Myoblasts for Survive 16 Weeks after Intracardiac Transfer and Start Differentiation

INTRODUCTION

Skeletal myoblasts have been shown to survive transfer into myocardial scar tissue. The purpose of this study was to investigate differentiation after intramyocardial transplantation. Additionally, we evaluated an intravital fluorescence dye.

MATERIALS AND METHODS

Skeletal myoblasts were harvested from 8 male inbred Lewis rats and expanded in culture. For each transplantation planned, 10(6) cells were trypsinized and incubated for three minutes with 2 ml of buffered PKH-26 solution (Sigma, St. Louis). This dye was integrated into the cell membrane. After washing three times, the cells were plated again for two more days. The cells were then transplanted into the hearts of 60 female Lewis-rats, mean weight 380 g (260 - 450 g). At implantation, 10(6) cells suspended in 100 microliters were injected into the apex region of the left ventricle. 12 animals served as the control group with only cell medium injected. Animals were sacrificed after 1, 2, 6, 8, 12, and 16 weeks (n = 10 each). The hearts were explanted and serial frozen sections of the hearts were prepared for detecting labeled cells. Sections with labeled cells were stained immunohistochemically for Myo D1 (myogenic origin), n-cam (early myotubes), desmin (muscular filament), myosin light chain (muscular contractile protein), and connexin 43 (tight junction).

RESULTS

Cell labeling was successful in all cases. After two days, the myoblasts had recovered from the staining procedure. The fluorescing dye, however, was only rarely transmitted by cell division. Marked cells were found in the intercellular spaces between the cardiac myofibers in at least 8 animals from each group. No fibrotic reaction or inflammation was seen surrounding the transplanted cells. Up to 6 weeks after implantation, the cells stained positive for n-cam and Myo D1, and particularly for desmin. More n-cam positive cells were found than labeled cells, indicating cell division after the cell transfer. Two animals suffered sudden death after a follow-up time of 8 and 10 weeks, which was possibly due to cardiac arrhythmia. After 8 weeks, the cells formed conglomerates and stained positive for desmin, myosin light chain, and connexin 43. The cells were not structurally integrated into the recipient myocardial tissue, however.

CONCLUSIONS

Myoblasts divided further after transplantation into rat myocardium. Positive staining for desmin demonstrated the development of myofibers. Starting at 8 weeks after transplantation, the cells started differentiation without reaching structural integration during follow-up. Labeling the cells with PKH-26 proved to be a reliable method to detect the cells.

Attitudes to Prophylactic Surgery and Chemoprevention in Australian Women at Increased Risk for Breast Cancer

BACKGROUND

Because of the uncertain efficacy of breast cancer screening in women at increased risk of developing breast cancer, bilateral prophylactic oophorectomy and mastectomy are considered management options for high-risk women. Data on the attitudes to prophylactic strategies of high-risk women who have not attended specialist clinics are needed to ascertain the need for patient education and provide the basis for planning of support services.

METHODS

Three hundred seventy-one women unaffected by cancer and with unknown mutation status from families with a dominantly inherited susceptibility to breast cancer, recruited through a large Australian population-based, epidemiological study, were assessed using a mailed self-administered questionnaire with validated measures of psychological outcome.

RESULTS

Sixteen percent of women reported considering prophylactic mastectomy, and 1% had already had the procedure. Among women with a family history of breast/ovarian cancer, 33% had considered and 5% had already had a prophylactic oophorectomy. Twenty-three percent of women reported considering taking tamoxifen if it were shown to prevent breast cancer. Consideration of prophylactic oophorectomy (OR = 1.51 for a 10% change in perceived risk, 95% CI 1.14-1.99, p = 0.0045) and tamoxifen (OR = 1.14 for a 10% change in perceived risk, 95% CI 1.002-1.30, p = 0.047) were positively associated with perceived cancer risk.

