Treatment of vulvar cancer recurrence with electrochemotherapy: a case-control study

BACKGROUND

Electrochemotherapy (ECT) is a combined treatment method based on electroporation and simultaneous chemotherapy. In cases where radiotherapy has previously been used, surgery is often the only treatment option for vulvar cancer recurrence with potential resection of clitoris, vagina, urethra or anal sphincter. The unique advantage of ECT is its selectivity for cancer cells while sparing the surrounding healthy tissue. The aim of the study was to compare the ECT treatment of vulvar cancer recurrence for non-palliative purposes with surgical treatment.

MATERIALS AND METHODS

Eleven patients with single vulvar cancer recurrence were treated with ECT and followed up for 12 months. As a control group, 15 patients with single vulvar cancer recurrence were treated with wide local excision. The following data were collected, analyzed and compared: Age, body mass index, comorbidities, histological type, location and size of vulvar cancer recurrence, treatment history, details of procedures and hospital stay.

RESULTS

The probability curves for local tumor control did not differ between the ECT group and the surgical group (p = 0.694). The mean hospital stay and the mean duration of procedure were statistically significantly shorter in the ECT group (p < 0.001). There were no statistically significant differences between the ECT and surgical groups in terms of mean body mass index, associated diseases, previous treatments, presence of lichen sclerosus, p16 status, gradus, anatomical site of the tumor, and type of anesthesia.

CONCLUSION

In this case-control study, treatment of vulvar cancer recurrence with ECT for non-palliative purposes was comparable to surgical treatment in terms of effectiveness. The results need to be confirmed in larger randomized trials.

High-Grade Serous Ovarian Cancer during Pregnancy: From Diagnosis to Treatment

BACKGROUND

Due to the rarity of ovarian cancer diagnosed during pregnancy, the literature on the treatment of subtypes of epithelial ovarian cancer in pregnancy is sparse. The aim of our review was to analyze cases of high-grade serous ovarian cancer in pregnancy.

METHODS

The PubMed and Scopus databases were searched for relevant articles published in English between January 2000 and December 2023. The references of all the relevant reviews found were also checked to avoid omitting eligible studies. Information on the all retrieved cases was extracted and reviewed in detail. The most important detail was the subtype of high-grade serous ovarian cancer, which was referred to as serous adenocarcinoma (grade 2 or grade 3) in older cases.

RESULTS

We found eleven cases with relevant details of high-grade serous ovarian cancer diagnosed in pregnancy. Despite the small number of cases we found, our study demonstrated the importance of an accurate initial vaginal ultrasound at the first examination in pregnancy and the safety of diagnostic surgery and chemotherapy in pregnancy.

CONCLUSIONS

There have not been long-term follow-ups of patients' oncologic and obstetric outcomes. As patients should be comprehensively informed, more detailed case reports or series with longer follow-up periods are needed.

Impact of early integrated rehabilitation on fatigue in 600 patients with breast cancer - a prospective study

BACKGROUND

Fatigue after breast cancer treatment is a common burden that is challenging to treat. The aim of this study was to explore if such integrated rehabilitation program reduces the prevalence of chronic fatigue compared to simple, non-integrated rehabilitation.

PATIENTS AND METHODS

The subjects of our prospective study were 600 female breast cancer patients (29-65 [mean 52 years] of age), who participated in the pilot study on the individualized integrated rehabilitation of breast cancer patients in 2019-2021 and were monitored for one year. The control group included 301 patients and the intervention group numbered 299 patients. The patients completed three questionnaires (EORTC QLQ-C30, -BR23 and NCCN): before cancer treatment, and then six and twelve months after the beginning of cancer treatment. The control group obtained the standard rehabilitation program, while the intervention group was part of the early, individualized multidisciplinary and integrated approach of rehabilitation. The rehabilitation coordinator referred patients for additional interventions (e.g., psychologist, gynecologist, pain management team, physiotherapy, clinical nutrition team, kinesiologist-guided online training, vocational rehabilitation, general practitioner). Data on the patients' demographics, disease extent, cancer treatment and complaints reported in questionnaires were collected and analyzed.

RESULTS

There were no differences between the control and the intervention group of patients in terms of age, education, disease extent, surgical procedures, systemic cancer treatment, or radiotherapy, and also no differences in the fatigue before the beginning of treatment. However, patients from the control group had a greater level of constant fatigue than patients from the intervention group half a year (p = 0.018) and a year (p = 0.001) after the beginning of treatment. Furthermore, a greater proportion of patients from the control group experienced significant interference with their usual activities from fatigue than from the intervention group, half a year (p = 0.042) and a year (p = 0.001) after the beginning of treatment. A multivariate logistic regression showed that one year after the beginning of treatment, the only independent factor correlated to fatigue was inclusion into the intervention group (p = 0.044). Inclusion in the intervention group was beneficial-patients from the control group were 1.5 times more likely to be fatigued.

CONCLUSIONS

Early individualized integrated rehabilitation is associated with a lower prevalence of chronic fatigue or fatigue interfering with usual activities in breast cancer patients in comparison to the control group of patients.

Evaluation of an Early Individualized Integrated Rehabilitation Program versus Standard Rehabilitation Program for Smoking Cessation in 115 Smokers Among 467 Female Breast Cancer Patients 2019-2021 in Slovenia

BACKGROUND Cigarette smoking affects cancer risk and cardiovascular risk. Smoking cessation is very beneficial for health. This study aimed to evaluate an early individualized integrated rehabilitation program and standard rehabilitation program for smoking cessation in breast cancer patients. MATERIAL AND METHODS This prospective study included 467 breast cancer patients (29-65 (mean 52) years of age) treated at the Institute of Oncology Ljubljana from 2019 to 2021 and were followed longer than 1 year. The control group and intervention group included 282 and 185 patients, respectively. Three questionnaires were completed by patients before and 1 year after the beginning of oncological treatment. The intervention group received interventions according to the patient's needs, while the control group underwent standard rehabilitation. The data obtained from the survey were analyzed using the chi-square test and analysis of variance. RESULTS In total, 115 patients were tobacco smokers before the beginning of cancer treatment. There were no differences between the intervention and control group in the prevalence of smoking before the treatment. Before the cancer treatment, smoking was present in the intervention group in 22% and in control group in 27% (P=0.27). One year after the beginning of cancer treatment, smoking was present in the intervention group in only 10% of cases, while it was present in control group in 20% of cases. Smoking was significantly less common in the intervention group than in the control group (P=0.004). CONCLUSIONS Smoking cessation was more common after early integrated rehabilitation than after standard rehabilitation.

