety of widely used neuropsychological measures and for most neurooncological patients, the preoperative neuropsychological baseline assessment can be considered valid and dependable. In patients with extreme levels of distress, however, distinct cognitive domains might be differentially affected.

[Minimally invasive retrograde drilling of osteochondral lesions of the femur using an arthroscopic drill guide]

OBJECTIVE

Retrograde drilling for penetration of subchondral sclerotic bone in osteochondrosis dissecans (OCD) of the femoral condyle with preserved cartilage integrity. Hereby, revascularization of the OCD and immigration of bone marrow cells to achieve stable reintegration of the OCD into the surrounding subchondral bone.

INDICATIONS

Stable juvenile and adult osteochondrosis dissecans (stage I-II of the International Cartilage Repair Society (ICRS) classification) of the medial and lateral femoral condyle with an intact articular surface and surrounding sclerosis zone, which is visible in the x-ray.

CONTRAINDICATIONS

OCD stage III-IV of the ICRS grading scale. Relative contraindication: preceding retrograde drilling.

SURGICAL TECHNIQUE

Arthroscopic inspection and palpation of the cartilage defect. Minimal incision over the M. vastus medialis (when the defect is located in the medial condyle) or the M. vastus lateralis (when the defect is located in the medial condyle). Preparation and dissection of the fascia of the vastus muscle. Insertion of retractors underneath the vastus muscle to expose the metaphysis of the distal femur. Intraarticular positioning of the arthroscopic drill guide, placement of the wire guide and a Kirschner(K) wire on the femur metaphysis and retrograde drilling with a 2.0-2.2 mm K wire under radiographic visualization. Length measurement of the intraosseous wire distance. Switch the guide mechanism to a multiple hole drill guide and, depending on the defect size, insertion of a further 7-10 K wires of same thickness and defined length.

POSTOPERATIVE MANAGEMENT

Sterile bandage and slightly compressive dressing. Continuous active and passive knee motion. Weight bearing of 20 kg for 6 weeks, with subsequent transition to continuous weight bearing. Radiographic controls at 6 and 12 weeks postoperatively. In case of a persistent sclerosis zone in the control x-ray or clinical abnormalities, control MRI is indicated.

RESULTS

A total of 55 patients with a mean age of 19.6 years were treated using the described technique: 49 patients (89.1%), and 54 knees respectively (35 juvenile OCD, 19 adult OCD), were seen with a mean follow-up of 37.9 months. An improvement was observed in 81.6% of the knees using the radiographic score, i.e., a mean improvement of 1.13 of the radiographic score published by Rodegerdts and Gleissner (preoperative 3.04 vs. postoperative 1.91). Juvenile OCD showed better radiographic results overall (88.2% healing) than adult OCD (66.7% healing).

Distress in patients with newly diagnosed brain tumours

OBJECTIVE

Patients with intracranial tumours often suffer from clinically relevant psychological distress. However, levels of distress and contributing factors have not been systematically evaluated for the early course of the disease. Using the National Comprehensive Cancer Network's Distress Thermometer (DT), we evaluated the extent and sources of distress within a population of patients with intracranial neoplasms.

METHODS

One hundred and fifty-nine patients were included who underwent craniotomy for newly diagnosed intracranial tumours at our department. All patients completed the DT questionnaire, a single-item 11-point visual analogue scale measuring psychological distress. The appendant problem list (PL) consists of 40 items representing problems commonly experienced by cancer patients. Patients were asked to mark any experienced sources of distress.

RESULTS

Percentage of patients suffering from relevant distress was 48.4% (cut-off ≥6). DT-scores were significantly associated with depression and anxiety as well as reported number of concerns. On average, patients reported 6.9 sources of cancer-related distress. Objective medical data (e.g. tumour stage) as well as sociodemographic data (e.g. gender, IQ) were not associated with psychological distress at this early phase.

CONCLUSIONS

Prevalence of elevated distress is high shortly after primary neurosurgical treatment in patients with intracranial tumours and cannot be predicted by objective data. As a consequence, sources of distress can and should be routinely assessed and targeted in these individuals in this particular period. Further studies are needed to help to identify patients who are at risk of suffering from long-term emotional distress in order to enable targeted psychosocial intervention.

