Cardiovascular and metabolic determinants of quality of life in patients with cancer

AIMS

Maintaining quality of life (QoL) in patients with cancer has gathered significant interest, but little is known about its major determinants. We sought to identify determinants of QoL in patients undergoing cancer treatment as well as in treatment-naïve patients about to commence such therapy.

METHODS AND RESULTS

QoL was assessed in 283 patients with cancer using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 questionnaire. All patients underwent a battery of tests including physical examination, resting electrocardiogram, hand grip strength, and biochemistry assessment. Using multivariable logistic regression, we found that age [odds ratio (OR) 0.954, 95% confidence interval (CI) 0.916-0.994], resting heart rate (OR 1.036, 95% CI 1.004-1.068), hand grip strength (OR 0.932, 95% CI 0.878-0.990), and the presence of cachexia (OR 4.334, 95% CI 1.767-10.631) and dyspnoea (OR 3.725, 95% CI 1.540-9.010; all P < 0.05) remained independently predictive of reduced QoL.

CONCLUSIONS

Therefore, it may be reasonable to address circumstances that are affecting muscle mass, body weight, and heart rate to maintaining QoL; however, prospective studies to test these endpoints are required.

Heart failure with preserved ejection fraction according to the HFA-PEFF score in COVID-19 patients: clinical correlates and echocardiographic findings

Aims

Viral‐induced cardiac inflammation can induce heart failure with preserved ejection fraction (HFpEF)‐like syndromes. COVID‐19 can lead to myocardial damage and vascular injury. We hypothesised that COVID‐19 patients frequently develop a HFpEF‐like syndrome, and designed this study to explore this.

Methods and results

Cardiac function was assessed in 64 consecutive, hospitalized, and clinically stable COVID‐19 patients from April–November 2020 with left ventricular ejection fraction (LVEF) ≥50% (age 56 ± 19 years, females: 31%, severe COVID‐19 disease: 69%). To investigate likelihood of HFpEF presence, we used the HFA‐PEFF score. A low (0–1 points), intermediate (2–4 points), and high (5–6 points) HFA‐PEFF score was observed in 42%, 33%, and 25% of patients, respectively. In comparison, 64 subjects of similar age, sex, and comorbidity status without COVID‐19 showed these scores in 30%, 66%, and 4%, respectively (between groups: P = 0.0002). High HFA‐PEFF scores were more frequent in COVID‐19 patients than controls (25% vs. 4%, P = 0.001). In COVID‐19 patients, the HFA‐PEFF score significantly correlated with age, estimated glomerular filtration rate, high‐sensitivity troponin T (hsTnT), haemoglobin, QTc interval, LVEF, mitral E/A ratio, and H₂FPEF score (all P < 0.05). In multivariate, ordinal regression analyses, higher age and hsTnT were significant predictors of increased HFA‐PEFF scores. Patients with myocardial injury (hsTnT ≥14 ng/L: 31%) vs. patients without myocardial injury, showed higher HFA‐PEFF scores [median 5 (interquartile range 3–6) vs. 1 (0–3), P < 0.001] and more often showed left ventricular diastolic dysfunction (75% vs. 27%, P < 0.001).

Conclusion

Hospitalized COVID‐19 patients frequently show high likelihood of presence of HFpEF that is associated with cardiac structural and functional alterations, and myocardial injury. Detailed cardiac assessments including echocardiographic determination of left ventricular diastolic function and biomarkers should become routine in the care of hospitalized COVID‐19 patients.

BH3-only proteins are tail-anchored in the outer mitochondrial membrane and can initiate the activation of Bax

During mitochondrial apoptosis, pro-apoptotic BH3-only proteins cause the translocation of cytosolic Bcl-2-associated X protein (Bax) to the outer mitochondrial membrane (OMM) where it is activated to release cytochrome c from the mitochondrial intermembrane space, but the mechanism is under dispute. We show that most BH3-only proteins are mitochondrial proteins that are imported into the OMM via a C-terminal tail-anchor domain in isolated yeast mitochondria, independently of binding to anti-apoptotic Bcl-2 proteins. This C-terminal domain acted as a classical mitochondrial targeting signal and was sufficient to direct green fluorescent protein to mitochondria in human cells. When expressed in mouse fibroblasts, these BH3-only proteins localised to mitochondria and were inserted in the OMM. The BH3-only proteins Bcl-2-interacting mediator of cell death (Bim), tBid and p53-upregulated modulator of apoptosis sensitised isolated mitochondria from Bax/Bcl-2 homologous antagonist/killer-deficient fibroblasts to cytochrome c-release by recombinant, extramitochondrial Bax. For Bim, this activity is shown to require the C-terminal-targeting signal and to be independent of binding capacity to and presence of anti-apoptotic Bcl-2 proteins. Bim further enhanced Bax-dependent killing in yeast. A model is proposed where OMM-tail-anchored BH3-only proteins permit passive 'recruitment' and catalysis-like activation of extra-mitochondrial Bax. The recognition of C-terminal membrane-insertion of BH3-only proteins will permit the development of a more detailed concept of the initiation of mitochondrial apoptosis.

