Hair cortisol in relation to acute and post-traumatic stress symptoms in children and adolescents

BACKGROUND

We report on the preliminary results of two independent studies that (1) compare the hair cortisol concentrations (HCC) of healthy controls with patients displaying post-traumatic stress symptoms (PTSS, study 1+2), (2) investigate whether pre-trauma HCC are predictive for the development of acute stress symptoms (ASS) and PTSS (study 1) and (3) determine whether HCC correlate with PTSS in a clinical sample of children (study 2).

METHODS

In study 1, the clinical symptoms of 35 minors were examined one (T1) and seven weeks (T2) after surgery following an accident. Hair samples were taken after the accident that reflect cortisol secretion over the past three months before the accident (healthy controls). In study 2, HCC and PTSS symptoms were cross-sectionally assessed in 22 minors who had experienced a psychological trauma.

RESULTS

The HCC of patients with PTSS were lower than the HCC of healthy controls (study 1+2). Secondary analyses showed that HCC were significantly lower in male PTSS patients than in male healthy controls, whereas the HCC in females were comparably low in both groups. Pre-trauma HCC did not predict the total ASS and PTSS scores (study 1) and HCC were not directly related to the total PTSS scores (study 2).

[Urinary tract infections in children]

Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).

Successful group psychotherapy of depression in adolescents alters fronto-limbic resting-state connectivity

BACKGROUND

Current resting state imaging findings support suggestions that the neural signature of depression and therefore also its therapy should be conceptualized as a network disorder rather than a dysfunction of specific brain regions. In this study, we compared neural connectivity of adolescent patients with depression (PAT) and matched healthy controls (HC) and analysed pre-to-post changes of seed-based network connectivities in PAT after participation in a cognitive behavioral group psychotherapy (CBT).

METHODS

38 adolescents (30 female; 19 patients; 13-18 years) underwent an eyes-closed resting-state scan. PAT were scanned before (pre) and after (post) five sessions of CBT. Resting-state functional connectivity was analysed in a seed-based approach for right-sided amygdala and subgenual anterior cingulate cortex (sgACC). Symptom severity was assessed using the Beck Depression Inventory Revision (BDI-II).

RESULTS

Prior to group CBT, between groups amygdala and sgACC connectivity with regions of the default mode network was stronger in the patients group relative to controls. Within the PAT group, a similar pattern significantly decreased after successful CBT. Conversely, seed-based connectivity with affective regions and regions processing cognition and salient stimuli was stronger in HC relative to PAT before CBT. Within the PAT group, a similar pattern changed with CBT. Changes in connectivity correlated with the significant pre-to-post symptom improvement, and pre-treatment amygdala connectivity predicted treatment response in depressed adolescents.

LIMITATIONS

Sample size and missing long-term follow-up limit the interpretability.

CONCLUSIONS

Successful group psychotherapy of depression in adolescents involved connectivity changes in resting state networks to that of healthy controls.

Neural Correlates of Psychotherapeutic Treatment of Post-traumatic Stress Disorder: A Systematic Literature Review

OBJECTIVES

Post-traumatic stress disorder (PTSD) is a common psychiatric disease with changes in neural circuitries. Neurobiological models conceptualize the symptoms of PTSD as correlates of a dysfunctional stress reaction to traumatic events. Functional imaging studies showed an increased amygdala and a decreased prefrontal cortex response in PTSD patients. As psychotherapeutic approaches represent the gold standard for PTSD treatment, it is important to examine its underlying neurobiological correlates.

METHODS

Studies published until August 2016 were selected through systematic literature research in the databases PubMed, PsychInfo, and Cochrane Library's Central Register of Controlled Trials or were identified manually by searching reference lists of selected articles. Search terms were "neural correlates" OR "fMRI" OR "SPECT," AND "therapy" AND "PTSD." A total of 19 articles were included in the present review whereof 15 studies compared pre-to-post-therapy signal changes, six studies related pre-treatment activity to pre-to-post-symptom improvement, and four studies compared neural correlates of responders versus non-responders. The disposed therapy forms were cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing, cognitive therapy, exposure therapy, mindfulness-based intervention, brief eclectic psychotherapy, and unspecified therapy.

