The psychological and psychiatric effects of rIL-2 therapy: a controlled clinical trial

Delirium incidence, risk factors, and treatments in older adults receiving chemotherapy: A systematic review and meta-analysis

INTRODUCTION

Older adults with cancer are at increased risk of delirium due to age, comorbidities, medications, cognitive impairment, and possibly cancer treatments. However, there is scant information on the risks of delirium with chemotherapy and approaches to prevent or treat it. We performed a systematic review and meta-analysis to summarize available evidence.

MATERIALS AND METHODS

We systematically searched peer-reviewed journal articles in English, French, German, and Dutch from five databases from 1990 to May 2019 to identify studies examining delirium in adult patients receiving chemotherapy. We also attempted to identify delirium risk prediction models and prevention or treatment trials. All reviews and data extraction were performed by two independent reviewers. Summary estimates were derived from random effects models.

RESULTS

A total of 23,389 titles and abstracts were screened, and 1272 full-text articles were reviewed. Nineteen articles reported on delirium using an acceptable diagnostic standard. Sample sizes varied from 7 to 324. The incidence of delirium ranged from 0 to 51% (weighted mean 9%, 95% confidence interval 5-16%). In a sensitivity analysis including 122 studies that used terminology suggestive of delirium but did not meet our inclusion criteria, the weighted incidence of delirium was 10% (95% confidence interval 8-12%). Age was not consistently associated with increased delirium risk. No intervention studies to prevent or treat delirium were identified.

CONCLUSIONS

Delirium may occur in 1 in 11 older adults receiving chemotherapy; however, there were substantial limitations in reported studies. This systemic review highlights key gaps in knowledge, particularly regarding risk factors, prevention, and treatments.

Neuroimmunology of Behavioral Comorbidities Associated With Cancer and Cancer Treatments

Behavioral comorbidities (depression, anxiety, fatigue, cognitive disturbances, and neuropathic pain) are prevalent in cancer patients and survivors. These mental and neurological health issues reduce quality-of-life, which is a significant societal concern given the increasing rates of long-term survival after various cancers. Hypothesized causes of behavioral comorbidities with cancer include tumor biology, stress associated with the cancer experience, and cancer treatments. A relatively recent leading mechanism by which these causes contribute to changes in neurobiology that underlie behavior is inflammation. Indeed, both basic and clinical research indicates that peripheral inflammation leads to central inflammation and behavioral changes in other illness contexts. Given the limitations of assessing neuroimmunology in clinical populations, this review primarily synthesizes evidence of neuroimmune and neuroinflammatory changes due to two components of cancer (tumor biology and cancer treatments) that are associated with altered affective-like or cognitive behaviors in rodents. Specifically, alterations in microglia, neuroinflammation, and immune trafficking to the brain are compiled in models of tumors, chemotherapy, and/or radiation. Evidence-based neuronal mechanisms by which these neuroimmune changes may lead to changes in behavior are proposed. Finally, converging evidence in clinical cancer populations is discussed.

Glial cells as key players in schizophrenia pathology: recent insights and concepts of therapy

The past decade has witnessed an explosion of knowledge on the impact of glia for the neurobiological foundation of schizophrenia. A plethora of studies have shown structural and functional abnormalities in all three types of glial cells. There is convincing evidence of reduced numbers of oligodendrocytes, impaired cell maturation and altered gene expression of myelin/oligodendrocyte-related genes that may in part explain white matter abnormalities and disturbed inter- and intra-hemispheric connectivity, which are characteristic signs of schizophrenia. Earlier reports of astrogliosis could not be confirmed by later studies, although the expression of a variety of astrocyte-related genes is abnormal in psychosis. Since astrocytes play a key role in the synaptic metabolism of glutamate, GABA, monoamines and purines, astrocyte dysfunction may contribute to certain aspects of disturbed neurotransmission in schizophrenia. Finally, increased densities of microglial cells and aberrant expression of microglia-related surface markers in schizophrenia suggest that immunological/inflammatory factors are of considerable relevance for the pathophysiology of psychosis. This review describes current evidence for the multifaceted role of glial cells in schizophrenia and discusses efforts to develop glia-directed therapies for the treatment of the disease.

Memory and cancer: a review of the literature

The mental health of cancer survivors has not always been the primary emphasis of treatment protocols since physical health outcomes have taken precedence. Older cancer survivors experience a double jeopardy since they are at risk for memory impairments and mild cognitive impairment and because they are greater than 55 years of age. Of the 9.6 million cancer survivors in the US who have completed active treatment, many report cognitive difficulties, with labels such as "chemo brain," "not as sharp," "woolly-headedness," or the "mind does not work as quickly". To date, most of our knowledge of cognitive impairment in cancer survivors comes from female breast cancer survivors. Studies indicate that these survivors have diminished executive function, verbal memory, and motor function. Cancer survivors want to live independently in the community for as long as possible however, these cognitive deficits may prevent this desired lifestyle. To broaden our understanding this paper reviews the literature on the cognitive impairment and memory deficits experienced by three groups of cancer survivors breast, colorectal, and prostate cancer, that make up 60% of all survivors nationally. Even though mental health declined after a cancer diagnosis, the long-term outcomes of cancer survivors did not differ from persons without cancer in depression or cognitive function.

