Immune checkpoint inhibition and targeted therapy for melanoma: A patient‐oriented cross‐sectional comparative multicenter study

BACKGROUND

Choosing the adequate systemic treatment for melanoma is driven by clinical parameters and personal preferences.

OBJECTIVE

Evaluation of the impact of disease and treatment on the daily life of patients receiving systemic therapy for melanoma.

METHODS

A German-wide, cross-sectional comparative study was conducted at 13 specialized skin cancer centres from 08/2020 to 03/2021. A questionnaire was distributed to assess patients' perception of disease and symptoms, the impact of their current treatment on quality of life (QOL) and activities, adverse events (AEs), therapeutic visits, as well as believe in and satisfaction with their current systemic melanoma treatment. Patient-reported outcomes (PROs) were rated on a continuous numerical rating scale or selected from a given list.

RESULTS

Four hundred and fourteen patients with systemic melanoma therapy were included. 359 (87%) received immune checkpoint inhibition (ICI) and 55 (13%) targeted therapy (TT). About 1/3 of patients were adjuvantly treated, the remaining because of unresectable/metastatic melanoma. In subgroup analyses, only in the adjuvant setting, TT patients reported a significant decrease in their treatment associated QOL compared to patients with ICI (p = 0.02). Patients with TT were 1.9 times more likely to report AEs than patients with ICI, a difference being significant just for the adjuvant setting (p = 0.01). ICI treatment intervals differed significantly between adjuvant and unresectable/metastatic setting (p = 0.04), though all patients, regardless of their specific ICI drug, evaluated their treatment frequency as adequate. TT patients with dabrafenib/trametinib (n = 37) or encorafenib/binimetinib (n = 15) did not differ regarding the strain of daily pill intake. Patients older than 63 years rated various PROs better than younger patients.

CONCLUSIONS

Patients evaluated their treatment mainly positively. ICI might be preferred over TT regarding QOL and patient-reported AEs in the adjuvant setting. Older melanoma patients appeared to be less impacted by their disease and more satisfied with their treatment.

[Psychological treatment of headache in times of COVID-19]

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has substantially changed life worldwide in 2020. This also influences the psychological treatment options of patients with headache.

AIM

The present article intends to illustrate the different psychological forms of treatment for headache patients and their implementation during the COVID-19 pandemic.

MATERIAL AND METHODS

Literature review and case reports.

RESULTS

Even during the COVID-19 pandemic, psychological treatment enables the increased stress level in headache patients to be counteracted by using cognitive behavioral therapy and relaxation techniques. The changed living conditions are often unfavorable but sometimes also favorable in the course of disease. It can be shown that even during the pandemic, such favorable changes can be used to support patients to cope with their headache.

CONCLUSION

The digital implementation of psychological approaches makes a major contribution to maintaining psychological treatment of headache patients, so that the individually changed needs can be addressed. With respect to content, stress regulation techniques and increased acceptance gain in importance. Regarding biofeedback there are limitations, which may be overcome by improved technical devices.

[Relaxation techniques and behavioural therapy for the treatment of migraine : Guidelines from the German Migraine and Headache Society]

Besides pharmacological and interventional possibilities nonpharmacological options, deriving from behavioural approaches may be helpful in the treatment of migraine. Already consulting a patient reduces frequency of attacks. Relaxation (especially progressive muscle relaxation), endurance sports, and biofeedback as well as cognitive behavioural therapy are effective in treatment of migraine. The combination of these treatment options also with pharmacological treatment increase the positive effects.

Entspannungsverfahren und verhaltenstherapeutische Interventionen zur Behandlung der Migräne

Neben medikamentösen und interventionellen Verfahren bestehen zur Behandlung der Migräne nicht medikamentöse Möglichkeiten, die überwiegend der Verhaltenstherapie entstammen. In der Zusammenschau kann dabei aufgezeigt werden, dass bereits eine ausführliche Beratung des Patienten zu positiven Effekten in der Migränehäufigkeit führen kann. Entspannungsverfahren (insbesondere die Progressive Muskelrelaxation nach Jacobson), Ausdauersport und verschiedene Arten von Biofeedback sind neben der Anwendung kognitiver Verhaltenstherapie in der Behandlung der Migräne effektiv. Die Kombination der Behandlungsverfahren selbst mit einer prophylaktischen medikamentösen Therapie führt zu zusätzlichen positiven Effekten.

