Dropout from exercise trials among cancer survivors-An individual patient data meta-analysis from the POLARIS study

INTRODUCTION

The number of randomized controlled trials (RCTs) investigating the effects of exercise among cancer survivors has increased in recent years; however, participants dropping out of the trials are rarely described. The objective of the present study was to assess which combinations of participant and exercise program characteristics were associated with dropout from the exercise arms of RCTs among cancer survivors.

METHODS

This study used data collected in the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) study, an international database of RCTs investigating the effects of exercise among cancer survivors. Thirty-four exercise trials, with a total of 2467 patients without metastatic disease randomized to an exercise arm were included. Harmonized studies included a pre and a posttest, and participants were classified as dropouts when missing all assessments at the post-intervention test. Subgroups were identified with a conditional inference tree.

RESULTS

Overall, 9.6% of the participants dropped out. Five subgroups were identified in the conditional inference tree based on four significant associations with dropout. Most dropout was observed for participants with BMI >28.4 kg/m2 , performing supervised resistance or unsupervised mixed exercise (19.8% dropout) or had low-medium education and performed aerobic or supervised mixed exercise (13.5%). The lowest dropout was found for participants with BMI >28.4 kg/m2 and high education performing aerobic or supervised mixed exercise (5.1%), and participants with BMI ≤28.4 kg/m2 exercising during (5.2%) or post (9.5%) treatment.

CONCLUSIONS

There are several systematic differences between cancer survivors completing and dropping out from exercise trials, possibly affecting the external validity of exercise effects.

Moderators of exercise effects on self-reported cognitive functioning in cancer survivors: an individual participant data meta-analysis

PURPOSE

This individual participant data meta-analysis (IPD-MA) assesses exercise effects on self-reported cognitive functioning (CF) and investigates whether effects differ by patient-, intervention-, and exercise-related characteristics.

METHODS

IPD from 16 exercise RCTs, including 1987 patients across multiple types of non-metastatic cancer, was pooled. A one-stage IPD-MA using linear mixed-effect models was performed to assess exercise effects on self-reported CF (z-score) and to identify whether the effect was moderated by sociodemographic, clinical, intervention- and exercise-related characteristics, or fatigue, depression, anxiety, and self-reported CF levels at start of the intervention (i.e., baseline). Models were adjusted for baseline CF and included a random intercept at study level to account for clustering of patients within studies. A sensitivity analysis was performed in patients who reported cognitive problems at baseline.

RESULTS

Minimal significant beneficial exercise effects on self-reported CF (β=-0.09 [-0.16; -0.02]) were observed, with slightly larger effects when the intervention was delivered post-treatment (n=745, β=-0.13 [-0.24; -0.02]), and no significant effect during cancer treatment (n=1,162, β=-0.08 [-0.18; 0.02]). Larger effects were observed in interventions of 12 weeks or shorter (β=-0.14 [-0.25; -0.04]) or 24 weeks or longer (β=-0.18 [-0.32; -0.02]), whereas no effects were observed in interventions of 12-24 weeks (β=0.01 [-0.13; 0.15]). Exercise interventions were most beneficial when provided to patients without anxiety symptoms (β=-0.10 [-0.19; -0.02]) or after completion of treatment in patients with cognitive problems (β=-0.19 [-0.31; -0.06]). No other significant moderators were identified.

CONCLUSIONS

This cross-cancer IPD meta-analysis observed small beneficial exercise effects on self-reported CF when the intervention was delivered post-treatment, especially in patients who reported cognitive problems at baseline.

IMPLICATIONS FOR CANCER SURVIVORS

This study provides some evidence to support the prescription of exercise to improve cognitive functioning. Sufficiently powered trials are warranted to make more definitive recommendations and include these in the exercise guidelines for cancer survivors.

Feasibility, acceptability, and behavioral outcomes of a multimodal intervention for prostate cancer patients: Experience from the MARTINI lifestyle program

BACKGROUND

Prostate cancer (PCa) is the most frequently diagnosed malignant tumor in men. The potential benefit of a healthy lifestyle contrasts sharply with the observed poor adherence to current international lifestyle guidelines. Thus, well-designed sustainable interventions of aftercare that can be translated into routine practice are highly recommended. The present pilot study aimed to evaluate the feasibility and acceptability of a multimodal lifestyle intervention program in PCa patients after radical prostatectomy (RP).

METHODS

In a single-arm study, carried out at the Martini-Klinik of the University Medical Center Hamburg-Eppendorf, Germany, 59 eligible men with locally advanced PCa were recruited within 3-6 months after RP and assigned to a multimodal lifestyle program. The program consisted of 10 weekly 6-7 h course days, with a focus on dietary control, physical activity (per World Cancer Research Fund recommendations) and psychological support. Primary objectives were feasibility, acceptability, completion rate, and safety. In addition, changes in lifestyle, psychological well-being, clinical and laboratory values were assessed. The study was registered in the German Clinical Trials Register (No. DRK S00015288 [MARTINI-Lifestyle-cohort] [www.germanctr.de]).

RESULTS

A high program acceptance was observed. Only three participants (5%) dropped out of the program prematurely. Personal feedback reflected appreciation for participation, personal gain through new knowledge and through the group experience. Without exception, all participants have taken part in follow-up examinations and no adverse events or incidents occurred. In addition, changes in lifestyle habits, clinical parameters and improved quality of life were detected.

CONCLUSION

The MARTINI lifestyle program appears feasible and safe, and acceptance of the multimodal intervention was high among PCa patients. These encouraging results favor conducting a large multicenter trial to implement the program into routine practice and to evaluate the effectiveness of the intervention on survival and quality of life.

Randomised controlled trial testing the feasibility of an exercise and nutrition intervention for patients with ovarian cancer during and after first-line chemotherapy (BENITA-study)

OBJECTIVES

Advanced ovarian cancer is a severe disease with major side effects caused by peritoneal carcinomatosis, ascites and gastrointestinal involvement as well as exhaustive treatment like debulking surgery and combination chemotherapy. Two most frequently reported side effects are muscle wasting and malnutrition, leading to frailty, decreased health-related quality of life (HRQoL) and cancer-related fatigue (CRF). As muscle wasting and malnutrition often commence during first-line chemotherapy and develop progressively into a refractory state, an early intervention is warranted. This pilot study aimed to evaluate the safety and acceptance of a combined exercise and nutrition intervention during and after first-line chemotherapy.

DESIGN

The pilot study was conducted as a monocentric 1:1 randomised controlled trial (RCT) with an intervention group (IG) and a control group (CG). Participants were divided by chance into IG or CG. Information on group allocation was conveyed to the study coordinator responsible for making an appointment with the patients for the baseline assessment as well as the physiotherapist and nutritionist responsible for the intervention and outcome assessment in both groups.

PARTICIPANTS

Eligibility criteria included women ≥18 years of age, diagnosed with ovarian cancer, tubal cancer or peritoneal cancer and primary or interval debulking, scheduled but not started adjuvant or neoadjuvant chemotherapy and sufficient German-language skills.

INTERVENTION

The IG received a 12-month exercise and nutrition programme, the CG continued to follow usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were recruitment rate, adherence to intervention, completion rate and adverse events. In addition, in-person assessments (eg, HRQoL, CRF, muscle quality and function and dietary intake and quality) were conducted at baseline (T0, before chemotherapy), week 9 (T1, mid-chemotherapy), week 19 (T2, after completion of chemotherapy) and after 12 months of intervention (T3).