CONCLUSIONS

Attitudes to prophylactic surgery and psychological distress levels in high-risk women participating in an epidemiological study appear to be comparable to those of women attending familial cancer clinics and indicate that women attending high-risk clinics may be representative of the larger population of women at increased risk.

The fertility- and menopause-related information needs of younger women with a diagnosis of breast cancer: a qualitative study

The use of chemotherapy and endocrine therapies in the treatment of pre-menopausal women carries with it reproductive and gynaecological implications which younger women may find both unpleasant and discordant with plans for childbearing. This study aims to investigate the fertility- and menopause-related information needs of younger women with a diagnosis of early breast cancer. A retrospective qualitative methodology was chosen. Twenty-four women aged between 26 and 45 years at diagnosis participated in focus group interviews and telephone interviews. Many women thought that the information they had received in the past about fertility and menopausal symptoms was either insufficient or unavailable. Some women felt that, while information on fertility and menopause issues had not been paramount at the time of diagnosis, it became increasingly important after diagnosis. Participants spoke about the need to revisit or review fertility- and menopause-related information with their doctors during the course of treatment. Many women believed that information about fertility should be given prior to or during treatment decision-making, and that information related to the management of menopausal symptoms should be delivered during or after treatment when menopausal symptoms begin. Consultation with a fertility and/or menopause specialist-rated as the most preferred mode of receiving fertility- and menopause-related information. Clinical implications are drawn from the results of this study to assist clinicians and researchers to improve their communication with younger patients about the fertility- and menopause-related side effects of breast cancer treatment.

Psychological outcomes and risk perception after genetic testing and counselling in breast cancer: a systematic review

OBJECTIVES

To conduct a systematic review of the effects of genetic counselling and testing for familial breast cancer on women's perception of risk and psychological morbidity.

DATA SOURCES

MEDLINE, PsychLIT and EMBASE were searched for the period 1980-2001.

STUDY SELECTION

Studies were eligible if published in a peer-reviewed journal in English, included women with a family history of breast cancer who underwent genetic counselling or testing and had either a randomised controlled trial or prospective design, with a pre- and at least one post-counselling assessment.

DATA SYNTHESIS

As there was considerable heterogeneity in populations and measures, results were summarised rather than subjected to meta-analysis.

RESULTS

Overall, genetic counselling and testing appear to produce psychological benefits and to improve accuracy of risk perception. Carriers of mutations in cancer predisposition genes did not experience significant increases in depression and anxiety after disclosure of their mutation status, while non-carriers experienced significant relief. Women who were tested but declined to learn their results seemed to be at greater risk of a worse psychological outcome.

CONCLUSIONS

To date, the data on psychological outcomes after genetic counselling and testing are reassuring. However, few studies used a randomised trial design, limiting the strength of the conclusions. Follow-up to date has been short, and we know little about the long-term impact of testing on patient behaviours, perceptions and psychological state.

A decision aid for women at increased risk for ovarian cancer

This paper reviews changes that have occurred within and without the medical profession that have fostered an increasing demand for decision aids as adjuncts to practitioners' counseling to prepare patients for decision making. In the absence of data on the efficacy of ovarian cancer screening and prophylactic strategies, decisions about optimal care are difficult for both women and their doctors. Because surveillance and preventive options are an area of great uncertainty, a decision aid has been developed specifically aimed at facilitating decisions involving ovarian cancer risk management options. This was achieved by reviewing and integrating the available literature on models of medical decision making, patient preferences for information and involvement in decision making, the utility of decision aids, and management options for ovarian cancer risk. Findings indicate that patients wish to be informed participants in the decision-making process and that decision aids are an acceptable and effective method of providing quality information in a format that facilitates an inclusive model of shared decision making. A decision aid designed for women at increased risk of ovarian cancer that facilitates informed decision making may be a valuable addition to patient support. A randomized controlled trial of this type of educational material will provide timely and much needed evidence on its acceptability and efficacy.