Modern approach to the management of genitourinary syndrome in women with gynecological malignancies

BACKGROUND

The term genitourinary syndrome of menopause was first used in 2014 by the North American Menopause Society and the International Society for the Study of Women's Sexual Health to describe conditions previously known as atrophic vaginitis, urogenital atrophy, or vulvovaginal atrophy. It is a complex, chronic, progressive condition characterized by a wide range of signs and symptoms affecting sexual function and the tissues of the urinary and genital tracts. The main cause of genitourinary syndrome of menopause is estrogen deficiency caused by ovarian removal or dysfunction. The most bothersome symptoms are vaginal dryness, decreased vaginal lubrication, and pain during penetration and intercourse. They all have a negative impact on the quality of life.

CONCLUSIONS

The main goal of treatment is to relieve the symptoms. Treatment modalities are pharmacological or non-pharmacological. The first-line treatment for mild to moderate symptoms is the use of personal lubricants and moisturizers, but the gold standard is estrogen replacement therapy. Hormone therapy may not be an option for women with hormone-dependent cancer.

Safety and Feasibility of Vulvar Cancer Treatment with Electrochemotherapy

Electrochemotherapy is a local ablative therapy used for the treatment of various superficial and deep-seated tumors. Electrochemotherapy involves the application of electric pulses locally to tumors to destabilize cell membranes and facilitate the entry of cytotoxic drugs, thereby enhancing their cytotoxicity locally. The aim of our study is to investigate the safety and feasibility of electrochemotherapy in patients with vulvar cancer recurrence used for nonpalliative purposes. Ten patients with single local vulvar cancer recurrence were treated with intravenous bleomycin, followed by a local application of electric pulses (electrochemotherapy) to the tumor. Adverse events were determined using the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The feasibility of treating vulvar cancer with electrochemotherapy was determined by an appropriate selection of electrodes based on the size and location of the tumor with safety margins included. Electrochemotherapy was feasible in all patients. No electrochemotherapy-related or other serious adverse events occurred. Our data suggest that electrochemotherapy is a feasible and safe technique for the treatment of vulvar cancer recurrence for nonpalliative purposes. Based on our results, electrochemotherapy might be a viable therapeutic tool for patients who would otherwise undergo surgery involving a mutilation of the external genitalia.

Treatment of vulvar cancer recurrences with electrochemotherapy - a detailed analysis of possible causes for unsuccessful treatment

BACKGROUND

Electrochemotherapy has good local effectiveness in the treatment of vulvar cancer. Most studies have reported the safety and effectiveness of electrochemotherapy for palliative treatment of gynecological cancers and mostly vulvar squamous cell carcinoma. Some tumors, however, fail to respond to electrochemotherapy. The biological features/determinants for the nonresponsiveness are not determined yet.

PATIENT AND METHODS

A recurrence of vulvar squamous cell carcinoma was treated by electrochemotherapy using intravenous administration of bleomycin. The treatment was performed by hexagonal electrodes according to standard operating procedures. We analyzed the factors that could determine nonresponsiveness to electrochemotherapy.

RESULTS

Based on the presented case of nonresponsive vulvar recurrence to electrochemotherapy, we hypothesize that the vasculature of the tumors prior to treatment may predict the response to electrochemotherapy. The histological analysis showed minimal presence of blood vessels in the tumor. Thus, low perfusion may reduce drug delivery and lead to a lower response rate because of the minor antitumor effectiveness of vascular disruption. In this case, no immune response in the tumor was elicited by electrochemotherapy.

CONCLUSIONS

In this case, of nonresponsive vulvar recurrence treated by electrochemotherapy, we analyzed possible factors that could predict treatment failure. Based on histological analysis, low vascularization of the tumor was observed, which hampered drug delivery and distribution and resulted in no vascular disrupting action of electro-chemotherapy. All these factors could contribute to ineffective treatment with electrochemotherapy.

Abstract P6-05-31: Early integrated rehabilitation helps smoking cessation in 467 breast cancer patients – a comparison between the intervention and control group in a prospective study

Background: Tobacco related illnesses are important public health issues worldwide. Cigarette smoking effects cancer risk and cardiovascular risk. Smoking cessation confers substantial benefits on health. Our aim was to determine whether the early introduction of integrated rehabilitation from the beginning of cancer treatment is associated with the smoking cessation in breast cancer patients. Material and Methods: The subjects of our prospective study were 467 female breast cancer patients (29-65 (mean 52) years of age), who participated in the pilot study on the individualized integrated rehabilitation of breast cancer patients in 2019-2022 and were followed for at least one year. The control group included 282 patients and the intervention group 185 patients. The patients completed three questionnaires (EORTC QLQ - C30, B23 and NCCN) before and one year after the beginning of cancer treatment. The control group obtained the same rehabilitation as was offered to all breast cancer patients in our hospital before the start of our prospective study. The multidisciplinary rehabilitation team reviewed the documentation of all the patients from the intervention group before and one year after the beginning of cancer treatment and recommended appropriate interventions according to the patient’s difficulties. The integrated rehabilitation coordinator referred patients for additional interventions in compliance with the institute’s clinical pathway (psychologist, general practitioner, clinical nutritionist, physical rehabilitation, kinesiologist-guided online exercises, gynecologist, analgesia, vocational rehabilitation). Smokers were referred to a smoking cessation workshop organized by a health promotion center within community health centres. Data on the patients’ demographics, disease extent, cancer treatment and prevalence of tobacco smoking before and one year after the beginning of cancer treatment were collected and analysed using the chi-square and ANOVA test. Results: There were no differences between the control and the intervention group of patients in terms of age, education, disease extent, surgical procedures, systemic cancer treatment, or radiotherapy. There were no differences between the groups in the prevalence of smoking before the treatment. Before the cancer treatment, smoking was present in the intervention and control group in 22% and 27% (p=0.22), respectively. However, one year after the beginning of cancer treatment, smoking was less common in the intervention group in comparison to the control group of patients (p=0.004). Smoking was present in the intervention and control group in 10% and 20%, respectively. Conclusions: Early integrated rehabilitation helps the smoking cessation in breast cancer patients.