RESULTS

Of 60 eligible patients, 15 patients signed informed consent (recruitment rate=25.0%) and were randomised into IG (n=8) and CG (n=7). Eleven participants completed the study (completion rate, 73.3%), one patient dropped out due to loss of interest, one due to poor health, one was lost to follow-up and one patient died.

CONCLUSION

The BENITA (Bewegungs- und Ernährungsintervention bei Ovarialkrebs) study demonstrated the safety and acceptance of an exercise and nutrition intervention integrated into first-line therapy and follow-up care of ovarian cancer. A large multicentre RCT is planned to investigate the effectiveness of the intervention on HRQoL, CRF and survival and to establish means of implementation into oncology guidelines and clinic routine.

TRIAL REGISTRATION NUMBER

DRKS00013231.

Arm Ergometry to Improve Mobility in Progressive Multiple Sclerosis (AMBOS)-Results of a Pilot Randomized Controlled Trial

Background: Walking disability is one of the most frequent and burdening symptoms of progressive multiple sclerosis (MS). Most of the exercise intervention studies that showed an improvement in mobility performance were conducted in low to moderately disabled relapsing-remitting MS patients with interventions using the legs. However, MS patients with substantial walking disability hardly can perform these tasks. Earlier work has indicated that aerobic arm training might also improve walking performance and could therefore be a therapeutic option in already moderately disabled progressive MS patients. Methods: Patients with progressive MS and EDSS 4-6.5 were randomized using a computer-generated algorithm list to either a waitlist control group (CG) or an intervention group (IG). The IG performed a 12-week home-based, individualized arm ergometry exercise training program. Maximum walking distance as measured by the 6-min walking test (6MWT) was the primary endpoint. Secondary endpoints included aerobic fitness, other mobility tests, cognitive functioning, as well as fatigue and depression. Results: Of n = 86 screened patients, 53 with moderate disability (mean EDSS 5.5, SD 0.9) were included and data of 39 patients were analyzed. Patients in the IG showed strong adherence to the program with a mean of 67 (SD 26.4) training sessions. Maximum work load (P max) increased in the training group while other fitness indicators did not. Walking distance in the 6MWT improved in both training and waitlist group but not significantly more in trained patients. Similarly, other mobility measures showed no differential group effect. Cognitive functioning remained unchanged. No serious events attributable to the intervention occurred. Conclusion: Although maximum work load improved, 3 months of high-frequency arm ergometry training of low to moderate intensity could not show improved walking ability or cognitive functioning in progressive MS compared to a waitlist CG. The study was registered at www.clinicaltrials.gov (NCT03147105) and funded by the local MS self-help organization.

Moderators of Exercise Effects on Cancer-related Fatigue: A Meta-analysis of Individual Patient Data

PURPOSE

Fatigue is a common and potentially disabling symptom in patients with cancer. It can often be effectively reduced by exercise. Yet, effects of exercise interventions might differ across subgroups. We conducted a meta-analysis using individual patient data of randomized controlled trials (RCT) to investigate moderators of exercise intervention effects on cancer-related fatigue.

METHODS

We used individual patient data from 31 exercise RCT worldwide, representing 4366 patients, of whom 3846 had complete fatigue data. We performed a one-step individual patient data meta-analysis, using linear mixed-effect models to analyze the effects of exercise interventions on fatigue (z score) and to identify demographic, clinical, intervention- and exercise-related moderators. Models were adjusted for baseline fatigue and included a random intercept on study level to account for clustering of patients within studies. We identified potential moderators by testing their interaction with group allocation, using a likelihood ratio test.

RESULTS

Exercise interventions had statistically significant beneficial effects on fatigue (β = -0.17; 95% confidence interval [CI], -0.22 to -0.12). There was no evidence of moderation by demographic or clinical characteristics. Supervised exercise interventions had significantly larger effects on fatigue than unsupervised exercise interventions (βdifference = -0.18; 95% CI -0.28 to -0.08). Supervised interventions with a duration ≤12 wk showed larger effects on fatigue (β = -0.29; 95% CI, -0.39 to -0.20) than supervised interventions with a longer duration.

CONCLUSIONS

In this individual patient data meta-analysis, we found statistically significant beneficial effects of exercise interventions on fatigue, irrespective of demographic and clinical characteristics. These findings support a role for exercise, preferably supervised exercise interventions, in clinical practice. Reasons for differential effects in duration require further exploration.

Aerobic Exercise Induces Functional and Structural Reorganization of CNS Networks in Multiple Sclerosis: A Randomized Controlled Trial

Objectives: Evidence from animal studies suggests that aerobic exercise may promote neuroplasticity and could, therefore, provide therapeutic benefits for neurological diseases such as multiple sclerosis (MS). However, the effects of exercise in human CNS disorders on the topology of brain networks, which might serve as an outcome at the interface between biology and clinical performance, remain poorly understood.

Methods: We investigated functional and structural networks in patients with relapsing-remitting MS in a clinical trial of standardized aerobic exercise. Fifty-seven patients were randomly assigned to moderate-intensity exercise for 3 months or a non-exercise control group. We reconstructed functional networks based on resting-state functional magnetic resonance imaging (MRI) and used probabilistic tractography on diffusion-weighted imaging data for structural networks.

Results: At baseline, compared to 30 healthy controls, patients exhibited decreased structural connectivity that was most pronounced in hub regions of the brain. Vice versa, functional connectivity was increased in hubs. After 3 months, we observed hub independent increased functional connectivity in the exercise group while the control group presented a loss of functional hub connectivity. On a structural level, the control group remained unchanged, while the exercise group had also increased connectivity. Increased clustering of hubs indicates a better structural integration and internal connectivity at the top of the network hierarchy.

Conclusion: Increased functional connectivity of hubs contrasts a loss of structural connectivity in relapsing-remitting MS. Under an exercise condition, a further hub independent increase of functional connectivity seems to translate in higher structural connectivity of the whole brain.

Short-term interval aerobic exercise training does not improve memory functioning in relapsing-remitting multiple sclerosis-a randomized controlled trial

Background

Only few aerobic exercise intervention trials specifically targeting cognitive functioning have been performed in multiple sclerosis.

Objective and Methods

This randomized controlled trial with 34 patients in the intervention group (IG) (mean: 38.2 years (±9.6)) and 34 patients in the control group (CG) (mean: 39.6 years (±9.7)) aimed to determine the effects of aerobic exercise on cognition in relapsing-remitting multiple sclerosis (RRMS). The primary outcome was verbal learning assessed by the verbal learning and memory test (VLMT). Patients were randomized to an IG or a waitlist CG. Patients in the IG exercised according to an individually tailored training schedule (with two to three sessions per week for 12 weeks). The primary analysis was carried out using the intention-to-treat (ITT) sample with ANCOVA adjusting for baseline scores.

Results

A total of 77 patients with RRMS were screened and 68 participants randomized (CG n = 34; IG n = 34). The sample comprised 68% females, had a mean age of 39 years, a mean disease duration of 6.3 years, and a mean expanded disability status scale of 1.8. No significant effects were detected in the ITT analysis for the primary endpoint VLMT or any other cognitive measures. Moreover, no significant treatment effects were observed for quality of life, fatigue, or depressive symptoms.

Conclusion

This study failed to demonstrate beneficial effects of aerobic exercise on cognition in RRMS. The trial was prospectively registered at clinicaltrials.gov (NCT02005237).