Akuttherapie und Prophylaxe der Migräne

Die Deutsche Migräne- und Kopfschmerzgesellschaft und die Deutsche Gesellschaft für Neurologie legen eine revidierte Fassung ihrer gemeinsamen evidenzbasierten Leitlinie für die Therapie der Migräne vor. Zur Akuttherapie der leichten Migräneattacke wird die frühzeitige und hochdosierte Einnahme von NSAR oder von Paracetamol empfohlen. Bei schweren Migräneattacken wird die Einnahme eines Triptans empfohlen, eine generelle Präferenz für eine bestimmte Substanz wird hierbei nicht ausgesprochen. Zur medikamentösen Prophylaxe der Migräne werden als Substanzen der ersten Wahl Metoprolol, Propranolol, Flunarizin, Valproinsäure und Topiramat empfohlen. Substanzen der zweiten Wahl sind Amitriptylin, Venlafaxin, Gabapentin, Naproxen, Acetylsalicylsäure, Pestwurz, Magnesium und Vitamin B2. Im Mittelpunkt der nicht medikamentösen Behandlung der Migräne stehen neben Empfehlungen zur Lebensführung, Entspannungsverfahren (progressive Muskelrelaxation), Biofeedbackverfahren und kognitive Verhaltenstherapie. Gerade die Kombination von nicht medikamentösen Verfahren untereinander oder mit einer medikamentösen Prophylaxe ist besonders wirksam.

Therapie idiopathischer Kopfschmerzen im Kindes- und Jugendalter

Nach den Richtlinien der Evidence Based Medicine sind die spezifischen kontrollierten Studien für die Behandlung von idiopathischen Kopfschmerzen im Kindes- und Jugendalter analysiert und in Therapieempfehlungen zusammengefasst worden. Mit der höchsten Evidenz wird für die Behandlung akuter Migräneattacken oder von Kopfschmerzen vom Spannungstyp Ibuprofen empfohlen. Als Mittel der zweiten Wahl wird für alle Altersstufen Paracetamol empfohlen, ab dem 12. Lebensjahr ist für Migräneattacken auch Sumatriptan Nasenspray Mittel der zweiten Wahl (im Einzelfall kann es auch bei jüngeren Kindern eingesetzt werden). Bei Versagen der Akutmedikamente der ersten und zweiten Wahl werden als Ausweichsubstanzen der dritten Wahl Zolmitriptan als Schmelztablette, Zolmitriptan als Nasenspray, Rizatriptan, Almotriptan und Dihydroergotamin empfohlen. Für die medikamentöse Prophylaxe der Migräne werden Magnesium, Betablocker (Propranolol oder Metoprolol) und Flunarizin empfohlen. Flunarizin ist auch prophylaktisches Mittel der ersten Wahl bei migräneähnlichen Syndromen. Für andere Kopfschmerzarten liegen keine kontrollierten Studien für das Kindesalter vor. In der nicht medikamentösen Prophylaxe von Kopfschmerzen im Kindesalter werden mit höchster Evidenz Entspannungsverfahren (progressive Muskelrelaxation), Biofeedbackverfahren und kindgerechte kognitiv-verhaltensorientierte Therapieprogramme empfohlen.

Therapie primärer chronischer Kopfschmerzen: Chronische Migräne, chronischer Kopfschmerz vom Spannungstyp und andere chronische tägliche Kopfschmerzen

Die IHS-Kriterien definieren vier primäre Kopfschmerzerkrankungen, die zu täglichen Dauerkopfschmerzen führen können: 1) chronische Migräne, 2) Kopfschmerz vom Spannungstyp, 3) Hemicrania continua, 4) neu aufgetretener Kopfschmerz. In der Praxis ist davon häufig der Kopfschmerz durch Medikamentenübergebrauch (früher: Analgetikakopfschmerz) abzugrenzen. Die jetzt von der Deutschen, Österreichischen und Schweizer Kopfschmerzgesellschaft gemeinsam vorgelegte Therapieleitlinie fasst die Literatur zur Therapie dieser Kopfschmerzformen zusammen und gibt Therapieempfehlungen, die die Literaturevidenz, aber auch die Praktikabilität berücksichtigen.

Central Mechanisms of Controlled-Release Metoprolol in Migraine: A Double-Blind, Placebo-Controlled Study

β-Blockers are widely used in the prophylaxis of migraine and have been described as very effective drugs in many studies. Some investigators have demonstrated that the clinical improvement of migraine corresponds to the normalization of the contingent negative variation (CNV), a slow cortical potential measuring cortical information processing. However, most of these studies have contained a variety of methodological pitfalls, which we attempted to address in the current study. Twenty patients suffering from migraine without aura were randomly divided into two groups. The groups were treated either with controlled-release metoprolol or placebo for 3 months, using a double-blind design. Twice before and once after each month of the treatment the CNV was recorded. After 3 months, a significant reduction of migraine frequency, duration and intensity was demonstrated for the metoprolol compared with the placebo group. The CNV was characterized by a marked reduction of the amplitude of the total CNV and postimperative negative variation and normalization of the eartly CNV habituation following treatment. Therefore, metoprolol may exert its prophylactic effect in migraine through the influence on cortical information processing and excitability represented by the CNV.

Frequency and predictors of acute ischaemic lesions on brain magnetic resonance imaging in young patients with a clinical diagnosis of transient ischaemic attack

BACKGROUND AND PURPOSE

Acute lesions in patients with transient ischaemic attack (TIA) are important as they are associated with increased risk for recurrence. Characteristics associated with acute lesions in young TIA patients were therefore investigated.