Citation Format: Nikola Besic, Zlatka Mavric, Anamarija Mozetic, Tina Zagar, Vesna Homar, Nena Kopcavar Gucek, Andreja Cirila Skufca Smrdel, Jana Knific, Simona Borstnar, Mateja Kurir Borovcic, Lorna Zadravec Zaletel, Natasa Kos, Branka Strazisar, Denis Mastnak Mlakar, Nina Kovacevic, Vedran Hadzic, Bojan Pelhan, Marko Sremec, Tina Rozman, Romi Cencelj-Arnez. Early integrated rehabilitation helps smoking cessation in 467 breast cancer patients – a comparison between the intervention and control group in a prospective study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-31.

The patient's needs before and six months after the initiation of breast cancer treatment: A prospective study in 600 breast cancer patients

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Background: Our aim was to determine the frequency of health-related problems faced by breast cancer patients before and six months after the initiation of breast cancer treatment. Methods: This prospective study involved 600 female breast cancer patients (26-65 years, mean 52), who participated in the pilot study in the novel individualized integrated rehabilitation programme in 2019-2022 and were followed for at least six months. The patients completed three questionnaires (EORTC QLQ - C30, B23 and NCCN) before the initiation of cancer treatment and six months after. The patients received neoadjuvant chemotherapy in 22% of the cases, tumorectomy in 53%, mastectomy in 39%, breast reconstruction in 27%, sentinel node biopsy in 67%, lymphadenectomy in 23%, external beam radiotherapy in 73%, chemotherapy in 45%, anti-HER-2 therapy in 11% and hormonal therapy in 74% of the cases. Data on the patients’ demographics, disease extent, cancer treatment and problems reported in the questionnaires were collected and analysed using descriptive analysis. Results: The problems reported by patients before the initiation of cancer treatment and after six months are presented in Table. In 14 out of 22 parameters, the frequency of problems increased in the six months after the initiation of treatment: fatigue, insomnia, lymphedema, shoulder movement impairment, disturbing scars, heart problems, hot flashes/sweating, gynaecological problems, sexual problems, body image worries, inappropriate nutrition, pain in the shoulder or arm, alopecia and concerns about returning to work. On the other hand, the frequency of problems decreased six months after the initiation of cancer treatment in 6 out of 22 parameters. Our patients less often had depression or anxiety, were too little physically active, smoked, consumed alcohol or used food supplements than before. Conclusions: Six months after the initiation of breast cancer treatment patients have more problems than at the time before treatment.[Table: see text]

The association of early integrated rehabilitation and moderate or severe fatigue in 600 patients with breast cancer: A comparison between the intervention group and control group in a prospective study

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Background: Fatigue after breast cancer treatment is a major health problem that is very difficult to treat. Our aim was to determine whether the early introduction of focused rehabilitation from the start of the cancer treatment is associated with the frequency of fatigue in breast cancer patients. Methods: The subjects of our prospective study were 600 female breast cancer patients (26-65 (mean 52) years of age), who participated in the pilot study on the individualized integrated rehabilitation of breast cancer patients in 2019-2022 and were followed for at least six months. The control group included 300 patients and the intervention group 300 patients. The patients completed three questionnaires (EORTC QLQ - C30, B23 and NCCN): before and six months after the beginning of cancer treatment. The control group obtained the same rehabilitation as was offered to all breast cancer patients in our hospital before the start of our study. The multidisciplinary rehabilitation team reviewed the documentation of all the patients from the intervention group before six months after the beginning of treatment and recommended appropriate interventions according to the patient's problems. The integrated rehabilitation coordinator referred patients for additional treatments in compliance with the institute’s new clinical pathway (psychologist, general practitioner, nutritional treatment, physical rehabilitation, kinesiologist-guided online exercises, gynaecologist, analgesia, vocational rehabilitation). Data on the patients’ demographics, disease extent, cancer treatment and complaints reported in questionnaires were collected. This data and the frequency of fatigue six months after the beginning of treatment in both groups of patients were analysed using the chi-square and ANOVA test. Results: There were no differences between the control and the intervention group of patients in terms of age, education, disease extent, surgical procedures, systemic cancer treatment, or radiotherapy. There were no differences between the groups in the prevalence of fatigue before the start of treatment. Before the cancer treatment, 50% of the patients in both groups reported fatigue, while moderate or severe fatigue was reported in the intervention and control groups in 9% and 10% (p = 0.69), respectively. Six months after the beginning of cancer treatment, fatigue was reported in the intervention and control groups in 66% and 70% (p = 0.38), respectively. However, moderate or severe fatigue were reported in the intervention and control groups in 17% and 26% (p = 0.02), respectively. Conclusions: Early integrated rehabilitation is associated with a lower prevalence of moderate or severe fatigue in breast cancer patients in comparison to the control group six months after the beginning of cancer treatment.