Targeting Exercise Interventions to Patients With Cancer in Need: An Individual Patient Data Meta-Analysis

Background

Exercise effects in cancer patients often appear modest, possibly because interventions rarely target patients most in need. This study investigated the moderator effects of baseline values on the exercise outcomes of fatigue, aerobic fitness, muscle strength, quality of life (QoL), and self-reported physical function (PF) in cancer patients during and post-treatment.

Methods

Individual patient data from 34 randomized exercise trials (n = 4519) were pooled. Linear mixed-effect models were used to study moderator effects of baseline values on exercise intervention outcomes and to determine whether these moderator effects differed by intervention timing (during vs post-treatment). All statistical tests were two-sided.

Results

Moderator effects of baseline fatigue and PF were consistent across intervention timing, with greater effects in patients with worse fatigue (Pinteraction = .05) and worse PF (Pinteraction = .003). Moderator effects of baseline aerobic fitness, muscle strength, and QoL differed by intervention timing. During treatment, effects on aerobic fitness were greater for patients with better baseline aerobic fitness (Pinteraction = .002). Post-treatment, effects on upper (Pinteraction < .001) and lower (Pinteraction = .01) body muscle strength and QoL (Pinteraction < .001) were greater in patients with worse baseline values.

Conclusion

Although exercise should be encouraged for most cancer patients during and post-treatments, targeting specific subgroups may be especially beneficial and cost effective. For fatigue and PF, interventions during and post-treatment should target patients with high fatigue and low PF. During treatment, patients experience benefit for muscle strength and QoL regardless of baseline values; however, only patients with low baseline values benefit post-treatment. For aerobic fitness, patients with low baseline values do not appear to benefit from exercise during treatment.

[Psychological Foundations of Pediatric Liver Transplantation]

Liver transplantation (LTX) is an established therapy for pediatric patients with liver failure. In recent decades, survival rates have risen continuously. With increased life expectancy, there has been greater attention to children's and adolescents' quality of life following transplantation. This article provides an overview of the tasks of pediatric transplant psychology. We summarize the reviewed literature of research on health-related quality of life in pediatric liver transplant recipients. Furthermore, we present studies on fatigue, mental health, cognitive development and family strain. In adolescents and young adults, the risk of non-adherence is particularly high. Therefore, adherence and transition, i. e. transfer from pediatric to adult-centered transplant care, are discussed separately. Subsequently, studies on long-term survival after LTX are summarized. In conclusion, recommendations for clinical practice are given.

[Psychosocial Evaluation of Transplant Patients - Recommendations for the Guidelines for Organ Transplantation]

For the last few years, the German Medical Association's guidelines for transplant medicine have been subject to an extensive revision process. The present contribution presents recommendations regarding the psychosocial evaluation of patients prior to organ transplantation, which were developed by experts from the Psychology/Psychosomatics committee of the German Transplant Society with the aim to incorporate the recommendations into the guidelines. The main objective is to establish a mandatory psychosocial evaluation for all patients prior to their admission to the transplant waiting list. Contents, potential contraindications, and the procedure of the evaluation are described. Furthermore, the qualification deemed necessary for the examiners is addressed in detail. Finally, the future need for action is determined.

Physical condition, nutritional status, fatigue, and quality of life in oncological out-patients

Objective:

Early detection of limited physical activity and nutritional deficiencies in cancer survivors could contribute to early treatment and preservation of quality of life. The aim of this study is to describe the association of physical condition and nutritional status with fatigue and quality of life in oncological out-patients.

Methods:

Data in this descriptive study was collected on bioelectrical impedance analysis, postural stability (stability index), body mass index, Karnofsky Index, quality of life (Short-Form 36-Item Health Survey) and fatigue (multidimensional fatigue inventory-20) in a consecutive sample of 203 oncological out-patients. Phase angle was calculated from bioelectrical impedance analysis. Values were intercorrelated and compared to appropriate standard values.

Results:

Phase angle and stability index outcomes were far below the values of a healthy population of similar age (p < 0.001). Quality of life was significantly lower than in the normal population (p < 0.001), and the level of fatigue was significantly higher (p < 0.001). Phase angle correlated with Karnofsky Index (p = 0.002) and Short-Form 36-Item Health Survey Summary physical function (p < 0.001). Furthermore, multidimensional fatigue inventory-20 scales ‘physical fatigue’ and ‘reduced activity’ were significantly associated with phase angle (p = 0.04, p = 0.005). Stability indices correlated with Short-Form 36-Item Health Survey physical function.

Conclusion:

The physical condition and the nutritional status are key components determining the individual quality of life of oncological out-patients. These variables also showed an association with the manifestation of fatigue. Results highlight the need for interdisciplinary cooperation to detect physical, nutritional and psychological deficiencies in oncological out-patients.

Aberrant peak lactate response in MS

BACKGROUND

The peak blood lactate response to an exhaustive exercise test in a number of chronic conditions has been shown to differ from that seen in healthy, untrained individuals. However, this has not been investigated for patients with multiple sclerosis (MS).

OBJECTIVE

The main objective was to determine and compare the peak blood lactate response to exercise and the maximal workload between two groups of MS patients with different illness severity.

METHODS

Twenty-five patients with a relapsing-remitting disease course (Group RR) and 41 patients with a secondary- or primary chronic progressive disease course (group CP) performed an exhaustive incremental bicycle ergometry. Peak blood lactate, maximal workload, peak oxygen consumption and maximal heart rate were measured.

RESULTS

The peak blood lactate levels and maximal workload differed significantly between the groups (group CP < group RR; p < 0.001). Furthermore spiroergometric peak performance markers in both groups were significantly lower than predicted for healthy age and sex matched untrained groups.

CONCLUSION

A reduced peak blood lactate response to exercise is a novel finding for MS patients. This calls into doubt if the lactate performance tests and lactate thresholds used for healthy individuals can be transferred to MS patients.

Dietary Interventions in Multiple Sclerosis: Development and Pilot-Testing of an Evidence Based Patient Education Program

Background

Dietary factors have been discussed to influence risk or disease course of multiple sclerosis (MS). Specific diets are widely used among patients with MS.

Objective

To design and pilot-test an evidence based patient education program on dietary factors in MS.

Methods

We performed a systematic literature search on the effectiveness of dietary interventions in MS. A web-based survey among 337 patients with MS and 136 healthy controls assessed knowledge, dietary habits and information needs. An interactive group education program was developed and pilot-tested.

Results

Fifteen randomised-controlled trials (RCTs) were included in the systematic review. Quality of evidence was low and no clear benefit could be seen. Patients with MS significantly more often adhered to a `Mediterranean Diet`(29.7% versus 14.0%, p<0.001) compared to controls. 143 (42%) of the patients with MS had tried special MS diets. Important information needs addressed effectiveness of MS diets (44%) and relation between nutrition and MS (43%). A pilot test of our newly developed patient education program with 13 participants showed excellent comprehensibility and the MS-specific content was judged as very important. However, the poor evidence base for dietary approaches in MS was perceived disappointing.

Conclusions

Development and pilot-testing of an evidence-based patient education program on nutrition and MS is feasible. Patient satisfaction with the program suffers from the lack of evidence. Further research should focus on generating evidence for the potential influence of lifestyle habits (diet, physical activity) on MS disease course thus meeting the needs of patients with MS.