RESULTS

Successful psychotherapy of PTSD was repeatedly shown to be accompanied by decreased activity in the amygdala and the insula as well as increased activity in the dorsal anterior cingulate cortex (dACC) and hippocampus. Elevated dACC activity prior to treatment was related to subsequent treatment success and a positive predictor for treatment response. Elevated amygdala and insula pre-treatment activities were related to treatment failure.

DISCUSSION

Decreased activity in limbic brain regions and increased activity in frontal brain areas in PTSD patients after successful psychotherapeutic treatment might reflect regained top-down control over previously impaired bottom-up processes.

[Vesico-ureteral reflux: Diagnosis and treatment recommendations]

BACKGROUND

Vesico-ureteral reflux (VUR) is one of the most common urologic diseases in childhood. About every third child that presents with a urinary tract infection (UTI) has urinary reflux to the ureter or kidney. Demonstration of a backflow of urine into the ureters or kidneys proves vesicoureteral reflux. In unclear cases, a positioned instillation of contrast agent (PIC) cystogram might be performed and is able to prove vesico-ureteral reflux.

OBJECTIVES

Since low-grade VUR has a high probability of maturation and self-limitation, infants with VUR should be given prophylactic antibiotics during their first year of life, reevaluating the status of VUR after 12 months. The aim of any treatment is to prevent renal damage.

THERAPY

The individual risk of renal scarring is decisive for the choice of adequate therapy. This risk is mainly dependent on reflux grade, age, and gender of the child as well as parental therapy adherence. In principle, therapeutic options include conservative as well as endoscopic or open surgical antireflux therapies.

CONCLUSION

Decisions on treatment should be made individually with parents taking into account all the findings available.

MICHI–eine Gruppen-Kurzzeitpsychotherapie zur Behandlung von Depressionen bei Jugendlichen

Kognitive Verhaltenstherapie (KVT) gilt als Mittel der Wahl bei der Behandlung von Depressionen im Jugendalter wobei bis dato noch kein deutsches Behandlungsmanual in einem randomisierten, kontrollierten Design untersucht wurde. 38 depressive Jugendliche (M=15,86, SD=±1,70 Jahre alt; 78,9 % weiblich) wurden randomisiert entweder der Kontrollgruppe (KG), die Behandlung wie üblich erhielt (TAU), oder Interventionsgruppe (IG), welche an einer ambulanten Gruppen-Kurzzeit-KVT (MICHI-Manual) teilnahm, zugeordnet. Als Effektivitätsmaße dienten die CDRS-R und das BDI-II. Die Interaktion aus Gruppe und Messzeitpunkt war sowohl für die CDRS-R (p=,02), mit einer mittleren Effektstärke (dkorr=,75), als auch für den BDI-II (p=,04), mit einer kleinen Effektstärke (dkorr=,39), signifikant. Die Gruppen-Kurzzeit-KVT entsprechend dem MICHI Manual ist verglichen mit TAU wirksam.

[Imaging in pediatric urology]

BACKGROUND

For many years, sonography and the intravenous pyelogram (IVP) were the most important examination methods for the evaluation of the urinary tract in children. Both methods have their pros and cons: sonography provides ideal visualization of normal kidneys and the evaluation of the pelvicalyceal system. For detection or exclusion of renal scarring, however, this method is not well suited. It provides no information regarding kidney function.

METHODS

With an IVP, it is possible to evaluate urinary excretion and, thus, indirectly assess kidney function. As this examination method involves radiation exposure and the necessity of a contrast agent, it should be avoided in the examination of children. The CT is an excellent examination method that can diagnose nearly all urological diseases in children or answer urological questions; however, a CT scan applies the highest radiation dose of all discussed methods. For this reason, examination via MRI is of increasing importance in uroradiology. Initially only the T2 sequences for the visualization of the urinary tract in children were applied.

CONCLUSION

The current technical developments as well as the use of the contrast agent gadolinium and the antidiuretic agent furosemide allow an all-in-one evaluation of the kidneys and urinary tract.