METHODS

The sifap1 study prospectively recruited a multinational European cohort (n = 5023) of patients aged 18-55 years with acute cerebrovascular event. The detection of acute ischaemic lesions was based on diffusion-weighted imaging (DWI). The frequency of DWI lesions was assessed in 829 TIA patients who met the criteria of symptom duration <24 h and their association with demographic, clinical and imaging variables was analysed.

RESULTS

The median age was 46 years (interquartile range 40-51 years); 45% of the patients were female. In 121 patients (15%) ≥1 acute DWI lesion was detected. In 92 patients, DWI lesions were found in the anterior circulation, mostly located in cortical-subcortical areas (n = 63). Factors associated with DWI lesions in multiple regression analysis were left hemispheric presenting symptoms [odds ratio (OR) 1.92, 95% confidence interval (CI) 1.27-2.91], dysarthria (OR 2.17, 95% CI 1.38-3.43) and old brain infarctions on MRI (territories of the middle and posterior cerebral artery: OR 2.43, 95% CI 1.42-4.15; OR 2.41, 95% CI 1.02-5.69, respectively).

CONCLUSIONS

In young patients with a clinical TIA 15% demonstrated acute DWI lesions on brain MRI, with an event pattern highly suggestive of an embolic origin. Except for the association with previous infarctions there was no clear clinical predictor for acute ischaemic lesions, which indicates the need to obtain MRI in young individuals with TIA.

Headache and Depression in Patients with Hypothalamic-pituitary Disorders-etiology and Risk Factors

INTRODUCTION

Headache and depression are common problems in patients with hypothalamic-pituitary disorders (HPD).

AIM

To determine the prevalence of headache and depression in patients with HPD and the specific characteristics in affected individuals in comparison to patients with cardiovascular problems (CD).

METHODS

Patients with HPD and CD were asked to complete a questionnaire regarding headache and depression.

RESULTS

There were no significant differences between the HPD and the CD group. Prevalence of headache was not associated with the treatment modality of pituitary disease, hormone excess syndromes or any hormonal replacement therapy. However, ACTH, TSH and GH deficiency were associated with less headache when compared to patients with adequate secretion. Interestingly, patients who had prior surgery suffered significantly more often from depression. In addition, headache and depression were significantly more common in patients with microadenomas than in macroadenomas.

DISCUSSION

The risk for headache and depression is mainly influenced by a combination of factors, but a specific pituitary hormone deficiency may decrease risk for headache.

[The Rostock Headache Questionnaire ("Rokoko")--validation of a tool to screen and to qualify primary headaches]

Primary headache disorders should be diagnosed based on the detailed history of the patient. However, only few questions are necessary to allocate the symptoms to migraine, tension-type headache or other primary headaches in most cases. The "Rostock Headache Questionnaire" (Rokoko) is suitable for being completed by the investigator or the patient him/herself within a few minutes. Validation parameters of a sample of n = 87 patients (median: 44 years), diagnosed by headache experts in a personal interview ("gold standard"), are presented. Sensitivity and specificity for migraine without aura (0.87/0.51), migraine with aura (0.71/0.95), tension-type headache (0.57/0.93), or a combination of both (0.22/0.93) are based on the parameters pain frequency (recurrent vs. permanent), and the presence or absence of aura symptoms. To differentiate tension-type headache into episodic or chronic forms, the questionnaire can be analysed individually based on the frequency of headache days. The questionnaire enables the fast acquisition of relevant data in headache diagnosis and headache research with sufficient sensitivity and specificity. In addition, further information about triggering and symptoms of headaches can be assessed. The questionnaire can be used both by neurologists or psychiatrists and by general practitioners. The questionnaire does not replace the physical examination.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Cerebrovascular reactivity during the Valsalva maneuver in migraine, tension-type headache and medication overuse headache

The aim of this study was to investigate, by means of transcranial Doppler ultrasound (TCD), cerebrovascular reactivity during the Valsalva maneuver (VM) during the headache-free interval in patients with migraine (M), migraine plus tension-type headache (M+TTH), and migraine plus medication overuse headache (M+MOH). A total of 114 patients (n=60 M, n=38 M+TTH, n=16 M+MOH) and n=60 controls were investigated; diagnoses were made according to the International Headache Society criteria. All subjects underwent TCD monitoring and, simultaneously, non-invasive assessment of arterial blood pressure and end-tidal CO2. Two indices were determined: the cerebrovascular Valsalva ratio (CVR) was calculated as the maximum end-diastolic flow velocity acceleration during the late straining phase of the VM [cm/s2] and the centroperipheral Valsalva ratio (CPVR) was defined as the quotient of CVR to the concomitant arterial blood pressure acceleration [cm/mmHg x s]. The dynamic cerebrovascular autoregulatory response to the VM, measured as CVR, was increased in patients with M and M+TTH compared to age-matched healthy subjects. By contrast, CPVR (i.e. the quotient of the cerebrovascular to the peripheral autonomic response), was increased in M patients compared to healthy subjects and all other headache conditions tested. Cerebrovascular autoregulatory response during the VM was increased in M patients compared to age-matched normal healthy subjects, indicating a disturbed autonomic control of cerebral vasoreactivity. The CPVR seems to be a sensitive parameter for distinguishing between M patients and M+TTH or M+MOH patients.

