Stress in Parents of Children With Genetically Determined Leukoencephalopathies: A Pilot Study

Genetically determined leukoencephalopathies comprise a group of rare inherited white matter disorders. The majority are progressive diseases resulting in early death. We performed a cross-sectional pilot study including 55 parents from 36 families to assess the level of stress experienced by parents of patients with genetically determined leukoencephalopathies, aged 1 month to 12 years. Thirty-four mothers and 21 fathers completed the Parenting Stress Index-4th Edition. One demographic questionnaire was completed per family. Detailed clinical data was gathered on all patients. Statistical analysis was performed with total stress percentile score as the primary outcome. Mothers and fathers had significantly higher stress levels compared with the normative sample; 20% of parents had high levels of stress whereas 11% had clinically significant levels of stress. Mothers and fathers had comparable total stress percentile scores. We identified pediatric behavioral difficulties and gross motor function to be factors influencing stress in mothers. Our study is the first to examine parental stress in this population and highlights the need for parental support early in the disease course. In this pilot study, we demonstrated that using the Parenting Stress Index-4th Edition to assess stress levels in parents of patients with genetically determined leukoencephalopathies is feasible, leads to valuable and actionable results, and should be used in larger, prospective studies.

0038 The Effects of Morning Blue Light Therapy on Insomnia Severity and PTSD Symptoms in a Clinical Sample

Introduction

Individuals with Post Traumatic Stress Disorder (PTSD) often present with insomnia, which may exacerbate other symptoms of the disorder. Morning Blue Light Therapy (BLT) can regulate circadian rhythms and may even improve sleep and mood in individuals with major depressive disorder. However, it is unclear whether morning BLT could also be an effective treatment for the insomnia associated with PTSD. We investigated whether 6 weeks of daily morning BLT would improve insomnia severity and symptom presentation in individuals with PTSD in comparison to a placebo condition of amber light (ALT). We hypothesized that changes in insomnia severity would correlate with improvement in PSTD symptom severity.

Methods

Forty-one participants with a clinical diagnosis of PTSD were randomized to receive 6 weeks of either daily morning BLT (n=22) or ALT (n=19). Insomnia and PTSD symptom severity were evaluated at pre- and post-treatment using the Insomnia Severity Index (ISI) and the Clinician-Administered PTSD Scale (CAPS) for DSM-5, respectively.

Results

Both groups showed a significant decrease in their PTSD symptom severity (p<0.001) and insomnia severity (p<0.001) over the 6-week treatment period. However, improvement in insomnia severity significantly predicted improvements in PTSD symptom severity for the BLT group only (BLT: r =0.542, p=0.009; ALT: r=-0.095, p=0.699). The difference between the two correlation coefficients was significant (Z=-2.07, p=0.039).

Conclusion

The results suggest that morning BLT may be effective in improving PTSD symptoms by regulating the circadian rhythm and improving sleep. While ALT also led to improved PTSD symptom severity, it appears that those changes cannot be explained by improved sleep and may have other underlying mechanisms (e.g., placebo effect). Morning BLT may be a promising adjunctive method to bolster current treatment approaches for PTSD. Because of its ease of administration, it could be easily added to ongoing treatment as usual. This approach warrants further research.

Support

US Army Medical Research and Materiel Command: W81XWH-14-1-0570

0081 Habitual Sleep Duration is Negatively Correlated with Emotional Reactivity within the Rostral Anterior Cingulate Cortex in Individuals with PTSD

Introduction

Sleep difficulties, such as insomnia, are highly prevalent in individuals with Post-Traumatic Stress Disorder (PTSD). However, sleep deprivation can also increase emotional reactivity to positive (as well as negative) stimuli. While the effects of sleep loss on emotional perception healthy individuals has been documented, it remains unclear how lack of sleep in individuals with PTSD may affect their emotional reactivity to positive stimuli. We hypothesized that lower habitual sleep duration would be associated with greater functional brain activation changes in response to subliminally presented happy faces in brain areas of the reward network, such as the rostral anterior cingulate cortex (rACC).

Methods

Thirty-nine individuals with DSM-5 confirmed PTSD were administered the Pittsburgh Sleep Quality Index (PSQI) as a measure of their average nightly sleep duration over the past month. Participants then underwent fMRI imagining while viewing subliminal presentations of faces displaying happiness, using a backward masked facial affect paradigm to minimize conscious awareness of the expressed emotion. Brain activation to masked happy expressions was regressed against sleep duration in SPM12.

