CTAD Task Force Paper: Neuropsychiatric Symptoms in AD: Clinical Trials Targeting Mild Behavioral Impairment: A Report from the International CTAD Task Force

The International CTAD Task Force (TF) addressed challenges related to designing clinical trials for agitation in dementia, presenting accomplishments from the two previous TFs on neuropsychiatric symptoms (NPS). In addition, this TF proposed a paradigm shift in NPS assessment and management, presenting Mild Behavioral Impairment (MBI) as a clinical syndrome. MBI is marked by later-life emergent and persistent NPS in dementia-free older persons (ranging from cognitively unimpaired to subjective cognitive decline to mild cognitive impairment), which facilitates earlier detection and better prognostication of Alzheimer's disease (AD). The TF has made the following recommendations for incorporation of NPS into AD preventative trials: (1) clinical trials targeting improvement in MBI symptoms should be undertaken; (2) treatment trials for MBI should be disease specific and confirm the diagnosis of participants using biomarkers; trials should include measures sensitive to cognitive changes in preclinical AD, which can serve as outcome measures, in addition to changes in biomarker levels; (3) as a first step, pharmacotherapeutic trials should address the full MBI complex as well as the specific symptoms/domains that constitute MBI; (4) clinical trials using problem-adaptation psychotherapy to target affective MBI should be considered; and (5) MBI should be considered in AD trials of disease modifying therapies. The well-validated and widely-used MBI Checklist (MBI-C) is an appropriate symptom rating scale for these studies, as it was developed specifically to identify and measure MBI in dementia-free persons. Other scales such as the Neuropsychiatric Inventory (NPI) may be used, although administration at two timepoints may be necessary to operationalize the MBI criterion of symptom persistence.

The personality of newly graduated and employed nurses: Temperament and character profiles of Swedish nurses

Background

One of the challenges of the 21st century is the high turnover rate in the nursing profession due to burnout and mental illness. From a biopsychosocial perspective, an individual's personality is an important vulnerability-resilience factor that comprises four temperament traits (i.e., a person's emotional reactions) and three character traits (i.e., self-regulation systems). Indeed, different personality profiles are associated to different coping strategies and health outcomes.

Objective

We investigated and mapped the temperament and character of Swedish newly graduated and employed nurses' in relation to the Swedish general population and an age-matched sub-sample.

Design

In this cross-sectional study, nurses self-reported their personality (Temperament and Character Inventory) at the beginning of their employment.

Setting

The data collection was conducted at a hospital in the South of Sweden.

Participants

A total of 118 newly graduated and employed nurses (Mage = 25.95±5.58) and 1,564 individuals from the Swedish general population participated in the study.

Methods

We calculated T-scores and percentiles for all seven personality dimensions using the Swedish norms (N = 1,564). The profiles were calculated by combining high/low percentiles scores in three temperament dimensions (Novelty Seeking: N/n, Harm Avoidance: H/h, and Reward Dependence: R/r) and in the three character dimensions (Self-Directedness: S/s, Cooperativeness: C/c and Self-Transcendence: T/t).

Results

Regarding T-scores, the nurses reported moderately lower Novelty Seeking (> 0.5 SD), slightly higher Harm-Avoidance (about 0.5 SD), moderately higher Persistence (> 0.5 SD) and Reward Dependence (> 0.5 SD), and extremely lower Self-Directedness (> 1 SD). The prevalence of the most common temperament profiles among the nurses (Swedish general population in brackets) were: 39.80% [10.90%] Cautious (nHR), 21.20% [10.90] Reliable (nhR), and 15.30% [16.50%] Methodical (nHr). The prevalence of the most common character profiles among the nurses were: 31.40% [4.90%] Dependent (sCt), 25.40% [14.40%] Apathetic (sct), and 19.50% [8.80%] Moody (sCT).

Conclusions

The analyses of the personality profiles showed that Low Novelty Seeking (79%), high Harm Avoidance (65%) high Reward Dependence (80%), low Self-Directedness (95%), and low Self-Transcendence (60%) were more prevalent among the newly graduated and employed nurses. This may partially explain newly graduated nurses' difficulties at work and high turnover rate. After all, a well-developed character is of special importance when working with patients with serious and terminal illness or under large global crises, such as the current pandemic. Hence, both education at universities and development at work need to be person-centered to reduce stress levels and promote positive self-regulation strategies.

