Pilot randomized controlled trial of a program to enhance experience and adherence with adjuvant endocrine therapy among women with non-metastatic breast cancer: 12-month quantitative results

PURPOSE

Adjuvant endocrine therapy (AET) reduces recurrence risk after hormone receptor-positive breast cancer, but non-adherence is common. We pilot-tested SOIE, a program to enhance AET experience and adherence, to assess its acceptability, feasibility, and effects on psychosocial precursors of AET adherence.

METHODS

We conducted a 12-month pilot randomized controlled trial among women who had a first AET prescription. Intervention group received SOIE while control group received usual care. Psychosocial factors from the Theory of Planned Behavior (TPB) (intention - primary outcome -, attitude, subjective norm, behavioral control), additional constructs (AET knowledge, social support, coping planning), impact of AET services received, and adherence were measured by questionnaires at baseline, 3-month, and 12-month endpoints. Group patterns were compared using repeated measures analyses with generalized estimating equations.

RESULTS

A total of 106 women were randomized (participation = 54.9%; intervention n = 52; control n = 54; retention = 93.8%). Among SOIE women, ≥ 90% received the program components and were satisfied. Both groups scored high on adherence intentions and group patterns over time were not statistically different. In the intervention group, AET knowledge and coping planning with side effects increased (group-by-time p-value = .002 and .016), a higher proportion reported that AET services received helped them take their AET (p < .05) and have a consistent daily intake (p = .01).

CONCLUSION

SOIE is feasible and acceptable for survivors with an AET. SOIE did not significantly impact adherence intentions but was beneficial for other program outcomes and daily intake.

IMPLICATIONS FOR CANCER SURVIVORS

SOIE may represent an encouraging avenue to enhance supportive care and empower survivors with managing AET.

A novel smartphone app for blood pressure measurement: a proof-of-concept study against an arterial catheter

Smartphones may provide a highly available access to simplified hypertension screening in environments with limited health care resources. Most studies involving smartphone blood pressure (BP) apps have focused on validation in static conditions without taking into account intraindividual BP variations. We report here the first experimental evidence of smartphone-derived BP estimation compared to an arterial catheter in a highly dynamic context such as induction of general anesthesia. We tested a smartphone app (OptiBP) on 121 patients requiring general anesthesia and invasive BP monitoring. For each patient, ten 1-min segments aligned in time with ten smartphone recordings were extracted from the continuous invasive BP. A total of 1152 recordings from 119 patients were analyzed. After exclusion of 2 subjects and rejection of 565 recordings due to BP estimation not generated by the app, we retained 565 recordings from 109 patients (acceptance rate 51.1%). Concordance rate (CR) and angular CR demonstrated values of more than 90% for systolic (SBP), diastolic (DBP) and mean (MBP) BP. Error grid analysis showed that 98% of measurement pairs were in no- or low-risk zones for SBP and MBP, of which more than 89% in the no-risk zone. Evaluation of accuracy and precision [bias ± standard deviation (95% limits of agreement)] between the app and the invasive BP was 0.0 ± 7.5 mmHg [- 14.9, 14.8], 0.1 ± 2.9 mmHg [- 5.5, 5.7], and 0.1 ± 4.2 mmHg [- 8.3, 8.4] for SBP, DBP and MBP respectively. To the best of our knowledge, this is the first time a smartphone app was compared to an invasive BP reference. Its trending ability was investigated in highly dynamic conditions, demonstrating high concordance and accuracy. Our study could lead the way for mobile devices to leverage the measurement of BP and management of hypertension.

Women with breast cancer's perceptions of nurse-led telephone-based motivational interviewing consultations to enhance adherence to adjuvant endocrine therapy: a qualitative study

BACKGROUND

Daily adjuvant endocrine therapy (AET) for 5 or 10 years is the standard of care for women diagnosed with non-metastatic hormone receptor-positive breast cancer. However, many women experience AET-related issues that may hamper quality of life and adherence. Here, we aimed to describe women's perceptions of motivational interviewing (MI)-guided consultations delivered by a trained nurse navigator over the telephone to enhance AET adherence.

METHODS

Eighteen women who were first prescribed AET for non-metastatic breast cancer in the last 5 years, who self-reported AET-related issues, and who participated in at least two MI-guided consultations over a year were interviewed about their perceptions of the intervention, using a semi-structured interview guide. Audio recordings were transcribed verbatim and analyzed using a thematic analysis approach.

RESULTS

Three main themes emerged from the data about women's perceptions on MI-guided consultations. These consultations were described as (1) a person-centred experience, (2) providing key information about AET, and (3) supportive of present and future AET experience, by contributing to AET side-effect management, motivation, adherence, calming negative emotions, improving well-being and self-esteem, and making women to feel empowered.

CONCLUSIONS

Nurse-led telephone-based MI-guided consultations about AET were found to respond to participants' needs and to enhance participants' perceptions of being informed and being supported in experiencing various facets of AET. Telephone-based consultations for AET are perceived as a promising strategy in an increasing virtual care world.

Evaluation of a cuffless watch-like sensor for 24-hour ambulatory blood pressure monitoring

Introduction

Ambulatory blood pressure monitoring (ABPM) is increasingly used in clinical practice for the formal diagnosis of hypertension, and particularly indicated in cases of suspected white-coat effect, masked, or nocturnal hypertension. However, the use of cuffs for ABPM may be painful and cause discomfort, particularly at night, where it may even provoke arousal from sleep and lead to non-representative nighttime blood pressure (BP) values.

Purpose

To investigate the feasibility of using a cuffless watch-like photoplethysmographic (PPG) sensor for 24-hour ABPM by comparing the PPG-based BP estimates with conventional cuff-derived ABPM values.