Electrochemotherapy as an Alternative Treatment Option to Pelvic Exenteration for Recurrent Vulvar Cancer of the Perineum Region

Objective: Pelvic exenteration in women with recurrent vulvar carcinoma is associated with high morbidity and mortality and substantial treatment costs. Because pelvic exenteration severely affects the quality of life and can lead to significant complications, other treatment modalities, such as electrochemotherapy, have been proposed. The aim of this study was to evaluate the feasibility and suitability of electrochemotherapy in the treatment of recurrent vulvar cancer. We aimed to analyze the treatment options, treatment outcomes, and complications in patients with recurrent vulvar cancer of the perineum. Methods: A retrospective analysis of patients who had undergone pelvic exenteration for vulvar cancer at the Institute of Oncology Ljubljana over a 16-year period was performed. As an experimental, less mutilating treatment, electrochemotherapy was performed on one patient with recurrent vulvar cancer involving the perineum. Comparative data analysis was performed between the group with pelvic exenteration and the patient with electrochemotherapy, comparing hospital stay, disease recurrence after treatment, survival after treatment in months, and quality of life after treatment. Results: We observed recurrence of disease in 2 patients with initial FIGO stage IIIC disease 3 months and 32 months after pelvic exenteration, and they died of the disease 15 and 38 months after pelvic exenteration. Two patients with FIGO stage IB were alive at 74 and 88 months after pelvic exenteration. One patient with initial FIGO stage IIIC was alive 12 months after treatment with electrochemotherapy with no visible signs of disease progression in the vulvar region, and the lesions had a complete response. The patient treated with electrochemotherapy was hospitalized for 4 days compared with the patients with pelvic exenteration, in whom the average hospital stay was 19.75 (± 1.68) days. Conclusion: Our experience has shown that electrochemotherapy might be a less radical alternative to pelvic exenteration, especially for patients with initially higher FIGO stages.

Subspecialty training in Europe: a report by the European Network of Young Gynaecological Oncologists

BACKGROUND

ESGO (European Society of Gynaecological Oncology) and partners are continually improving the developmental opportunities for gynaecological oncology fellows. The objectives of this survey were to evaluate the progress in the infrastructure of the training systems in Europe over the past decade. We also evaluated training and assessment techniques, the perceived relevance of ENYGO (European Network of Young Gynaecological Oncologists) initiatives, and unmet needs of trainees.

METHODOLOGY

National representatives of ENYGO from 39 countries were contacted with an electronic survey. A graduation in well/moderately/loosely-structured training systems was performed. Descriptive statistical analysis and frequency tables, as well as two-sided Fisher's exact test, were used.

RESULTS

National representatives from 33 countries answered our survey questionnaire, yielding a response rate of 85%. A national fellowship is offered in 22 countries (66.7%). A logbook to document progress during training is mandatory in 24 (72.7%) countries. A logbook of experience is only utilized in a minority of nations (18%) for assessment purposes. In 42.4% of countries, objective assessments are recognized. Trainees in most countries (22 (66.7%)) requested additional training in advanced laparoscopic surgery. 13 (39.4%) countries have a loosely-structured training system, 11 (33.3%) a moderately-structured training system, and 9 (27.3%) a well-structured training system.

CONCLUSION

Since the last publication in 2011, ENYGO was able to implement new activities, workshops, and online education to support training of gynaecological oncology fellows, which were all rated by the respondents as highly useful. This survey also reveals the limitations in establishing more accredited centers, centralized cancer care, and the lack of laparoscopic training.

Support to responsive parenting through communication tools

Issue

Counselling unit for positive parenting “Halobeba” has been established at Institute of Public Health of Belgrade with support of UNICEF in order to enable continuum of mother and child health care. Availability of information on child care and development was noticed as significant factor for parental confidence and practice.

Description of the problem

Trained nurses provide responses to parental questions through 24/7 phone and e mail communication to assist in problem solving and offer emotional support. Nurses are skilled in active listening, proper questioning, counselling and effective encouragement. Free mob app on breastfeeding was developed as knowledge base for parents. New interactive mob app was recently launched as parenting tool for child health and development monitoring.

Results

Since 2002, more than 1,700,000 responses were provided through phone communication and over 20,000 via email and number of beneficiaries has increased over the years. Most common topics were about breastfeeding, introducing solid food, treatment of fever and respiratory infections, gastrointestinal problems, injuries, immunization, and developmental milestones. Less than 15% of cases were referred to pediatric clinic. Level of parental overall satisfaction was very high and availability and effectiveness of service were especially valued as well as nurses communication skills.

Lessons

Family centered service that corresponds to caregivers needs is effective approach to support nurturing care for young children. Personalized M-health tools make child care more accessible and build capacities of caregivers.

Key messages

Sending consistent and trusted messages through different communication channels contribute to enhancing users' knowledge and skills. Knowledgeable and responsive caregivers properly interpret child’s needs, respond appropriately, facilitate the child’s social and emotional development, and provide proper care.

Menopause-specific Quality of Life Questionnaire: factor and Rasch analytic approach

OBJECTIVE

The study aimed to assess the psychometric properties of the Menopause-specific Quality of Life Questionnaire (MENQOL) in Serbian climacteric women.

METHODS

Two hundred mid-aged (40-65 years) women filled out a general sociodemographic and medical questionnaire, the MENQOL, the Short Form-36 questionnaire (SF-36), and Beck's Depression Inventory (BDI). The MENQOL was translated according to recommended methodology and its psychometric properties (internal consistency, discriminant, construct and criterion validity, factor and Rasch analyses) were assessed.

RESULTS

Cronbach's alpha coefficient for the Serbian MENQOL was 0.957 (Vasomotor =0.917, Psychosocial =0.907, Physical =0.928, Sexual =0.913). Corrected item-total correlation coefficients were >0.50 for all items. Factor analysis extracted six domains with total variance of 72.02%. Beside the four original domains, two new domains were observed: Attractiveness and Pain. Factor loadings for all items were appropriate (>0.4). The MENQOL correlated with the SF-36 and BDI total scores, suggesting good criterion validity. Rasch analysis showed adequate reliability (item =0.91; person =0.79) and separation (item =1.95; person =3.21) indexes, proving good reproducibility and reliability of the Serbian MENQOL. All items had infit and outfit mean squares in the standard accepted range.

