How to determine whether conceptual endophenotypes can improve clinical outcomes in patients suffering from major depression: An exploratory approach

Depression is a complex mental health disorder, resulting in a high degree of disability. Since symptom constellation, course, and outcome are heterogeneous in these patients, current research initiatives are striving to establish stratified diagnostic and treatment approaches. In the past two decades, Dirk Hellhammer and his team introduced Neuropattern, a new diagnostic concept, which is based on conceptual endophenotypes of the stress response network. We explore how to use this concept in clinical practice in order to ultimately determine whether it brings any value over standard care. In view of the novelty of the concept and the difficulties dealing with such a concept at a practical level, it was necessary to initiate an exploratory study to determine key factors for planning future clinical trials. We report results and knowledge gained from an exploratory single-site study investigating the use and potential benefits of Neuropattern in standard care. Inpatients (ICD-10 diagnosis F32, F33; Nö=ö178) were allocated to either treatment as usual (standard group, SG) or a novel Neuropattern oriented exploratory treatment (intervention group, IG). Symptom severity was assessed with psychometric tests at admission to hospital, during the first six weeks, and upon discharge from the hospital. In addition, direct and indirect costs were assessed for the 3-month-intervals prior to and after the hospital stay. Compared to the SG, depression scores of patients in the IG showed a faster decline once psychotherapeutic and pharmacological treatment were based on an individualized explanatory model. The patients in the IG with an F33 diagnosis showed a more pronounced reduction of depression severity during the stay in the hospital and a stronger and quicker reduction of general symptom severity. Comparing the average depression scores at the start of the study and after six weeks, symptom severity was reduced in all Neuropattern groups. Some limitations of the study have to be mentioned: The study was not blinded, was single-site, included highly depressed inpatients only, and was conducted for no longer than 8 months. The results highlight some important issues regarding taking the Neuropattern approach to the bedside and researching its efficacy and effectiveness to support personalized treatments in clinical care.

Comparison of mucosal and mucoperiosteal wound cover for the treatment of medication-related osteonecrosis of the jaw lesions: a retrospective cohort study

OBJECTIVES

Actually, there is no detailed guidance on how to deal with wound closure after surgical removal of medication-related osteonecrosis of the jaw (MRONJ) lesions. This study attempts to compare the difference in outcome between the mucosal and the mucoperiosteal flap closure after surgery.

PATIENTS AND METHODS

In this retrospective monocentric cohort study, patients (n = 61; 35 female/26 male) suffering from MRONJ and requiring surgical therapy at the University of Aachen between 2013 and 2015 were included. Due to intra-institutional variances, one group was treated with the mucosal, the other group with the mucoperiosteal technique. The success rate, i.e., mucosal closure and no relapse at the point of follow-up, was evaluated and compared. All patients were clinically investigated for the postoperative follow-up during a special consultation appointment.

RESULTS

The success rates between the different techniques after 2 years follow-up were very similar. In the group of mucosal wound closure, 22 of 29 (75.86%) patients revealed mucosal integrity without signs of MRONJ. The rate in the mucoperiosteal wound closure group was almost identical (24 of 32 (75%)).

CONCLUSION

No differences in the success rates between the two different techniques could be evaluated.

CLINICAL RELEVANCE

The results of this study suggest that the complete removal of the necrotic bone might have a higher impact on the success rates than the technique of the wound closure. Due to the fact that the mucoperiosteal wound closure technique offers a better overview of the extent of the MRONJ lesion, the authors advise to use this technique.

Chiral Lithiated Allylic α-Sulfonyl Carbanions: Experimental and Computational Study of Their Structure, Configurational Stability, and Enantioselective Synthesis