A decision aid for women at increased risk for ovarian cancer

This paper reviews changes that have occurred within and without the medical profession that have fostered an increasing demand for decision aids as adjuncts to practitioners' counseling to prepare patients for decision making. In the absence of data on the efficacy of ovarian cancer screening and prophylactic strategies, decisions about optimal care are difficult for both women and their doctors. Because surveillance and preventive options are an area of great uncertainty, a decision aid has been developed specifically aimed at facilitating decisions involving ovarian cancer risk management options. This was achieved by reviewing and integrating the available literature on models of medical decision making, patient preferences for information and involvement in decision making, the utility of decision aids, and management options for ovarian cancer risk. Findings indicate that patients wish to be informed participants in the decision-making process and that decision aids are an acceptable and effective method of providing quality information in a format that facilitates an inclusive model of shared decision making. A decision aid designed for women at increased risk of ovarian cancer that facilitates informed decision making may be a valuable addition to patient support. A randomized controlled trial of this type of educational material will provide timely and much needed evidence on its acceptability and efficacy.

The new German allocation system for donated thoracic organs causes longer ischemia and increased costs

OBJECTIVE

Allocation criteria changed in 2000 as a result of Germany's new transplantation law. Before, thoracic organs were primarily allocated electively within the donor region (according to urgency and waiting time). Afterwards, all patients in Germany eligible for heart transplants were registered in a national waiting list. With the exception of high-urgency patients that are approved by an audit committee, waiting time has become the major criteria for allocation. In this study, we investigated the impact of the new allocation system on economic aspects as on clinical results.

METHODS

One year in the new allocation system (NA) was compared to the previous year in the old allocation system (OA) regarding explantation/transportation distance, costs, ischemia time and clinical outcome. All explantations performed by our institution within Germany were evaluated.

RESULTS

The number of transplantations and the spectrum was similar between the two time periods (NA vs. OA: 61 vs. 57 overall). Eighty-two percent of these explanted organs were transplanted within the donor region in the OA time period, but only 37 % in the NA period. This resulted in higher transportation distances (NA: 441 +/- 177 km vs. OA: 179 +/- 118 km), higher transportation cost (NA: EUR 4,472 +/- 2,858 per explantation vs. OA: EUR 1,858 +/- 2,293 explantation, p = 0.001), and therefore longer ischemia times in the NA period (NA: 264 +/- 56 min: OA: 208 + 61 min, p = 0.001). Perioperative results and survival after a mean clinical follow-up of 21 +/- 8 (OA) and 11 +/- 5 (NA) months were comparable (86 % vs. 87 % (p = 0.93).

CONCLUSION

Transportation distance, costs for explantation and ischemia time increased significantly with the NA period. While the clinical short-term outcome proved to be comparable, we cannot yet judge the long-term impact of the prolonged ischemia time on the development of chronic rejection.

Psychological impact of genetic testing in women from high-risk breast cancer families

Psychological adjustment in 90 women (30 carriers and 60 non-carriers) who had undergone genetic testing for mutations in BRCA1 and BRCA2 breast/ovarian cancer susceptibility genes was compared with that of 53 women who were not offered genetic testing. Women were assessed prior to genetic testing and 7-10 days, 4 and 12 months after carrier status disclosure using self-administered questionnaires. Compared with women not offered testing, mutation carriers had significantly higher breast cancer distress 7-10 days (t=2.80, P=0.005) and 12 months (t=2.01, P=0.045) post-notification. Non-carriers showed a significant decrease in state anxiety 7-10 days post-notification (t=2.27, P=0.024) and in depression 4 months post-notification (t=2.26, P=0.024), compared with women not offered testing. These data show that non-carriers derive psychological benefits from genetic testing. Women testing positive may anticipate a sustained increase in breast cancer distress following disclosure, although no other adverse psychological outcomes were observed in this group.