A Framework for Developing Pharmacotherapy for Agitation in Alzheimer's Disease: Recommendations of the ISCTM* Working Group

Dementia is characterized by a significant decline in one of several cognitive domains such as memory, language and executive function, affecting independence and representing a significant deterioration from a previous level of functioning (1). Alzheimer’s Disease (AD) represents the most common form of dementia and contributes up to 70% of the almost 50 million dementia cases worldwide, a number that is projected to double in 20 years (2).

Resilience personality profiles among Swedish long-term unemployed

Our aim was to investigate the prevalence of resilience personality profiles in a sample of Swedish long-term unemployed in relation to the general Swedish population. We found that only 1.50% (vs. 26% in the general population) in the long-term unemployed sample had a resilient personality profile, that is, low in harm avoidance (e.g., relaxed and optimistic), high in persistence (e.g., hard-working), and high in self-directedness (i.e., goal-oriented and resourceful).

Validation of Two Short Personality Inventories Using Self-Descriptions in Natural Language and Quantitative Semantics Test Theory

Background

If individual differences are relevant and prominent features of personality, then they are expected to be encoded in natural language, thus manifesting themselves in single words. Recently, the quantification of text data using advanced natural language processing techniques offers innovative opportunities to map people’s own words and narratives to their responses to self-reports. Here, we demonstrate the usefulness of self-descriptions in natural language and what we tentatively call Quantitative Semantic Test Theory (QuSTT) to validate two short inventories that measure character traits.

Method

In Study 1, participants (N₁ = 997) responded to the Short Character Inventory, which measures self-directedness, cooperativeness, and self-transcendence. In Study 2, participants (N₂ = 2373) responded to Short Dark Triad, which measures Machiavellianism, narcissism, and psychopathy. In both studies, respondents were asked to generate 10 self-descriptive words. We used the Latent Semantic Algorithm to quantify the meaning of each trait using the participants’ self-descriptive words. We then used these semantic representations to predict the self-reported scores. In a second set of analyses, we used word-frequency analyses to map the self-descriptive words to each of the participants’ trait scores (i.e., one-dimensional analysis) and character profiles (i.e., three-dimensional analysis).

Results

The semantic representation of each character trait was related to each corresponding self-reported score. However, participants’ self-transcendence and Machiavellianism scores demonstrated similar relationships to all three semantic representations of the character traits in their respective personality model. The one-dimensional analyses showed that, for example, “loving” was indicative of both high cooperativeness and self-transcendence, while “compassionate,” “kind,” and “caring” was unique for individuals high in cooperativeness. The words “kind” and “caring” indicated low levels of Machiavellianism and psychopathy, whereas “shy” or “introvert” indicated low narcissism. We also found specific keywords that unify or that make the individuals in some profiles unique.

Conclusion

Despite being short, both inventories capture individuals’ identity as expected. Nevertheless, our method also points out some shortcomings and overlaps between traits measured with these inventories. We suggest that self-descriptive words can be quantified to validate measures of psychological constructs (e.g., prevalence in self-descriptions or QuSTT) and that this method may complement traditional methods for testing the validity of psychological measures.

Identifying Better Outcome Measures to Improve Treatment of Agitation in Dementia: A Report from the EU/US/CTAD Task Force

For the second time in the past 3 years, the EU-US CTAD Task Force addressed challenges related to designing clinical trials for agitation in dementia, which is one of the most disruptive aspects of the condition for both patients and caregivers. Six recommendations emerged from the Task Force meeting: 1 - Operationalizing agitation criteria established by the IPA; 2 - Combining clinician- and caregiver-derived outcomes as primary outcome measures; 3 - Using global ratings to define clinically meaningful effects and power studies; 4 - Improving the accuracy of caregiver reports by better training and education of caregivers; 5 - Employing emerging technologies to collect near real-time behavioral data; and 6 - Utilizing innovative trial designs and increasing the use of biomarkers to maximize the productivity of clinical trials for neuropsychiatric symptoms.