[Does multiple sclerosis facilitate migraine]

Known comorbidities for migraine are affective disorders. Only few studies exist which explore migraine as comorbidity in a given diagnosis. The aim of our study is to determine the frequency of the comorbidity "migraine" subject to a given diagnosis. Out of 2562 observations comorbidity "migraine" was diagnosed with a frequency of 16.2 % when an affective disorder was diagnosed. In multiple sclerosis and epilepsy, migraine as comorbidity was diagnosed in 15 % and 9.6 %, respectively. Migraine in patients with Parkinson's disease is rare. The correlation between affective disorders and epilepsies is known, but the high frequency of migraine in multiple sclerosis should be taken into account when diagnosing central demyelinating disorders.

Multicenter analysis of glucocerebrosidase mutations in Parkinson's disease

BACKGROUND

Recent studies indicate an increased frequency of mutations in the gene encoding glucocerebrosidase (GBA), a deficiency of which causes Gaucher's disease, among patients with Parkinson's disease. We aimed to ascertain the frequency of GBA mutations in an ethnically diverse group of patients with Parkinson's disease.

METHODS

Sixteen centers participated in our international, collaborative study: five from the Americas, six from Europe, two from Israel, and three from Asia. Each center genotyped a standard DNA panel to permit comparison of the genotyping results across centers. Genotypes and phenotypic data from a total of 5691 patients with Parkinson's disease (780 Ashkenazi Jews) and 4898 controls (387 Ashkenazi Jews) were analyzed, with multivariate logistic-regression models and the Mantel-Haenszel procedure used to estimate odds ratios across centers.

RESULTS

All 16 centers could detect two GBA mutations, L444P and N370S. Among Ashkenazi Jewish subjects, either mutation was found in 15% of patients and 3% of controls, and among non-Ashkenazi Jewish subjects, either mutation was found in 3% of patients and less than 1% of controls. GBA was fully sequenced for 1883 non-Ashkenazi Jewish patients, and mutations were identified in 7%, showing that limited mutation screening can miss half the mutant alleles. The odds ratio for any GBA mutation in patients versus controls was 5.43 across centers. As compared with patients who did not carry a GBA mutation, those with a GBA mutation presented earlier with the disease, were more likely to have affected relatives, and were more likely to have atypical clinical manifestations.

CONCLUSIONS

Data collected from 16 centers demonstrate that there is a strong association between GBA mutations and Parkinson's disease.

Effects of pregnancy on slow cortical potentials in migraine patients and healthy controls

Increased negative amplitudes and lack of habituation of contingent negative variation (CNV) in migraine are well established and are supposed to reflect an altered cortical excitability level. Migraine attacks occur less during pregnancy but often relapse after delivery. We investigated the effect of pregnancy on slow cortical potentials and reaction time in migraine patients and healthy controls. Four groups were examined: 14 pregnant migraine patients, 12 non-pregnant migraine patients, 15 pregnant healthy women and 16 non-pregnant healthy women aged 19-38 years. Two recordings were performed in the pregnant subjects: in the 36th week of gestation and 4 weeks after delivery. The non-pregnant subjects were recorded at the same time interval of 8 weeks. Pregnant migraine patients showed significantly fewer migraine days during the third trimester of pregnancy and returned to nearly the former level 4 weeks post delivery. Non-pregnant migraine patients demonstrated a significant reduction of migraine days at the second measurement. There was no effect of pregnancy on CNV amplitudes, but there was an effect of pregnancy on the habituation coefficient and reaction time of migraine patients. Faster habituation from a higher preactivation level was found. As an explanation for the changed habituation level we favour the model of correlation between preactivation level and habituation level, the so-called law of initial value. We found a correlation between preactivation level and habituation. Our study confirms a specific effect of pregnancy on slow cortical potentials in migraine patients.

Subjective and objective perception of upper incisors

The purpose of this study was to evaluate the subjective judgment (SJ) of patients on their own dental appearance and to correlate the results with objective measurements (OM) of their dentition concerning the appearance of the upper incisors. Seventy-five participants (30 men and 45 women) with normal well-being were included in the study. In a questionnaire they judged the appearance of their upper incisors. Furthermore, OM were evaluated by the investigator with regard to the following points: (i) absolute length of the upper central incisors, (ii) their length exposed during laughing, (iii) width-to-length ratio of central incisors and (iv) the proportion between the width of the lateral and central incisors. The subjective results were registered on visual-analogue scales. For the objective results standardized photographs were taken. No gender dependent differences could be found for the objectively measured parameters (median): OM1, 10.7 mm; OM2, 8.1 mm; OM3, 0.81; OM4, 0.79. However, significant correlations between subjective and objective results (SJ1/OM1, SJ2/OM2, SJ3/OM3) could be shown for men, but not for women. The maximum of the calculated regression-curves for men reflect 'golden standard values' well known from the literature. The degree of satisfaction concerning appearance of anterior incisors in accordance with golden standard values is higher for men than for women.