Results

There was a negative correlation between habitual sleep duration and activation within the rACC in response to the masked happy faces (x=14,y=40,z=0; k=102, pFWE-corr= 0.008).

Conclusion

Individuals with PTSD who average less sleep at night showed greater emotional reactivity, as indexed by greater functional brain activation changes within an area of the reward network, than individuals who obtained more sleep per night. Future research involving actual sleep duration manipulation will be necessary to determine whether this finding reflects the well-known antidepressant effect of sleep deprivation or a form of greater emotional expression error monitoring among traumatized patients when lacking sleep. Regardless, these findings suggest that insufficient sleep could affect unconsciously perceived emotion in faces and potentially affect social and emotional responses among individuals with PTSD.

Support

US Army Medical Research and Materiel Command: W81XWH-14-1-0570

Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations

Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.

P4375Value of echocardiography to diagnose coronary arteries patterns in transposition of great arteries

Material and methods

Retrospective analysis of data in neonates diagnosed with TGA (isolated or associated with VSD). Preoperative echocardiographic (TTE) coronary artery pattern and surgical intraoperative reports (SURG) were compared. Mismatch between TTE and SURG, and its impact on perioperative outcome were assessed. Coronary patterns were classified in 4 groups: I= normal CA, II= CA with intramural course, III= CA loop, IV= CA loop and intramural segment.

Results

108 neonates who underwent arterial switch operation (ASO) for isolated TGA (67 cases) or TGA+VSD (41) were included in the study: 68 ranged in group I, 7 in group II, 32 in group III and 1 in group IV. Five patients died (4.6%), from coronary cause in 3. Survival rates were 96% at 1-month and 95.2% beyond. Intraoperative complications occurred in 10 cases. TTE and SURG CA diagnosis differed in 19 cases = 17.6% (mismatch). Diagnosis of CA anatomy differed in 4.4%, 42.8%, 37.5% and 100% of respectively groups I, II, III and IV. Mortality was 28.6% in group II (intramural CA) compared to 2.9% in group I, 3.1% in group III and 0% in group IV (p=0.002). Death rates was 15.8% if TTE/SURG mismatch and 2.2% if TTE and SURG were concordant (p=0.0108). Mortality in group II (intramural CA) increased up to 50% in case of mismach TTE/SURG versus 0% if concordance, and was similar in the other groups. Survival rates were 84.2% in TTE misdiagnosed CA anomalies compared to 97.6% if TTE assessment correlated with surgical reports. By multivariate analysis, groups II and III coronary anatomy were risk factors for mismatch between TTE and SURG (respectively p=0.008 and p=0.0005), and mismatch TTE/SURG was the only risk factor for perioperative mortality (p=0.045).

Conclusion

Echocardiography can accurately assess coronary artery anatomy in neonates with TGA. Intramural coronary course is often misdiagnosed. Missed diagnosis of coronary artery anomaly preoperatively may impact on perioperative mortality.

Maternal alcohol use and children's emotional and cognitive outcomes in rural South Africa

BACKGROUND

Alcohol use in South Africa (SA) is increasing. The World Health Organization (WHO) states that SA is the third-largest drinking population in Africa, with the highest rate of fetal alcohol syndrome in the world. Internationally, parental drinking during childhood is a risk factor for poor child mental health, behavioural problems and weaker educational outcomes in middle childhood. However, parental alcohol use in Africa is under-researched, and much of the literature on maternal alcohol consumption is restricted to clinical and pregnancy samples.

OBJECTIVES

To investigate alcohol use and hazardous drinking (HD) among mothers/primary caregivers of children aged 7 - 11 years in a rural SA cohort. We explored risk factors for drinking and the association between HD and child behaviour/cognition.

METHODS

The primary outcome measure was the WHO Alcohol Use Disorder Identification Test (AUDIT) using the standardised cut-off for HD (≥8). Secondary measures were the Patient Health Questionnaire Depression Scale (PHQ-9), Patient Health Questionnaire General Anxiety Disorder Scale (GAD-7), Parenting Stress Index, short form (PSI-36), Child Behaviour Checklist (CBCL, parent reported), Kaufman Developmental Assessment Battery (KABC-II) for child cognition, and Neuropsychological Assessment Battery, 2nd edition, subtests (NEPSY-II) for executive function. We compared characteristics of those drinking/not drinking, using χ2 tests, and modelled outcomes on parenting stress, cognitive outcomes and CBCL scores for children using logistic regression analysis. We grouped mothers/caregivers engaged in HD to examine its effect on parent/child outcomes using t-tests to test for significant differences.