A starring role for microglia in brain sex differences

Microglia, the resident innate immune cells in the brain, have long been understood to be crucial to maintenance in the nervous system, by clearing debris, monitoring for infiltration of infectious agents, and mediating the brain's inflammatory and repair response to traumatic injury, stroke, or neurodegeneration. A wave of new research has shown that microglia are also active players in many basic processes in the healthy brain, including cell proliferation, synaptic connectivity, and physiology. Microglia, both in their capacity as phagocytic cells and via secretion of many neuroactive molecules, including cytokines and growth factors, play a central role in early brain development, including sexual differentiation of the brain. In this review, we present the vast roles microglia play in normal brain development and how perturbations in the normal neuroimmune environment during development may contribute to the etiology of brain-based disorders. There are notable differences between microglia and neuroimmune signaling in the male and female brain throughout the life span, and these differences may contribute to the vast differences in the incidence of neuropsychiatric and neurological disorders between males and females.

[Anxiogenic and depressogenic side-effects of non-psychiatric drugs]

Although medications such as anticancer, antimicrobial, immunomodulatory, neurological or hormonal therapies may have a negative impact on mood, adequate attention was not paid until the withdrawal of rimonabant in 2008. In the present study the authors review full spectrum of currently available medications discussing anxiety and depression as possible adverse effects of treatment. A relatively high risk of depression should always be considered when pharmacotherapy applied, especially if current depressive episodes, positive family history, or neurotic personality traits increasing susceptibility to depressogenic effects. Prior to start of medical treatment, the potential effectiveness of the given drug should be precisely evaluated, and alternative medical and non-medical treatment options should also be carefully considered. In addition, monitoring patients during treatment for signs of depressive or anxious symptoms is necessary.

Different distribution patterns of lymphocytes and microglia in the hippocampus of patients with residual versus paranoid schizophrenia: further evidence for disease course-related immune alterations?

Certain cytokines have been identified in the peripheral blood as trait markers of schizophrenia, while others are considered relapse-related state markers. Furthermore, data from peripheral blood, cerebrospinal fluid (CSF) and nuclear imaging studies suggest that (1) blood-brain barrier (BBB) dysfunction (e.g., immigration of lymphocytes into brain tissue and intrathecal antibody production) correlates with the development of negative symptoms, while (2) the brain's mononuclear phagocyte system (microglial cells) is activated during acute psychosis. Based on these neuroinflammatory hypotheses, we have quantified the numerical density of immunostained CD3+ T-lymphocytes, CD20+ B-lymphocytes, and HLA-DR+ microglial cells in the posterior hippocampus of 17 schizophrenia patients and 11 matched controls. Disease course-related immune alterations were considered by a separate analysis of residual (prevailing negative symptoms, n=7) and paranoid (prominent positive symptoms, n=10) schizophrenia cases. Higher densities of CD3+ and CD20+ lymphocytes were observed in residual versus paranoid schizophrenia (CD 3: left: P=0.047, right: P=0.038; CD20: left: P=0.020, right: P=0.010) and controls (CD3: left: P=0.057, right: P=0.069; CD20: left: P=0.008, right: P=0.006). In contrast, HLA-DR+ microglia were increased in paranoid schizophrenia versus residual schizophrenia (left: P=0.030, right: P=0.012). A similar trend emerged when this group was compared to controls (left: P=0.090, right: P=0.090). BBB impairment and infiltration of T cells and B cells may contribute to the pathophysiology of residual schizophrenia, while microglial activation seems to play a role in paranoid schizophrenia. The identification of diverse immune endophenotypes may facilitate the development of distinct anti-inflammatory schizophrenia therapies to normalize BBB function, (auto)antibody production or microglial activity.

The value of assessing cognitive function in drug development

This paper reviews the value and utility of measuring cognitive function in the development of new medicines by reference to the most widely used automated system in clinical research. Evidence is presented from phase 1 to 3 of the nature and quality of the information that can be obtained by applying the Cognitive Drug Research computerized assessment system to ongoing clinical trials. Valuable evidence can be obtained even in the first trial in which a novel compound is administered to man. One application of such testing is to ensure that novel compounds are relatively free from cognition-impairing properties, particularly in relation to competitor products. Another is to ensure that unwanted interactions with alcohol and other medications do not occur, or, if they do, to put them in context. In many patient populations, cognitive dysfunction occurs as a result of the disease process, and newer medicines which can treat the symptoms of the disease without further impairing function can often reveal benefits as the disease-induced cognitive dysfunction is reduced. Another major application is to identify benefits for compounds designed to enhance cognitive function. Such effects can be sought in typical phase 1 trials, or a scopolamine model of the core deficits of Alzheimer's disease can be used to screen potential antidernentia drugs. Ultimately, of course, such effects can be demonstrated using properly validated and highly sensitive automated procedures in the target populations. The data presented demonstrate that the concept of independently assessing a variety of cognitive functions is crucial in helping differentiate drugs, types of dementia, and different illnesses. Such information offers a unique insight into how the alterations to various cognitive functions will manifest themselves in everyday behavior. This reveals a major limitation of scales that yield a single score, because such limited information does not permit anything but a quantitative interpretation; and the concept of "more" cognitive function or "less" is manifestly inappropriate for something as complex and diverse as the interplay between cognitive function and human behavior. Finally, the next generations of cognitive testing are described. Testing via the telephone has just been introduced and will have dramatic effects on the logistics of conducting cognitive testing in large patient trials. Testing via the Internet is not far off either, and will come fully into play as the proportion of homes connected to the Internet increases in Europe and North America. There are no sound reasons for not wishing to include cognitive function testing in the development protocol of any novel medicine.