Proapoptotic signalling through Toll-like receptor-3 involves TRIF-dependent activation of caspase-8 and is under the control of inhibitor of apoptosis proteins in melanoma cells

Toll-like receptor-3 (TLR3), a member of an immune recognition receptor family, is widely expressed in tumour cells and has been shown previously to have the capacity to not only activate immune signalling pathways, but also to exert proapoptotic activity in some cells. We show here that HaCaT human keratinocytes are susceptible to apoptosis induction by the TLR3 ligand poly I:C, and use these cells as a model to analyse the apoptotic signalling pathway. Although the BH3-only protein Noxa was transcriptionally induced by poly I:C and translocated to mitochondria, RNAi experiments showed that the BH3-only proteins Noxa, Bim and Puma were individually dispensable for poly I:C-induced apoptosis. Instead, poly I:C-induced activation of caspase-8 via TLR3 and its adapter TRIF was required for apoptosis. In human melanoma cell lines poly I:C failed to induce apoptosis unless protein synthesis was blocked. Significantly, sensitisation towards poly I:C-dependent caspase-8 activation and apoptosis in melanoma cells was also achieved by the synthetic Smac mimetic/inhibitor of apoptosis protein (IAP) antagonist, LBW242, or by specific downregulation of cIAP1 by siRNA. Inactivation of caspase-8 by CrmA overexpression reduced poly I:C/LBW242-induced apoptosis. These results indicate that the proapoptotic activity of TLR3/TRIF/caspase-8 in melanoma cells is under the control of IAPs, and the use of novel Smac mimetics might be a feasible approach to target melanoma.

N-cadherin engagement provides a dominant stop signal for the migration of MDA-MB-468 breast carcinoma cells

The development of a primary tumor as such is not the main cause of death, but is rather the spreading of metastases, which causes over 90% of deaths in cancer patients. This largely depends on the ability of tumor cells to migrate away from the tumor and relocate at other areas of the body. Cell migration is known to be regulated by various extracellular signal substances such as neurotransmitters. However, before single tumor cells can start to invade into distant tissue, they have to dissociate from the primary tumor. This requires the disruption of cell-cell contacts, which are provided by a plethora of adhesion molecules like the family of cadherins. Using our well, established three-dimensional collagen-based cell migration assay, we show that engagement of N-cadherin results in a significant decrease of the spontaneous and the norepinephrine-induced migration of MDA-MB-468 breast carcinoma cells, which was due to an increase in the average break length. Moreover, this N-cadherin driven influence on the migratory activity is intracellularly integrated via multiple signaling pathways. Our results show that the impact of N-cadherin on the locomotion of MDA cells involves the activation of the adenylyl cyclase and the phosphatidylinositol-3-kinase (PI3K), but is independent of the protein kinase C (PKC) alpha. In summary, we provide evidence that the engagement of N-cadherin provides a stop signal for breast carcinoma cell migration, and accordingly the use of anti-N-cadherin antibodies or soluble ligands might be a tool to inhibit metastasis formation in E-cadherin negative but N-cadherin positive tumors.

Umbilical Cord Stromal Cells (UCSC)

The identification of appropriate cell types is necessary to establish cell-based therapies in regenerative medicine. These cell types must (1) be available in an appropriate amount, (2) be easy to obtain, (3) be sufficiently expandable in vitro, and (4) fit to or at least be able to differentiate into the required cell type. Since the umbilical cord is available without any intervention and represents a notable amount of tissue, we consider it to be a promising source for isolating cells for cell-based therapies. This study demonstrates that umbilical cord stromal cells (UCSC), the connective tissue cells of the umbilical cord, can be isolated in sufficient quantities and be well expanded. UCSC feature phenotypic plasticity and thus are functionally similar to stem cells. UCSC can be differentiated into cells with osteoblastic properties (expression of alkaline phosphatase, formation of bone nodules). It is concluded that the umbilical cord should no longer be regarded as valueless tissue and be unthinkingly discarded. Instead, it should be considered a valuable resource for the isolation of potent cells for cell-based therapies, especially for treatment of bone defects.

Evaluation of a computerized contraceptive decision aid for adolescent patients

Recent efforts to involve patients more actively in therapeutic decisions have suggested the relevance of computer-based interventions at clinic visits. This paper presents a longitudinal, experimental study evaluating a computer-based contraceptive decision aid in Chicago and Madison family planning clinic visits. Patient interviews at three time points evaluated patient acceptance by and program impact on 949 young women. Both Chicago and Madison patients reported high acceptance. The program resulted in improved short-term knowledge and confidence in oral contraceptive (OC) efficacy for Chicago and Madison patients. In addition, compared to their control group, Madison experimental group patients had higher OC knowledge 1 year after the initial visit and a trend for fewer pregnancies (P < 0.074). Compared to their control group, a higher percent of the Chicago experimental group patients adopted OC's after stating their intention to do so at the initial visit. Exposure to the computer program had no observable impact on the number of months on the oral contraceptive for Chicago or Madison patients. Overall findings suggest the usefulness of informatics tools as a supplement to patient-provider interactions.