[Duration of migraine disease correlates with amplitude and habituation of event-related potentials]

BACKGROUND

Duration of a migraine disease and hypervigilance are factors which possibly enable the transformation from episodic into chronic migraine. To elucidate this assumption, attentional parameters were measured by recording contingent negative variation (CNV) and correlated with the individual duration of migraine disease.

PATIENTS AND METHODS

A total of 28 patients (episodic migraine with or without aura) were compared with 16 healthy controls. CNV analysis included amplitude and habituation calculation. Data were correlated with the individual duration of the migraine disease. The migraine group was divided into two groups based on a median split (short vs long lasting) which were compared by t-tests.

RESULTS

Migraine patients produce higher CNV amplitudes than controls. Moreover, migraineurs showed dishabituation while habituation was seen in controls. There was a Pearson correlation coefficient of r = -0.767 between duration of disease and early component of CNV. Patients with long-lasting disease showed lower dishabituation by a higher intercept than patients with short-lasting disease.

CONCLUSION

The correlation between duration of disease and attentional parameters and the changing dishabituation can be interpreted as an enhancement in preactivation level in patients with long-lasting migraine. Maybe this change is a prerequisite for transformation into chronic migraine.

[Non pharmacological treatment of migraine]

Actual recommendations for treatment of migraine consist both of pharmacological and non-pharmacological treatment. The latter enables the patient higher responsibility and self-efficacy in coping with migraine. Therefore, the active involvement in the treatment of the patients is obligatory in all psychological pain therapy methods. Focus of therapy are emotional, cognitive, behavioural and social factors of migraine illness, with the aim to modify unfavourable habits and migraine attack-inducing factors. As non-pharmacological methods counselling, relaxation training, biofeedback and cognitive-behavioural treatments are employed. The long-term effects are comparable with those of pharmacological treatment, combination of pharmacological and non-pharmacological treatment lead to even higher efficacy and is often indicated. In case of headache in children, behavioural therapy should be the method of first choice. In the text, empirically proven methods of psychological pain therapy in migraine will be explained.

Psychologische Schmerzdiagnostik bei Kindern

Pain in premature infants, neonates, and young children impairs their development to a great extent and may lead to long-lasting pain memories and undertreatment of pain. Up to 15 years ago, the opinion prevailed that babies -- especially neonates -- could not feel pain generally, because they could not report their pain sensations to adults and were not able to verbalize their feelings. In the past decade, standardized scales have been developed to assess pain in children. While in neonates and children up to 2 years standardized scales were developed for observation of their reactions, for children 3 years and older self-report scales are used to assess pain sensations. The text describes a variety of standardized pain assessment scales which fulfil the requirements of reliability and validity.

What kind of habituation is impaired in migraine patients?

The acoustically evoked cortical potentials of 20 migraine patients were investigated using a combined conditioning-testing and oddball paradigm. The short- and long-term habituation results of the P50 and P300 waves were compared with 16 healthy subjects. Migraineurs were characterized by a sensory gating deficit of the P50 wave (reduced short-term habituation) in the non-target condition and a reduced long-term habituation of the P300 wave in the target condition. The study describes disturbances of information processing on the automatic and cognitive levels in migraine patients and emphasizes the role of sensory gating and orienting response in migraine pathogenesis.

[Does intraoperative hyperventilation improve neurological functions of older patients after general anaesthesia?]

The purpose of the study was to investigate the effect of intraoperative hyperventilation on postoperative cognitive functions.

METHODS

A total of 120 patients (60 older and 60 younger than 65 years old) were allocated randomly to group I "hyperventilation" (p(et)CO(2)=30 mmHg) or group II "normoventilation" (p(et)CO(2)=45 mmHg). Before the operation and on days 1, 3 and 6 after the operation, a battery of neuropsychological tests was performed (concentration endurance test d2, number connection test, digit symbol test). A decline of 20% in at least one test was regarded as postoperative cognitive deficit (POCD). Anaesthesia was maintained with isoflurane in nitrous oxide/oxygen supplemented with fentanyl.

RESULTS

In all patients pooled, POCD was present in 26 patients (22%). In patients older than 65 years, POCD was present in 3 cases after hyperventilation and 13 cases after normoventilation ( p<0.01). In younger subjects, 5 cases of POCD were diagnosed in each ventilation group. Furthermore, POCD was more severely pronounced in older patients after normoventilation.

CONCLUSION

In older patients, POCD occurred more frequently after intraoperative normoventilation. We assume that a reduced amount of noxious substances reach the brain after hyperventilation, because hyperventilation reduces the cerebral blood flow.

[The abbreviated mental test in a German version for detection of postoperative delirium]

OBJECTIVES

Delirium is the most common acute organic psychosis postoperatively, and occurs more frequently in the elderly than anticipated. The abbreviated mental test (AMT) is a widely used cognitive test in Great Britain. The present study assessed the AMT in a German version for diagnosis of postoperative delirium.