RESULTS

Of 1 505 women (1 266 mothers and 239 caregivers) with 1 536 children, 12% reported consuming alcohol and 3% reported HD. Higher maternal/caregiver age (31 - 40 years, adjusted odds ratio (aOR) 0.57 (95% confidence interval (CI) 0.4 - 0.9); >41 years, aOR 0.30 (95% CI 0.2 - 0.5)), education (matriculation, aOR 0.49 (95% CI 0.3 - 0.9); post matriculation, aOR 0.30 (95% CI 0.1 - 0.6)), and a stable relationship with the father (aOR 0.6 (95% CI 0.4 - 1.0)) were associated with no alcohol use. Food insecurity increased the odds of alcohol use (aOR 1.52 (95% CI 1.1 - 2.1)), while parental mental health (parenting stress, anxiety) and child mental health problems were associated with approximately double the odds of consuming alcohol in univariate analysis. Children of HD mothers/caregivers had higher mean scores for psychological problems (CBCL total score: no HD (mean 45.0) v. HD (mean 48.9); p=0.029) and lower cognitive scores (KABC Learning Scale: no HD (mean 14.3) v. HD (mean 12.8); p=0.017).

CONCLUSIONS

While HD rates were low, maternal/caregiver alcohol use negatively impacted on parenting and children's behavioural/cognitive outcomes. International evidence suggests that integrated approaches engaging parents and families may be more effective for parent-child outcomes than individual psychiatric or medical care for the parent on their own.

Lower serum osteocalcin concentrations in patients with type 2 diabetes and relationships with vascular risk factors among patients with coronary artery disease

BACKGROUND

Lower serum concentrations of the osteoblast-derived protein, osteocalcin, have been associated with poorer glycemic control, insulin resistance and atherosclerosis, and with the development of type 2 diabetes (T2DM).

METHODS

This study compares concentrations of two physiological forms of osteocalcin, carboxylated (cOCN) and uncarboxylated (unOCN), between participants with T2DM (n = 20) and age-, gender- and body mass index (BMI)-matched participants without T2DM (n = 40) among patients with coronary artery disease (CAD), and it explores relationships between osteocalcin concentrations and cardiovascular risk factors.

RESULTS

Concentrations of unOCN (2.71 ± 1.86 vs. 4.70 ± 2.03 ng/mL; t = -3.635, p = 0.001) and cOCN (8.70 ± 2.27 vs. 10.77 ± 3.69 ng/mL; t = -2.30, p = 0.025) were lower in participants with T2DM. In participants without T2DM, concentrations of cOCN were associated with fitness (VO_2Peak rho = 0.317, p = 0.047) and lower body fat (rho = -0.324, p = 0.041). In participants with T2DM, lower unOCN was associated with HbA1c (rho = -0.516, p = 0.020). Higher body mass was associated with higher unOCN (rho = 0.423, p = 0.009) in participants without T2DM, but with lower concentrations of both unOCN (rho = -0.590, p = 0.006) and cOCN (rho = -0.632, p = 0.003) in participants with T2DM.

CONCLUSION

In patients with CAD, lower osteocalcin concentrations were related to type 2 diabetes, and to adverse fitness, metabolic and obesity profiles.

Experimental Observation of Proton Bunch Modulation in a Plasma at Varying Plasma Densities

We give direct experimental evidence for the observation of the full transverse self-modulation of a long, relativistic proton bunch propagating through a dense plasma. The bunch exits the plasma with a periodic density modulation resulting from radial wakefield effects. We show that the modulation is seeded by a relativistic ionization front created using an intense laser pulse copropagating with the proton bunch. The modulation extends over the length of the proton bunch following the seed point. By varying the plasma density over one order of magnitude, we show that the modulation frequency scales with the expected dependence on the plasma density, i.e., it is equal to the plasma frequency, as expected from theory.

Experimental Observation of Plasma Wakefield Growth Driven by the Seeded Self-Modulation of a Proton Bunch

We measure the effects of transverse wakefields driven by a relativistic proton bunch in plasma with densities of 2.1×10^{14} and 7.7×10^{14}  electrons/cm^{3}. We show that these wakefields periodically defocus the proton bunch itself, consistently with the development of the seeded self-modulation process. We show that the defocusing increases both along the bunch and along the plasma by using time resolved and time-integrated measurements of the proton bunch transverse distribution. We evaluate the transverse wakefield amplitudes and show that they exceed their seed value (<15  MV/m) and reach over 300  MV/m. All these results confirm the development of the seeded self-modulation process, a necessary condition for external injection of low energy and acceleration of electrons to multi-GeV energy levels.