Methods

Our study was approved by the local ethical committee and conducted in 70 participants (43±18 y, 35 with hypertension, 41 male) undergoing cuff-based ABPM. At the contralateral side of the cuff, a cuffless watch-like PPG sensor was worn at the wrist or upper arm. Systolic (SBP) and diastolic (DBP) BP values were estimated by pulse wave analysis on the measured PPG signals. Following a calibration procedure, the PPG-based daytime and nighttime BP estimates were compared to their cuff-based counterparts. The agreement between both methods was evaluated via the mean (bias) and standard deviation (SD) of their differences by Bland-Altman analysis. The agreement on the nocturnal dipping estimates of both devices was also assessed. Finally, the concordance rate (CR) was assessed as the percentage of dipping values showing a concordant direction (dipping vs. non-dipping) between both methods.

Results

The data of 4 participants were incomplete due to technical issues and had to be rejected prior to analysis. In 4 additional participants, the PPG data quality was insufficient to provide enough BP estimates, probably due to poor sensor tightening. In the remaining 62 participants, we found (see Figure 1) differences between the daytime PPG-based and cuff-based BP estimates of −0.9±3.6 mmHg and −1.4±2.9 mmHg for SBP and DBP, respectively. The differences between the nighttime estimates were −0.8±6.8 mmHg and 0.5±5.3 mmHg, resulting in dipping differences of 0.1±6.8% and −2.0±8.6% for SBP and DBP, respectively. CR on dipping was 97% for both SBP and DBP.

Conclusions

Good agreement was found between the PPG-based and the cuff-based daytime and nighttime BP averages, with generally negligible (∼1 mmHg) biases. The direction of dipping was highly concordant between both methods. The estimation of its amplitude showed a low bias (∼1%) but a non-negligible spread (SD), which can be in part attributed to the uncertainty on the cuff-based dipping estimates (95% confidence interval range of 12.5% and 16.5% on average for SBP and DBP, respectively), more than twice as large than their PPG-based counterparts (5.7% and 7.8%). Although our study was designed as a method-comparison feasibility study, these results encouragingly suggest that cuffless ABPM may soon become a clinical possibility.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Pilot study of comparability of a smartphone blood pressure monitoring algorithm to conventional cuff-based blood pressure measurements

Background/Introduction

There is a growing market for smartphone applications (apps), offering medical assessments such as blood pressure measurements (BPM). These apps have the potential to improve blood pressure (BP) control by making BPM broadly and easily accessible. Yet, to be suitable for clinical and diagnostic purposes, BPM measured with smartphone apps need to be comparable to conventional BPM.

Purpose

We sought to compare a novel photoplethysmographic BPM algorithm used in a smartphone app to conventional cuff-based BPM.

Methods

We included consecutive patients with an indication for ambulatory BPM. Office blood pressure measurements (OBPM) were taken with an oscillometric cuff-based device (Welch Allyn SureBP). The algorithm of the smartphone app detects the pulse wave in finger capillaries using the phone's camera and estimates BP based on the form of the pulse wave. Before estimating a BP value, the algorithm performs a quality assessment to automatically reject recordings with insufficient quality. On the first day (D1), we took 6 OBPM alternating with 5 smartphone BPM (TestBP). On the second day (D2), 4 OBPM alternating with 3 TestBP were measured. TestBP calibrated based on the first OBPM of D1. Each TestBP was then compared to its RefBP (defined as mean of the previous and following OBPM).

Results

50 patients were included in the study, resulting in 50 TestBP values on D1 and 33 on D2. There was no difference at the 5% significance level between the TestBP and RefBP distributions on both days, and for both systolic and diastolic pressures. The mean ± standard deviation (SD) of the differences between TestBP and RefBP was 0.7±9.4 / 1.0±4.5 mmHg on D1 and 2.6±8.2 / 1.3±4.1 mmHg on D2 for systolic/diastolic values, respectively. The number of TestBP measurements within 5, 10 and 15 mmHg from RefBP are shown in Table 1. Bland-Altman plots depicting the agreement between TestBP and RefBP are shown in Figure 1.

Conclusion

This smartphone algorithm shows comparable values to oscillometric cuff-based especially diastolic values. Its differences between TestBP – RefBP have a good stability 1 day after calibration. Before clinical use, this algorithm needs to undergo formal validation against a reference BP method accepted by international standards (auscultatory or invasive methods).

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Centre Suisse d'Electronique et de Microtechnique Table 1Figure 1

Towards VO2 monitoring: Validation of a heart rate based algorithm

This article presents and validates a novel algorithm for the continuous monitoring of the VO₂ during exercise. The algorithm relies on instantaneous HR measurements to provide a continuous estimation, and can be integrated in a wearable device (e.g., smartwatch, sensor patch). It can be customized by user's main anthropomorphic parameters and automatically learns from newly incoming data recalibrating itself if needed. The system is evaluated against a database of 14 healthy subjects performing various maximal endurance tests. The proposed method provides a VO₂ estimation with average RMSE of 4.63 ml/kg/min.

An autonomous medical monitoring system: Validation on arrhythmia detection

In this paper, we present a generic platform for autonomous medical monitoring and diagnostics. We validated the platform in the context of arrhythmia detection with publicly available databases. The big advantage of this platform is its capacity to deal with various types of physiological signals. Many pre-processing steps are performed to bring the input information into a uniform state that will be explored by a machine learning algorithm. Since this block plays a crucial role in the entire processing pipeline, three different methods were evaluated for detection and classification of anomalies. The results presented in this work are validated on cardiac beats, where the highest accuracy was obtained on the classification of normal beats (94%). On the other hand, atrial fibrillation and premature ventricular contraction beats were classified with an accuracy of 78%.

Non-invasive monitoring of pulmonary artery pressure at the bedside

Current solutions for the monitoring of pulmonary artery pressure (PAP) in patients suffering from pulmonary hypertension are limited to invasive means. Non-invasive alternatives, such as Doppler echocardiography, are incompatible with continuous monitoring due to their dependency on qualified personnel to perform the measurements. In the present study, a novel non-invasive and unsupervised approach based on the use of electrical impedance tomography (EIT) is presented. The approach was evaluated in three healthy subjects undergoing hypoxia-induced variations in PAP. A timing parameter - physiologically linked to the PAP via the so-called pulse wave velocity principle - was automatically extracted from the EIT data. Reference systolic PAP estimates were obtained by echocardiography. Strong correlation scores (r e [0.844, 0.990]) were found between the EIT-derived parameter and the reference PAP, thereby suggesting the validity of the proposed approach. If confirmed in larger datasets, these findings could open the way for a new branch of fully non-invasive hemodynamic monitors for patients with pulmonary hypertension.