The activation of monocyte and T cell networks in patients with bipolar disorder

OBJECTIVES

We recently described a monocyte pro-inflammatory state in patients with bipolar disorder (BD). We hypothesized that the CD4(+)T cell system is also activated and determined percentages of Th1, Th2, Th17 and CD4(+)CD25(high)FoxP3(+) regulatory T cells.

METHODS

We carried out a detailed FACS analysis to determine the various T cell subsets and used frozen stored peripheral blood mononuclear cells (PBMC) of 38 BD patients (of whom we previously had tested monocytes for pro-inflammatory gene expression (Drexhage et al., 2010b; Padmos et al., 2008)) and of 22 age/gender matched healthy controls (HC). In addition the cytokines CCL2, IL-1β, IL-6, TNF-α, PTX3, IL-10, IFN-γ, IL-17A, IL-4, IL-5 and IL-22 were measured in serum.

RESULTS

(a) Serum sCD25 levels and percentages of anti-inflammatory CD4(+)CD25(high)FoxP3+ regulatory T cells were higher, the latter in BD patients <40 years of age. Percentages of Th1, Th2 and Th17 cells were normal. (b) Of the pro-inflammatory monocyte cytokines CCL2 and PTX3 were raised in serum. (c) The monocyte pro-inflammatory state and the raised percentages of CD4(+)CD25(high)FoxP3(+) regulatory T cells occurred independently from each other. (d) In BD patients positive for thyroid autoimmune disease a significantly reduced percentage of CD4(+)CD25(high)FoxP3(+) regulatory T cells was found as compared to BD patients without AITD.

CONCLUSION

Our data show an enhancement of pro-inflammatory monocyte and anti-inflammatory T cell forces in BD patients. A lack of anti-inflammatory T cell forces co-occurred with AITD in BD patients.

Depressogenic effects of medications: a review

The literature is filled with reports that link medications with the onset or progression of depression. Because depression is so common in patients with medical illness, assessing whether a medication has in fact caused depression, or whether the relationship is coincidental, can be challenging. In this article, we review the literature on the association between medications and depression. For most agents, there are case reports or small studies linking the medication with the onset of depression, but more rigorous prospective studies are either lacking or found no association between the agent and depression. However, several medications, (eg, barbiturates, vigabatrin, topiramate, flunarizine, corticosteroids, mefloquine, efavirenz, and interferon-α) do appear to cause depression in some patients and should be used with caution in patients at risk for depression.

A randomised, controlled trial of the psychological effects of reflexology in early breast cancer

PURPOSE

To conduct a pragmatic randomised controlled trial (RCT) to evaluate the effects of reflexology on quality of life (QofL) in women with early breast cancer.

PATIENTS AND METHODS

One hundred and eighty-three women were randomised 6 weeks post-breast surgery to self-initiated support (SIS) (comparator intervention), SIS plus reflexology, or SIS plus scalp massage (control for physical and social contact). Reflexology and massage comprised eight sessions at weekly intervals. The primary end-point was 18 weeks post surgery; the primary outcome measure was the Trial Outcome Index (TOI) of the Functional Assessment of Cancer Therapy (FACT-B) - breast cancer version. The secondary end-point was 24 weeks post surgery. Secondary outcome measures were the Hospital Anxiety and Depression Scale (HADS) and the Mood Rating Scale (MRS).

RESULTS

At primary end-point, massage, but not reflexology, was significantly better than SIS on the TOI. Reflexology and massage were both better than SIS for MRS relaxation. Massage was better than reflexology and SIS for MRS easygoingness. At secondary end-point, reflexology, but not massage, was better than SIS on the TOI and MRS relaxation. There were no significant differences between reflexology or massage. There were no significant between group differences in HADS anxiety and depression. Self-reported use of out of study complementary therapies indicated that this was unlikely to have a significant effect on findings.

CONCLUSIONS

When compared to SIS, reflexology and massage have statistically significant, and, for reflexology, clinically worthwhile, effects on QofL following surgery for early breast carcinoma.