CONCLUSION

Principal component analysis showed somewhat different constructs from the original scale. However, Rasch analysis confirmed that the MENQOL represents a good metric instrument for menopausal symptoms.

Integrating patient safety education into early medical education utilizing cadaver, sponges, and an inter-professional team

BACKGROUND

Introducing patient safety and quality improvement science to medical students is integral to improving healthcare. However, developing and implementing a patient safety curriculum can be challenging in a medical school curriculum that is already densely packed. Our aim was to develop and evaluate the impact of a workshop introducing patient safety and quality improvement science to a large class of first-year medical students.

METHOD

As a part of an evolving longitudinal patient safety curriculum, an introductory workshop on patient safety was integrated into an anatomy course. A high impact event (a simulated "retained sponge" discovery during an anatomy dissection lab) was used to introduce medical error. The educational session which followed consisted of a presentation by an interprofessional team utilizing the retained sponge as example of an error. Use of safety tools was introduced and quality improvement science was discussed using the evolution of methods to decrease retained foreign objects during surgery. A patient's story told by a close family member about the personal impact of medical errors was presented. Students then participated in an interactive breakout activity and completed a module on safety. The impact of the workshop was assessed through pre- and post- session tests.

RESULTS

Quantitative and qualitative evaluation reflected a positive effect of the session in improving students' safety knowledge and attitudes. Students' mean total knowledge improved from 7.58 to 8.98 (p = 0.000). Mean total attitudes score improved from 47.73 to 50.56 (p = 0.000). Students' comments after the workshop reflected increased awareness and appreciation of the importance of addressing medical errors.

CONCLUSION

A workshop introducing patient safety and quality improvement to first year medical students improved knowledge and attitudes regarding safety and increased awareness of the importance of addressing medical errors in their future careers. Integrating patient safety education into an existing foundational science course is a model for teaching patient safety at other medical schools.

Serbian version of the Women's Health Questionnaire: psychometric properties

OBJECTIVE

The aim of this study was to translate the Women's Health Questionnaire (WHQ) into the Serbian language and assess its validity and reliability in a population of Serbian menopausal women.

METHODS

The study included peri- and postmenopausal women from two Community Health Centers in Belgrade. Women filled out the WHQ, the Short Form-36 questionnaire (SF-36) and Beck's Depression Inventory (BDI). The WHQ was translated according to recommended methodology for cultural adaptation of questionnaires and its psychometric characteristics (internal consistency, inter-rater reliability, factor analysis, sensitivity, discriminant, construct and criterion validity) were tested.

RESULTS

In the Serbian population, the mean values of the WHQ domains were mostly comparable with reference Mediterranean countries. Whole-scale Cronbach's α was 0.838. Moreover, five WHQ domains had a value of Cronbach's α above the acceptable limit. There were no significant differences in WHQ scores between our two investigators. On exploratory factor analysis, we obtained ten factors (two items formed a new factor - 'Menstrual pathology'). Almost all SF-36 domains were significantly associated with WHQ domains, while the BDI was associated with domains: depressive mood, anxiety and sleep problems. Based on ROC analysis, WHQ is slightly more reliable for perimenopausal than postmenopausal Serbian women.

CONCLUSION

The Serbian version of the WHQ showed very good reliability and validity in assessment of quality of life among menopausal women. The WHQ is applicable for both peri- and postmenopausal women.

Spatiotemporal dependency of age-related changes in brain signal variability

Recent theoretical and empirical work has focused on the variability of network dynamics in maturation. Such variability seems to reflect the spontaneous formation and dissolution of different functional networks. We sought to extend these observations into healthy aging. Two different data sets, one EEG (total n = 48, ages 18–72) and one magnetoencephalography (n = 31, ages 20–75) were analyzed for such spatiotemporal dependency using multiscale entropy (MSE) from regional brain sources. In both data sets, the changes in MSE were timescale dependent, with higher entropy at fine scales and lower at more coarse scales with greater age. The signals were parsed further into local entropy, related to information processed within a regional source, and distributed entropy (information shared between two sources, i.e., functional connectivity). Local entropy increased for most regions, whereas the dominant change in distributed entropy was age-related reductions across hemispheres. These data further the understanding of changes in brain signal variability across the lifespan, suggesting an inverted U-shaped curve, but with an important qualifier. Unlike earlier in maturation, where the changes are more widespread, changes in adulthood show strong spatiotemporal dependence.

Hippocampal signal complexity in mesial temporal lobe epilepsy: a noisy brain is a healthy brain

Patients with mesial temporal lobe epilepsy (mTLE) show structural and functional abnormalities in hippocampus and surrounding mesial temporal structures. Brain signal complexity appears to be a marker of functional integrity or capacity. We examined complexity in 8 patients with intracranial hippocampal electrodes during performance of memory tasks (scene encoding and recognition) known to be sensitive to mesial temporal integrity. Our patients were shown to have right mesial temporal seizure onsets, permitting us to evaluate both epileptogenic (right) and healthy (left) hippocampi. Using multiscale entropy (MSE) as a measure of complexity, we found that iEEG from the epileptogenic hippocampus showed less complexity than iEEG from the healthy hippocampus. This difference was reliable for encoding but not for recognition. Our results indicate that both functional integrity and cognitive demands influence hippocampal signal complexity.