Altered cytokine responses to cognitive stress in multiple sclerosis patients with fatigue

This study intended to examine if the immune response to a cognitive task as a variant of psychological stress in MS patients is distinct from healthy controls. The experiment was part of a larger study on mechanisms and measurements of MS fatigue. Patients (n=23) and controls (n=25) participated in a cognitive task lasting 40 minutes, in which the heart rate was continuously monitored. Blood samples were taken at baseline and directly after the stress-inducing task. Whole blood stimulated cytokine production representative of the TH-1 (i.e. IFNγ, TNFα) and TH-2 paradigm (i.e. IL-10) was evaluated in relation to disability, fatigue, cognitive deficit, and anxiety. Patients scored high on a disease specific fatigue score compared to controls, whereas baseline cytokine patterns did not differ between the groups. MS patients displayed a blunted response of IFNg (P=0.03) whereas TNFα and IL-10 responses did not change. Additionally MS patients showed a significantly lower heart rate increase after the task (P<0.001). Cognitive impairment was associated with a decreased heart rate reactivity (P=0.02) while depressive symptoms correlated with stronger IL-10 responses (P=0.05). Overall, cognitive stress induces IFNγ production in healthy controls but not in MS patients with fatigue. Furthermore, a reduced cardiac response might indicate an autonomic dysfunction in this group of patients.

Determination of ethyl glucuronide in hair improves evaluation of long-term alcohol abstention in liver transplant candidates

BACKGROUND & AIMS

Prior to listing patients for Orthotopic liver transplantation (OLT) an abstention period of 6 months is required. Ethyl glucuronide in the hair is a new reliable marker for the assessment of alcohol consumption. Here, the diagnostic value of determining the ethyl glucuronide concentration in the hair of liver transplant candidates was evaluated.

METHODS

In 63 transplant candidates with alcoholic liver cirrhosis and 25 control patients with cirrhosis of other aetiologies alcohol markers, i.e. hEtG, urine EtG, blood ethanol, methanol and carbohydrate deficient transferrin were determined in parallel to an interview with a psychologist.

RESULTS

A total of 19 (30%) transplant candidates admitted alcohol consumption within the last 6 months, while 39/63 (62%) were positive for at least one alcohol marker. In 52% of the 44 candidates denying alcohol consumption, abstention was disproved by detecting at least one positive alcohol marker, in 83% of cases by a positive hEtG result. In the control patients stating abstention from alcohol all hEtG tests were negative. No impact of renal or liver function on hEtG results was detected. A specificity of 98% and a positive predictive value of 92% were calculated for testing hEtG in proximal hair segment and applying a cut-off of 30 pg/mg.

CONCLUSIONS

In 52% of patients denying alcohol consumption within the last 6 months, alcohol abstention was disproved, in 83% of cases by hEtG testing. Therefore, hEtG is a promising new marker for the evaluation of long-term alcohol abstention in liver transplant candidates.

Effects of exercise on fitness and cognition in progressive MS: a randomized, controlled pilot trial

Background:

Exercise may have beneficial effects on both well-being and walking ability in multiple sclerosis (MS). Exercise is shown to be neuroprotective in rodents and may also enhance cognitive function in humans. It may, therefore, be particularly useful for MS patients with pronounced neurodegeneration.

Objective:

To investigate the potential of standardized exercise as a therapeutic intervention for progressive MS, in a randomized-controlled pilot trial.

Methods:

Patients with progressive MS and moderate disability (Expanded Disability Status Scale (EDSS) of 4–6) were randomized to one of three exercise interventions (arm ergometry, rowing, bicycle ergometry) for 8–10 weeks or a waitlist control group. We analyzed the drop-out rate as a measure of feasibility. The primary endpoint of the study was aerobic fitness. Secondary endpoints were walking ability, cognitive function as measured by a neuropsychological test battery, depression and fatigue.

Results:

A total of 42 patients completed the trial (10.6% drop-out rate). Significant improvements were seen in aerobic fitness. In addition, exercise improved walking ability, depressive symptoms, fatigue and several domains of cognitive function.

Conclusion:

This study indicated that aerobic training is feasible and could be beneficial for patients with progressive MS. Larger exercise studies are needed to confirm the effect on cognition.

Trial Registration:

ISRCTN (trial number 76467492) http://isrctn.org

Supportive care needs in patients with cardiovascular disorders

OBJECTIVES

Unmet medical needs are a focus in cardiovascular disorder (CVD) research. However, few studies have investigated patients' perceived needs. The present study examined supportive care needs in patients with CVD and their relation to health characteristics.

METHODS

In total 260 in-patients with CVD were consecutively assessed with the supportive care needs survey. Primarily, frequency and content of unmet needs were examined. Secondarily, CVD-diagnoses were compared and correlations with risk factors, treatment characteristics, mood-state and quality of life were analyzed.

RESULTS

Supportive care needs were indicated by 21% of all patients: unmet health information (37%) and psychological (23%) needs were most frequent. The number of unmet needs did not differ between most CVD-diagnoses. Unmet needs were not related to cardiac risk factors. However, treatment characteristics (r=.17-.23, p<.01), anxiety (r=.44-.71, p<.01), depression (r=.38-.63, p<.01), physical (r=.21-.47, p<.01) and mental (r=.29-.65, p<.01) quality of life were associated with unmet needs.

CONCLUSIONS

Supportive care needs are common in patients with CVD. They are based on patients' treatment characteristics, emotions and subjective well-being rather than on cardiac factors.

PRACTICE IMPLICATIONS

Needs assessments in patients with CVD could detect unmet needs, enhance patient education and communication and, therefore, effectively target patients' perceived needs and medical needs.

A prospective study on living related kidney donors' quality of life in the first year: choosing appropriate reference data

Prospective studies on living kidney donors' quality of life (QoL) are still rare. Most existing studies compare healthy donors with the general population, including subjects with diseases. This is the first prospective study comparing living donors' QoL with reference data of both the general population and healthy individuals. We investigated QoL, anxiety, and depression in living kidney donors (n = 79) before donation and at two post-operative data points (three months and one yr). Subsequently, data from the donors were compared with the reference data. Our results show an impaired physical QoL three months post-donation. One yr after surgery, physical QoL had returned to the pre-operative level. Neither mental QoL nor anxiety or depression showed major changes across time. Pre-operative QoL was comparable to that of healthy individuals and higher than that in the general population. Donors' perception of the recipient's health showed moderate correlations with donors' mental outcome three months after donation. In conclusion, the impact on physical QoL seems to persist for at least three months after kidney donation. It could be demonstrated that in the context of living donation, healthy individuals provide more adequate reference data. Future research needs to determine the length and the nature of the post-operative QoL impairment and further explore possible influencing factors.

Decreased hydrocortisone sensitivity of T cell function in multiple sclerosis-associated major depression

Multiple sclerosis (MS) is an inflammatory, demyelinating disease of the CNS with a high prevalence of depression. Both MS and depression have been linked to elevated cortisol levels and inflammation, indicating disturbed endocrine-immune regulation. An imbalance in mineralocorticoid versus glucocorticoid signaling in the CNS has been proposed as a pathogenetic mechanism of depression. Intriguingly, both receptors are also expressed in lymphocytes, but their role for 'escape' of the immune system from endocrine control is unknown. Using steroid sensitivity of T cell function as a read-out system, we here investigate a potential role of mineralocorticoid receptor (MR) versus glucocorticoid receptor (GR) regulation in the immune system as a biological mechanism underlying MS-associated major depression. Twelve female MS patients meeting diagnostic criteria for current major depressive disorder (MDD) were compared to twelve carefully matched MS patients without depression. We performed lymphocyte phenotyping by flow cytometry. In addition, steroid sensitivity of T cell proliferation was tested using hydrocortisone as well as MR (aldosterone) and GR (dexamethasone) agonists. Sensitivity to hydrocortisone was decreased in T cells from depressed MS patients. Experiments with agonists suggested disturbed MR regulation, but intact GR function. Importantly, there were no differences in lymphocyte composition and frequency of T cell subsets, indicating that the differences in steroid sensitivity are unlikely to be secondary to shifts in the immune compartment. To our knowledge, this study provides first evidence for altered steroid sensitivity of T cells from MS patients with comorbid MDD possibly due to MR dysregulation.