X-ray crystal structure analysis of the lithiated allylic α-sulfonyl carbanions [CH2 CHC(Me)SO2 Ph]Li⋅diglyme, [cC6 H8 SO2 tBu]Li⋅PMDETA and [cC7 H10 SO2 tBu]Li⋅PMDETA showed dimeric and monomeric CIPs, having nearly planar anionic C atoms, only OLi bonds, almost planar allylic units with strong CC bond length alternation and the s-trans conformation around C1C2. They adopt a C1S conformation, which is similar to the one generally found for alkyl and aryl substituted α-sulfonyl carbanions. Cryoscopy of [EtCHCHC(Et)SO2 tBu]Li in THF at 164 K revealed an equilibrium between monomers and dimers in a ratio of 83:17, which is similar to the one found by low temperature NMR spectroscopy. According to NMR spectroscopy the lone-pair orbital at C1 strongly interacts with the CC double bond. Low temperature (6) Li,(1) H NOE experiments of [EtCHCHC(Et)SO2 tBu]Li in THF point to an equilibrium between monomeric CIPs having only OLi bonds and CIPs having both OLi and C1Li bonds. Ab initio calculation of [MeCHCHC(Me)SO2 Me]Li⋅(Me2 O)2 gave three isomeric CIPs having the s-trans conformation and three isomeric CIPs having the s-cis conformation around the C1C2 bond. All s-trans isomers are more stable than the s-cis isomers. At all levels of theory the s-trans isomer having OLi and C1Li bonds is the most stable one followed by the isomer which has two OLi bonds. The allylic unit of the C,O,Li isomer shows strong bond length alternation and the C1 atom is in contrast to the O,Li isomer significantly pyramidalized. According to NBO analysis of the s-trans and s-cis isomers, the interaction of the lone pair at C1 with the π* orbital of the CC double bond is energetically much more favorable than that with the "empty" orbitals at the Li atom. The C1S and C1C2 conformations are determined by the stereoelectronic effects nC -σSR * interaction and allylic conjugation. (1) H DNMR spectroscopy of racemic [EtCHCHC(Et)SO2 tBu]Li, [iPrCHCHC(iPr)SO2 tBu]Li and [EtCHC(Me)C(Et)SO2 tBu]Li in [D8 ]THF gave estimated barriers of enantiomerization of ΔG(≠) =13.2 kcal mol(-1) (270 K), 14.2 kcal mol(-1) (291 K) and 14.2 kcal mol(-1) (295 K), respectively. Deprotonation of sulfone (R)-EtCHCHCH(Et)SO2 tBu (94 % ee) with nBuLi in THF at -105 °C occurred with a calculated enantioselectivity of 93 % ee and gave carbanion (M)-[EtCHCHC(Et)SO2 tBu]Li, the deuteration and alkylation of which with CF3 CO2 D and MeOCH2 I, respectively, proceeded with high enantioselectivities. Time-dependent deuteration of the enantioenriched carbanion (M)-[EtCHCHC(Et)SO2 tBu]Li in THF gave a racemization barrier of ΔG(≠) =12.5 kcal mol(-1) (168 K), which translates to a calculated half-time of racemization of t1/2 =12 min at -105 °C.

Incidence of bisphosphonate-related osteonecrosis of the jaw in consideration of primary diseases and concomitant therapies

BACKGROUND

Since its first description by Marx in 2003, the etiology of bisphosphonate-related osteonecrosis of the jaw (BRONJ) is the subject of numerous scientific discussions for oral and maxillofacial surgeons. Many retrospective studies on its etiology and pathogenesis have been carried out to explain pathological mechanisms; most of them just take a close look at the issue of dosage and application. Recently, attempts have been made, to identify co-factors which might promote the development of BRONJ.

PATIENTS AND METHODS

The present study is based on data of 169 patients with osseous metastatic malignancies. All patients received intravenous bisphosphonate therapy. On the basis of medical history, malignancy, and primary treatment, the modality of bisphosphonate therapy, and existing comorbidities and medication were analyzed. The role of immunosuppressive drugs, influence of underlying diseases, and general factors such as age and gender were examined. The predictability of necrotic involvement, influenced by the underlying malignancy and its specific therapy, e.g. radiation and cytostatic therapy were analyzed and statistically evaluated.

RESULTS

A total of 8.9% (n=15) of patients developed BRONJ. The average time between diagnosis of malignancy and BRONJ was 80 months. Nine patients suffered from breast cancer, five had prostate cancer and one renal cancer. Separation into stage and histological subtype did not show any significant correlation, nor did age or gender, to the occurrence of BRONJ. However statistical analysis did show a significant correlation concerning monocytostatic (p=0.0215) and triple-cytostatic therapy (p=0.0137). The majority of patients with BRONJ (60%) received a bisphosphonate therapy including zoledronate. Single application with one bisphosphonate was administered in 28 cases; 44 patients had a medical history of different use of bisphosphonate. Concomitant medication did not suggest possible correlation, nor did accompanying diseases, arterial hypertension (33.33%) or arterial microcirculatory disturbances (20%).