Real-time monitoring of swimming performance

This article presents the performance results of a novel algorithm for swimming analysis in real-time within a low-power wrist-worn device. The estimated parameters are: lap count, stroke count, time in lap, total swimming time, pace/speed per lap, total swam distance, and swimming efficiency (SWOLF). In addition, several swimming styles are automatically detected. Results were obtained using a database composed of 13 different swimmers spanning 646 laps and 858.78 min of total swam time. The final precision achieved in lap detection ranges between 99.7% and 100%, and the classification of the different swimming styles reached a sensitivity and specificity above 98%. We demonstrate that a swimmers performance can be fully analyzed with the smart bracelet containing the novel algorithm. The presented algorithm has been licensed to ICON Health & Fitness Inc. for their line of wearables under the brand iFit.

Physical activity profiling: Activity-specific step counting and energy expenditure models using 3D wrist acceleration

In this paper, we present the evaluation of a new physical activity profiling system embedded in a wrist-located device. We propose a step counting and an energy expenditure (EE) method, and evaluate their accuracy against gold standard references. To this end, we used an actimetry sensor on the waist and an indirect calorimetry monitoring device on a population of 13 subjects to obtain step count and metabolic equivalent task (kcal/kg/h) referenced values. The subjects followed a protocol that spanned a given set of activities (lying, standing, walking, running) at a wide range of intensities. The performance of the EE model was characterized by a root-mean-square error (RMSE) of 1.22±0.34kcal/min, and step-count model at regular walking/running speeds by 0.71±0.06step/10sec.

Accurate walking and running speed estimation using wrist inertial data

In this work, we present an accelerometry-based device for robust running speed estimation integrated into a watch-like device. The estimation is based on inertial data processing, which consists in applying a leg-and-arm dynamic motion model to 3D accelerometer signals. This motion model requires a calibration procedure that can be done either on a known distance or on a constant speed period. The protocol includes walking and running speeds between 1.8km/h and 19.8km/h. Preliminary results based on eleven subjects are characterized by unbiased estimations with 2(nd) and 3(rd) quartiles of the relative error dispersion in the interval ±5%. These results are comparable to accuracies obtained with classical foot pod devices.

Physical activity in youth with osteogenesis imperfecta type I

INTRODUCTION

Individuals with Osteogenesis Imperfecta (OI) type I often show muscular weakness. However, it is unclear whether muscular weakness is a consequence of physical inactivity or a result of the disease itself. The aim was to assess muscle function in youth with OI type I and evaluate physical activity (PA).

METHODS

Fourteen children with OI type I (mean age [SD]: 12.75 [4.62] years) were compared to 14 age- and gender-matched controls (mean age [SD]: 12.75 [4.59] years). Muscle force and power were determined through mechanography. PA and daily energy expenditure were measured with an accelerometer and a questionnaire.

RESULTS

Compared to controls, children with OI type I had lower muscle force and power. OI type I children were as active as their healthy counterparts.

CONCLUSIONS

Children and adolescents with OI type I and their healthy counterparts did not reached daily recommendations of PA. Given their muscle function deficit, youth with OI type I would benefit to reach these recommendations to prevent precocious effect of aging on muscles.

Impact of muscle activation on ranges of motion during active elbow movement in children with spastic hemiplegic cerebral palsy

BACKGROUND

Children with spastic hemiplegic cerebral palsy are restricted in their daily activities due to limited active ranges of motion of their involved upper limb, specifically at the elbow. Their impaired muscles are frequently targeted by anti-spastic treatments that reduce muscle tone. But these treatments do not necessarily improve the limb function. There is a lack of comprehensive knowledge of the quantitative relations between muscle activation and joint active ranges of motion. Consequently, the objective of this study is to quantify the impact of muscle activation on the elbow active ranges of motion.

METHODS

During voluntary elbow pronation/supination and extension/flexion movements, kinematic and electromyographic measurements were collected from the involved upper limb of 15 children with spastic hemiplegic cerebral palsy (mean age=8.7 years, standard deviation=2.2) and the dominant upper limb of 15 age-matched children who are typically developing. Representative indicators of the muscle activation, such as the muscle co-activation, were extracted from the electromyographic measurements.

FINDINGS

Muscle co-activation in the involved upper limb accounted for 78% and 59% of the explained variance of the supination and extension limited active ranges of motion respectively. The agonist and antagonist muscle activations were both longer in the involved upper limb.

INTERPRETATIONS

This study succeeded in quantifying the impact of longer antagonist muscle activation on decreased elbow active ranges of motion in children with spastic hemiplegic cerebral palsy. Longer agonist muscle activation suggests that strengthening agonist muscles could increase the extension and supination ranges of motion, which constitutes a perspective of future clinical studies.

Validity of an accelerometer as a vertical ground reaction force measuring device in healthy children and adolescents and in children and adolescents with osteogenesis imperfecta type I

INTRODUCTION

Vertical ground reaction forces (vGRFs) are closely related to bone strength and development. It is therefore relevant to assess these forces in bone disorders accompanied with muscle weakness such as in osteogenesis imperfecta type I (OI type I). The purpose of the present study was to assess the validity of vGRFs derived from an accelerometer.

METHODS

Fourteen children and adolescents with a diagnosis of OI type I (age range: 7 to 21; mean age [SD]: 14.1 [4.8] years; 5 males) and fourteen healthy controls (age range: 6 to 21; mean age [SD]: 12.5 [4.2] years; 5 males) performed three repetitions of five different jump and rise tests on a ground reaction force plate. Jumps and rises outcomes were measured simultaneously with the ground reaction force plate and an accelerometer.