Influence of kinship on donors' mental burden in living donor liver transplantation

In the context of living donor liver transplantation (LDLT), German transplantation law stipulates that donor candidates should primarily be relatives of the recipients or persons with distinct and close relationships. In this study, we investigated the influence of the relationship between the donor and the recipient on the donor's emotional strain before transplantation. Donors were categorized according to the following subgroups: (1) parents donating for their children, (2) children donating for their parents, (3) siblings, (4) spouses, (5) other relatives, and (6) nonrelatives. The sample consisted of 168 donor candidates. Anxiety (F = 2.8, P = 0.02), depression (F = 2.6, P = 0.03), and emotional quality of life (F = 3.1, P = 0.01) differed significantly according to the relationship between the donor and the recipient. In comparison with healthy controls, parents donating for their children were significantly less stressed before LDLT and demonstrated fewer anxiety (P < 0.01) and depression symptoms (P < 0.05). Adult children donating for their parents demonstrated the highest mental burden and the lowest emotional quality of life. However, this was not due to the responsibility of these children for their own families because differences between donors with children and donors without children could not be ascertained. This group should be given special attention before LDLT and during follow-up visits, and psychological help should be provided when it is necessary.

Dynamic development of glucocorticoid resistance during autoimmune neuroinflammation

CONTEXT

Glucocorticoids (GC) are powerful endogenous and therapeutic modulators of inflammation and play a critical role for controlling autoimmunity. GC resistance can be seen in patients with cell-mediated autoimmune disorders, but it is unknown whether this represents a stable trait or a state.

OBJECTIVE

The objective of the study was to determine whether GC resistance of T cell responses is dynamically regulated in experimental autoimmune encephalomyelitis (EAE) and multiple sclerosis (MS).

DESIGN

This was a translational observational study. PATIENTS AND ANIMALS: EAE was induced in C57BL/6 mice. A cross-sectional sample of 25 patients with relapsing-remitting MS was included as well as four MS patients during pregnancy and postpartum.

MAIN OUTCOME MEASURES

Outcome measures included GC sensitivity of T cell proliferation and GC-mediated apoptosis.

RESULTS

GC resistance was seen in both autoantigen-specific and nonspecific responses of T cells obtained from mice with EAE. GC resistance preceded clinical symptoms and central nervous system infiltration of immune cells. T cells obtained during EAE were resistant to GC-induced apoptosis, and this was linked to down-regulation of GC receptor-α expression. GC resistance in T cells was also seen in MS patients with radiological evidence for ongoing inflammation. GC resistance was absent in the MS patients during pregnancy, when relapse risk is decreased, but recurred postpartum, a time of increased relapse risk.

CONCLUSIONS

These data demonstrate that GC resistance during autoimmune neuroinflammation is dynamically regulated. This has implications for the timing of steroid treatments and provides a putative pathway to explain the observed association between psychological stress and exacerbation of autoimmune diseases.

Endocrine and immune substrates of depressive symptoms and fatigue in multiple sclerosis patients with comorbid major depression

OBJECTIVE

Depression and fatigue are among the most common symptoms of multiple sclerosis (MS). These symptoms frequently co-occur and partially overlap in MS but their underlying biological substrates are unclear. In this study, the relative role of cytokines and hypothalamic-pituitary-adrenal (HPA) axis activity in depression and fatigue were examined in patients with relapsing-remitting MS (RRMS).

METHODS

HPA axis function and frequency of stimulated cytokine (interferon γ (IFNγ) and tumour necrosis factor α (TNFα)) producing T cells was measured cross sectionally in 44 female patients with RRMS. All subjects completed a neurological examination, the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and self-report questionnaires.

RESULTS

10 patients met diagnostic criteria for major depressive disorder (MDD). MS patients with comorbid MDD showed normal morning but elevated evening salivary cortisol levels, resulting in a flattened slope. While a higher frequency of cytokine producing CD8+ T cells was also seen in MS patients with MDD, these markers were more closely associated with fatigue than depression.

CONCLUSIONS

This study supports a role for HPA axis hyperactivity in major depression in MS. In addition, inflammatory and neuroendocrine factors may differentially mediate fatigue and depressive symptoms.

Effects of a physical exercise rehabilitation group program on anxiety, depression, body image, and health-related quality of life among breast cancer patients

BACKGROUND

Since physical exercise programs have the potential to help cancer patients regain physical fitness and may exert a range of positive consequences for recovery and psychological well-being, the impact of a physical exercise program was investigated in this prospective study.

PATIENTS AND METHODS

Women with primary nonmetastatic breast cancer after a minimum 4-week period post chemotherapy and/or radiotherapy completion were randomly assigned to one of 2 groups: intervention group (IG) (n = 30) and waiting group (WG) (n = 28). The 10-week twice weekly exercise group program consisted of gymnastics, movement games, relaxation, walking, and jogging. Anxiety, depression, body image, and quality of life were measured using standardized questionnaires. Maximal oxygen uptake (VO(2)max/kg) was assessed as a measure of physical fitness.

RESULTS

Patients in the IG improved significantly over time with regard to anxiety (p = 0.03, d = 0.45), depression (p = 0.05, d = 0.43), individual body image (p = 0.006, d = 0.44), and VO(2)max/kg (p < 0.001, d = 0.50), whereas no improvements were observed in the WG. However, this randomized controlled trial failed to demonstrate significant intervention effects in quality of life and social body image.

CONCLUSIONS

This prospective study provided evidence for the effectiveness of a 10-week physical exercise intervention to significantly improve psychosocial wellbeing, individual body image, and physical fitness.

Cognitive abilities, behaviour and quality of life in children after liver transplantation

AIMS

We investigated interrelations between cognitive abilities, behavioural problems, quality of life and disease-related variables of children after LTX.

METHODS

Our sample consisted of 25 children. They were 8.5/2.8 (M/SD) years old and had received the transplant 5.5/3.1 years previously. For assessment we used well-established instruments.

RESULTS

Liver transplanted children scored below the population mean on the cognitive as well as on the behavioural instrument and showed scores below average in the scales Self-esteem, Friends and Total Score regarding QoL. Behavioural problems were associated with poorer cognitive performance (r=-0.38 to -0.63). QoL regarding physical well-being was correlated with sequential processing (r=0.41). Lower sequential processing scores were associated with lower QoL. Also between behavioural parameters and QoL correlations could be determined. Children with more behavioural problems experienced lower QoL (r=-0.40 to r=-0.76). Age at onset of disease showed correlations with behavioural and QoL parameters (r=-0.49 resp. r=0.44). Cognitive functioning was associated with medical complications (r=-0.44).

CONCLUSIONS

High interrelations between cognitive functioning, behavioural deficits and QoL were obtained. Especially noticeable are correlations between sequential processing and internalized behavioural functions as both are associated with left lateralized brain functioning. This relationship could indicate differential effects on brain development during the preoperative phase.