METHODS

40 patients (older than 65 years), scheduled for total knee or hip replacement, were tested repeatedly for delirium according to the ICD-10. These patients were investigated with the AMT simultaneously by a second investigator.

RESULTS

Delirium was present in four orthopaedic patients (10 %) and was diagnosed correctly in these patients by the AMT. All but one patient without delirium showed no deterioriation in AMT score.

CONCLUSION

As in Great Britain, the AMT in its German version is useful in diagnosing delirium. We recommend the use of the AMT preoperatively in elderly patients at risk for delirium.

Serum concentration of S-100 protein in assessment of cognitive dysfunction after general anesthesia in different types of surgery

BACKGROUND

S-100 protein serum concentration (S-100) serves as a marker of cerebral ischemia in cardiac surgery, head injury and stroke. In these circumstances S-100 corresponds well with the results of neuropsychological tests. The aim of the present study was to investigate the value of S-100 and neuron specific enolase (NSE) in reflecting postoperative cognitive deficit (POCD) after general surgical procedures.

METHODS

One hundred and twenty patients undergoing vascular, trauma, urological or abdominal surgery were investigated. Serum values of S-100 and NSE were determined preoperatively and 0.5, 4, 18 and 36 h postoperatively. Neuropsychological tests for detecting POCD were performed preoperatively and on day 1, 3, and 6 after the operation. A decline of more than 10% in neuropsychological test results was regarded as POCD. Furthermore, we retrospectively compared the S-100 in patients with and without POCD in different types of surgery.

RESULTS

According to our definition, forty-eight patients had POCD (95% confidence interval: 37.5-58.5). These patients showed higher serum concentrations of S-100 (median 024 ng/ml; range 0.01-3.3 ng/ml) compared with those without POCD (n=69; median 0.14 ng/ml; range 0-1.34 ng/ml) 30 min postoperatively (P=0.01). Neuron specific enolase was unchanged during the course of the study. Differences of S-100 in patients with and without POCD were found in abdominal and vascular surgery but not in urological surgery.

CONCLUSION

When all patients are pooled, S-100 appears to be suitable in the assessment of incidence, course and outcome of cognitive deficits. We suspect that in some surgical procedures, such as urological surgery, S-100 appears to be of limited value in detecting POCD. Neuron specific enolase did not reflect neuropsychological dysfunction after noncardiac surgery.

Contingent negative variation and attentional performance in humans

The relation between a paper-pencil test of sustained attention (d2-letter cancellation test, d2-LCT) and the contingent negative variation (CNV) as a cortical slow potential was calculated in 23 healthy undergraduate students. Both d2-LCT and CNV reflect selective, focussed attention. There was a Pearson correlation coefficient of r = -0.670 between the early component of the CNV and the number of checked letters in d2-LCT, indicating significant differences in early CNV between low and high performance in d2-LCT. The results showed a linear relationship between paper-pencil registered attentional properties and the cortically recorded early component of CNV.

Contingent negative variation as indicator of duration of migraine disease

Amplitudes of early wave contingent negative variation (iCNV) reveal significant differences between migraine patients and healthy controls, indicating a lack of habituation and pronounced attentional functions in migraine patients. CNV amplitudes were recorded in 20 migraine patients. The CNV amplitudes were Pearson correlated with the individual duration of the migraine disease. Only iCNV correlates inversely with the duration (r = -.544). The data show an influence of duration of migraine disease on iCNV amplitudes. It is suggested that iCNV is an indicator of chronicity in persistent migraine.

Polysomnographic findings in nights preceding a migraine attack

Sleep recordings were performed in eight patients to analyse sleep alterations preceding migraine attacks. Polysomnographic recordings from nights before an attack were compared with nights without following migraine. We analysed standard sleep parameters and electroencephalogram (EEG) power spectra. The main findings preceding migraine attacks were a significant decrease in the number of arousals, a decrease in rapid eye movement (REM) density, a significant decrease of beta power in the slow wave sleep, and a decrease of alpha power during the first REM period. The results suggest a decrease in cortical activation during sleep preceding migraine attacks. According to the models of sleep regulation, alterations in the function of aminergic or cholinergic brainstem nuclei have to be discussed.

The validity of the ICD-10 classification of recurrent affective disorders: do endogenous and psychogenic depressions form a homogeneous diagnostic group?

Fifty-five hospital-treated patients with the ICD-10 diagnosis of 'recurrent depressive episode(s)' were classified according to the Newcastle Depressive Diagnostic Scale as having either psychogenic (n = 25) or endogenous (n = 30) depression and interviewed using several inventories on personality and psychopathology (Composite International Diagnostic Interview, Symptom Check List, Inventory of Interpersonal Problems, IIP, NEO Five-Factor Personality Inventory, Social Adjustment Scale, Questionnaire of the Motivation to Seek Psychotherapy). Except for the IIP, individual subscales disclosed significant differences between the two groups. In light of these results, the grouping of these two disorders into one diagnostic group in the ICD-10 is critically discussed.