Improving hospital discharge planning for elderly patients

Hospital discharge planning has become increasingly important in an era of prospective payment and managed care. Given the changes in tasks, decisions, and environments involved, it is important to identify how to move such planning from an art to an empirically based decisionmaking process. The authors use a decision-sciences framework to review the state-of-the-art of hospital discharge planning and to suggest methods for improvement.

Integrating an outcomes information system into managed care for substance abuse

The following paper describes a program launched recently to combine the efforts of two very different sectors of the outcomes management field--a managed behavioral healthcare company and a research-oriented academic center--and to pragmatically integrate outcomes data collection into routine clinical assessment and treatment processes in the substance abuse treatment field. This program has important implications not only for the behavioral healthcare industry's ability to satisfy external demands for outcomes data, but also as a foundation for better internal management and quality improvement processes.

The effects of school-based health clinics in St. Paul on school-wide birthrates

School-based clinics in St. Paul have provided comprehensive health services, including reproductive health care, for almost two decades. This study examines the effects of those clinics on the birthrates in their respective schools, using a newly developed methodology with numerous advantages over previous methods for estimating student birthrates. Confidentially matching the names of female students from school records with the names of mothers on birth records at the Department of Health provided birthrates for each of the St. Paul public high schools with clinics for each year between 1971 and 1986. The results show that birthrates fluctuated dramatically from one year to the next, but school-wide birthrates were not significantly lower in the years immediately following the opening of a clinic than in the years preceding it.

Kinetics of the translactal passage of digoxin from breast feeding mothers to their infants

In order to find out whether digoxin therapy of nursing mothers might produce discomfort in suckling infants we have investigated the kinetics of the transfer of digoxin from plasma to milk in 11 nursing mothers. After intravenous or oral application of a single dose of 0.5 mg or 0.75 mg digoxin simultaneous serum, fore- and hindmilk samples were taken. Obviously, a rapid equilibrium occurred between the serum and the milk compartments and there was no difference between fore- and hindmilk. All three digoxin concentration profiles ran parallel with a milk to serum ratio of 0.6 to 0.7. The curves could best be fitted by the sum of two exponential functions. For predicting the digoxin intake into the suckling infant, simulations were carried out on the basis of two coupled compartment models. When the kinetic milk data as well as the kinetic data obtained in infants were fitted by this model it could be shown that even in the case of long half-lives only about 3% of the therapeutic drug levels were reached in the baby. Thus, one can conclude that digoxin accumulation to toxic concentrations should not occur in infants of women treated with appropriate doses of digoxin.

[Hyperglycemia as a risk factor in pregnancy (author's transl)]

Glycosylated hemoglobins were used for the retrospective assessment of glucose metabolism, for therapy control, and as predictor of the weight of the newborn. Glycosylated hemoglobins were determined with the microcolumn method in 50 pregnant diabetics, in 11 overweight pregnant women, in 11 pregnant women under tocolytic treatment, and in 28 metabolically healthy women. Whereas the levels of glycosylated hemoglobins were found to be reduced in metabolically healthy women, the corresponding levels were increased in tocolytically treated, adipose, and diabetic pregnant women. The HbAI values correlated with the mean values of the daily blood glucose profiles (r = 0.79 - 0.94) and decreased during improvement of the metabolic state. A statistic correlation could not be established between the maternal HbAI and the weight of the newborn as the pregnancy period is shortened by dearrangement of the carbohydrate metabolism.

[Follow-up of patients who underwent reduction mammoplasty according to Strombeck between 1972 and 1975. Postoperative complications and results. Modification of the technique. Postoperative mammographic results (author's transl)]

Follow-up examinations were carried out in 60 women who underwent a reduction mammoplasty. Their review concentrated on the questions of the frequency of postoperative complications, the possibility to avoid complications by a modification of the technique and the question of mammographic evaluation of the breast in the face of scars from the mammoplasty. There were 12 severe complications. There were 6 necroses of the nipples, there were 3 abscesses, there were 2 suture fistulas and there was one case of massive hematoma. The complications depend on the amount of tissue resected. Especially necroses of the nipples depend upon the amount of tissue resected. With increasing experience of the surgeon, the nipple is moved without tension by lateral division of tissues and omission of resection of tissue above the nipple. This reduces the risk of necrosis of the nipple. Ugly scars are avoided by additional subcutaneous dexon double O sutures and additional subcuticular structures. Prolonged immobilization and later removal of the sutures help to obtain fine scars. A comparison of the preoperative and postoperative mammographies showed that 78% of the X-rays could be evaluated for carcinoma more readily postoperatively than before. For the differential diagnosis to scars from the operative, a preoperative and postoperative mammogram is necessary for comparison.