Mental and physical quality of life in actual living liver donors versus potential living liver donors: a prospective, controlled, multicenter study

In a quasi-experimental design, we investigated the quality of life (QOL) in actual liver donors (n = 43) and potential liver donors (n = 33) before and 3 months after liver transplantation. This is the first study in this field combining a prospective design with an adequate control group. Potential donors served as a control group because they also had a relative in need of a liver transplant and were as emotionally involved with the recipient as actual donors, but they were not subjected to the donor operation. Groups did not differ in age, gender, marital status, donor-recipient relationship, urgency of transplantation, or recipient group (adult versus child). Actual donors showed decreased physical QOL, whereas potential donors were not affected. However, for both groups, a decrease in anxiety was found. Furthermore, actual donors showed a better mental QOL postoperatively than potential donors. The recipients of these 2 groups did not differ with respect to postoperative complications. Furthermore, the groups did not report a different caregiver burden, but actual donors showed higher self-esteem. Because of the surgery, the worsening of physical symptoms in actual donors was expected. It is remarkable, however, that although actual donors still showed a limited physical QOL 3 months after the operation, in both groups, a similar reduction in anxiety could be observed, and actual donors even demonstrated a better mental QOL postoperatively than potential donors. The latter might be due to a psychological benefit that actual donors derived from the fact that they were able to help the recipients.

The factorial structure of the Chronic Liver Disease Questionnaire (CLDQ)

OBJECTIVE

The Chronic Liver Disease Questionnaire (CLDQ) is a disease-specific instrument designed to assess health-related quality of life in patients with chronic liver disease. The aim of this paper is to present the psychometric properties of a German version of this questionnaire. A special focus is placed on the analysis of the CLDQ's factorial structure.

METHODS

Five hundred and twenty-four patients completed the CLDQ from May 1999 to October 2006. The results were subject to item analysis, reliability and validity assessments, and confirmatory and exploratory factor analysis.

RESULTS

The distribution characteristics on the item and scale level were satisfactory. Internal consistency was good to excellent; retest reliability acceptable. Validity could be confirmed by characteristic subscale correlations with other quality-of-life scales. Confirmatory factor analysis could not sufficiently reproduce the original factor structure. Exploratory factor analysis suggested five out of six subscales of the original version and yielded a new subscale: leep."

CONCLUSION

CLDQ's reliability and validity have been confirmed. In addition, the demonstrated practical administration of the questionnaire suggests that it should serve as a routine quality of life assessment of patients with chronic liver disease.

Psychological strain in urgent indications for living donor liver transplantation

The ethical soundness of living donor liver transplantation (LDLT) in urgent indications is still under discussion. The aim of the survey was to investigate the psychological distress of donors in cases of hepatocellular carcinoma (HCC) or acute liver failure (ALF). In a prospective multicenter study (n = 123), health-related quality of life (QOL), anxiety, and depression were measured. The psychological distress of donors was correlated to the degree of urgency of the recipients' indication, which was classified as nonurgent, HCC, or ALF. During the donor evaluation prior to LDLT, the donors with recipients for HCC and ALF demonstrated significantly reduced mental QOL in comparison to donors for a nonurgent indication and to the German normative sample. Compared to healthy controls, anxiety and depression were significantly increased in donors for ALF. Three months after the transplantation, scores for mental QOL as well as for anxiety and depression improved and were within the normal range for the whole group as well as for the ALF donors. In conclusion, the psychological burden was temporary in nature. Our findings can be considered as arguments for the current practice to address family members as donors in cases of HCC and ALF.

Bedarf und Inanspruchnahme psychosozialer Betreuung nach Lebertransplantation

Studies on the need of psychosocial support after liver transplantation (LTX) are rare. At our centre we conducted a survey regarding this question in a one year period with a consecutive sample of 146 patients on average 38 month (SD = 28) after liver transplantation. An assessment of the need was estimated in self-assessment, in a rating after completion of an interview, by the estimate of the attending physicians and with the help of standardized questionnaires. 44.5 % of the patients expressed either a present need (15 %) or a need at an earlier time (29.5 %). The physicians classified 20 % as in need of psychosocial care and from the interviewer's point of view 50 % of the patients needed care. The rating correlated to r = 0.32 (physician) and r = 0.55 (interviewer) with the self-assessment. In the modified Hornheider questionnaire 18 % of the patients were classified as in need of care. In the German version of the Hospital Anxiety and Depression Scale (HADS-D) 25 % of the patients exhibit increased anxiety values and 16 % of the patients depressive symptoms. The results of the questionnaires are highly intercorrelated and correlated low (estimate of physicians) to medium high (estimate of interviewer) with the ratings of need. Grouped according to their self-assessment of need, the groups of patients differ significantly in the applied questionnaires. Patients who do not indicate any need show the lowest anxiety and depression values and report the fewest problems. The offer of psychosocial support in the survey period was utilized by 27 of the participating patients (19 %). Altogether we can estimate the current need at a certain time between 15 and 20 % and a total need after LTX up to 50 %. These results require further examination and the appropriate form of psychosocial offers for these patients should be developed in further research.

Psychosocial aspects of pediatric living donor liver transplantation

While the medical aspects of living donor liver transplantation (LDLT) have been investigated to a comparatively large degree, only in recent years have psychosocial aspects like donors' quality of life and attitude towards living donation been dealt with. In the course of a retrospective study, we examined 36 pediatric living liver donors at an average of 4.5 +/- 2.8 years postoperatively. The donation's impact on the family was considered "very high," "high," or "average" by 48% of the donors. The physical impact of the donation was regarded as being higher than the emotional impact. Subjective full recovery was achieved at an average of 4.5 months postoperatively. All patients stated that they would donate again. Donors' quality of life, as assessed with the 36-Item Short-Form Quality of Life Questionnaire (SF-36), was significantly higher than the German normative sample. Anxiety and depression, assessed with the Hospital Anxiety and Depression Scale-German version, were significantly lower compared to healthy controls. However, 14 patients (39%) described persistent, mostly physical, symptoms more than 1 yr postoperatively. In conclusion, the study's findings may enable clinicians to achieve a better understanding of living donors' situations, both pre- and postoperatively, and may help to assess the psychosocial risk of LDLT. Knowledge of possible ongoing problems may facilitate intervention at an early stage and should be included among the information given to potential living liver donors. Prospective studies using more specific instruments with an emphasis on the long-term psychosocial outcome of LDLT are needed for future research.

Physical exercise in multiple sclerosis: supportive care or a putative disease-modifying treatment

Multiple sclerosis (MS) is a neuroinflammatory and neurodegenerative disease affecting young adults and leading to considerable disability. For many years, patients have been advised to avoid physical activity. Today, however, an increasing number of studies have shown beneficial effects of exercise training in MS. It has been reported that such programs not only improve fitness parameters but can also enhance quality of life and beneficially affect some suggestive disability measures. Pilot studies even indicate a neuroprotective potential. This review summarizes the findings of the major clinical trials on exercise in MS. Possible biological effect mediators, such as neurotrophic factors or anti-inflammatory cytokines, will be discussed. Exercise management guidelines will be proposed and possible further research strategies are presented.

Hypothalamo–pituitary–adrenal axis activity predicts disease progression in multiple sclerosis

Clinical studies have shown that groups of multiple sclerosis (MS) patients exhibit a chronically activated hypothalamo-pituitary-adrenal (HPA) axis. However, the association of HPA axis activity and disease progression in MS is unknown. In this longitudinal study over a 3-year follow-up period, we report that patients who exhibited stronger HPA reactivity at baseline were significantly more likely to experience progression as measured by the Expanded Disability Status Scale (EDSS) during the follow-up period. Furthermore, HPA axis activity correlated with progression ratings and cognitive impairment three years later. Tests of HPA axis activity may be useful biomarkers for disease progression in MS.