CONCLUSION

The evaluation of our results is pioneering. The influence of cytostatics and combined therapy of cytotoxic drugs on the pathogenesis of BRONJ is demonstrated here statistically. We confirmed a drug- and dose-dependent occurrence of BRONJ. Further prospective studies should be performed to elucidate the role of tissue perfusion and oxygen saturation, and the influence of immunosuppressive drugs in relation to the occurrence of BRONJ, as well as on wound healing of initial lesions.

Neuropattern: a new translational tool to detect and treat stress pathology I. Strategical consideration

Translational research is most prominently represented by the search for biomarkers and preclinical research. Aside from generating such new measures and methodologies, translational research additionally refers to translation of integrated knowledge. This strategy involves synthesis, exchange, and dissemination of available knowledge, with the goal of improving health services and health care systems. For stress-related disorders, such as depression and anxiety disorders, this strategy meets numerous challenges, as the great majority of these patients are treated by family physicians. Here, we introduce Neuropattern, a new diagnostic tool, which allows translation of psychobiological knowledge to this stress "bedside." Neuropatterns are conceptualized endophenotypes of the activity and reactivity status of neurobiological interfaces, which participate in the crosstalk between the brain and peripheral organs under stressful conditions. Neuropattern can easily be implemented in routine clinical work, and helps the physician to individualize those therapeutic interventions that are already available.

[The quality of diagnostic classification using abridged versions of the tinnitus questionnaire: comparative analysis]

BACKGROUND

There are different abridged versions of the tinnitus questionnaire (TQ) and reference values for grading tinnitus-related distress, the diagnostic value of which is unclear, as is the relation of sensitivity to specificity, as well as positive and negative predictive values. The present study is aimed at clarifying these issues and at benchmarking the existing abridged TQ versions.

PATIENTS AND METHODS

TQ data from 209 outpatients who had tinnitus for a period of at least 4 months were collected at the beginning of treatment. The rate of correct severity ratings, the quality of making a distinction between (extremely) severe and compensated/moderate tinnitus (area-under curve under the receiver-operating-characteristics curve, and rate of correct classifications), as well as positive and negative predictive values were calculated.

RESULTS

Applying unspecific reference values (independent of inpatient/outpatient status), the most favourable evaluation was achieved by the shortest TQ version (10 items). With the 12-item version (mini-TQ), better classification was achieved when reference values specific for outpatients were applied instead of unspecific values.

Gender specific quality of life in patients with oral squamous cell carcinomas

Background

The goal of this study was to evaluate the somatic and psychological effects by means of QUALITY OF LIFE (QOL) of surgical treatment of patients with oral squamous cell carcinoma. The factors gender, age, nicotine consumption, and tumour stage were taken into consideration.

Methods

54 patients after surgical resection of oral squamous cell carcinomas (OSCC) were analysed from 01.09.2005 to 31.05.2008. Inclusion criteria for the study were: age at least 18 years, no indication or treatment of synchronous and metachronous tumours.

German translations of the EORTC H&N-35 and EORTC QLQ-C-30 questionnaires, as well as a general socioeconomic patient history were used as measuring instruments. The questionnaires were completed independently by the patients. The answers were translated into scale values for statistical evaluation using appropriate algorithms.

Results

Analysis of the EORTC-QLQ-C-30 questionnaires demonstrated a tendency of more negative assessment of emotional function among the female participants, and a more negative evaluation of social function among the male participants. Greater tumour sizes showed significantly lower bodily function (p = 0.018). While a smaller tumour size was significantly associated with lower cognitive functioning (p = 0.031). Other cofactors such as age, nicotine consumption, and tumour stage only showed a tendency to influence the quality of sleep and daily life.