Switching to letrozole or exemestane improves hot flushes, mood and quality of life in tamoxifen intolerant women

We report an open-label, prospective, crossover study involving 184 post-menopausal women experiencing hot flushes on adjuvant tamoxifen (T). Six weeks after switching to an AI, the primary end point, hot flush score, improved by 47.3% (P<0.001) compared to those reported on T. The mean mood rating scale (MRS) score improved by 9.7% (P=0.01). The total mean combined FACT (b+es) score improved from 134.2 (95% CI +/-2.96) to 143.5 (95% CI +/-2.96 <0.001), and the endocrine subscale improved by 9.8% from 51.73 (95% CI +/-1.38) to 57.34 (CI +/-1.38, P<0.001). At 6 weeks, significantly more women chose to remain on an AI: 133 (72%), vs 40 (22%) (P<0.001) preferring T. At 3 months, 107 (58%) preferred to remain on an AI, 55(30%) on T, and 22 (12%) withdrew. The overall arthralgia rate at 3 months was 47% on AI and 30% on T (P=0.001). In all 182 (99%) women reported appreciating the opportunity to experience both drugs. These data suggest that if patients suffering significant adverse effects on T are given the opportunity to try an AI, this empowers them to prioritize relative side-effects, improving wellbeing in a significant proportion. These data also highlight the need for hospital follow-up in this intolerant cohort.

A systematic review of the use of quality of life measures in colorectal cancer research with attention to outcomes in elderly patients

PURPOSE

Quality of life (QOL) measures are critical to the evaluation of new cancer treatments, particularly for elderly patients. Our intent was to assess patterns of use of QOL endpoints in colorectal cancer (CRC) treatment research and to summarize current knowledge about how CRC treatment affects elderly patients.

PATIENTS AND METHODS

We searched MEDLINE for English-language, human trials published from 1995 to 2005 that met the following criteria: reported on patients with CRC, were not surgery-only cohorts, and included a QOL or functional endpoints. Trials specifically reporting data on elderly patients were reviewed in depth and summarized.

RESULTS

One hundred twenty-one eligible studies and 10 trials with elderly-specific data were found. The median number of trials published annually increased from 5 (range, 4-8 trials) between 1995 and 1999 to 14.5 (range, 11-22 trials) between 2000 and 2005. Chemotherapy was the most commonly studied treatment (55%), and metastatic CRC (55%) was the most commonly studied population. The European Organization for Research and Treatment of Cancer C30, with or without C38, was the most frequently used instrument (49%). Studies reporting on elderly patients showed that many patients experience a decline in physical function immediately after surgery and have increased need for supportive services. Little information is available on the effect of chemotherapy in elderly patients. Use of QOL and functional measures in treatment-related CRC research has increased; however, it continues to be hampered by a lack of dissemination and methodologic problems.

CONCLUSION

Missing data from patient attrition, limitations of assessment methods, and a small number of patients treated with chemotherapy in the trials reporting on elderly patients seriously limit our ability to draw conclusions from this survey about how treatment affects QOL or function in CRC.

An investigation into the psychometric properties of the Hospital Anxiety and Depression Scale in patients with breast cancer

BACKGROUND

To determine the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in patients with breast cancer and determine the suitability of the instrument for use with this clinical group.

METHODS

A cross-sectional design was used. The study used a pooled data set from three breast cancer clinical groups. The dependent variables were HADS anxiety and depression sub-scale scores. Exploratory and confirmatory factor analyses were conducted on the HADS to determine its psychometric properties in 110 patients with breast cancer. Seven models were tested to determine model fit to the data.

RESULTS

Both factor analysis methods indicated that three-factor models provided a better fit to the data compared to two-factor (anxiety and depression) models for breast cancer patients. Clark and Watson's three factor tripartite and three factor hierarchical models provided the best fit.

CONCLUSION

The underlying factor structure of the HADS in breast cancer patients comprises three distinct, but correlated factors, negative affectivity, autonomic anxiety and anhedonic depression. The clinical utility of the HADS in screening for anxiety and depression in breast cancer patients may be enhanced by using a modified scoring procedure based on a three-factor model of psychological distress. This proposed alternate scoring method involving regressing autonomic anxiety and anhedonic depression factors onto the third factor (negative affectivity) requires further investigation in order to establish its efficacy.

Neuroimmune and cortisol changes in selective serotonin reuptake inhibitor and placebo treatment of chronic posttraumatic stress disorder

BACKGROUND

To explore relations between neuroimmune and neuroendocrine systems relative to posttraumatic stress disorder (PTSD) treatment, cortisol and cytokine changes in response to selective serotonin reuptake inhibitor (SSRI) and placebo treatment of chronic PTSD were assessed prospectively.

METHODS

Baseline measures of PTSD, depression, salivary 8 am and 4 pm cortisol, and serum interleukin-1beta (IL-1beta; pro-inflammatory) and soluble interleukin-2 receptors (IL-2R; cell-mediated immunity) were obtained for 58 PTSD and 21 control subjects. The PTSD subjects participated in a 10-week, double-blind treatment with citalopram (n = 19), sertraline (n = 18), or placebo (n = 7).

RESULTS

At baseline, PTSD subjects had significantly greater PTSD, depression, and IL-1beta and lower IL-2R levels than control subjects, with no group differences found for am or pm cortisol levels. Both SSRI groups' IL-1beta correlated negatively with IL-2R; neither cytokine correlated with cortisol levels. Treatment significantly lowered PTSD, depression, and IL-1beta levels and increased IL-2R for all groups to control subject levels. After treatment, both SSRI groups' IL-1beta correlated with an end cortisol measure (one negatively, one positively).

CONCLUSIONS

Our results support a complex relationship between neuroimmune and neuroendocrine systems with PTSD treatment. Implications of normalization of cytokine levels with effective SSRI treatment and placebo are discussed.