The development of a noisy brain

Early in life, brain development carries with it a large number of structural changes that impact the functional interactions of distributed neuronal networks. Such changes enhance information processing capacity, moving the brain from a deterministic system to one that is more stochastic. The evidence from empirical studies with EEG and functional MRI suggests that this stochastic property is a result of an increased number of possible functional network configurations for a given situation. This is captured in the variability of endogenous and evoked responses or "brain noise ". In empirical data from infants and children, brain noise increases with maturation and correlates positively with stable behavior and accuracy. The noise increase is best explained through increased noise from network level interactions with a concomitant decrease of local noise. In old adults, brain noise continues to change, although the pattern of changes is not as global as in early development. The relation between high brain noise and stable behavior is maintained, but the relationships differ by region, suggesting changes in local dynamics that then impact potential network configurations. These data, when considered in concert with our extant modeling work, suggest that maturational changes in brain noise represent the enhancement offunctional network potential--the brain's dynamic repertoire.

Evaluation of the anti-inflammatory and cytotoxic activities of naphthazarine derivatives from Onosma leptantha

The root extracts of Onosma leptanhtha were evaluated for their anti-iflammatory and cytotoxic activities. The cyclohexane extract, which appeared as the most active in both assays, has been further subjected to bioassay-directed fractionation to afford the naphthazarine derivatives: beta,beta-dimethylacrylshikonin (1), isovalerylshikonin (2) and acetylshikonin (3). The evaluation of the anti-inflammatory activity was performed on carrageenan-induced rat paw edema test. All the tested compounds proved to be active, while compound 3 showed the best anti-inflammatory effect. In addition, the cytotoxic activity of the extracts and isolated compounds, was also assayed against L1210 murine lymphoblastic leukemia cell line, and human fibrosarcoma HT-1080 cells. Compound 1 exhibited remarkable cytotoxic activity (390 nM for L1210 cells), which is superior to that of shikonin, which was used as control.

Semiautomatic brain region extraction: a method of parcellating brain regions from structural magnetic resonance images

Structural MR imaging has become essential to the evaluation of regional brain changes in both healthy aging and disease-related processes. Several methods have been developed to measure structure size and regional brain volumes, but many of these methods involve substantial manual tracing and/or landmark identification. We present a new technique, semiautomatic brain region extraction (SABRE), for the rapid and reliable parcellation of cortical and subcortical brain regions. We combine the SABRE parcellation with tissue compartment segmentation [NeuroImage 17 (2002) 1087] to produce measures of gray matter (GM), white matter (WM), ventricular CSF, and sulcal CSF for 26 brain regions. Because SABRE restricts user input to a few easily identified landmarks, inter-rater reliability is high for all volumes, with all coefficients between 0.91 and 0.99. To assess construct validity, we contrasted SABRE-derived volumetric data from healthy young and older adults. Results from the SABRE parcellation and tissue segmentation showed significant differences in multiple brain regions in keeping with regional atrophy described in the literature by researchers using lengthy manual tracing methods. Our findings show that SABRE is a reliable semiautomatic method for assessing regional tissue volumes that provides significant timesavings over purely manual methods, yet maintains information about individual cortical landmarks.

A robust method for extraction and automatic segmentation of brain images

A new protocol is introduced for brain extraction and automatic tissue segmentation of MR images. For the brain extraction algorithm, proton density and T2-weighted images are used to generate a brain mask encompassing the full intracranial cavity. Segmentation of brain tissues into gray matter (GM), white matter (WM), and cerebral spinal fluid (CSF) is accomplished on a T1-weighted image after applying the brain mask. The fully automatic segmentation algorithm is histogram-based and uses the Expectation Maximization algorithm to model a four-Gaussian mixture for both global and local histograms. The means of the local Gaussians for GM, WM, and CSF are used to set local thresholds for tissue classification. Reproducibility of the extraction procedure was excellent, with average variation in intracranial capacity (TIC) of 0.13 and 0.66% TIC in 12 healthy normal and 33 Alzheimer brains, respectively. Repeatability of the segmentation algorithm, tested on healthy normal images, indicated scan-rescan differences in global tissue volumes of less than 0.30% TIC. Reproducibility at the regional level was established by comparing segmentation results within the 12 major Talairach subdivisions. Accuracy of the algorithm was tested on a digital brain phantom, and errors were less than 1% of the phantom volume. Maximal Type I and Type II classification errors were low, ranging between 2.2 and 4.3% of phantom volume. The algorithm was also insensitive to variation in parameter initialization values. The protocol is robust, fast, and its success in segmenting normal as well as diseased brains makes it an attractive clinical application.

Instrumented implant for measuring tibiofemoral forces

Experimental measurement of loads occurring in the human knee joint will allow validation of analytical models and provide data for the design of total knee implants. A customized transducer was developed to measure the dynamic tibiofemoral force and center of pressure after total knee arthroplasty. The transducer consists of a standard tibial component to which four uniaxial load cells and an additional tibial tray have been added. The transducer was calibrated using a loading device traceable to the National Institute of Standards and Technology (NIST). The transducer was accurate to within 1% in magnitude, 0.07 mm in medial/lateral location and 0.24 m in anterior/posterior location.