RESULTS

Pearson correlation coefficients were over 0.96 (p<0.001) for the five tests. The limits of agreement represented between 17 and 31% of the average peak force measured by both devices. The accelerometer is a promising tool to assess ground reaction forces in everyday life settings and has been shown to be sufficiently sensitive to detect muscular weakness in children and adolescent with OI type I.

Gait analysis using a force-measuring gangway: intrasession repeatability in healthy adults

OBJECTIVES

The goal of the present study was to determine the repeatability of gait parameters measured by a force plate gait analysis system (Leonardo Mechanograph® GW).

METHODS

Fifteen healthy adult participants walked at a self-selected speed on a 10 m long walkway. Vertical ground reaction forces were measured in the central 6 m of the walkway. Each participant performed three trials while walking barefoot and three trials while wearing shoes, each trial consisting of three 10 m walks.

RESULTS

There were minimal differences between trials at each condition. All primary force, time, distance and velocity parameters had intraclass correlation coefficients above 0.90 and coefficients of variation in the order of 2% to 4%. Compared to walking barefoot, walking in shoes resulted in 14% lower maximal vertical ground reaction force, 5% longer step length and 2% higher average velocity and caused less lateral translation of the center of force.

CONCLUSIONS

In this group of healthy adults, gait analysis with a force plate system produced repeatable intra-day results. The observation that barefoot and shod walking yield different results indicates that it is important to standardize test conditions.

Sensorimotor adaptation in Parkinson's disease: evidence for a dopamine dependent remapping disturbance

Sensorimotor adaptation is thought to involve a remapping of the kinematic and kinetic parameters associated with movements performed within a changing environment. Patients with Parkinson's disease (PD) are known to be affected on this type of learning process, although the specific role of dopamine depletion in these deficits has not yet been elucidated. The present study was an attempt to clarify whether dopamine depletion in PD may directly affect the capacity to internally reorganize the visuomotor remapping of a distorted environment. Fourteen PD patients were tested twice, while they were treated and while they were withdrawn from their regular levodopa treatment. Fourteen control subjects were also enrolled and tested twice. Two parallel forms of the Computed Mirror Pointing Task (CMPT), requiring making a reaching movement in a visually transformed environment (mirror inversion), were administered to each participant. Each of them had to perform 40 trials at each of the 2 testing sessions. At each trial, sensorimotor adaptation was evaluated by the initial direction angle (IDA), which reflects the direction of movement before any visually guided readjustment. Results revealed no IDA difference at baseline, between control subject and PD patients, whether they were treated or not. In all group, IDA values at that time were large, reflecting a tendency to make movements according to the real life visuomotor mapping (based on the natural direct vision). However, striking differences appeared during sensorimotor learning, in that IDA reduction along trials was poorer in patient not treated with levodopa than both control subjects and the same PD patient treated with levodopa. No difference was observed between the treated PD patients and control subjects. Given that IDA is thought to reflect the internal representation of the visuomotor mapping, it is concluded that dopamine depletion in PD would affects sensorimotor adaptation, in that it facilitates old and poorly adapted movements (real life mapping), instead of new and more adapted ones (mirror transformed mapping).

Postural control anomalies in children with Tourette syndrome

The goal of the present study was to determine whether postural control is affected in Gilles-de-la-Tourette syndrome (TS). Center of pressure (COP) displacements were recorded in children with TS and unaffected siblings in three conditions using a force platform: (1) Eyes-Open, (2) Eyes-Closed, (3) One-Leg standing with eyes open. The COP range and velocity were higher in children with TS than in unaffected siblings in all conditions. These differences could not be attributed to age, present tic severity, comorbidities (hyperactivity and compulsions) or medication. The data suggest that sub-clinical postural control anomalies are present in TS.

Sensorimotor mapping affects movement correction deficits in early Huntington's disease

Huntington's disease (HD) is associated with early voluntary movement problems linked to striatal dysfunction. In pointing movements, HD increases the irregularity of the terminal part of movements, suggesting a dysfunction in error feedback control. We tested this hypothesis in movements requiring continuous feedback control. Patients in the early stages of HD and controls traced as fast and accurately as possible circles within a 5-mm annulus on a digitizing tablet when visual feedback of the hand and the circle was direct or indirect (through a monitor). Patients deviated more often from the annulus and showed larger corrections toward the circle than controls when using indirect visual feedback but not with direct visual feedback. When velocity requirements were removed, patients showed little change in these control problems. These results suggest that HD does not affect error feedback control in all movements and that the striatal contribution to voluntary movement is sensitive to sensorimotor mapping.

A distance effect in a manual aiming task to remembered targets: a test of three hypotheses

It has been noted that manual aiming error and variability when pointing to remembered targets increase as a function of target eccentricity. In the present study we evaluated which one of three hypotheses (target localization, motor, or movement duration) best explains this 'distance effect'. In experiment 1, older and younger participants aimed with their unseen hand at the remembered location of targets distributed between 129 and 309 mm from the starting base. Target presentation time was of either 50 or 500 ms and aiming movements could be initiated following either a 100- or a 10,000-ms recall delay. Participants had either no constraints concerning movement time or were asked to reach the near target in a longer movement time than the farther targets. The results revealed a significant distance effect when no time constraints were imposed but showed a significantly reversed distance effect when the instructions were to reach the near targets in a longer movement time than the far targets. The same results were obtained regardless of target presentation time, recall delay, or age of the participants. These results supported a movement duration interpretation of the distance effect. In experiment 2, a distance effect was replicated when pointing with one's unseen hand toward a remembered target but did not take place when pointing to visible targets. Taken together these results suggest that prolonged movement execution interferes with the stored egocentric target representation.