[Perioperative pain therapy in interventions for elbow stiffness]

Conservative treatment and surgical release of a stiff elbow requires correct pain management which should be oriented to the individual needs of the patient. Regional anesthesia in combination with opioids is necessary postoperatively to obtain sufficient pain relief. There is a need for prospective randomized studies to develop an optimal pain therapy concept following operations for elbow stiffness.

Measurement of psychological distress in patients with intracranial tumours: the NCCN distress thermometer

Identification of patients suffering from elevated psychosocial distress, the sources of the distress, and the necessary treatment of the distress can be rather difficult within the neurosurgical setting (e.g., lack of time, cognitive or aphasic disorders of the patients). The distress thermometer (DT) is a single-item rapid distress screening tool by use of which these difficulties can be minimized. The objective of this study was to determine the optimum DT cut-off score that would identify significant distress in patients with intracranial tumours thus validating its use in the neurosurgical setting. In all, 150 patients were tested either during in-patient stay or during a follow-up examination before and after the neurosurgical removal of a primary intracranial neoplasm. Patients were administered the DT with the hospital anxiety and depression scale (HADS), the gold standard against which the DT was compared. The area under the receiver operating characteristics curve (ROC) was ≥0.82. Thus, the ability of the DT to correctly identify patients as significantly distressed was excellent. The DT ranges from 0 to 10. Its optimum cut-off score for identifying distressed patients was at or above 6 (sensitivity ≥ 88%; specificity ≥ 53%). The DT is a valid and practicable screening instrument for assessment of levels and sources of distress in patients with intracranial tumours in the neurosurgical setting.

Patient Perception of Combined Awake Brain Tumor Surgery and Intraoperative 1.5-T Magnetic Resonance Imaging

OBJECTIVE

To assess patients' perspective of combined awake craniotomy and intraoperative magnetic resonance imaging (MRI) in a prospective study.

METHODS

We evaluated 25 consecutive patients prospectively. Qualitative and quantitative results were obtained by a psychologist via a structured interview 5 ± 2 days postoperatively, supplemented by preoperative and postoperative assessment of the patients' mood with the Hospital Anxiety and Depression Scale, as well as parts of a structured clinical interview during the postoperative assessment.

RESULTS

Satisfaction with the experience was high in almost all cases. Only 1 patient recalled experiencing considerable discomfort during the operation. About one-third (39%) of our sample described minor to moderate difficulties; the remaining were entirely satisfied.

CONCLUSION

Although the combination of awake craniotomy and intraoperative MRI is demanding, it was both tolerable and reasonable for the patients. Our data confirm that intraoperative MRI appears to have no additional significant impact on the subjective patient perception, although it does prolong the procedure.

[Elevated postoperative pain levels following orthopedic surgery. Depression as a strong predictor]

The aim of this study was to examine whether depression is a strong predictor of elevated postoperative pain levels following orthopedic surgery and whether the implementation of standardized pain management is more beneficial for patients with depression. We performed a non-randomized, prospective study with two different groups of patients who underwent orthopedic surgery. Group 1 (n=249) received non-standardized pain therapy whereas group 2 (n = 243) was treated with a standardized pain management concept. Effects of the treatment were monitored with a VAS-based pain assessment protocol. Depression was measured preoperatively with the self-reported Patient Health Questionnaire (PHQ-9). Patients with the probable diagnosis of a current episode of major depression showed significantly higher postoperative pain than patients without a depressive episode. On the other hand, patients with depression benefited from the implementation of standardized pain management. Our data suggest a predictive value of depression for severe postoperative pain. Patients with depression benefited from standardized postoperative pain therapy, but were still suffering from significantly higher postoperative pain.

Strategy instruction in Parkinson's disease: influence on cognitive performance

OBJECTIVES

Though strategic deficits are extensively investigated in Parkinson's disease (PD), little is known about the effects of instruction for PD patients. Thus, we compared the ability to internally generate a cognitive strategy with the ability to use a strategy after elaborate strategy instruction.