Das Stresskonzept von Allostase und Allostatic Load: Einordnung psychoneuroimmunologischer Forschungsbefunde an Beispielen zur Autoimmunität und Onkologie

Classical theories have conceptualized stress as a reaction to threat to the homeostasis within the organism requiring an adaptive response. However, postulating mechanisms that could link such responses to long-term detrimental health outcomes remains difficult. The allostatic load concept enables us to think about how mediators can be protective in the short run but may have damaging effects when overused and/or not shut off. It further facilitates the formulation of cause-effects cascades to explain the link of dysregulations in stress mediators such as glucocorticoids and catecholamines and increased susceptibility for certain diseases. In the first section, we briefly summarize the theoretical background. We then employ the concept to integrate findings from basic and clinical research on dysregulations of the stress response systems in multiple sclerosis and breast cancer. Based on this model, it seems likely that such dysregulations are implicated in progression and possibly pathogenesis of these diseases. When using allostatic load as a heuristic model, one needs to consider that stress mediators and outcomes are interconnected in a non-linear network.

Cognitive Abilities in Children after Liver Transplantation

BACKGROUND

The authors investigated the cognitive status during the late postoperative phase in children who had undergone liver transplantation (LTx).

METHODS

The authors examined 44 children who had undergone liver transplantation at their center. The children were 8.9+/-2.3 (mean+/-SD) years of age and had received the transplant 6.1+/-2.6 years previously. In 24 of the 44 children, a living-related transplantation had been carried out. Cognitive abilities were assessed with the three subscales of the Kaufman Assessment Battery for Children (K-ABC): the sequential processing scale (SES), the simultaneous processing scale (SIS), and the achievement scale (AS).

RESULTS

The children scored below the population mean but within the normal range on all subscales of the K-ABC. In the SIS and the AS, age at transplantation influenced the cognitive outcome, as the children who were younger at transplantation scored significantly better than the older children and their results were within the normal range. However, for the SES, no such differences were found. A multiple regression analysis revealed that duration of illness and height at transplantation predicts the performance in the SIS and the AS. To a lesser degree, type of transplantation (cadaveric vs. living-related) predicts performance in the AS. Performance in the SES was not predicted by any of these variables. Time since LTx and type of immunosuppressive regimen were not associated with the cognitive status after transplantation.

CONCLUSIONS

Children who are younger, with a shorter duration of illness, and who are more physically developed before LTx have a better prognosis regarding their mental development. However, this result does not hold for sequential processing functions, which showed no relationship with any of these variables. This could indicate differential effects of liver disease and consecutive metabolic derangements on brain development during the preoperative phase.

Evolution of donor morbidity in living related liver transplantation: a single-center analysis of 165 cases

OBJECTIVE

During the last 14 years, living donor liver transplantation (LDLT) has evolved to an indispensable surgical strategy to minimize mortality of adult and pediatric patients awaiting transplantation. The crucial prerequisite to performing this procedure is a minimal morbidity and mortality risk to the healthy living donor. Little is known about the learning curve involved with this type of surgery.

PATIENTS AND METHODS

From January 1991 to August 2003, a total of 165 LDLTs were performed in our center. Of these, 135 were donations of the left-lateral lobe (LL, segments II and III), 3 were of the left lobe (L, segments II-IV), 3 were full-left lobes (FL, segments I-IV), and 24 were of the full-right lobe (FR, segments V-VIII). We divided the procedures into 3 periods: period 1 included the years 1991 to 1995 (LL, n = 49; L, n = 2; FR, n = 1), period 2 covered 1996 to 2000 (LL, n = 47), and period 3 covered 2001 to August 2003 (LL, n = 39; FR, n = 23; FL, n = 3; L, n = 1). Perioperative mortality and morbidity were assessed using a standardized classification. Length of stay in intensive care unit, postoperative hospital stay, laboratory results (bilirubin, INR, and LFTs), morbidity, and the different types of grafts in the 3 different periods were compared.

RESULTS

One early donor death was observed in period 1 (03/07/93, case 30; total mortality, 0.61.%). Since 1991, the perioperative morbidity has continually declined (53.8% vs. 23.4% vs. 9.2%). In period 1, 28 patients had 40 complications. In period 2, 11 patients had 12 complications, and in period 3, 6 patients had 9 complications. Within the first period, 1 donor underwent relaparotomy because of bile leakage. Postoperative hospital stay was 10 days, 7 days, and 6 days, respectively. Donation of the full right lobe, in comparison with that of the left lateral lobe, resulted in a significantly diminished liver function (bilirubin and INR) during the first 5 days after donation but did not increase morbidity. One donor from period 1 experienced late death caused by amyotrophic lateral sclerosis.

CONCLUSIONS

In a single center, morbidity after living liver donation strongly correlates to center experience. Despite the additional risks associated with temporary reduction of liver function, this experience enabled the team to bypass part of the learning curve when starting right lobe donation. Specific training of the surgical team and coaching by an experienced center should be implemented for centers offering this procedure to avoid the learning curve.

Impact of aerobic training on immune-endocrine parameters, neurotrophic factors, quality of life and coordinative function in multiple sclerosis

In recent years it has become clear that multiple sclerosis (MS) patients benefit from physical exercise as performed in aerobic training but little is known about the effect on functional domains and physiological factors mediating these effects. We studied immunological, endocrine and neurotrophic factors as well as coordinative function and quality of life during an 8-week aerobic bicycle training in a waitlist control design. In the immune-endocrine study (1) 28 patients were included, the coordinative extension study (2) included 39 patients. Training was performed at 60% VO(2)max after determining individual exertion levels through step-by-step ergometry. Metabolic (lactate), endocrine (cortisol, adrendocortico-releasing hormone, epinephrine, norepinephrine), immune (IL-6, soluble IL-6 receptor), and neurotrophic (brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF)) parameters were compared from a prestudy and a poststudy endurance test at 60% VO(2)max for 30 min. In study (1), lowered lactate levels despite higher workload levels indicated a training effect. Disease-specific quality of life (as measured by the Hamburg Quality of Life Questionnaire for Multiple Sclerosis, HAQUAMS) significantly increased in the training group. No significant training effects were seen for endocrine and immune parameters or neurotrophins. In study (2), two out of three coordinative parameters of the lower extremities were significantly improved. In summary, low-level aerobic training in MS improves not only quality of life but also coordinative function and physical fitness.

Endocrine and cytokine responses to standardized physical stress in multiple sclerosis

Since the earliest descriptions psychological and physical stress has been considered a controversial but potentially important factor in the onset and course of multiple sclerosis (MS). During recent years it has become clear that MS patients benefit from physical exercise as performed in aerobic training. As acute exercise has profound effects on immune and endocrine parameters we studied endocrine and immune response to standardized physical stress in MS within a study of aerobic training. Fifteen MS patients completed an eight-week aerobic training program, 13 patients were part of a wait-control group. Twenty healthy controls were recruited as well. A step-by-step bicycle ergometry was performed to determine individual exertion levels. For the endurance test patients exercised at 60% VO2 max for 30 min. Blood samples were drawn before, directly after and 30 min after completion of the exercise. Heart rate and lactate increased in all groups (p<.0001). We furthermore saw significant increases in endocrine parameters (epinephrine, norepinephrine, ACTH, and beta-endorphin; all p<.0001) in healthy individuals and in MS patients but without a differential effect. Whole-blood stimulated production of IFN-gamma (IFNgamma) was induced similarly in all groups (p<.01). TNF-alpha (TNFalpha) and IL-10 were less inducible in MS patients (trend). From these data we could not demonstrate a proinflammatory immune deviation in response to physical stress in MS. The observed trend of hyporesponsive TNFalpha and IL-10 responses in MS warrants further investigation.