EU/US/CTAD Task Force: Lessons Learned from Recent and Current Alzheimer's Prevention Trials

At a meeting of the EU/US/Clinical Trials in Alzheimer's Disease (CTAD) Task Force in December 2016, an international group of investigators from industry, academia, and regulatory agencies reviewed lessons learned from ongoing and planned prevention trials, which will help guide future clinical trials of AD treatments, particularly in the pre-clinical space. The Task Force discussed challenges that need to be addressed across all aspects of clinical trials, calling for innovation in recruitment and retention, infrastructure development, and the selection of outcome measures. While cognitive change provides a marker of disease progression across the disease continuum, there remains a need to identify the optimal assessment tools that provide clinically meaningful endpoints. Patient- and informant-reported assessments of cognition and function may be useful but present additional challenges. Imaging and other biomarkers are also essential to maximize the efficiency of and the information learned from clinical trials.

Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States

The shortage of deceased-donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009-2012 and State Inpatient Databases (SIDs) from 2008-2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi-organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient-level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009-2012, 96,028 (3.3%) were a "possible deceased-organ donor." The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased-donors who become actual donors; range: 20.0-57.0%); and (2) organs transplanted per possible donor (range: 0.52-1.74). These metrics allow for comparisons of OPO performance and geographic-level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.

The Swedish version of the Regulatory Mode Questionnaire

The data include responses to the Swedish version of a questionnaire used to operationalize self-regulation or regulatory mode: assessment and locomotion. The data was collected among 567 Swedish high school and university students (see Garcia and Lindskär, 2016 [1]). In this article, we also include the Swedish version of the Regulatory Mode Questionnaire. The data is available, SPSS file, as supplementary material in this article.

Risk factors for lymph node metastases in women with endometrial cancer: A population-based, nation-wide register study-On behalf of the Swedish Gynecological Cancer Group

The role of lymphadenectomy in the management of early endometrial cancer remains controversial. In the recent ESMO-ESGO-ESTRO guidelines, lymphadenectomy is recommended for patients with endometrioid adenocarcinoma Grade 3 with deep myometrial invasion, but complete agreement was not achieved. In Sweden, DNA aneuploidy has been included as a high-risk factor. The aim of our study was to evaluate the impact of tumor histology, FIGO grade, DNA ploidy and myometrial invasion (MI) on occurrence of lymph node metastasis (LNM) in patients with endometrial cancer. The study design is a retrospective cohort study based on prospectively recorded register data. Endometrial cancer patients registered in the Swedish Quality Registry for Gynecologic Cancer 2010-2015 with FIGO Stages I-III and verified nodal status were included. Data on DNA ploidy, histology, FIGO grade and MI were included in multivariable log-binomial regression analyses with LNM as dependent variable. 1,165 cases fulfilled the inclusion criteria. The multivariable analyses revealed increased risk of LNM in patients with tumors with MI ≥ 50% (risk ratio [RR] = 4.1; 95% confidence interval [CI] 3.0-5.6), nonendometrioid compared to endometrioid histology (RR 1.8; CI 1.4-2.4) and FIGO Grade 3 compared to Grade 1-2 tumors (RR 1.5; CI 1.1-2.0). No statistically significant association between DNA ploidy status and LNM was detected. This population-based, nation-wide study in women with endometrial cancer confirms a strong association between MI ≥ 50%, nonendometrioid histology and FIGO Grade 3, respectively, and LNM. DNA ploidy should not be included in the preoperative decision making of removing nodes or not.

Out of Flatland: The Role of the Notion of a Worldview in the Science of Well-being

This paper discusses the suggestion of the notion of a worldview as part of the Science of Well-Being. We present, at first, an allegoric comparison as to why the view of a ternary unity of being (i.e. a coherence of the three parts of the being, body, mind, and psyche to maximize well-being) is difficult to grasp. We also discuss that humans do have unique experiences and memories, but that we are also connected to both all living things and to our environment. Finally, we point to a ternary model of personality to increase our understanding of a person's well-being: Temperament, character, and identity.

The (mis)measurement of the Dark Triad Dirty Dozen: exploitation at the core of the scale

Background. The dark side of human character has been conceptualized in the Dark Triad Model: Machiavellianism, psychopathy, and narcissism. These three dark traits are often measured using single long instruments for each one of the traits. Nevertheless, there is a necessity of short and valid personality measures in psychological research. As an independent research group, we replicated the factor structure, convergent validity and item response for one of the most recent and widely used short measures to operationalize these malevolent traits, namely, Jonason’s Dark Triad Dirty Dozen. We aimed to expand the understanding of what the Dirty Dozen really captures because the mixed results on construct validity in previous research.