METHODS

Patients with PD (n=14) and matched healthy controls (n=22) were administered a Numerosity Judgement task in which they had to determine different numerosities of blocks presented in a square grid. In more complex task configurations, healthy participants tend to use a subtraction strategy. Participants in our study were confronted with a counting condition (A), a strategy initiation condition without instruction (B), and a strategy elaboration and strategy training condition (C).

RESULTS

Patients and controls were comparable with respect to basic cognitive measures. PD patients and controls performed equivalently within the counting condition (A), but patients needed significantly more trials to initiate the subtraction strategy. With the exception of 1 PD patient, all patients were able to internally initiate the strategy (condition B). In condition C, both groups increased reaction times, but patients were significantly slower than controls. Moreover, only patients significantly increased error rates after strategy instruction.

CONCLUSION

As long as sufficient time is provided for solving the task, results do not show a general deficit in the ability to internally generate a cognitive strategy in PD. Failures in strategy utilization strongly depend on cognitive load (working memory, executive functions). This bears important implications for the neuropsychological rehabilitation of PD patients.

[Implementation of standardized postoperative pain therapy for orthopaedic patients. Comparison between unsystematic and standardized pain therapy]

BACKGROUND

The painless clinic and postoperative pain therapy are currently major issues in the management of surgical procedures. The aim of this study was to evaluate the benefit of a standardized pain therapy on the postoperative pain level after orthopaedic procedures.

PATIENTS AND METHODS

We investigated two different groups of patients who underwent an orthopaedic surgical procedure. Group 1 (n = 249) received a pain therapy which was based on an individual and surgery-dependent concept whereas group 2 (n = 243) was treated with a standardized pain therapy concept. The effect of the treatment was monitored with a VAS-based protocol.

RESULTS

Up to day 9 after surgery there was a significant difference between the two groups in regard to the postoperative pain. The patients of group 2 had less pain but had more unwanted side effects caused by the pain therapy during the first 3 days after surgery. Mobility and mental disposition were positively affected.

CONCLUSION

The implementation of a standardized pain therapy is successful in reducing postoperative pain. Mobility and mental disposition are also influenced positively. As a consequence the incidence of unwanted side effects is rising.

Investigations of the potential risk factors associated with cases of bovine spongiform encephalopathy in Bavaria, Germany

In order to identify the management and feeding practices that might have contributed to the occurrence of bovine spongiform encephalopathy (BSE) in Bavaria, Germany, information from 110 dairy farms on which a case of BSE had been reported was compared with information derived from a questionnaire sent to approximately 10,000 Bavarian farms on which no case of BSE had been reported up to February 2003. Representative information was obtained from 4006 dairy farms. The results indicated that in comparison with these control farms a higher proportion of the BSE farms had also kept pigs or poultry, although the difference was not significant, and that a significantly higher proportion of the BSE farms had fed proprietary concentrates and/or milk replacers to their calves.

In situ Analysis of Coronary Terminal Arteriole Diameter Responses: Technical Report of a New Experimental Model

INTRODUCTION

To date, investigation of coronary arteriole vasomotor activity has been limited to arterioles >30- 40 microm. Here, we introduce a new experimental model to allow for in situ microscopy of terminal coronary arterioles.

METHODS

Rat hearts were perfused in a closed loop system (priming volume 20 ml) which was placed on a computer-controlled microscope stage. FITC-dextran and tetrodotoxin (TTX, 50 microM) were added. Tilting of the microscope by 90 degrees allowed for visual access to the ventricular surface. Arterioles were identified by the flow direction of fluorescent beads (1 microm). Images were recorded on video tape, and arteriole diameters were measured offline. Stability of the preparation and maintenance of coronary flow reserve were analyzed. Responses of coronary flow and arteriole diameters to the vasodilators papaverine and Na-nitroprusside were recorded.

RESULTS

In TTX-arrested control hearts coronary flow and terminal arteriole diameters were stable for 2 h. Administration of papaverine and Na-nitroprusside increased coronary flow from 6.4 +/- 0.7 to 13.3 +/- 1.3 ml/min, decreasing coronary resistance by 52 +/- 3%. Terminal coronary arteriole diameters increased from 12.0 +/- 0.9 to 13.6 +/- 1.0 microm, decreasing hindrance of this vessel segment by 45 +/- 11%.