A randomized clinical trial of care for women with preterm labour: home management versus hospital management

BACKGROUND

Preterm labour occurs in about 10% of all pregnancies and is the most important cause of premature birth. Women with preterm labour are admitted to hospital to have the contractions stopped. Thereafter, many women remain in hospital until delivery. We conducted a randomized clinical trial to compare hospital care with home care of women who had been admitted to hospital for preterm labour.

METHODS

After they had received treatment for an acute episode of premature labour, women at 2 regional perinatal centres associated with teaching hospitals were randomly assigned to home care or hospital care. Eligible women (n = 250) were aged 18 years or older, lived within 50 km of the hospital, had a gestational age between 20 and 35 weeks, had no prior preterm delivery and were experiencing their first episode of preterm labour and first admission to hospital for preterm labour. Analysis was by intention to treat.

RESULTS

There were no significant differences between the 2 groups in mean gestational age at delivery (home: 37.52 weeks, hospital: 37.50 weeks) or in mean birth weight (home: 2974 g, hospital: 3020 g). There were no significant differences between the 2 groups with respect to the proportions of babies born before term or the mean duration of neonatal hospital stay, neonatal intensive care unit stay and intermediate care nursery stay. The mean duration of the first stay in hospital for the women in the home group (3.8 days) was significantly shorter than the mean duration for women in the hospital group (6.1 days). In addition, the mean duration of all maternal stays in hospital was significantly shorter for the women in the home group (3.7 days) than in the hospital group (5.0 days).

INTERPRETATION

Home care management is an efficient and acceptable alternative to hospital care for women experiencing preterm labour.

Increased cortisol levels and impaired cognition in human aging: implication for depression and dementia in later life

Perhaps the most prominent feature of human aging is the variability in decline of intellectual processes. Although many research avenues have been used to study the origin of such an increased variability with aging, new studies show that some biological factors may be associated with normal and pathological cognitive aging. One biological parameter that came under scrutiny in the past few years is the hypothalamic-pituitary-adrenal (HPA) axis, an endocrine closed-loop system controlling the secretion of stress hormones (glucocorticoids). In this review, we summarize data obtained in both animals and humans suggesting that cumulative exposure to high levels of glucocorticoids can be particularly detrimental for the aged hippocampus, a brain structure involved in learning and memory in both animals and humans. We then analyze the implication of these data for the study of dementia and depression in later life, two disorders characterized by increased glucocorticoid secretion in a significant proportion of patients. Finally, we suggest various factors that could explain the development of glucocorticoid hypersecretion in later life.

Mitochondrial peripheral-type benzodiazepine receptor expression. Correlation with gonadotropin-releasing hormone (GnRH) agonist-induced apoptosis in the corpus luteum

We have demonstrated that continuous administration of a gonadotropin-releasing hormone agonist (GnRH-Ag) decreases the expression of the mitochondrial peripheral-type benzodiazepine receptor (PBR) and increases the rate of DNA degradation in a time-dependent manner in the corpora lutea of pregnant rats. In the present study, we show in situ the GnRH-Ag-induced DNA fragmentation and correlate the increase of the rate of DNA degradation with the decrease in mitochondrial PBR ligand binding (r = 0.89). The GnRH-Ag-induced decrease in the 18-kDa PBR protein also correlated with the reduction in the Bcl-X(L), but not Bcl-2 (cell survival), gene product levels and the increase in the Bax (cell death) gene product expression in the luteal mitochondrial preparations. Considering the function of PBR in cholesterol uptake and intramitochondrial movement, we propose that decreased PBR expression may lead to reduced levels of mitochondrial membrane cholesterol, which, together with the ability of Bcl-X(L) and Bax to form ion channels, produces breaks in the outer membranes allowing the exit of cytochrome c, thus triggering apoptosis. Alternatively, PBR may exert an as yet unidentified anti-apoptotic function.

Detection of DNA damage and identification of UV-induced photoproducts using the CometAssay kit

We introduce the first commercially available comet assay for the detection and quantification of DNA damage in individual eukaryotic cells. The major difficulty of the comet assay is the preparation of the slides needed to immobilize the samples throughout the lysis and electrophoretic procedures. The CometAssay kit uses a proprietary technology to precoat glass microscope slides to allow direct application of the agarose embedded sample without any additional slide treatment. In this report, we discuss the detection of DNA damage in individual cells exposed to ultraviolet irradiation using the new CometSlides and their cost compared to traditional slides.

Juvenile xanthogranuloma presenting as obstructive jaundice

The authors report the case of a 9-month-old infant presenting with obstructive jaundice. Preoperative investigation findings showed distension of the extrahepatic biliary tract. Urine analysis result was positive for cytomegalovirus. At laparotomy, a 1-cm round mass was found within the head of the pancreas, near its upper border and in the course of the common bile duct. Findings on frozen sections could not rule out a malignant process and an hepaticoduodenostomy was constructed. Final diagnosis was juvenile xanthogranuloma. An association between cytomegalovirus and juvenile xanthogranuloma has been reported previously in the literature.

Cycling activity of benign prostatic epithelial cells during long-term androgen blockade: evidence for self-renewal of luminal cells

Combined androgen blockade (CAB) therapy (LHRH agonist and flutamide) for 6 months leads to marked regressive changes of the prostate gland. This is associated with a reduction in the ratio of luminal to basal cells in the peripheral zone (PZ) in hyperplastic glands of the transitional zone (TZ). To examine the cycling activity of luminal and basal cells, double immunostaining was performed. For precise definition of basal cells, the basal cell-specific antibody 34 beta E12 was used, while cycling cells were identified by the MIB-1 antibody. In 6-month-treated specimens, the fraction of cycling luminal cells increased from 0.3 to 2.5 per cent in the PZ and from 0.2 to 3.9 per cent in the TZ. This was associated with an inversion of the ratio of MIB-1-labelled luminal to basal cells, with values of 5.7:1 (PZ) and 3.9:1 (TZ), compared with 1:4 (PZ) and 1:5 (TZ) in untreated specimens. The predominance continued for at least 11 years of CAB. The findings strongly suggest that luminal cells are capable of self-renewal under conditions of low androgen levels. The substantial decrease of prostatic volume on long-term CAB implies that cell loss outweighs cell proliferation.