Slow cortical potentials in migraine families

Amplitude and habituation of event-related potentials are abnormal in migraine. We investigated 43 migraine and 41 healthy families to evaluate the influences of age, sex and familial contribution on the variance of amplitude and habituation of the contingent negative variation (CNV). Analysis of individual differences in relation to the CNV habituation was performed. The study demonstrated that habituation of the early CNV component characterizes migraine considerably better than the CNV amplitudes. Habituation, however, is strongly influenced by age. Migraine adults and children generally showed reduced habituation. Surprisingly, more than 30% of the healthy adults demonstrated a marked loss of habituation. The reduced CNV habituation represented a high sensitivity but low specificity to migraine, especially in children. CNV amplitude and habituation parameters revealed a considerable familial contribution associated with migraine. No familial influence on either morphology or habituation of the CNV in healthy families or between healthy members of migraine families was observed. The low specificity and familial transmission of CNV parameters in members of migraine families suggest that increased amplitudes and reduced habituation of CNV do not constitute a primary risk factor for migraine, but rather represent a predisposition. Genetic components probably affect variation of the CNV amplitude and habituation.

[Diagnostic value of s-100 protein and neuron-specific enolase as serum markers for cerebral deficiency after general anesthesia. Study in patient with hip or knee replacement]

S-100 protein and neuron-specific enolase (NSE) serum concentrations serve as markers of cerebral damage in cardiac surgery, neurology, or after head injury. In these circumstances, S-100 and NSE levels correspond with the results of neuropsychological tests. The present study investigated the diagnostic value in orthopaedic patients after joint replacement.

METHODS

Forty patients scheduled for elective hip or knee arthroplasty were investigated. Serum values of NSE and S-100 were determined preoperatively and 30 min and 4, 18, and 36 h postoperatively. Neuropsychological tests (syndrome short test, SKT, delirium assessment according to DSM IV) were performed preoperatively and two, three, and four days following surgery. General anaesthesia was induced with fentanyl and etomidate and maintained with isoflurane in oxygen/air.

FINDINGS

The S-100 increased from a median of 0.04 ng/ml (range 0.004-0.19 ng/ml) preoperatively to 1.03 ng/ml (range 0.18-3.65 ng/ml) at 30 minutes postoperatively (P < 0.0001). These levels returned to normal in the course of the following 2 days. NSE values were 8.55 ng/ml (range 4.6-14.9 ng/ml) preoperatively and 7.07 ng/ml (range 4-16.4 ng/ml) postoperatively (P = 0.167). There were no differences in serum concentrations of S-100 and NSE between normal patients and those with postoperative cognitive deficit. Furthermore, no correlation was found between the serum marker and neuropsychological tests.

INTERPRETATION

Obviously, increased NSE levels seem to indicate cerebral damage only in more severe cases. S-100 does not seem to be brain-specific in patients undergoing orthopaedic surgery. Therefore, the value of S-100 in the assessment of brain disorders is limited.

Neurofeedback--the significance of reinforcement and the search for an appropriate strategy for the success of self-regulation

Nine healthy children took part in five sessions of feedback and instrumental conditioning of slow cortical potentials (SCPs). The feedback conditions (the relation between the feedback signal and amplitude of SCP) were inverted after two sessions. Neither the children nor the therapists were aware of this change. The adjustment of the children to the new feedback setting and the self-regulation strategies employed were investigated. The results were as follows: (a) Healthy children achieved control over cortical negativity within two sessions. (b) The change of feedback conditions worsened the regulation abilities, which then improved again within the following three sessions. (c) After the first two sessions, the participants were able to describe strategies that were successful during different phases of self-regulation. (d) Following the change in the feedback conditions, the children reevaluated the way they influenced their SCPs. However, they did not alter the cognitive or behavioral strategies. The study demonstrated that positive and negative reinforcement and the knowledge of results are more important for successful self-regulation than the search for effective strategies. The relevance of these findings is discussed.

[Prediction of verbal and numerical comprehension in patients with cochlear implants]

BACKGROUND

Cognitive abilities determine the outcome of cochlear implantation. Neuropsychological tests of intellectual, memory, attentional and emotional functions were applied pre-operatively in 33 deaf patients receiving a cochlear implant. The outcome of verbal and numerical comprehension was measured in a subgroup of 14 patients post-operatively and correlated with pre-operative neuropsychological performance.

METHODS

Neuropsychological performance was recorded using standardized tests for intellectual abilities (abbreviated Wechsler Adult Intelligence Scale [WAIS], crystallized intelligence scale), memory performance (Benton Visual Retention Test), attentional functions (d2 letter-cancellation-test), reaction time (Vienna Reaction Test) and emotional state (personality inventories). Verbal and numerical comprehension was measured post-operatively following adaptation of the speech processor. Performance and comprehension data were correlated.

RESULTS

Cognitive performance parameters did not differ significantly from those of a healthy group. There was a correlation of r = +0.65 between numerical comprehension and the "mosaic-test", a subtest of the WAIS and of r = +0.78 between numerical comprehension and the crystallized intelligence scale.