Cilengitide combined with cetuximab and platinum-based chemotherapy as first-line treatment in advanced non-small-cell lung cancer (NSCLC) patients: results of an open-label, randomized, controlled phase II study (CERTO)

BACKGROUND

This multicentre, open-label, randomized, controlled phase II study evaluated cilengitide in combination with cetuximab and platinum-based chemotherapy, compared with cetuximab and chemotherapy alone, as first-line treatment of patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Patients were randomized 1:1:1 to receive cetuximab plus platinum-based chemotherapy alone (control), or combined with cilengitide 2000 mg 1×/week i.v. (CIL-once) or 2×/week i.v. (CIL-twice). A protocol amendment limited enrolment to patients with epidermal growth factor receptor (EGFR) histoscore ≥200 and closed the CIL-twice arm for practical feasibility issues. Primary end point was progression-free survival (PFS; independent read); secondary end points included overall survival (OS), safety, and biomarker analyses. A comparison between the CIL-once and control arms is reported, both for the total cohorts, as well as for patients with EGFR histoscore ≥200.

RESULTS

There were 85 patients in the CIL-once group and 84 in the control group. The PFS (independent read) was 6.2 versus 5.0 months for CIL-once versus control [hazard ratio (HR) 0.72; P = 0.085]; for patients with EGFR histoscore ≥200, PFS was 6.8 versus 5.6 months, respectively (HR 0.57; P = 0.0446). Median OS was 13.6 for CIL-once versus 9.7 months for control (HR 0.81; P = 0.265). In patients with EGFR ≥200, OS was 13.2 versus 11.8 months, respectively (HR 0.95; P = 0.855). No major differences in adverse events between CIL-once and control were reported; nausea (59% versus 56%, respectively) and neutropenia (54% versus 46%, respectively) were the most frequent. There was no increased incidence of thromboembolic events or haemorrhage in cilengitide-treated patients. αvβ3 and αvβ5 expression was neither a predictive nor a prognostic indicator.

CONCLUSIONS

The addition of cilengitide to cetuximab/chemotherapy indicated potential clinical activity, with a trend for PFS difference in the independent-read analysis. However, the observed inconsistencies across end points suggest additional investigations are required to substantiate a potential role of other integrin inhibitors in NSCLC treatment.

CLINICAL TRIAL REGISTRATION ID NUMBER

NCT00842712.

Abituzumab combined with cetuximab plus irinotecan versus cetuximab plus irinotecan alone for patients with KRAS wild-type metastatic colorectal cancer: the randomised phase I/II POSEIDON trial

BACKGROUND

Integrins are involved in tumour progression and metastasis, and differentially expressed on colorectal cancer (CRC) cells. Abituzumab (EMD 525797), a humanised monoclonal antibody targeting integrin αν heterodimers, has demonstrated preclinical activity. This trial was designed to assess the tolerability of different doses of abituzumab in combination with cetuximab and irinotecan (phase I) and explore the efficacy and tolerability of the combination versus that of cetuximab and irinotecan in patients with metastatic CRC (mCRC) (phase II part).

METHODS

Eligible patients had KRAS (exon 2) wild-type mCRC and had received prior oxaliplatin-containing therapy. The trial comprised an initial safety run-in using abituzumab doses up to 1000 mg combined with a standard of care (SoC: cetuximab plus irinotecan) and a phase II part in which patients were randomised 1 : 1 : 1 to receive abituzumab 500 mg (arm A) or 1000 mg (arm B) every 2 weeks combined with SoC, or SoC alone (arm C). The primary end point was investigator-assessed progression-free survival (PFS). Secondary end points included overall survival (OS), response rate (RR) and tolerability. Associations between tumour integrin expression and outcomes were also assessed.