Conclusions

The data obtained within this investigation demonstrated that gender had the most significant power on the subjectively perceived postoperative quality of life. This factor is important e.g. in preoperative decision making regarding immediate microvascular reconstruction after e.g. mandibular resection and therefore QOL assessment should become integral component of the care of patients with OSCC.

[Attention diversion in tinnitus therapy. Comparison of the effects of different treatment methods]

BACKGROUND

Diversion or distraction of auditory attention is a core principle of tinnitus retraining therapy as introduced by P. Jastreboff and J. Hazell. The aim of this study was to evaluate the effectiveness of a different form of attention diversion in tinnitus therapy.

METHODS AND PATIENTS

In a prospective and randomized study, 40 patients suffering from chronic tinnitus were assigned to two different groups, A or B. All patients received appropriate counselling and were instructed in relaxation training. Patients in group A learned to distract attention away from the tinnitus by using sound or music. White noise generators or hearing aids were applied in this group. Patients in group B were instructed to direct their attention away from the tinnitus using imagination that was facilitated by the use of light and warmth stimuli as distracters. Different standardized questionnaires were used for an evaluation of therapy effectiveness.

RESULTS

In both groups, patients were significantly less annoyed and disabled by their tinnitus immediately after therapy and after 6 months. Tinnitus annoyance still proved to be reduced 1 year after the end of the therapy. There were no significant differences in the effects of each treatment.

CONCLUSIONS

Attention diversion is an important method for decreasing tinnitus-related distress. Patients should be instructed to use not only auditory but also visual and thermal sensations in order to distract attention away from their tinnitus.

Highly selective palladium catalyzed kinetic resolution and enantioselective substitution of racemic allylic carbonates with sulfur nucleophiles: asymmetric synthesis of allylic sulfides, allylic sulfones, and allylic alcohols

We describe the highly selective palladium catalyzed kinetic resolutions of the racemic cyclic allylic carbonates rac-1 a-c and racemic acyclic allylic carbonates rac-3 aa and rac-3 ba through reaction with tert-butylsulfinate, tolylsulfinate, phenylsulfinate anions and 2-pyrimidinethiol by using N,N'-(1R,2R)-1,2-cyclohexanediylbis[2-(diphenylphosphino)-benzamide] (BPA) as ligand. Selectivities are expressed in yields and ee values of recovered substrate and product and in selectivity factors S. The reaction of the cyclohexenyl carbonate 1 a (>/=99 % ee) with 2-pyrimidinethiol in the presence of BPA was shown to exhibit, under the conditions used, an overall pseudo-zero order kinetics in regard to the allylic substrate. Also described are the highly selective palladium catalyzed asymmetric syntheses of the cyclic and acyclic allylic tert-butylsulfones 2 aa, 2 b, 2 c, 2 d and 4 a-c, respectively, and of the cyclic and acyclic allylic 2-pyrimidyl-, 2-pyridyl-, and 4-chlorophenylsulfides 5 aa, 5 b, 5 ab, 6 aa-ac, 6 ba and 6 bb, respectively, from the corresponding racemic carbonates and sulfinate anions and thiols, respectively, in the presence of BPA. Synthesis of the E-configured allylic sulfides 6 aa, 6 ab, 6 ac and 6 bb was accompanied by the formation of minor amounts of the corresponding Z isomers. The analogous synthesis of allylic tert-butylsulfides from allylic carbonates and tert-butylthiol by using BPA could not be achieved. Reaction of the cyclopentenyl esters rac-1 da and rac-1 db with 2-pyrimidinethiol gave the allylic sulfide 5 c having only a low ee value. Similar results were obtained in the case of the reaction of the cyclohexenyl carbonate rac-1 a and of the acyclic carbonates rac-3 aa and rac-3 ba with 2-pyridinethiol and lead to the formation of the sulfides 5 ab, 6 ab, and 6 bb, respectively. The low ee values may be ascribed to the operating of a "memory effect", that is, both enantiomers of the substrate give the substitution product with different enantioselectivities. However, in the reaction of the racemic carbonate rac-1 a as well as of the highly enriched enantiomers 1 a (>/=99 % ee) and ent-1 a (>/=99 % ee) with 2-pyrimidinethiol the ee values of the substrates and the substitution product remained constant until complete conversion. Similar results were obtained in the reaction of the cyclic carbonates rac-1 a, ent-1 a (>/=99 % ee) and ent-1 c (>/=99 % ee) with lithium tert-butylsulfinate. Thus, in the case of rac-1 a and 2-pyrimidinthiol and tert-butylsulfinate anion as nucleophiles the enantioselectivity of the substitution step is, under the conditions used, independent of the chirality of the substrate; this shows that no "memory effect" is operating in this case. Hydrolysis of the carbonates ent-1 a-c, ent-3 aa and ent-3 ba, which were obtained through kinetic resolution, afforded the enantiomerically highly enriched cyclic allylic alcohols 9 a-c (>/=99 % ee) and acyclic allylic alcohols 10 a (>/=99 % ee) and 10 b (99 % ee), respectively.