Elevated somatostatin in pancreatic islets of adrenalectomized dogs

We have observed both hyperglucagonemia and hypoinsulinemia in adrenalectomized (Adx) dogs. To determine whether these hormonal alterations are related to changes in distribution of islet hormones in the pancreas, we examined the concentration and total mass of insulin, glucagon, and somatostatin in the head, body, and tail of the pancreas by immunoassay and immunocytochemistry. We studied 6 normal dogs, 5 Adx dogs deprived of cortisol for 24 h (Adx I) and 5 for 48-72 h (Adx II). In normal dogs, single and double immunocytochemical staining showed that, in contrast to some other species, B (insulin) cells are mostly in the central region of islet, whereas A (glucagon) and D (somatostatin) cells are distributed randomly. This topographic distribution was not altered by adrenalectomy. In normal dogs, insulin concentration (micrograms per g) and total mass (micrograms) were higher in the tail (174 +/- 22, 2001 +/- 396) and body (165 +/- 22, 2850 +/- 600) than in the head (91 +/- 17, 668 +/- 156) of pancreas. Glucagon concentration (micrograms per g) and total mass (micrograms) were 17 +/- 2, 178 +/- 17 in the tail; 9.5 +/- 2, 158 +/- 32 in the body, and negligible (0.78 +/- 0.32, 7 +/- 3) in the head, whereas somatostatin concentration (micrograms per g) and total mass (micrograms) were 0.58 +/- 0.26, 4.20 +/- 1.5 in the T, 0.23 +/- 0.10, 3.9 +/- 1.6 in the B, and 0.22 +/- 0.05, 1.8 +/- 0.6 in the H. The striking finding was that adrenalectomy caused large increases in somatostatin in all three regions of pancreas in both Adx I and Adx II. The total mass of somatostatin in Adx I and Adx II increased 4-fold in the tail (P less than 0.02-0.005), 5-fold in the body (P less than 0.01-0.001), and 7-9-fold in the head (P less than 0.05-0.005) and concentration increased 6-fold in the body (P less than 0.005) and 7- to 8-fold in the head (P less than 0.01-0.001). There were no significant changes in the content of insulin and glucagon after adrenalectomy. Plasma concentration of glucagon increased by 50% in Adx I (P less than 0.005) and 70% in Adx II (P less than 0.02), insulin decreased by 39% (P less than 0.005), 23% (NS), respectively, and somatostatin increased by 258% (P less than 0.001) in Adx II. Thus the adrenal glands appear to play an important role in regulation of the content of somatostatin in pancreatic islets.

Glucoregulation in alloxan-diabetic dogs

In order to establish whether a prolonged subnormal secretion of insulin may affect glucoregulation against hypoglycemic stimuli, the level of plasma glucose was decreased in alloxan-diabetic dogs by the infusion of either 50 micrograms/kg . min phlorizin (PHL), ie, reducing the concentration of plasma glucose without hyperinsulinemia; or with 7 mU/kg . min insulin (combined hyperinsulinemia and hypoglycemia). The concentration of glucose, immunoreactive glucagon (IRG), and insulin (IRI) and catecholamines were followed in the plasma. Hepatic glucose production (Ra) and the overall rate of glucose removal from the circulation were calculated by a tracer method. During a 200-minute infusion of PHL plasma glucose fell from 328 +/- 29 to 114 +/- 16 mg/dl, while IRG rose from a mean of 470 +/- 123 to 623 +/- 200 pg/mL, however this increase was significant only in 3 out of 6 dogs. There was no change in the plasma level of epinephrine. Plasma IRI decreased significantly, the IRI/IRG ratio remained low, and Ra did not increase. When the animals were treated with insulin for one week, plasma glucose was restored to normal, while plasma IRI and the IRI/IRG ratio were raised above the normal level. Under these circumstances the infusion of PHL increased plasma IRG significantly from 59 +/- 5 to 110 +/- 32 pg/mL, decreased IRI slightly, and increased Ra by an average of 50 +/- 16%. No measurable change in plasma glucose was observed indicating the restoration of nonhypoglycemic glucoregulation. In diabetic dogs during a 95-minute infusion of insulin, plasma glucose dropped from a mean of 338 +/- 5 to 74 +/- 24 mg/dL.(ABSTRACT TRUNCATED AT 250 WORDS)

Modification of the pattern of central neurons by sensory inputs from the reproductive organs in Aplysia depilans L

In the abdominal ganglion of Aplysia a number of motoneurons regulating visceral organs reacted to the stimulation of the reproductive organs. The response was mostly biphasic and often delayed. The multifunctional interneuron I (cell L10) reacted to the stimulation of the reproductive organs with burst firing, followed by an inhibitory phase. The interneuron II, involved in the regulation of visceral functions, was also activated during stimulation of the reproductive organs and its burst-pattern could be identified on a number of other neurons. Several members of the neurosecretory cell group reacted to the stimulation of reproductive organs. The response was, as a rule, biphasic and similar to the hormone action, long-lasting. Three further cells (near the cell L12, above the cell L21, and the neuron between R2 and R7 with unknown function) showed a stereotyped response to the stimulation of the reproductive organs. All the neurons reacting to the stimulation of the reproductive organs also received inputs from the cardiorenal system. The data support the existence of common networks composing variable units in the regulation of visceral functions of gastropods.

Bending stiffness of unilateral and bilateral fixator frames

The structural and geometric fixator properties that best neutralize the prevailing anteroposterior and transverse bending moments at a tibial fracture site were analyzed in anatomic specimens. Clinically and mechanically, anterior unilateral frames were most effective, particularly when applied with relatively stiff components with a maximal spread between the pins in each main bony fragment and with placement of the longitudinal rod close to the tibia.

Chromatographic pattern of extrapancreatic glucagon and glucagon-like immunoreactivity before and during stimulation by epinephrine and participation of glucagon in epinephrine-induced hepatic glucose overproduction

To characterize the glucagon released in response to epineephrine in depancreatized dogs, plasma samples before and during epinephrine infusion were subjected to molecular-sieve chromatography on Bio-Gel P-30 columns. The chromatographic profile for extrapancreatic immunoreactive glucagon (eIRG) revealed two glucagon moieties of molecular weight 9,000 to 12,000. GLI of this molecular weight was released in response to epinephrine only under conditions of prevailing hyperglycemia. To determine if glucagon's participation in epinephrine-induced hepatic glucose overproduction in diabetes was dependent upon the degree of metabolic control, six conscious depancreatized dogs were infused with epinephrine or epinphrine plus somatostatin, under conditions of prevailing hyperglycemia or normoglycemia. Under normoglycemic conditions, epinephrine stimulated eIRG release, but there was a similar rise in hepatic glucose production (Ra) with or without glucagon suppression by somatostatin. Under hyperglycemic conditions, epinephrine stimulated eIRG and GLI release, and the rise in Ra was significantly greater with epinephrine than with epinephrine plus somatostatin infusion. Thus, under conditions of good metabolic control, epinephrine increased hepatic glucose production independently of glucagon, whereas with poor metabolic control, glucagon contributed to hepatic overproduction of glucose.