Cognitive impairment in multiple sclerosis does not affect reliability and validity of self-report health measures

Patient self-report health measures have received increasing recognition as supplementary outcome parameters in multiple sclerosis (MS). Given the high prevalence of cognitive problems in this population, reliability and validity of self-report instruments in patient groups with cognitive impairment is essential, especially when using such scales longitudinally. A sample of 80 MS patients with cognitive dysfunction according to Symbol Digit Modalities Test (SDMT) score and 107 unimpaired patients were included in the analyses. Data was available from the Hamburg Quality of Life Questionnaire in Multiple Sclerosis (HAQUAMS), the Hospital Anxiety and Depression Scale (HADS), clinical rating scores [Expanded Disability Status Scale (EDSS) and FS (Functional Status) scales, CAMBS (Cambridge MS Basic Score)] and objective tests of upper and lower limb function [Timed 8 Meter Walk (T8) and Nine Hole Peg Test (9HPT)). Both self-report questionnaires showed satisfactory internal consistencies and retest reliability. Pattern and magnitude of correlations with other health status measures supported the validity of both instruments. However, there was a marked discrepancy between subjective and objective measures of cognitive function. Cognitively impaired patients furthermore showed significantly higher depression and anxiety as well as lower quality of life (QoL). The report provides evidence that QoL and affective symptomatology can be reliably assessed in MS patients with cognitive dysfunction. The common pattern of poor correlation between self-rated and objective cognitive function thus appears to be a result of the patients' (adaptive or maladaptive) coping mechanisms rather than being due to inaccurate measurement.

Delivering the diagnosis of MS--results of a survey among patients and neurologists

OBJECTIVES

The need for an early disclosure of the diagnosis of multiple sclerosis (MS) has become more pressing with the publication of two recent randomized trials which have indicated that very early treatment may favourably alter the disease course. We assessed the current status of diagnostic and therapeutic information on MS from the point of view of patients and neurologists.

METHODS

A standardized questionnaire was sent out through the patients' self-help organization in Hamburg, Germany and to all neurologists.

RESULTS

A total of 434 of 1300 patients and 80 of 250 neurologists replied. Neurologists gave 90% of the diagnoses but only 50% of patients reported them as the major aid helping to understand the disease. Fifty per cent of patients were not informed about any form of therapy at the time of diagnosis regardless of whether their MS diagnosis was disclosed within the last 5 years or earlier. In contrast to physicians, patients voted for information about a possible MS even if the diagnosis may not yet be clear.

CONCLUSION

From the patients' perspective, information about the diagnosis of MS should be more straightforward, and more information about therapies should be provided.

Basal serum levels and reactivity of nerve growth factor and brain-derived neurotrophic factor to standardized acute exercise in multiple sclerosis and controls

Neurotrophins like brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) are thought to play an important role in neuronal repair and plasticity. Recent experimental evidence suggests neuroprotective effects of these proteins in multiple sclerosis (MS). We investigated the response of serum NGF and BDNF concentrations to standardized acute exercise in MS patients and controls. Basal NGF levels were significantly elevated in MS. Thirty minutes of moderate exercise significantly induced BDNF production in MS patients and controls, but no differential effects were seen. We conclude that moderate exercise can be used to induce neutrophin production in humans. This may mediate beneficial effects of physical exercise in MS reported recently.

Cognitive performance of children who have undergone liver transplantation

BACKGROUND

We investigated the cognitive status and quality of life (QoL) in the late postoperative phase of children who had undergone liver transplantation (LTx).

METHODS

The sample consisted of 29 children who had undergone LTx at our center. The children were at least 6 years of age and had received the transplant between 3 and 10 years (mean 6.4 years) previously. In 16 of the 29 children, a living-related transplantation had been performed. Cognitive function was assessed with the three subscales of the Kaufman Assessment Battery for Children (K-ABC): the sequential processing scale, simultaneous processing scale, and achievement scale. QoL was measured with a specific questionnaire for children.

RESULTS

The children scored below the population mean but within the normal range on all subscales of the K-ABC, except for the sequential processing scale, on which the children scored significantly below the norm and below their own performance on the simultaneous processing scale. Scores were below average for everyday and psychic functions and in the normal range for social and physical functions on the QoL questionnaire. Age at transplantation and achievement in the K-ABC were highly negatively correlated. A multiple regression analysis revealed that age and height at transplantation, and also to a lesser degree the type of transplantation, predict the level of cognitive functioning in the late postoperative phase.

CONCLUSION

We conclude that the cognitive functions and QoL of children in the late postoperative phase who have undergone LTx are at the lower end of the norm in the long-term follow-up. Children who are younger and more physically developed at the time of transplantation will have a better mental-development prognosis.

Oral terbutaline differentially affects cytokine (IL-10, IL-12, TNF, IFNg) release in multiple sclerosis patients and controls

Administration of beta-receptor agonists alleviate experimental multiple sclerosis (MS) in animal models. In this study, we investigated the effects of terbutaline (5 mg) on IL-10, IL-12, IFN-gamma and TNF-alpha production in whole blood stimulation cultures. IL-10 and IL-12 production were significantly enhanced in controls but not in MS patients (p=0.03 and p=0.001). Effects were not associated with an ongoing immunomodulatory therapy. We conclude that administration of terbutaline induces anti-inflammatory (IL-10) as well as IL-12 protein production in healthy controls but not in MS patients. Our findings might reflect a disturbed autonomic control of the immune system in MS.

When should a substance be designated as sensitizing for the skin ('Sh') or for the airways ('Sa')?

In the List of MAK and BAT Values compounds are designated with 'Sa' ('sensitizing for the airways') or 'Sh' ('sensitizing for the skin') if, according to scientific evidence, they are allergens. Mainly based on suggestions by a WHO working group and based on our own experience, extended criteria have been elaborated by the working group 'skin and allergy' of the Commission of the Deutsche Forschungsgemeinschaft for the Investigation of Health Hazards of Chemical Compounds in the Work Area, which are presented in this article. They serve as guidelines for deciding which substances have to be labelled 'Sa' and 'Sh', respectively, for the prevention of sensitization and subsequent allergic diseases in workers. Although in some special cases their strict application may not be deemed necessary or possible, the proposed new criteria should be used to make the procedure of classification of substances: 1) more rational, 2) more consistent, 3) more comprehensible, and 4) more transparent. This paper informs readers working scientifically or administratively in this field and invites a critical discussion of the issue.

Endocrine and cytokine responses to acute psychological stress in multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system. An impaired hypothalamopituitary axis and stress reactivity have extensively been discussed without convincing experimental evidence. We choose a standardized acute psychological stressor to determine whether MS patients show altered endocrine and immune responses to stress. In 35 relapsing-remitting MS patients we found elevated baseline levels for catecholamines, prolactin, and IL-6 compared to 15 healthy controls. All neuroendocrine parameters declined during the stress intervention in MS as well as in stress-exposed controls. But only prolactin showed a significantly larger decline in stressed MS patients versus controls. During exposure to the stress we found no significant changes in serum levels of IL-6, IL-6 receptor, or TNF-alpha in either MS patients or controls after stimulation of a whole blood culture. An altered neural immune signaling in relapsing-remitting MS patients during acute experimental stress could not be proven for the parameters analyzed.