High concentrations of the macrophage migration inhibitory factor in human seminal plasma and prostatic tissues

During purification procedures to isolate kallikrein hK2 from human seminal plasma, kallikrein hK2 was found to be associated with another protein after several chromatographic steps. This study was conducted to identify the hK2 companion protein and characterize its properties and distribution. The protein was identified as macrophage migration inhibitory factor (MIF) by its NH2-terminal amino acid sequence. It had an enzymatic activity identical to that of recombinant MIF. Its concentration varied between 1 and 10 micrograms/mL in various seminal plasma. By immunohistochemical analysis, MIF was found to be localized mainly in the epithelial cells of normal and cancerous prostates. Since MIF is a well-known proinflammatory mediator, these results suggest that it may have important functions in both human reproduction and prostatic physiology.

Speech perception abilities of adult and pediatric Nucleus implant recipients using the Spectral Peak (SPEAK) coding strategy

A series of 73 postlinguistically deafened adults and 34 prelinguistically deafened children were evaluated with the Spectral Peak (SPEAK) coding strategy of the Nucleus 22-channel cochlear implant. The adults who received consecutive implants demonstrated rapid acquisition of open-set speech recognition skills in the initial postoperative period. Group mean sentence recognition improved to 53.5% (n = 52) after 2 weeks, 62.1% (n = 55) after 1 month, 69.8% (n = 57) after 3 months, and 74.4% (n = 42) after 6 months of use. At the 6-month evaluation interval, 43% of subjects scored greater than 90% on sound-alone sentence recognition in quiet and only one patient (2.4%) scored less than 10%. Mean monosyllabic word recognition was 35.6% after 6 months of use. The 34 prelinguistically deafened children were converted from the Multipeak strategy to Spectral Peak strategy at four large pediatric implant centers. After 6 months of using the new coding strategy, the children demonstrated significant improvements in their speech perception abilities.

Placenta percreta: balloon occlusion and embolization of the internal iliac arteries to reduce intraoperative blood losses

Obstetric hemorrhage is still a potential cause of maternal mortality and morbidity. Angiographic embolization techniques have been described in cases of postcesarean bleeding, vaginal wall hematomas, cervical ectopic pregnancies, and postpartum bleeding to control persistent bleeding from pelvic vessels. We describe two cases of pregnancy complicated with placenta percreta. Balloon occlusion and embolization of the hypogastric arteries were performed during the cesarean section and hysterectomy, resulting in a remarkable reduction in intraoperative blood loss. Balloon occlusion and embolization of the internal iliac arteries significantly reduce intraoperative blood losses.

Neoadjuvant hormonal therapy: the Canadian experience

OBJECTIVE

To assess the effect of neoadjuvant combination therapy with the antiandrogen flutamide and a luteinizing-hormone-releasing hormone (LHRH) agonist administered for 3 months before radical prostatectomy, compared with surgery alone in early stage prostate cancer on histopathologic findings at surgery and serum prostate-specific antigen (PSA).

METHODS

A sample of 161 randomly screened patients diagnosed as having stage B (134 patients) or C (27 patients) prostate cancer were randomly assigned to radical prostatectomy alone or to 3 months of neoadjuvant combination therapy with the antiandrogen flutamide and an LHRH agonist before radical prostatectomy.

RESULTS

Neoadjuvant combination therapy before radical prostatectomy decreased cancer-positive surgical margins from 33.8% in the control group to only 7.8%, thus leaving 92.2% of patients with negative margins at surgery. A net 54% improvement of staging was observed in favor of combination therapy. Organ-confined disease, on the other hand, increased from 49.3% to 77.8% of patients after 3 months of combination therapy, for a 57.8% increase in the incidence of organ-confined disease. No cancer was found in 6 (6.7%) prostatectomy specimens from the treated group. A close correlation was found between serum PSA at diagnosis and the stage of the disease at surgery. Upstaging increased from 30% at serum PSA values of 0 to 3.0 ng/mL up to 100% at serum PSA values above 15 ng/mL.

CONCLUSIONS

Although long-term follow-up of these patients is required to determine the impact on survival, the marked influence of neoadjuvant combination therapy on the stage of the disease suggests the possibility of a major improvement in the morbidity and mortality from prostate cancer.

Beneficial effect of combination hormonal therapy administered prior and following external beam radiation therapy in localized prostate cancer

PURPOSE

The aim of the present study is to investigate whether combined androgen blockade associated with radiation therapy for localized prostate cancer decreases at 12 and 24 months the rate of positive follow-up biopsies and serum PSA compared to radiation therapy alone. This is the report of an interim analysis.

METHODS AND MATERIALS

One hundred and twenty patients with clinical Stage B1-T2a, B2-T2b/T2c, and C-T3/T4, adenocarcinoma of the prostate were entered in a prospective randomized study. After written informed consent, the subjects were randomly allocated between external beam radiation therapy (EBRT) alone (group 1), 3 months of neoadjuvant combination therapy (LHRH-agonist + Flutamide) prior to EBRT (group 2), and a third group receiving combination therapy 3 months before, during, and 6 months after EBRT. There is no significant difference between the three groups concerning age, stage of disease, grade of tumor, and pretreatment PSA levels. Control transrectal ultrasound (TRUS)-guided needle biopsies (one core was taken from the initial cancer site regardless of the presence or absence of TRUS abnormalities) were done 12 and 24 months after the end of EBRT. Serum PSA measurements were done on schedule visits.

RESULTS

Ninety-two and 68 patients underwent biopsies at 12 and 24 months, respectively, after the end of radiation therapy. While 62% of control patients at 12 months in Group 1 disclosed residual neoplasm, only 30% and 4% showed residual disease in groups 2 and 3, respectively (p = 0.00005). When looking at 24 months, 65, 28, and 5% showed residual cancer for groups 1, 2, and 3, respectively (p = 0.00001). The PSA measurements indicate also at 12 months a difference between the three groups (p < 0.0001), except at 24 months, the difference between the group 2 and 3 is no longer significant.