RESULTS

Phase I showed that abituzumab doses up to 1000 mg were well tolerated in combination with SoC. Seventy-three (arm A), 71 (arm B) and 72 (arm C) patients were randomised to the phase II part. Baseline characteristics were balanced. PFS was similar in the three arms: arm A versus SoC, hazard ratio (HR) 1.13 [95% confidence interval (CI) 0.78-1.64]; arm B versus SoC, HR 1.11 (95% CI 0.77-1.61). RRs were also similar. A trend toward improved OS was observed: arm A versus SoC, HR 0.83 (95% CI 0.54-1.28); arm B versus SoC, HR 0.80 (95% CI 0.52-1.25). Grade ≥3 treatment-emergent adverse events were observed in 72%, 78% and 67% of patients. High tumour integrin αvβ6 expression was associated with longer OS in arms A [HR 0.55 (0.30-1.00)] and B [HR 0.41 (0.21-0.81)] than in arm C.

CONCLUSION

The primary PFS end point was not met, although predefined exploratory biomarker analyses identified subgroups of patients in whom abituzumab may have benefit. The tolerability of abituzumab combined with cetuximab and irinotecan was acceptable. Further study is warranted. CLINICALTRIALS.GOV IDENTIFIER: NCT01008475.

Suicidal behavior in german adolescents. Prevalence and association with depressive and manic symptoms

OBJECTIVE

Research in adults has identified an association between bipolar disorder and suicidal behavior. This relationship, however, has been insufficiently investigated in adolescents to date.

METHODS

1,117 adolescents from 13 German schools (mean age = 14.83, SD = .63; 52.7% females) completed an extended German version of the Center for Epidemiological Studies Depression Scale (CES-D), which assesses depressive and manic symptoms during the last week, as well as the Self-Harm Behavior Questionnaire (SHBQ) for the assessment of lifetime suicidal behavior.

RESULTS

In the present sample 39.4% of the girls and 23.1% of the boys reported lifetime suicidal thoughts and 7.1% of the girls as well as 3.9% of the boys a lifetime history of suicide attempts. 18.7% of the adolescent sample revealed elevated symptoms of depression and 9% elevated levels of mania symptoms. Elevated sum scores of depression and mania were associated with a higher number of suicidal ideations and suicide attempts. A block-wise regression analysis revealed that sum scores of depression and mania predicted suicidal ideations best. Concerning suicide attempts, the best predictors were age as well as depression and mania sum scores.

CONCLUSIONS

Suicidal behavior was reported more often when adolescents demonstrate symptoms of mania as well as symptoms of depression than when they demonstrate only depressive symptoms. The presence of bipolar symptoms in adolescents should alert clinicians to the heightened possibility of suicidal behavior.

[Agreement between self-report and clinician's assessment in depressed adolescents, using the example of BDI-II and CDRS-R]

OBJECTIVES

Preceding studies demonstrated a high agreement between self-report and clinician's assessment of depression. The concordance on the level of sum scores, subscales, and single items, however, has yet to be investigated in a psychiatric adolescent sample. Also, the influence of additional variables such as age, sex, and IQ has been insufficiently studied in adolescents.

METHODS

Scores on the BDI-II and CDRS-R, assessed within 1 week, were collected from 105 adolescents (mean age = 15.94 years). Analyses of correlation were done on levels of sum scores, subscales, and single items.

RESULTS

There was a high correlation between self-report and clinician's assessment (r = .67). At the level of subscales, items assessing somatic contents demonstrated no higher agreement than did items assessing cognitive and affective contents. The highest agreement at the symptom level was shown for the item assessing suicidal ideations. Additional variables had no significant influence on concordance. Adolescents with a high IQ and outpatient adolescents tended to overestimate their symptoms.

CONCLUSIONS

The overall correlation was high and did not differ from results of comparable studies of correlations. The highest congruence was shown for the item assessing suicidal ideations, which underlines the accurate assessment of suicidality by clinicians as well. In summary, questionnaires can provide information about the existence of a depressive disorder, although one diagnostic instrument should not be replaced by the other despite a high correlation.