[Aberrant salivary gland tissue in differential diagnosis of branchiogenic neck cyst]

A neck fistula next to the sternocleidomastoid muscle is suspicious of a branchial origin. Here we report on a 29-year-old patient with a discharging cutaneous orifice caused by an ectopic salivary gland. The clinical and histological findings are demonstrated and discussed with reference to the literature. Surgical removal of ectopic salivary gland tissue is the treatment of choice. However, surgery is limited in extent compared to surgical removal of a branchial fistula. Our case demonstrates that an ectopic salivary gland should be considered in the differential diagnosis of a branchial fistula.

Retraining therapy for chronic tinnitus. A critical analysis of its status

Tinnitus retraining therapy (TRT), as conceived of mainly by PJ Jastreboff, has recently received increasing attention in the media, as well as in seminars and congresses on treatment methods for chronic tinnitus. It is often claimed, though not explicitly in scientific publications, that TRT is currently the most efficacious therapy for tinnitus, obtaining improvement rates exceeding 80%. This assertion is highly significant in light of the most likely increasing prevalence of chronic tinnitus and ensuing urgent demand for effective therapies. Before examining the evidence regarding the effectiveness of TRT, Jastreboff's theoretical idea of tinnitus as a neurophysiological disorder is examined and evaluated. This idea is plausible and is supported by some evidence. The interaction between neuroacoustic and emotional processes emphasized by Jastreboff is, however, neither new nor sufficiently elaborated with respect to the underlying psychological factors. The TRT intervention technique and its main components 'directive counselling' and use of 'noise generators' are found to be theoretically well grounded. The lack of detailed information concerning TRT implementation and the potential consequence that differing interventions may be labelled TRT are criticized. Jastreboff's obvious opposition to psychologists' participation in TRT, despite the increase in efficacy they could affect through utilization of cognitive restructuring techniques and behaviour modification interventions, is also criticized. Finally, studies regarding the efficacy of TRT are reviewed and severe methodological shortcomings (e.g. lack of controlled randomized group studies) in TRT research are noted. Taking the current state of evidence into account, we conclude that there is no convincing empirical support for the assumption that TRT is superior to other treatments, since no comparative studies have been conducted. It is contended that there is more substantial empirical support for the efficacy of cognitive-behavioural interventions in reducing tinnitus annoyance and tinnitus-related suffering. The necessity for methodologically well-designed studies to pinpoint effect sizes of TRT and compare them with other techniques, especially cognitive-behavioural ones, is emphasized.

Reliability and validity studies of the Facial Discrimination Task for emotion research

The Facial Discrimination Task (FDT) (Erwin, R.J., Gur, R.C., Gur, R. E., Skolnick, B., Mawhinney-Hee, M., Smailis, J., 1992. Facial emotion discrimination: I. Task construction and behavioural findings in normal participants. Psychiatry Research 42, 231-240.) consists of standardized black-and-white photographs of Caucasian actors exhibiting happy, sad, and neutral faces. Originally designed for brain-imaging research in emotion recognition in schizophrenia and major depression, it has since been successfully employed in emotion recognition studies on mental retardation and psychosomatic disorders. This article presents new basic psychometric data from three studies with a total of 401 college undergraduates. Content validity, item reliability (test-retest, item-total correlation, item difficulty) and test reliability (internal consistency) were established. Happy and sad items were easier to agree upon than neutral ones. In general, happy items had the highest validity, highest test-retest reliability, and highest item-total correlations. Recognition errors of neutral items were biased toward negative affect. Advantages and limitations of the FDT for clinical research applications are discussed.