Tailoring communication in consultations with women from high risk breast cancer families

This multicentre study examined the influence of patient demographic, disease status and psychological variables on clinical geneticists/genetic counsellors (consultants) behaviours in initial consultations with women from high-risk breast cancer families. One hundred and fifty-eight women completed a pre-clinic self-report questionnaire. The consultations were audiotaped, transcribed verbatim and coded. Consultants did not vary their behaviour according to women's expectations. However, significantly more aspects of genetic testing were discussed with women who were affected with breast cancer (P<0.001), screening and management with unaffected women (P=0.01) and breast cancer prevention with younger women (P=0.01). Prophylactic mastectomy was discussed more frequently with women with medical and allied health training (P=0.02), and prophylactic oophorectomy with women affected with breast cancer (P=0.03), those in non-professional occupations (P=0.04) and with a family history of breast and ovarian cancer (P<0.001). Consultants used significantly more behaviours to facilitate understanding with women who were in non-professional occupations (P=0.04); facilitated active patient involvement more with women affected with breast cancer (P<0.001) and used more supportive and counselling behaviours with affected women (P=0.02). This study showed that patient demographics were more likely to predict consultants' communication behaviours than the woman's psychological status. Methods to facilitate assessment of psychological morbidity are needed to allow more tailored communication.

Psychological impact of prophylactic oophorectomy in women at increased risk of developing ovarian cancer: a prospective study

OBJECTIVES

The objectives of this study were twofold: to prospectively assess whether expressed intention to undergo prophylactic oophorectomy translated into uptake and to evaluate the psychological impact of the procedure in a sample of unaffected women with a strong family history of breast/ovarian cancer.

METHODS

Ninety-five women, initially assessed at the time of their first attendance at a familial cancer clinic, were followed-up 3 years later. A total of 22 women (23.2%) in this study had undergone a prophylactic oophorectomy. Ten women (10.5%) who had undergone a prophylactic oophorectomy during the 3-year follow-up period were compared to 73 women (76.9%) who did not have a prophylactic oophorectomy. Twelve women (12.6%) who had the procedure prior to study entry were also assessed for psychological adjustment and associated information needs.

RESULTS

Age emerged as a significant predictor of uptake of prophylactic oophorectomy (chi(2) = 7.13, P = 0.009). Among those who had the procedure after study entry, a significant reduction in ovarian cancer anxiety was observed (Z = -2.19, P = 0.029). Of the 22 women who had undergone a prophylactic oophorectomy in total (both before and after study entry), 86.4% reported a high degree of satisfaction with their decision to have the procedure. A low level of screening uptake was also reported by women who did not have a prophylactic oophorectomy but for whom screening was recommended.

CONCLUSION

Findings demonstrate that prophylactic oophorectomy is successful in reducing anxiety about ovarian cancer. The results also suggest that women perceive that the benefit of anxiety reduction may outweigh the potentially adverse effects of the procedure, given that women expressed a high level of satisfaction with their decision.

What is the impact of genetic counselling in women at increased risk of developing hereditary breast cancer? A meta-analytic review

Meta-analytic methods were used to determine the impact of genetic counselling on women with a family history of breast cancer. Published studies with prospective designs and randomized controlled trials were included in the review, and the psychological outcomes assessed were generalized psychological distress, generalized anxiety, depression, and breast cancer anxiety. Other outcomes investigated were the accuracy of perceived risk of developing breast cancer, breast cancer genetics knowledge and breast cancer screening uptake. A meta-analysis was performed to estimate effect size, where sufficient data were available. A total of 12 studies, most of which measured several outcomes, met at least one of the inclusion criteria. A sufficiently large number of studies were available to assess the magnitude of effects on three outcomes: generalized psychological distress, generalized anxiety and accuracy of perceived risk of developing breast cancer. The quantitative synthesis showed that genetic counselling leads to statistically significant decreases in generalized anxiety, with an average weighted effect sizes of r = - 0.17 (p<0.01). In contrast, the reduction in psychological distress exhibited a trend towards statistical significance only, with r = -0.074 (p = 0.052). The impact of genetic counselling on the accuracy of perceived risk was associated with an effect size of r = 0.56 (p<0.01). Thus in this meta-analysis, we demonstrated the efficacy of genetic counselling in meeting two of its objectives: reducing women's anxiety levels and improving the accuracy of their perceived risk. This review highlighted that most research so far focused on generalized distress and anxiety and accuracy of perceived risk, to the exclusion of other, perhaps equally important, types of outcomes. Future studies are likely to lead to more comprehensive assessments if additional emotional, cognitive and behavioural outcomes are included in the assessment.