CONCLUSIONS

Pre-operative cognitive parameters may predict the outcome of cochlear implants.

Reliability and stability of contingent negative variation

Reliability parameters of a test indicate the stability (and quality) of the test itself. Reliability coefficients greater than 0.70 suggest an attribute as being sufficiently stable over time to be characterized as a trait. Reliability parameters of contingent negative variation (CNV) amplitudes in 27 healthy individuals were determined using a test-retest design. CNV was recorded at Cz, with an interstimulus interval of 3 s, on 2 separate occasions: initial session and 10 days later. Correlation coefficients between the 2 recording sessions were 0.675 for the total-CNV (tCNV), 0.855 for the early component (iCNV), 0.631 for the late component (lCNV), and 0.420 for the post-imperative negative variation (PINV). Statistical retest parameters for Spearman Brown were 0.806 for tCNV, 0.922 for iCNV, 0.774 for lCNV, and 0.655 for PINV. The iCNV, more than the other parameters, remained stable over the period of 10 days. It is suggested that the described standardized CNV recording procedure ensures reproducible and stable results in healthy subjects.

Intensity dependence of auditory evoked cortical potentials in migraine families

Intensity dependence of auditory evoked cortical potentials is abnormal in migraine. This study investigated intensity dependence in migraine and healthy families using group comparisons and analysis of individual differences. Migraineurs were characterized by a steeper amplitude/stimulus function slope and more pronounced difference between the amplitudes of N1-P2 on the more and the less intensive tones than healthy age matched subjects. Apart from migraine, the age of the participants was an important predictive variable of intensity dependence. Analysis of individual differences revealed low sensitivity and moderate specificity of intensity dependence for migraine. Familial prevalence of intensity dependence among first-degree relatives in migraine families was equal to that in healthy families. These findings support the assumption that high-intensity dependence reflects a functional CNS trait which is more pronounced and prevalent in migraine, but may also be found in healthy individuals and in other neuropsychiatric disorders. Increased intensity dependence is only one of several factors contributing to the risk for this form of headache.

Self-regulation of slow cortical potentials in children with migraine: an exploratory study

Migraine patients are characterized by increased amplitudes of slow cortical potentials (SCPs), representing pronounced excitability of cortical networks. The present study investigated the efficiency of biofeedback training of SCPs in young migraineurs. Ten children suffering from migraine without aura participated in 10 feedback sessions. They were compared with 10 healthy children for regulation abilities of cortical negativity and with 10 migraineurs from the waiting list for clinical efficacy. During the first two sessions, the migraine children were characterised by lacking ability to control cortical negativity, especially during transfer trials, compared with healthy controls. However, there was no difference following 10 sessions of training. Feedback training was accompanied by significant reduction of cortical excitability. This was probably responsible for the clinical efficacy of the training; a significant reduction of days with migraine and other headache parameters was observed. It is suggested that normalization of the threshold regulation of cortical excitability during feedback training may result in clinical improvement.

Are the periodic changes of neurophysiological parameters during the pain-free interval in migraine related to abnormal orienting activity?

OBJECTIVE AND METHODS

Migraine patients are characterized by increased amplitude and reduced habituation of contingent negative variation (CNV). Furthermore, the CNV underlies periodic changes during the pain-free interval, being maximal before attack. The periodicity of CNV is related to periodic changes in habituation, probably due to variation of orienting activity during the pain-free interval. CNV and orienting response (OR) were studied in 20 females suffering from migraine without aura and in 12 matched healthy females. The neurophysiological recordings in the group of patients were performed 1-4 days before and 4 days after a migraine attack. The amplitudes and habituation of early and late components and total CNV were calculated. The OR was assessed using the habituation of the skin conductance response (SCR) and alpha blocking (AB). The non-parametric tests were employed for statistical analysis.

RESULTS

There were no differences between the two groups for habituation of all CNV components and of SCR following an attack. However, the habituation of AB was significantly reduced in migraine. Before attack we observed a significantly reduced habituation of the early and total CNV and of the AB compared to controls and recordings performed after an attack. The habituation of the late component and of SCR remained unchanged.

CONCLUSIONS

The abnormal habituation could be explained by the periodic changes of physiological parameters during the pain-free interval. The impaired habituation of early CNV in migraine is associated with increased orienting activity seen only in the central component (AB) of OR.

Migraine in childhood--are periodically occurring migraine attacks related to dynamic changes of cortical information processing?

Amplitudes and habituation of contingent negative variation (CNV) were analyzed in relation to spontaneously occurring migraine attacks in ten children suffering from migraine without aura. Recording took place during feedback training and instrumental conditioning of slow brain potentials. Both the amplitude of the early CNV component and its habituation deficit increase during the 5 days prior to a migraine attack, with maximum abnormalities the day before the ictal episode. Abrupt reduction of the amplitude and normalization of the CNV habituation were observed during the attack. This study provides evidence for neurophysiological periodicity in young migraineurs and emphasizes that the time relative to the migraine attacks must be considered in studies of juvenile migraine during the headache-free period.