CONCLUSION

The preliminary analysis of this clinical trial indicates that patients treated with radiation therapy alone show a significantly higher rate of positive biopsies at 12 and 24 months after the end of radiation therapy as compared with those treated with total antiandrogen blockade (TAB) and radiation therapy. When analyzing the median PSA serum levels, we found the same advantage at 12 months, but, at the time of the analysis at 24 months, the PSA levels are not different between groups 2 and 3.

Diagnosis of advanced or noncurable prostate cancer can be practically eliminated by prostate-specific antigen

OBJECTIVES

To determine the percentage of localized and potentially curable prostate cancers diagnosed at follow-up screening visits compared with the first screening visit.

METHODS

Within the context of a prospective screening study performed in randomly chosen men aged between 45 and 80 years, up to 6-year follow-up screening visits have been performed with serum prostate-specific antigen (PSA) measurement and digital rectal examination (DRE) followed by transrectal ultrasonography of the prostate when PSA or DRE is abnormal.

RESULTS

Of the 117 prostate cancers diagnosed at 14,554 annual follow-up visits, only 1 cancer (0.9%) was metastatic compared with 8% (26/322) at 8029 first visits. Moreover, 97% of the cancers detected at follow-up visits could be identified by PSA alone compared with 86% at first visit. The incidence of 0.8% per year during 15 years of screening between the ages of 55 and 70 years would diagnose localized prostate cancer in 12% of the population, a value not too different from the 10% diagnosed with prostate cancer during life-time in the absence of screening.

CONCLUSIONS

The present data show that annual screening with PSA diagnoses clinically localized prostate cancer in more than 95% of cases, thus almost completely eliminating the diagnosis of metastatic prostate cancer. Moreover, the number of prostate cancers diagnosed is not significantly increased by screening.

Kallikreins expression in a mature cystic ovarian teratoma

We report an example of benign cystic ovarian teratoma that was incidentally discovered in a nulliparous 24-year-old woman taking contraceptive pills. Histological examination of the cyst revealed the presence of prostatelike tissue in association with a wide variety of other tissues. The use of highly specific monoclonal antibodies developed against the two prostate-specific kallikreins (hK2 and hK3) in humans allowed the demonstration that the multiple islets of epithelial cells were prostatic tissue in nature and that only part of these cells had conserved their intrinsic property of producing kallikreins.

Tendon transfers and functional electrical stimulation for restoration of hand function in spinal cord injury

Spinal cord injury at the C5 and C6 level results in loss of hand function. Electrical stimulation of paralyzed muscles is one approach that has demonstrated significant capacity for restoring grasp and release function. One potential limitation of this approach is that key muscles for stimulation may have lower motor neuron damage, rendering the muscles unexcitable. We have used surgical modification of the biomechanics of the hand to overcome this limitation. Tendon transfer of paralyzed but lower motor neuron intact muscles can compensate for potential function lost owing to muscles with lower motor neuron damage. Such procedures have been performed to provide finger extension, thumb extension, finger flexion, and wrist extension. Additional surgical procedures have been performed to enhance the function provided with electrical stimulation. These are side-to-side synchronization of the finger flexor and extensor tendons, the flexor digitorium superficialis Zancolli-lasso procedure, and thumb interphalangeal joint arthrodesis. These procedures have been performed in 11 patients with C5 and C6 level spinal injuries and functional electrical stimulation neuroprostheses. In these patients, 41 different functional electrical stimulation-related procedures were performed and 38 gave the desired result after surgery. One procedure resulted in no increase or decrease in function or muscle output, and two procedures resulted in a decrease in muscle force or joint range of motion. The issues that must be considered in performing functional electrical stimulation-related tendon transfers are discussed.

Metastatic prostate cancer pulmonary nodules: beneficial effects of combination therapy and subsequent withdrawal of flutamide

A case is presented of a middle-aged man suffering from stage D2 prostate cancer with pulmonary metastases who responded favorably, first, to endocrine combination therapy with the antiandrogen flutamide and an LHRH agonist for 5.5 years, and, second, to the subsequent withdrawal of Flutamide at the time of the progression of the disease. This case has several exceptional features: absence of bone metastases, pulmonary metastatic nodules characterized as focal neuroendocrine differentiation, and a positive response to antiandrogen withdrawal upon relapse of metastases after initial positive response. The concept of escape to androgen blockade and development of androgenic hypersensitivity is discussed.

Optimized strategy for detection of early stage, curable prostate cancer: role of prescreening with prostate-specific antigen

In 1,002 men aged 45-80 y, 81% of the cancers detectable by serum prostate-specific antigen (PSA), digital rectal examination (DRE), and transrectal ultrasonography (TRUS) were present in a subpopulation (19% of total) identified by serum PSA above the threshold value of 3.0 micrograms/L. This study was extended to 7,350 men using serum PSA and DRE as first approach, followed by TRUS only when 1 of these 2 tests was abnormal. Because the aim of prostate cancer detection is to find cancers at an early, potentially curable stage, it is of major interest that 71.8% of evaluable cancers were clinical stage B; 8.4% and 10.7% were stages C1 and C2, respectively; only 9.2% were stage D (metastatic) at first visit while none was at stage D at follow-up visits. This study, the first performed in an unselected, unscreened population, shows that serum PSA is the most sensitive technique to identify men at high risk of having prostate cancer and that 12% more cancers can be found at first visit by doing DRE in addition to PSA. Follow-ups can be done every second year using serum PSA alone, as 97% of the cancers detected at annual follow-up by DRE + PSA were PSA+. Cancers are discovered by the present approach at an estimated cost of $2,665 per cancer. Such cancers are potentially curable in at least 80% of cases detected at first visit and in 97% of cases at follow-up. This strategy offers the possibility to improve markedly morbidity and mortality from prostate cancer, presently the second leading cause of cancer death in North American men.