Psychometric properties of the Impact of Event Scale amongst women at increased risk for hereditary breast cancer

The Impact of Event Scale (IES; Horowitz MJ, Wilner N, Alvarez W. 1979. Psychosom Med 41: 209-218) has been widely used in the psycho-oncology literature as a measure of cancer-related anxiety. More recently, the IES has been applied to the assessment of breast cancer-related anxiety amongst women who are at increased risk of developing hereditary breast cancer. Despite its widespread use, no studies to date have described the validity of the IES amongst these women. The present study is a replication of reliability analyses and exploration of the factor structure and validity of the IES amongst a sample of 480 female hereditary breast cancer clinic patients. Results suggest good internal consistency (Cronbach's alpha=0.84-0.91), and satisfactory test-retest reliability (IES-Total r=0.80). The IES was found to have good face validity and be an acceptable instrument to women at increased risk of breast cancer. The two-factor (intrusion and avoidance) structure originally reported (Horowitz et al. 1979; Zilberg NJ, Weiss DS, Horowitz MJ. 1982. J Consult Clin Psychol 50: 407-414) was replicated by factor analysis in the present study. Analysis of correlation coefficients between the IES, breast cancer-related events and attitudes and other standardized measures of distress and general somatic concern, provide some preliminary support for the concurrent and discriminative validity of the IES amongst women at increased risk of developing hereditary breast cancer.

Long-term outcomes of genetic counseling in women at increased risk of developing hereditary breast cancer

This multicenter study evaluated the impact of genetic counseling in 218 women at risk of developing hereditary breast cancer. Women were assessed prior to counseling and 12-month post-counseling using self-administered, mailed questionnaires. Compared to baseline, breast cancer genetics knowledge was increased significantly at follow-up, and greater increases in knowledge were associated with educational level. Breast cancer anxiety decreased significantly from baseline to follow-up, and these decreases were associated with improvements in perceived risk. A significant decrease in clinical breast examination was observed at the 12-month follow-up. Findings suggest that women with a family history of breast cancer benefit from attending familial cancer clinics as it leads to increases in breast cancer genetics knowledge and decreases in breast cancer anxiety. The lowered rates of clinical breast examination indicate that the content of genetic counseling may need to be reviewed to ensure that women receive and take away the right message.

Cultural aspects of cancer genetics: setting a research agenda

BACKGROUND

Anecdotal evidence suggests that people from non-Anglo-Celtic backgrounds are under-represented at familial cancer clinics in the UK, the USA, and Australia. This article discusses cultural beliefs as a potential key barrier to access, reviews previous empirical research on cultural aspects of cancer genetics, draws implications from findings, and sets a research agenda on the inter-relationships between culture, cancer genetics, and kinship.

METHODS

The CD-ROM databases MEDLINE, PsychLIT, CINAHL, and Sociological Abstracts were searched from 1980 onwards.

RESULTS

Cultural aspects of cancer genetics is the focus of an emerging body of publications. Almost all studies assessed African-American women with a family history of breast cancer and few studies included more diverse samples, such as Americans of Ashkenazi Jewish background or Hawaiian- and Japanese-Americans. Our analysis of published reports suggests several directions for future research. First, an increased focus on various Asian societies appears warranted. Research outside North America could explore the extent to which findings can be replicated in other multicultural settings. In addition, control group designs are likely to benefit from systematically assessing culture based beliefs and cultural identity in the "majority culture" group used for comparative purposes.