All-atom empirical potential for molecular modeling and dynamics studies of proteins

New protein parameters are reported for the all-atom empirical energy function in the CHARMM program. The parameter evaluation was based on a self-consistent approach designed to achieve a balance between the internal (bonding) and interaction (nonbonding) terms of the force field and among the solvent-solvent, solvent-solute, and solute-solute interactions. Optimization of the internal parameters used experimental gas-phase geometries, vibrational spectra, and torsional energy surfaces supplemented with ab initio results. The peptide backbone bonding parameters were optimized with respect to data for N-methylacetamide and the alanine dipeptide. The interaction parameters, particularly the atomic charges, were determined by fitting ab initio interaction energies and geometries of complexes between water and model compounds that represented the backbone and the various side chains. In addition, dipole moments, experimental heats and free energies of vaporization, solvation and sublimation, molecular volumes, and crystal pressures and structures were used in the optimization. The resulting protein parameters were tested by applying them to noncyclic tripeptide crystals, cyclic peptide crystals, and the proteins crambin, bovine pancreatic trypsin inhibitor, and carbonmonoxy myoglobin in vacuo and in crystals. A detailed analysis of the relationship between the alanine dipeptide potential energy surface and calculated protein φ, χ angles was made and used in optimizing the peptide group torsional parameters. The results demonstrate that use of ab initio structural and energetic data by themselves are not sufficient to obtain an adequate backbone representation for peptides and proteins in solution and in crystals. Extensive comparisons between molecular dynamics simulations and experimental data for polypeptides and proteins were performed for both structural and dynamic properties. Energy minimization and dynamics simulations for crystals demonstrate that the latter are needed to obtain meaningful comparisons with experimental crystal structures. The presented parameters, in combination with the previously published CHARMM all-atom parameters for nucleic acids and lipids, provide a consistent set for condensed-phase simulations of a wide variety of molecules of biological interest.

A brief cognitive-behavioural group therapy programme for the treatment of depression in adolescent outpatients: a pilot study

BACKGROUND

The goal of this pilot study was to examine the feasibility and clinical outcomes of a brief (6-session) group therapy programme in adolescent outpatients with depression. The programme had previously been assessed in in-patients, with positive results.

METHODS

A total of 15 outpatients aged 13 to 18 years took part in the programme between October 2010 and May 2011, in 3 separate groups of 4-6 participants each. The outcomes measured were feasibility of the programme, as assessed by attendance rate, user feedback, fidelity of implementation, and response to treatment, as assessed by pre- and post-intervention measurement of depressive symptoms, quality of life, and suicidal ideation.

RESULTS

The programme demonstrated good feasibility, with a mean attendance rate of 5.33 out of 6 sessions, a mean rating by participants on overall satisfaction with the programme of 7.21 out of 10 (SD = 1.89), and a 93% concurrence between the contents of the sessions and the contents of the treatment manual. Compared to baseline scores, depressive symptoms at follow-up test were significantly reduced, as assessed by the Children's Depression Rating Scale Revised (F(1, 12) = 11.76, p < .01) and the Beck Depression Inventory Revision (F(1, 32) = 11.19, p < .01); quality of life improved, as assessed by the Inventory of Quality of Life (F(1, 31) = 5.27, p < .05); and suicidal ideation was reduced. No significant changes were seen on the measures of the Parent Rating Scale for Depression and the Clinical Global Impression scale.

CONCLUSIONS

Based on the results of this pilot study, it is feasible to further assess this brief outpatient treatment programme in a randomized controlled trial without further modifications.

Innovations in Practice: MICHI, a brief cognitive-behavioural group therapy for adolescents with depression - a pilot study of feasibility in an inpatient setting

BACKGROUND

Group therapy is an economic intervention, allowing for fast access, for the treatment of several depressed adolescents simultaneously; evaluated manualised programs, however, are scarce.

METHOD

Nine depressive adolescent inpatients (M = 16.33 years; SD  = 1.92) participated between October 2009 and March 2010 in a brief manualised group therapy programme (MICHI), which was evaluated with respect to feasibility and trends of efficacy.

RESULTS

MICHI demonstrated good feasibility, was positively evaluated by the participants by means of an evaluation questionnaire ranging from 1 (very bad) to 10 (very good) (M = 7.22; SD  = 1.79), and showed significant reduction of depressive symptoms (z = -2.66, p = .008) assessed by means of a clinical interview.