What is the effect of systemic anticancer treatment on cognitive function?

Treatment regimens for solid tumours have been extensively investigated for their physical toxic effects, but far less is known about the potential impairment of cognitive function by anticancer treatment regimens. Here, we review published studies that examined cognitive function in adult patients receiving systemic therapy for solid tumours. Our review suggests that patients can experience cognitive changes related to their treatment. However, several studies had methodological limitations, such as use of a limited sample size, lack of baseline assessment, and lack of control for potential confounding factors. Better designed clinical trials are required so that the difficulties patients face in terms of reduced cognitive function as a result of anticancer treatment can be fully elucidated. These trials should have sufficient statistical power and, importantly, should also be prospective.

Neuropsychological effects of treatments for adults with cancer: a meta-analysis and review of the literature

A meta-analysis was conducted to evaluate possible neuropsychological effects of treatments for cancer in adults. A search revealed 30 studies, encompassing 29 eligible samples, and leading to inclusion of a total of 838 patients and control participants. A total of 173 effect sizes (Cohen's d) were extracted across 7 cognitive domains and as assessed in the literature via 3 methods of comparison (post-treatment compared with normative data, controls, or baseline performance). Statistically significant negative effect sizes were found consistently across both normative and control methods of comparison for executive function, verbal memory, and motor function. The largest effects were for executive function and verbal memory normative comparisons (-.93 and -.91, respectively). When limiting the sample of studies in the analyses to only those with relatively "less severe" diagnoses and treatments, the effects remained. While these results point toward some specific cognitive effects of systemic cancer therapies in general, no clear clinical implications can yet be drawn from these results. More research is needed to clarify which treatments may produce cognitive decrements, the size of those effects, and their duration, while ruling out a wide variety of possible mediating or moderating variables.

Relationship between striatal levels of interleukin-2 mRNA and plus-maze behaviour in the rat

Our previous experiments have shown that adult male Wistar rats can differ systematically in elevated plus-maze (EPM) behaviour, which was related to the neurotransmitter serotonin in the ventral striatum. The EPM serves as a model of anxiety-like behaviour, and there is evidence that interleukin (IL)-2 in the brain may be related to anxiety-like behaviour, and that IL-2 interacts with the striatal serotonergic system. We asked whether EPM behaviour may also be related to constitutive levels of cytokines in the striatum. Based on open arm time in the EPM, male Wistar rats were divided into sub-groups with either low or high anxiety-like behaviour. Then, IL-1beta, IL-2, IL-6, and tumour necrosis factor (TNF)-alpha cDNA levels were measured post mortem in striatal tissues using semi-quantitative, competitive, reverse transcription polymerase chain reaction. Rats with high anxiety-like behaviour in the EPM showed significantly higher levels of IL-2 mRNA compared to those with low anxiety-like behaviour, but did not differ significantly in expression of IL-1beta, IL-6, and TNF-alpha mRNA. These results provide new evidence indicating that specific cytokine patterns in the striatum may be associated with EPM behaviour in adult male Wistar rats.

Changes in family relationships affect the development of chemotherapy-related nausea symptoms

This study examined the effect of changes in family relationships (cohesion, expression, and conflict) on patients' physical adjustment to chemotherapy and whether the effect would differ depending on the patient's age and gender. Two hundred thirty-three married cancer patients completed questionnaires consisting of measures of family relationships and chemotherapy-related nausea symptoms, at two assessments. Results revealed that the prevalence of nausea symptoms was related to the degree of conflict in the family, depending on the patient's age and gender. An increase in family conflict was associated with an increased duration of post-treatment nausea and greater severity of anticipatory nausea for younger adult patients but not for older adult patients. An increase in family conflict was also associated with a greater severity of anticipatory nausea for female patients but not for male patients. These findings suggest that intervention programs to help reduce family conflict may be especially beneficial for younger adult and female patients.

Healing the mind/body split: bringing the patient back into oncology

The effect on oncology of the doctrine of Cartesian dualism is examined. It is argued that (1) this doctrine continues to exert a baneful (though unacknowledged) influence on the practice of oncology, (2) Descartes's doctrine of a mind/body split is mistaken, and (3) mind and body (brain) are inextricably interwoven. A biopsychosocial model of disease is advocated. The role of psychooncology in healing the mind/body split by focusing research attention on the patient is outlined.

Interleukin 1alpha alters hippocampal serotonin and norepinephrine release during open-field behavior in Sprague-Dawley animals: differences from the Fawn-Hooded animal model of depression