CONCLUSION

More data on which to base the provision of culturally appropriate familial cancer clinic services to ethnically diverse societies are needed. Empirical data will assist with culturally appropriate categorisation of people from other cultures into risk groups based on their family histories and provide the basis for the development of culturally appropriate patient education strategies and materials.

Influence of ischemic time on hyperacute xenograft rejection of pig hearts in a working heart perfusion model with human blood

In xenotransplantation long ischemic time of grafts is supposed to have a marked influence on hyperacute rejection (HXR). We investigated the influence of different cold ischemic times on HXR of ex vivo "working pig hearts" perfused with human blood. Xenoreactive natural antibodies (XNAb) as a trigger of HXR were eliminated by Ig-Therasorb immunoadsorption (IA). Explanted Landrace pig hearts of group G1 and group G3 (with additional IA) underwent 4 h of cold ischemia prior to xenoperfusion. Control groups G2 and G4 (with IA) were kept ischemic for only 46.6 +/- 15.8 and 51.2 +/- 4.2 min, respectively. Ischemic time prolonged the perfusion time in our working heart model (G1: 356 +/- 46.1 min; G2: 125 +/- 31 min; P < 0.05). IA had no additional impact on perfusion time but was effective by itself. The heart weight increased fourfold more in G2 as compared to the other groups. IA without ischemia significantly improved cardiac output in G4 (G3: 198.8 +/- 15.4 mL/min; G4: 338.5 +/- 16.0 mL/min). Coronary flow in G2 was significantly lower than in G1 (G1: 157.9 +/- 9.15 mL/min; G2: 59.4 +/- 20.1 mL/min). Histological signs of HXR (light and electron microscopy) could be found in G2 in contrast to the other groups. Parameters of serological damage showed a minimum in G4 and the maximum in G2. In G1 XNAb were nearly equally eliminated immediately after the start of xenoperfusion as in IA groups G4 and G3. Four hours of ischemic time showed beneficial effects in preventing HXR, possibly caused by changes of the endothelial cell surface (for example, glycosylation or loss of alpha1-3Gal epitopes with a hapten effect).

Prevention of hyperacute xenograft rejection in orthotopic xenotransplantation of pig hearts into baboons using immunoadsorption of antibodies and complement factors

To prevent hyperacute xenograft rejection (HXR) caused by preformed natural antibodies (XNAb) after orthotopic heart xenotransplantation (oXHTx) of landrace pig hearts into baboons, we used immunoadsorption of immunoglobulins IgG, IgM and IgA and complement with the reusable Ig-Therasorb column. In addition to functional data, tissue was sampled for histological, immunohistochemical and electron microscopical analysis. We performed three oXHTx of landrace pig hearts to baboons using extracorporeal circulation (ECC) connected to the immunoadsorption unit. Intraoperative treatment consisted of four cycles of immunoabsorption (IA). One oXHTx of a baboon without IA served as a control. A mismatch of donor and recipient heart size was prevented by selecting a 30-40% lower body weight of donor pigs than recipients. Four cycles of IA removed more than 80% of IgG, IgM and IgA, 86% of antipig antibodies and 66% of complement factors C3 and C4 from plasma. The graft of the control animal failed after 29 min. Orthotopic xenotransplantation with IA was selectively terminated after 100 min, 11 h and 21 h, respectively without any histological signs of HXR in light and electron microscopy. After weaning off from ECC these donor xenografts showed sufficient function with normal ECG and excellent cardiac output in echocardiography and invasive measurement (1.93 +/- 0.035 l/min). The myocardium of the control xenograft demonstrated more deposits of Ig and complement components (C3, C4) than in the IA group. Baboons survive HXR after orthotopic pig heart xenotransplantation due to antibody depletion by reusable Ig-Therasorb column treatment. Long-term survival in an orthotopic baboon xenotransplantation model after IA, especially in combination with transgenic pig organs, could be a reliable preclinical trial for future clinical xenotransplantation programs.