Pathological fractures of the mandible. A review of the etiology and treatment

A retrospective study was undertaken to analyse the etiology, site and treatment procedures of 30 pathological fractures of the mandible. Fifty percent of the fractures had an inflammatory cause. The remaining cases were associated with severe atrophy of edentulous mandibles (4), benign tumours (3), cysts (3), and primary or secondary malignancies (5). Regardless of the cause, the majority of the fractures occurred in the body of the mandible. Pathological fractures of the mandible most often have to be treated by eliminating the cause of the underlying condition while immobilizing the fragments either with osteosynthesis or archbars and intermaxillary fixation.

Decoding of facially expressed emotions in patients with psychosomatic gastrointestinal disorders

The hypothesis that individuals with psychosomatic conditions are lacking in empathy was tested by investigating decoding abilities of facially expressed emotions. Fourteen subjects with psychosomatic gastrointestinal disorders and 14 matched controls participated. Slides of one male and one female model's facial expressions of anger, disgust, fear, happiness, sadness, and surprise, and a neutral face, were presented to subjects, with exposure durations of 1/60, 1/15, and 4 seconds. Subjects had to decide whether the face presented was neutral or expressed one of the basic emotions. There were no significant group differences in decoding neutral expressions, but significant differences resulted in decoding emotional expressions. This was mainly due to the significantly poorer performance of the psychosomatic group in decoding disgust. Subjects' responding was found to be reliable. The findings show that at least certain subgroups of psychosomatic patients tend to misinterpret another person's facial expressions that signal unpleasantness or interpersonal conflict.

Sealing ability of five different retrograde filling materials

The sealing ability of Amalgam, Harvard-Cement, Diaket, gold-leaf, and Ketac-Endo as retrofilling materials was investigated. Paper cones were fixed with Harvard-Cement in the instrumented roots of 100 extracted human incisors. Apicectomy was performed and a 2-mm-deep retrograde cavity was prepared. Teeth were assigned to five groups (n = 20); each group received a different filling material. Surfaces of the roots were isolated with nail polish. Teeth, were stored in 1% methylene blue dye for 72 h. Roots were sectioned, and the depth of dye penetration was evaluated through a stereomicroscope. Retrofills with Ketac-Endo showed significantly less leakage compared with amalgam. There was no significant difference between the amalgam and Diaket groups. The sealing ability of Harvard-Cement and gold foil was lower than amalgam. It was concluded that retrograde fillings with Ketac-Endo or Diaket can be considered as alternatives for amalgam.

Subjective stress sensitivity and physiological responses to an aversive auditory stimulus in migraine and control subjects

Subjective stress sensitivity and physiological parameters were compared between 24 migraine subjects and 24 matched headache-free controls during a multifrequency 85-dB (A) aversive auditory stressor and during a recovery period. Measures consisted of frontalis EMG, temporal artery blood volume pulse, heart rate, a stress sensitivity questionnaire, stress reaction during the stress-expectation period, and ratings of noise aversiveness. Migraine subjects showed a higher level of general stress sensitivity, increased situational stress sensitivity, and higher ratings of noise aversiveness; this supports the general notion that migraine sufferers are psychologically more sensitive toward stress stimulation than nonheadache controls. Physiologically, the migraine subjects differed from the control group only with regard to the temporal blood volume pulse during stress stimulation; this finding is consistent with Wolff's weak-link theory.

The impact of medical, reeducational, and psychological variables on rehabilitation outcome in amputees

178 male unilateral above-knee amputees (cause of amputation: war injury or accident) participated in the study. Medical reeducational, social, vocational, and psychological predictor variables as well ad medical, social, vocational, and psychological outcome variables were assessed by means of interviews, expert ratings, questionnaires, and by ratings from the amputees partners. A series of risk factors for poor rehabilitation was specified by means of discriminant and correlational analyses. Optimization of medical/reeducational care, helping the amputee to gain insight into the necessity of amputation, making available to him a person to confide in with personal problems, and helping him to overcome social withdrawal seem to be the most important measures to prevent poor rehabilitation outcome.