Downstaging of localized prostate cancer by neoadjuvant therapy with flutamide and lupron: the first controlled and randomized trial

Although the only opportunity to cure prostate cancer is treatment at an early stage, radical prostatectomy has remained relatively unpopular because 40-50% of prostate cancers estimated at diagnosis as confined to the prostate are found to be at a more advanced stage following histopathological analysis of the surgical specimen. This first prospective, randomized trial investigated the potential advantages of 3-month neoadjuvant combination therapy with flutamide and lupron before radical prostatectomy vs. prostatectomy alone in early stage prostate cancer. Cancer-positive margins were reduced from 38.5% (25 of 65) in control patients to only 13.0% (10 of 77) in men who received neoadjuvant combination therapy with the antiandrogen flutamide and the luteinizing hormone-releasing hormone (LHRH) super-agonist Lupron before radical prostatectomy (p = 0.006). Moreover, comparison of the final stage determined by histopathological examination of the surgical specimen with that estimated at diagnosis showed that a more advanced stage (upstaging) was found in 53.8% of controls, but patients who received combination therapy had an opposite effect: a more favorable stage than expected at diagnosis was found in 23.4% of cases (downstaging), a 77.2% advantage of neoadjuvant combination therapy. The concern about radical prostatectomy, underestimation of stage, is thus markedly improved by 3-month neoadjuvant therapy with flutamide and a LHRH superagonist. Cancer-negative margins are expected to be accompanied by a life expectancy not different from that of men of similar age with no prostate cancer; therefore, the present data, combined with efficient detection of early stage prostate cancer, offer the basis for dramatic improvement in the morbidity and mortality of prostate cancer.

In utero acute graft-versus-host disease in a neonate with severe combined immunodeficiency

We describe a male neonate with severe combined immunodeficiency who at birth had acute graft-versus-host disease (GVHD) as a result of maternal-fetal transfusion during pregnancy. Several clinical signs helped establish this diagnosis. Findings of a skin biopsy specimen confirmed the diagnosis of acute GVHD. Immunologic evaluation disclosed an absence of T and B lymphocytes. Acute GVHD in severe combined immunodeficiency most often occurs during the first weeks of life; intrauterine occurrence is unusual.

Incidence of liver toxicity associated with the use of flutamide in prostate cancer patients

PURPOSE

The incidence of flutamide-related liver toxicity was studied in 1,091 consecutive patients treated for stage C or D prostate cancer with the antiandrogen flutamide and the luteinizing hormone-releasing factor (LHRH) agonist [D-Trp6, des-Gly-NH2(10)] LHRH ethylamide.

PATIENTS AND METHODS

Liver function tests, namely measurement of serum aspartate amino-transferase (AST) and alanine aminotransferase (ALT), total bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase (gamma-GT), and prothrombin and thromboplastin times, were performed at 4, 8, and 12 weeks and every 3 months thereafter. Clinical signs and symptoms of liver dysfunction were also sought. The causal link between the antiandrogen used and liver injury was assessed on the basis of the temporal relationship with the use of the drug in the absence of other possible causes and, in two patients, through rechallenge of the putative causative drug after a period of normalization of liver function.

RESULTS

An increase in AST and ALT at fourfold or more above upper normal limits was observed in only four patients (0.36%). Total serum bilirubin and alkaline phosphatase were elevated in only one patient at 126 mmol/L and 640 IU/L, respectively. Among the four patients, only two developed clinical manifestations of liver disease (0.18%). Biopsy was performed in one patient, and the histopathologic findings showed a mixed pattern of cytotoxic and cholestatic changes. All clinical and biologic manifestations of liver toxicity rapidly disappeared upon discontinuation of flutamide alone. No sequelae were observed in the long-term follow-up at 18, 22, 31, and 62 months. The 1,087 remaining patients experienced no or mild (less than fourfold upper normal limit) and transient elevation in aminotransferase serum levels during the first 6 months of treatment, with normalization at later time intervals.

CONCLUSION

Despite the fact that the cases reported so far, along with our large series, indicate that the incidence of flutamide-induced liver toxicity is very low, we recommend serial blood aminotransferase measurements at 2 and 4 weeks of treatment in order to detect early signs of possible flutamide-induced hepatic injury, thus avoiding the low potential risk of clinically significant liver toxicity.

[Pathologic study of Morton's neuroma]

The clinical syndrome of Morton's neuroma [correction of nephroma] was described over a century ago, but its etiopathology remains unknown. Recent studies suggest that it may be induced by compression neuropathy. Histologic changes in digital nerves resected for therapeutic purposes were compared with histologic findings of digital nerves sampled at autopsy of asymptomatic subjects. Results show that approximately one-third of resected "diseased" digital nerves were histologically normal. The authors question the therapeutic approach, which consists of resecting the nerves.

Intact "biological motion" and "structure from motion" perception in a patient with impaired motion mechanisms: a case study

A series of psychophysical tests examining early and later aspects of image-motion processing were conducted in a patient with bilateral lesions involving the posterior visual pathways, affecting the lateral parietal-temporal-occipital cortex and the underlying white matter (as shown by magnetic resonance imaging studies and confirmed by neuro-ophthalmological and neuropsychological examinations). Visual acuity, form discrimination, color, and contrast-sensitivity discrimination were normal whereas spatial localization, line bisection, depth, and binocular stereopsis were severely impaired. Performance on early motion tasks was very poor. These include seeing coherent motion in random noise (Newsome & Paré, 1988), speed discrimination, and seeing two-dimensional form from relative speed of motion. However, on higher-order motion tasks the patient was able to identify actions from the evolving pattern of dots placed at the joints of a human actor (Johansson, 1973) as well as discriminating three-dimensional structure of a cylinder from motion in a dynamic random-dot field. The pattern of these results is at odds with the hypothesis that precise metrical comparison of early motion measurements is necessary for higher-order "structure from motion" tasks.