CONCLUSION

Preservation of coronary terminal arteriolar tone and adequate responsiveness to vasodilators in the TTX-arrested isolated heart were demonstrated. Thus, this model may serve to complement our understanding of coronary microvascular control mechanisms by extending observations to the terminal arteriolar bed.

Relapse in the skull after myeloablative therapy for high-risk neuroblastoma

Patterns of relapse were determined for 20 high-risk neuroblastoma patients treated with chemotherapy, surgery, primary and metastatic site radiation (21 Gray), myeloablative chemotherapy, peripheral blood stem cell rescue, and 13-cis-retinoic acid. The median follow-up duration after transplant is 21 months (range, 8-34 months). The event-free survival and overall survival at 2 years were 45 and 75%, respectively. There were 2 primary site recurrences. Metastatic sites that became MIBG-scan negative on induction chemotherapy were not irradiated. Four patients relapsed in irradiated metastatic sites, 3 in the skull, 1 in the liver. Failure also occurred at 2 skull sites treated with chemotherapy only, and at 5 new sites: 1 skull, 2 distant lymph nodes, and 2 bones other than skull. Eight of 20 patients had skull metastasis at presentation; 6 were irradiated and 3 were controlled. Skull metastasis warrants more aggressive evaluation and treatment.

Inhibition of host cell apoptosis by Toxoplasma gondii is accompanied by reduced activation of the caspase cascade and alterations of poly(ADP-ribose) polymerase expression

The obligate intracellular protozoan parasite Toxoplasma gondii has been shown to protect different cell types from apoptosis induced by a variety of pro-apoptotic treatments. However, the precise cell biological mechanisms of this inhibition remained unknown. As shown in this study, apoptosis in human-derived HL-60 and U937 cells induced by treatment with actinomycin D or TNF-α in combination with cycloheximide, respectively, was indeed dose-dependently downregulated by prior infection with T. gondii, as determined by DNA fragmentation assays. Cleavage of caspase 3 and caspase 9 after treatment with pro-apoptotic stimuli was considerably diminished by T. gondii. Furthermore, release of mitochondrial cytochrome c during apoptosis in HL-60 cells was prevented by intracellular parasites and this was correlated with the absence of DNA strand breaks on the single cell level. Inhibition of cytochrome c release coincided with a twofold upregulation of Mcl-1 protein levels in HL-60 and U937 cells, while Bcl-2 expression did not increase after infection. Parasitic interference with the caspase cascade led to a reduced proteolytic cleavage of the nuclear target molecule protein kinase Cδ. In parallel, poly(ADP-ribose) polymerase protein levels were prominently downregulated by T. gondii, irrespective of whether HL-60 and U937 cells had been treated with pro-apototic stimuli or left untreated. However, poly(ADP-ribose) polymerase mRNA levels remained unchanged after infection as determined by RT-PCR analyses. These observations suggest that T. gondii has evolved different mechanisms that may contribute to downregulation of host cell apoptosis, namely inhibition of cytochrome c release and subsequent caspase activation as well as downregulation of poly(ADP-ribose) polymerase protein levels.

Are some memory deficits unique to lesions of the mammillary bodies?

The role of the mammillary bodies in human memory is still in debate. A recent model of human amnesia proposes similar functions for the mammillary bodies and the hippocampus. But the main evidence for this model comes from animal studies using the delayed non-matching to sample paradigm. We describe a patient who developed a severe memory impairment after surgical removal of a germinoma. Postsurgical high resolution MRI revealed bilaterally shrunken mammillary bodies and an infarct of the left mammillary body. There were no other relevant lesions. Neuropsychological testing showed mildly impaired frontal lobe functions (executive functions, working memory and word fluency), almost intact learning and recognition, but severely impaired free and delayed recall. Experimental investigations revealed a reduced but preserved release of proactive interference and a pronounced impairment of recency and source judgments. We conclude that the mammillary bodies do play a prominent role in human memory, although the role differs slightly from that of the hippocampus.