Detection of two biogenic amine neurotransmitters, serotonin (5-HT) and norepinephrine (NE) within the CA1 region of the hippocampus (HPC) of behaving male laboratory animals (Rattus norvegicus), was performed with miniature carbon sensors (BRODERICK PROBES) and in vivo semidifferential microvoltammetry after acute administration of the soluble immune factor, human recombinant, interleukin (IL) 1alpha (10 and 100 ng/kg i.p.). Two animal models were compared, i.e., (a) the Sprague-Dawley (SD) model, a strain neither biochemically nor immune-challenged and (b) the Fawn-Hooded (FH) model, a biochemically (5-HT-deficient) and immune-challenged animal. Open-field behaviors, locomotion (ambulations) and stereotypy (fine movements of sniffing and grooming) were monitored with infrared photobeams while 5-HT and NE were selectively and separately detected within seconds in real time. Subchronic studies were performed in the same animals 24 h later at which time no further drug was administered. Results from acute treatment studies showed that IL-1alpha altered HPC monoamines and behavior viz-a-viz habituation values (baseline) in the SD strain differently from those in the FH strain as follows: (1) although 5-HT release was significantly increased within CA1 region of HPC in both SD and FH strains (P<.0001), the extent of the HPC 5-HT increase in the 5-HT-deficient FH strain was significantly less than that of the SD strain at both doses (P<.0001). The subchronic studies showed that 5-HT release within the HPC in the SD strain significantly increased (135%) over drug treatment values (P<.001), whereas HPC 5-HT release in the FH strain remained the same as that seen in the acute drug treatment studies; the difference between strains for the subchronic study was also statistically significant (P<.01). (2) IL-1alpha significantly decreased HPC NE release in the SD strain (P<.0004) while IL-1alpha decreased HPC NE release in the FH strain only at the 10-ng/kg dose (P<.001); at the 100-ng/kg dose in the FH strain, NE rebounded towards baseline and increased 15% above baseline reaching statistical significance (P<.05). Subchronic studies in the SD strain showed a further decreased NE signal to 38% below baseline (P<.0001), whereas subchronic studies in the FH strain showed a significant increase in NE release (P<.02). The difference between strains in the subchronic NE studies was significant (P<.001). (3) Ambulations were increased after IL-1alpha administration in acute studies in both the SD and the FH strains, but the increase did not reach statistical significance, whereas in the subchronic studies, both strains exhibited significant increases as revealed by post hoc analyses (P<.05). There was a statistically significant difference between strains in acute studies (P<.001), whereas no significant differences between models were seen in ambulation behavior in subchronic studies. (4) Fine movements increased over baseline after IL-1alpha administration in both animal models in acute studies, however, results did not reach statistical significance, likely due to the episodic effect of IL-1alpha on movement behavior in both the SD and the FH strains. However, the SD strain showed a significant increase in fine movement behavior during the subchronic studies (P<.02). Significant differences in fine movements between animal models were not observed either acutely or in subchronic studies. In summary, the data show that immune modulation by IL-1alpha affects HPC neurochemistry and behavior in SD versus FH animal models differently and/or to different degrees. The data show that while the FH animal model is subsensitive to 5-HT agonists, 5-HT function can be stimulated. Comparison of genetically diverse animal models provides a reliable means to identify and discern cytokine-induced depressive versus stressor properties. Selective sensor technology provides a powerful tool as movement behavior is monitored and interpreted as a function of monoamine neurotransmission.

In vitro cytokine secretion in individuals with schizophrenia: results, confounding factors, and implications for further research

The present paper reviews the results of all publications on in vitro cytokine secretion in patients with schizophrenia, as published by March 2001. The authors supply easy to read tables with respect to the individual cytokines and soluble cytokine receptors investigated, the in vitro methodology used, characterization of the patient samples, and the results on cytokine secretion as stated in these studies. Inconsistent results, e.g., regarding in vitro secretion of IL-2 with 11/18 studies finding decreased secretion, 5/18 finding no change, and 2/18 finding increases, cannot systematically be correlated with any methodological procedures nor any diagnostic subtypes, per se. However, factors such as medication and cigarette smoking are likely to play a role. The authors suggest that more hypothesis-driven research, together with more carefully designed studies, as well as better communication between basic or animal researchers and clinicians might help to answer the question of whether there are meaningful peripheral changes in the immune system related to schizophrenia.

Interleukin-15 and interleukin-2 enhance non-REM sleep in rabbits

Interleukin (IL)-15 and -2 share receptor- and signal-transduction pathway (Jak-STAT pathway) components. IL-2 is somnogenic in rats but has not been tested in other species. Furthermore, the effects of IL-15 on sleep have not heretofore been described. We investigated the somnogenic actions of IL-15 in rabbits and compared them with those of IL-2. Three doses of IL-15 or -2 (10, 100, and 500 ng) were injected intracerebroventriculary at the onset of the dark period. In addition, 500 ng of IL-15 and -2 were injected 3 h after the beginning of the light period. IL-15 dose dependently increased non-rapid eye movement sleep (NREMS) and induced fever. IL-15 inhibited rapid eye movement sleep (REMS) after its administration during the light period; however, all doses of IL-15 failed to affect REMS if given at dark onset. IL-2 also dose dependently increased NREMS and fever. IL-2 inhibited REMS, and this effect was observed only in the light period. IL-15 and -2 enhanced electroencephalographic (EEG) slow waves during the initial 9-h postinjection period, then, during hours 10-23 postinjection, reduced EEG slow-wave activity. Current data support the notion that the brain cytokine network is involved in the regulation of sleep.