Contrast-enhanced magnetic resonance angiography for control of minimally invasive coronary artery bypass conduits (MIDCAB/OPCAB)

OBJECTIVE

The purpose of this study was to delineate the course and determine the patency of venous and arterial conduits in the early postoperative period following minimally invasive bypass grafting. A less invasive magnetic resonance angiogram was evaluated as alternative to standard contrast angiography and cardiac catheterization.

METHODS

Twelve patients (8 males and 4 females) with a mean age of 65.3 (+/- 7.4 ) years were evaluated four to seven days following minimally invasive direct coronary artery bypass surgery (MIDCAB) or off-pump multivessel revascularization with the Octopus stabilizer on the beating heart. Altogether 17 coronary bypass grafts were investigated: 12 left-sided mammary artery grafts to the LAD and five aortocoronary venous bypass grafts. The examination was performed with a 1.5 Tesla Magnetom Vision (Siemens AG, Erlangen) with phased array coil technology. Data acquisition was done with an ultrafast 3D gradient-echosequence in single breathhold and sagittal and coronal views. Contrast enhancement of the vessels was performed with automatic intravenous bolus injection of Gadolinium-DTPA after determination of the individual contrast transit time. Traditional contrast angiography was obtained in all patients during the same time period as a comparison to assess the sensitivity and specificity of the magnetic resonance imaging.

RESULTS

All five venous grafts and 11 of the 12 IMA grafts were detected and shown to be patent with the MRA technique. Contrast angiography demonstrated complete patency for all 17 bypass grafts with adequate anastomoses and no evidence of stenosis. The calculated sensitivity for the visualization with MRA was therefore 92% for IMA grafts and 100% for venous grafts.

CONCLUSION

The contrast-enhanced ultrafast MRA in single breathhold technique is a reliable, noninvasive method for visualization and determination of the patency of arterial and venous coronary grafts.

Tacrolimus versus cyclosporine after lung transplantation: a prospective, open, randomized two-center trial comparing two different immunosuppressive protocols

BACKGROUND

The need for better immunosuppressive protocols after lung transplantation led us to investigate tacrolimus (Tac) in combination with mycophenolate mofetil (MMF) and steroids or cyclosporine (CsA) in combination with MMF and steroids in a prospective, open, randomized trial after lung transplantation.

METHODS

Between September 1997 and April 1999, 50 lung transplant recipients were randomized to receive either Tac (n = 26) or CsA (n = 24) in combination with MMF and steroids. All patients underwent induction therapy with rabbit antithymocyte globulin (ATG) for 3 days. Freedom from acute rejection (AR), patient survival, infection episodes, and side effects were monitored.

RESULTS

There was no difference in patient demographics between the two groups. Six-month and 1-year survival was similar (84.6% and 73.1% in the Tac group vs 83.3% and 79.2% in the CsA group). Freedom from AR at 6 months and 1 year after lung transplantation was slightly higher in the Tac group (57.7% and 50% vs 45.8% and 33.3%, p = not significant [n.s.]), whereas the number of treated rejection episodes per 100 patient days in the Tac group was significantly lower (0.225 vs 0.426, p < .05). Four patients in the CsA group had to be switched to Tac. Two patients in the CsA group had to be retransplanted. Incidence of infections was similar in both groups with a trend toward more fungal infections in the Tac group (n = 7 vs n = 1, p = n.s.).

CONCLUSIONS

The combination of Tac and MMF seems to have slightly higher immunosuppressive potential compared with CsA and MMF. The effectiveness of Tac as a rescue agent is not paralleled with undue signs of overimmunosuppression.