Endocrine cells in oxyntic mucosa of a dog 5 years after pancreatectomy

Immunofluorescence shows that the oxyntic mucosa of a dog depancreatized for 5 years and having a poorly-controlled diabetes has more glucagon- and somatostatin-containing cells than the mucosa of a control dog. At the ultrastructural level, 4 endocrine cell types are identified: A-, A-like, D- and enterochromaffin-like (ECL) cells, with increased numbers of A-, A-like and D-cells in gastric glands of the depancreatized dog, together with a higher concentration of immunoreactive glucagon in the gastric mucosa. The increase in A-, A-like and D-cells is compatible with: a) a change induced by the diabetic state itself; b) a hyperplasia secondary to the loss of corresponding pancreatic cells. At any rate, the fact that A-, A-like and D-cells increase parallely may indicate that these three cell types are functionally related one with another.

Plasma glucagon in pups, decreased by fasting, unaffected by somatostatin or hypoglycemia

In pups less than 4 days old, the mean basal plasma immunoreactive glucagon (IRG) level was about 3 times higher than in adult dogs. This high level decreased with age, and in pups older than 12 days the mean plasma IRG level did not differ from that in adults. Insulin-induced hypoglycemia did not raise plasma IRG concentration in young pups. Fasting decreased plasma IRG in young, but not in older pups. This decrease is consistent with the decrease in gluconeogenesis and in contrast to the metabolic adjustments observed in the adult organism. In pups less than 7 days old, both the pancreas and gastric mucosa contained considerably more IRG than the normal value reported for adult dogs. Gastroduodenal IRG was immunologically indistinguishable from pancreatic glucagon. In pups, somatostatin did not decrease the plasma concentration of either IRG or immunoreactive insulin (IRI) and caused no change in plasma glucose or in the rates of glucose production and utilization calculated from experiments with tracers. The experiments indicate that in pups the pancreatic and gastric alpha-cells are unresponsive to stimuli normally effective in grown dogs.

The essentiality of insulin and the role of glucagon in regulating glucose utilization and production during strenuous exercise in dogs

In order to elucidate the role of insulin and glucagon during strenuous exercise (100 m/min, slope 10-12 degrees), we have determined the rates of production (Ra), utilization (Rd), and metabolic clearance (M) of glucose in normal dogs before pancreatectomy and 2 wk after total pancreatectomy (a) when they were being maintained on constant intraportal basal insulin infusion, (245 muU/kg-min) and (b) when insulin supply had been withheld before and during exercise. Such an intense exercise induced in normal dogs a prompt decrease in mean immunoreactive serum insulin (IRI) from 20 +/- 3 to 11 +/- 2 muU/ml. In depancreatized insulin-infused dogs serum IRI during rest and exercise was between 14 +/- 1 and 12 +/- 2 muU/ml. In the third group, after cessation of insulin infusion, IRI decreased by 76% (from 17 +/- 5 to 4 +/- 1) and did not decrease futher during exercise. During exercise, serum immunoreactive glucagon (IRG) increased threefold in normal dogs. In depancreatized dogs serum IRG was the same as in normal resting dogs (indicating a nonpancreatic source of the hormone) but it did not increase during exercise. In normal dogs exercise induced proportional increases in Ra, Rd, and M (threefold) and normoglycemia was maintained. Changes in glucose turnover in depancreatized insulin-infused dogs were similar to those seen in normal dogs suggesting that a decrease in insulin secretion and a rise in IRG are not essential to prevent hypoglycemia in diabetic dogs. With the cessation of insulin infusion in resting depancreatized dogs, Ra increased, M decreased, and hyperglycemia ensued. During exercise, Ra continued to rise, but M did not increase significantly.

CONCLUSIONS

(a) Regulation of glucose production by liver during exercise is multifactorial. A decrease in IRI and an increase in IRG are not the only factors which can promote delivery of glucose to the peripheral tissues. The insulin glucagon molar ratio was found not to be an essential metabolic functional unit in regulating glucose metabolism during exercise. (b) It is hypothesized that increases in blood flow and capillary surface area can lead to an increase in the amount of insulin delivered to the muscle even when serum levels of IRI are reduced during exercies. It is suggested that small, but adequate amounts of insulin (as found in normal and depancreatized insulin-infused dogs) are essential in regulating glucose uptake in the working muscle. (c) Since totally depancreatized dogs had normal serum levels of IRG (originating presumably from the gastrointestinal tract), the question of essentiality of basal glucagon activity in glucose homeostasis during exercise could not be resolved by these experiments. It appears, however, that regulation of secretion of nonpancreatic glucagon differs from that of pancreatic glucagon.

Turnover of plasma oleic acid measured by radio-gas chromatography

Gas-liquid chromatography with radioactivity detection (Radio-GLC) was investigated as an analytical means of determining the fractional turnover rates of plasma free fatty acids. For this purpose normal dogs were infused with 1.838 muCi/min of [1-14C]oleic acid complexed with albumin and plasma samples were taken at 0 to 110 minutes. The plasma free fatty acids were isolated by a modified Dole extraction and the methyl esters, prepared by diazomethylation, were identified and quantitated by GLC and radio-GLC using radioactive methyl heptadecanoate as internal standard. The study demonstrates that physiologically feasible infusion rates and loads of radioactive acids can be found which permit accurate analyses of plasma free fatty acids by radio-GLC. During a 2-hour infusion no labeled acid other than oleic appeared in plasma indicating that the method could be used to study the turnover of a mixture of fatty acids simultaneously. These results also indicate that conventional methods of determination of radioactivity in purified extracts can be employed without concern for recycling of label among the fatty acids, at least over short periods of time. The radio-GLC technique described yields approximately 20% higher fractional turnover times for oleic acid than do standard methods.