Strategies for managing cancer-related fatigue syndrome: a rehabilitation approach

Although technologic advances and insights into the mechanisms of cancer and cancer treatments have resulted in hope of increased survival and even cure in many cancer populations, parallel efforts to promote quality of life through a commitment to rehabilitation and aggressive palliation have lagged. Recent studies have demonstrated fatigue to be the most distressing phenomenon experienced by cancer patients. This article examines fatigue from a rehabilitation perspective. Application of innovations in therapeutic exercise training, diet therapy, sleep therapy, cognitive therapy, and pharmacologic therapy and their attendant rationales are discussed. From clinical as well as research perspectives of palliation and rehabilitation, the manifestations of fatigue are better appreciated if fatigue is conceptualized as a syndrome, namely, cancer-related fatigue syndrome (CRFS). Experience of CRFS by cancer patients, regardless of their diagnosis, stage of disease, treatment regimen, or age, influences all aspects of quality of life and aggravates the experience of other distressing symptoms such as pain, nausea, and dyspnea. Understanding the underlying mechanisms for energy loss and gain, as well as the relationship between the right amount and type of activity and sleep, can lead toward more effective and innovative rehabilitation programs. Development of research based clinical interventions in these areas holds promise for significant improvement in functioning and quality of life for cancer survivors and may constitute valuable rehabilitative techniques that can be adjunctive to standard therapies.

Timing and specificity of the cognitive changes induced by interleukin-2 and interferon-alpha treatments in cancer patients

OBJECTIVE

Neuropsychological changes develop in patients treated by cytokine immunotherapy with interleukin-2 (IL-2) and interferon-alpha (IFN-alpha). However, the time course of appearance of these effects remains unclear, and their precise nature is still incompletely characterized. The objective of this study was to assess and characterize the early cognitive changes induced by IL-2 and IFN-alpha in cancer patients at the end of the first week of treatment and to investigate the subsequent evolution of these changes.

METHODS

The study was conducted in 47 cancer patients who received subcutaneous IL-2, administered alone (N = 17) or with IFN-alpha (N = 7), or IFN-alpha alone, administered subcutaneously at low doses (N = 7) or intravenously at high doses (N = 16). An automated battery of neuropsychological tests (Cambridge Neuropsychological Test Automated Battery) was used to measure reaction time, spatial working memory, and planning tasks. Cognitive tests were performed before treatment (day 1) and after 5 days (day 5) and 1 month of treatment.

RESULTS

On day 5, patients treated with IL-2 alone had impaired spatial working memory and lower accuracy of planning abilities. In contrast, patients treated with IFN-alpha did not show any impairment in performance accuracy in these tasks but showed longer latencies in the test of reaction time. Most of these early alterations persisted at the end of the first month of treatment without any obvious sign of worsening.

CONCLUSIONS

These findings suggest the existence of early differential neuropsychological changes in patients treated with IL-2 and IFN-alpha.

Early depressive symptoms in cancer patients receiving interleukin 2 and/or interferon alfa-2b therapy

PURPOSE

Depressive symptomatology is frequently associated with interleukin (IL)-2 and interferon alfa-2b (INFalpha-2b) therapy in cancer patients. The objective of the present study was to evaluate the depressive and anxiety symptoms induced by IL-2 and/or INFalpha-2b in cancer patients during the first days of cytokine immunotherapy.

PATIENTS AND METHODS

The study included 48 patients with renal cell carcinoma or melanoma. Patients were treated either with subcutaneous IL-2, alone (n = 20) or in combination with INFalpha-2b (n = 6); or with INFalpha-2b alone, administered subcutaneously at a low dose (n = 8) or intravenously at a high dose (n = 14). Depressive symptoms were evaluated using the Montgomery and Asberg Depression Rating Scale (MADRS), and anxiety symptoms were evaluated using the Covi scale. Evaluations were performed just before initiation of treatment (day 1) and on days 3 and 5 of treatment.

RESULTS

Patients treated with IL-2 alone or in association with INFalpha-2b had significantly higher MADRS scores after 5 days of cytokine therapy, and patients who received both cytokines had increased scores on day 3. In contrast, patients treated with INFalpha-2b alone did not have varying MADRS scores during the course of treatment. Cytokine therapy had no effect on anxiety, except in patients treated with IL-2 in combination with INFalpha-2b. In these patients, the enhancement in anxiety scores that was observed on day 5 was mainly attributable to increased somatic complaints.

CONCLUSION

IL-2 and INFalpha-2b have differential effects on mood, and IL-2 therapy induces depressive symptoms early in treatment.

Plasma levels of cytokines and soluble cytokine receptors in psychiatric patients upon hospital admission: effects of confounding factors and diagnosis