Psychological impact of genetic testing for Huntington's disease: an update of the literature

Genetic testing has been available for Huntington's disease for longer than any other adult onset genetic disorder. The discovery of the genetic mutation causing Huntington's disease made possible the use of predictive testing to identify currently unaffected carriers. Concerns have been raised that predictive testing may lead to an increase in deaths by suicide among identified carriers, and these concerns set in motion research to assess the psychological impact of predictive testing for Huntington's disease. This review article provides an overview of the literature and draws implications for clinical practice. About 10%-20% of people at risk request testing when approached by registries or testing centres. Most of the evidence suggests that non-carriers and carriers differ significantly in terms of short term, but not long term, general psychological distress. Adjustment to results was found to depend more on psychological adjustment before testing than the testing result itself. Although risk factors for psychological sequelae have been identified, few adverse events have been described and no obvious contraindications for testing people at risk have been identified. The psychological impact of testing may depend on whether testing was based on linkage analysis or mutation detection. Cohorts enrolled in mutation detection programmes have higher levels of depression before and after testing, compared with people who sought genetic testing when linkage analysis was available. There is evidence that people who choose to be tested are psychologically selected for a favourable response to testing. The impact of testing on people in settings where less intensive counselling protocols and eligibility criteria are used is unknown, and genetic testing is therefore best offered as part of comprehensive specialist counselling.

Psychological impact of prophylactic oophorectomy in women at increased risk for ovarian cancer

Women with a family history consistent with a hereditary breast/ovarian cancer syndrome are at significantly increased risk for ovarian cancer. Prophylactic oophorectomy is an option for high-risk women. This study explores the psychosexual impact of prophylactic oophorectomy. A qualitative methodology was selected as most appropriate as no previous research has examined this issue. In-depth interviews were conducted with fourteen women, between 4 months and 7 years after prophylactic oophorectomy. Of these, six were pre- and eight were postmenopausal at the time of oophorectomy. Even though individual differences were observed, a majority view was expressed on several issues. All but one participant reported being satisfied with their decision to undergo oophorectomy. Women emphasised that the procedure had decreased their anxiety about developing ovarian cancer. Postmenopausal women reported no negative impact on their libido. Amongst premenopausal women all but one commenced hormone replacement therapy (HRT) following surgery and, in these women, HRT appeared to mitigate the sexual impact of the procedure. Premenopausal women reported unmet information needs both before and after the procedure, including the effects of surgical menopause and the link between HRT and breast cancer. This exploratory study suggests that prophylactic oophorectomy is a psychologically acceptable risk reduction strategy in high-risk women.

Clinical use of a computer-enhanced surgical robotic system for endoscopic coronary artery bypass grafting on the beating heart

The aim of the study was to perform endoscopic coronary artery bypass grafting on the beating heart using a surgical robotic system. In the study, the surgical system ZEUS was used in combination with 3D visualization for endoscopic coronary artery bypass grafting in 25 patients. In a total of 10 cases, the coronary artery anastomosis was done on the beating heart using endoscopic stabilizers without cardiopulmonary bypass. In all cases, total OR time ranged from 4.0 to 8.0 hours (median 5.5 h); the times for endoscopic coronary artery anastomoses ranged from 14 to 50 minutes (median 25 minutes) with no difference between arrested-heart or beating-heart procedures. All patients had an uneventful angiographic control result. An endoscopic coronary artery anastomosis is possible on the arrested as well as on the beating heart.

Procalcitonin, a new indicator for non-viral infections in heart, lung or liver transplant patients

PCT is a highly specific analyse which shows significant diagnostic validities when non-viral infections are compared with rejection episodes. PCT discriminates inflammatory events such as rejection or viral infections and non-viral infections including bacterial, fungal and protozoal infections. The half-life of PCT is 24 h indicating a clearly competent antibiotic treatment. PCT provides vital information early to clinicians and allows them to improve the management of bacterial/fungal infection in immunocompromised transplant patients. PCT thus facilitates and improves the outcome of survival rate and the quality of life in the postoperative period of patients with heart, lung or liver grafts.