CONCLUSIONS

Feasibility of MICHI was demonstrated and larger trials for efficacy will follow.

Convergence of Children's Depression Rating Scale-revised Scores and Clinical Diagnosis in Rating Adolescent Depressive Symptomatology

The Children’s Depression Rating Scale-Revised (CDRS-R) is a widely used instrument for research on depression in minors. A raw score of ≥40 has often been used as indicator of depressive symptomatology. As a validated German version of the CDRS-R has recently became available, we assessed CDRS-R raw summary scores of a video taped interview session in two different rater groups and compared them with clinical ratings of International Classification of Diseases (ICD-10) depression diagnosis as observed by a third independent group. We found that for the German version a raw score between 35 and 40 is indicative for mild depressive symptomatology as described by the ICD-10. CDRS-R scores show potential clinical applicability to deduct levels of depression.

Low molecular weight heparins for thromboprophylaxis during induction chemotherapy in patients with multiple myeloma

BACKGROUNDS

Patients with multiple myeloma have a high risk of venous thromboembolism (VTE), especially during the induction chemotherapy. The aim of our observational study was to determine the impact of prophylaxis with low molecular weight heparin (LMWH) on the incidence of thromboembolic complications.

PATIENTS AND METHODS

We analyzed the incidence of thromboembolic events in 258 patients treated with induction chemotherapy containing vincristin, doxorubicin or idarubicin, and dexamethasone, followed by stimulation chemotherapy with cyclophosphamide and G-CSF, and high-dose chemotherapy with melphalan. Two groups of these patients were compared based on the practice of thromboprophylaxis. Patients in the first group (Control, n = 140) were either not treated or treated with a short duration of anticoagulation therapy while the patients in the second group (Prophylactic, n = 118) underwent standard prophylaxis with LMWH throughout the entire period of induction chemotherapy. A total of 102 patients were selected for a close monitoring of the prophylactic effect of different LMWH doses and to be compared to patients without treatment.

RESULTS

Standard prophylaxis with LMWH significantly (p < 0.007) lowered a risk of VTE when compared to patients without such prophylaxis (3.4% versus 12.9%, respectively). Furthermore, analysis of the subgroup of 102 patients revealed that higher LMWH doses (> 70 IU/kg per day) achieved full prophylaxis in 28 patients while lower doses were less effective leading to DVT in 3 (7.7%) out of 39 patients. In contrast, VTE was diagnosed in 5 (14.3%) out of 35 patients without any LMWH prophylaxis.

CONCLUSION

Prophylaxis with LMWH leads to a significant reduction of the risk of thromboembolic complications during the induction chemotherapy in patients suffering from MM. The prophylactic effect of LMWH is dose-dependent.

Retrospective analysis of the results of high-dose chemotherapy with the support of autologous blood stem cells in patients with multiple myeloma. The experience of a single centre

Despite new medical products introduced in multiple myeloma therapy, autologous stem cell transplant (ASCT) remains a standard procedure in younger patients with symptomatic disease. We analyzed a group of 190 patients who underwent ASCT at our clinic for multiple myeloma as primary therapy in years 1995-2008. The total number of transplants performed in this group was 291. 110 patients underwent one ASCT, 59 patients had double transplant, out of which 51 patients underwent tandem transplant, 21 patients underwent triple ASCT, out of which 15 patients were transplanted front-line throughout a clinical trial and 6 patients underwent follow-up transplants due to disease progression. The assessment of the best therapeutic effect of ASCT showed the total rates of patients with complete remission--22%, very good partial remission (VGPR)--8%, partial remission--63%, stabilized disease--6% and progression--1%. The transplant related mortality (TRM) was 4.1%. With the median follow-up of surviving patients 2.6 years, the median progression-free survival (PFS) and overall survival (OS) were 21 and 54 months, respectively; the likelihood of a 7-year overall survival was 28%. Comparing tandem versus single transplants, there was a significant increase in the median PFS (25.8 versus 20.8 months, respectively); however, there was no difference in overall survivals. The IVE mobilization regimen was found to be more efficacious for PBPC collection than high-dosed cyclophosphamide.