It has been hypothesized that the immune system plays a pathogenetic role in psychiatric disorders, in particular in major depression and schizophrenia. This hypothesis is supported by a number of reports on altered circulating levels and in vitro production of cytokines in these disorders. However, the respective evidence is not consistent. This may be in part due to an incomplete control for numerous confounding influences in earlier studies. We investigated the plasma levels of cytokines and soluble cytokine receptors in psychiatric patients (N = 361) upon hospital admission and compared the results to those obtained in healthy controls (N = 64). By multiple regression analysis we found that circulating levels of interleukin-1 receptor antagonist (IL-1Ra), soluble IL-2 receptor (sIL-2R), tumor necrosis factor-alpha (TNF-alpha), soluble TNF receptors (sTNF-R p55, sTNF-R p75) and IL-6 were significantly affected by age, the body mass index (BMI), gender, smoking habits, ongoing or recent infectious diseases, or prior medication. Cytokine or cytokine receptor levels were significantly increased in patients treated with clozapine (sIL-2R, sTNF-R p75), lithium (TNF-alpha, sTNF-R p75, IL-6) or benzodiazepines (TNF-alpha, sTNF-R p75). Taking all these confounding factors into account, we found no evidence for disease-related alterations in the levels of IL-1Ra, sIL-2R, sTNF-R p75 and IL-6, whereas levels of TNF-alpha and sTNF-R p55 in major depression and sTNF-R p55 in schizophrenia were slightly decreased compared to healthy controls. We conclude that, if confounding factors are carefully taken into account, plasma levels of the above mentioned cytokines and cytokine receptors yield little, if any, evidence for immunopathology in schizophrenia or major depression.

T-lymphocyte activation increases hypothalamic and amygdaloid expression of CRH mRNA and emotional reactivity to novelty

Stimulation of T-cells with staphylococcal enterotoxin B (SEB) significantly elevates interleukin-2 (IL-2) and contemporaneous activation of the hypothalamic-pituitary-adrenal (HPA) axis and c-fos in the paraventricular nucleus (PVN) of BALB/cByJ mice. Such neural signaling may promote cognitive and emotional adaptation before or during infectious illness. Because corticotropin-releasing hormone (CRH) is an anxiogenic neuropeptide that may mediate the stressor-like effects of immunological stimuli, we measured neuronal CRH mRNA alterations in mice challenged with SEB. Increased CRH mRNA levels were observed in the PVN and central nucleus of the amygdala (ceA) 4-6 hr after SEB administration. This was associated with plasma ACTH increases, which could be abrogated by the systemic administration of anti-CRH antiserum. Additional experiments did not support a role for IL-2 or prostaglandin synthesis in activating the HPA axis. Behavioral experiments testing for conditioned taste aversion did not confirm that SEB challenge promotes malaise. However, consistent with the notion that central CRH alterations induced by SEB may affect emotionality (e.g., fear), SEB challenge augmented appetitive neophobia in a context-dependent manner, being marked in a novel and stressful environment. It is hypothesized that immunological stimuli generate a cascade of events that solicit integrative neural processes involved in emotional behavior. As such, these data support the contention that affective illness may be influenced by immunological processes and the production of cytokines and are consistent with other evidence demonstrating that autoimmune reactivity is associated with enhanced emotionality.

Psychological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy

The diagnosis and treatment of breast cancer are stressful, and stress may be associated with a poorer response to chemotherapy. There is a need, therefore, to develop and evaluate interventions that might enhance quality of life and, possibly, improve treatment response. The effects of relaxation combined with guided imagery (visualizing host defences destroying tumour cells) on quality of life and response to primary chemotherapy, to date, have not been adequately evaluated. Ninety-six women with newly diagnosed large or locally advanced breast cancer (T2 > 4 cm, T3, T4, or TxN2 and M0) took part in a prospective, randomized controlled trial. Patients were randomized following diagnosis to a control condition (standard care) or to the experimental condition (standard care plus relaxation training and imagery). Psychometric tests to evaluate mood and quality of life were carried out before each of the six cycles of chemotherapy and 3 weeks after cycle 6: tests of personality and coping strategy were carried out prior to cycles one and six. Clinical response to chemotherapy was evaluated after six cycles of chemotherapy using standard UICC criteria and pathological response was assessed from the tissue removed at surgery. As hypothesized, patients in the experimental group were more relaxed and easy going during the study (Mood Rating Scale). Quality of life was better in the experimental group (Global Self-assessment and Rotterdam Symptom Checklist). The intervention also reduced emotional suppression (Courtauld Emotional Control Scale). The incidence of clinically significant mood disturbance was very low and the incidence in the two groups was similar. Finally, although the groups did not differ for clinical or pathological response to chemotherapy, imagery ratings were correlated with clinical response. These simple, inexpensive and beneficial interventions should be offered to patients wishing to improve quality of life during primary chemotherapy.

Psychosocial aspects of cancer in the elderly

A number of studies have shown that older people are less distressed by the diagnosis of cancer than their younger counterparts. This may be because older people have fewer dependants and they are less likely to suffer financial difficulties and to experience disruption to their daily routine following the diagnosis. It is surprising, therefore, that many elderly patients do not receive the biologically optimal treatment of their disease, even when comorbid medical conditions are taken into account. This appears to reflect an age bias amongst professionals involved in the management of cancer. There is a paucity of studies examining the perspective of elderly patients themselves regarding factors they consider important in their management. Elderly patients with cancer are not an homogeneous group in terms of their views about management. The vast majority of elderly patients, in common with younger patients, consider that giving the most effective treatment for breast cancer is just as important for older patients as it is for younger patients and that, in making a decision about the best treatment for them, the surgeon should only take account of the biological aspects of the disease. Clinicians, therefore, should avoid making assumptions about what patients wish simply on the basis of the age of the patient. Although there is a recent trend towards more elderly patients participating in oncology treatment trials, there is a great dearth of information about the acceptability and effectiveness of psychosocial interventions in elderly patients.