Method. We used the largest sample to date to respond to the Dirty Dozen (N = 3,698). We firstly investigated the factor structure using Confirmatory Factor Analysis and an exploratory distribution analysis of the items in the Dirty Dozen. Secondly, using a sub-sample (n = 500) and correlation analyses, we investigated the Dirty Dozen dark traits convergent validity to Machiavellianism measured by the Mach-IV, psychopathy measured by Eysenck’s Personality Questionnaire Revised, narcissism using the Narcissism Personality Inventory, and both neuroticism and extraversion from the Eysenck’s questionnaire. Finally, besides these Classic Test Theory analyses, we analyzed the responses for each Dirty Dozen item using Item Response Theory (IRT).

Results. The results confirmed previous findings of a bi-factor model fit: one latent core dark trait and three dark traits. All three Dirty Dozen traits had a striking bi-modal distribution, which might indicate unconcealed social undesirability with the items. The three Dirty Dozen traits did converge too, although not strongly, with the contiguous single Dark Triad scales (r between .41 and .49). The probabilities of filling out steps on the Dirty Dozen narcissism-items were much higher than on the Dirty Dozen items for Machiavellianism and psychopathy. Overall, the Dirty Dozen instrument delivered the most predictive value with persons with average and high Dark Triad traits (theta > −0.5). Moreover, the Dirty Dozen scale was better conceptualized as a combined Machiavellianism-psychopathy factor, not narcissism, and is well captured with item 4: ‘I tend to exploit others towards my own end.’

Conclusion. The Dirty Dozen showed a consistent factor structure, a relatively convergent validity similar to that found in earlier studies. Narcissism measured using the Dirty Dozen, however, did not contribute with information to the core of the Dirty Dozen construct. More importantly, the results imply that the core of the Dirty Dozen scale, a manipulative and anti-social trait, can be measured by a Single Item Dirty Dark Dyad (SIDDD).

The dark cube: dark and light character profiles

Background. Research addressing distinctions and similarities between people's malevolent character traits (i.e., the Dark Triad: Machiavellianism, narcissism, and psychopathy) has detected inconsistent linear associations to temperament traits. Additionally, these dark traits seem to have a common core expressed as uncooperativeness. Hence, some researchers suggest that the dark traits are best represented as one global construct (i.e., the unification argument) rather than as ternary construct (i.e., the uniqueness argument). We put forward the dark cube (cf. Cloninger's character cube) comprising eight dark profiles that can be used to compare individuals who differ in one dark character trait while holding the other two constant. Our aim was to investigate in which circumstances individuals who are high in each one of the dark character traits differ in Cloninger's "light" character traits: self-directedness, cooperativeness, and self-transcendence. We also investigated if people's dark character profiles were associated to their light character profiles. Method. A total of 997 participants recruited from Amazon's Mechanical Turk (MTurk) responded to the Short Dark Triad and the Short Character Inventory. Participants were allocated to eight different dark profiles and eight light profiles based on their scores in each of the traits and any possible combination of high and low scores. We used three-way interaction regression analyses and t-tests to investigate differences in light character traits between individuals with different dark profiles. As a second step, we compared the individuals' dark profile with her/his character profile using an exact cell-wise analysis conducted in the ROPstat software (http://www.ropstat.com). Results. Individuals who expressed high levels of Machiavellianism and those who expressed high levels of psychopathy also expressed low self-directedness and low cooperativeness. Individuals with high levels of narcissism, in contrast, scored high in self-directedness. Moreover, individuals with a profile low in the dark traits were more likely to end up with a profile high in cooperativeness. The opposite was true for those individuals with a profile high in the dark traits. The rest of the cross-comparisons revealed some of the characteristics of human personality as a non-linear complex dynamic system. Conclusions. Our study suggests that individuals who are high in Machiavellianism and psychopathy share a unified non-agentic and uncooperative character (i.e., irresponsible, low in self-control, unempathetic, unhelpful, untolerant), while individuals high in narcissism have a more unique character configuration expressed as high agency and, when the other dark traits are high, highly spiritual but uncooperative. In other words, based on differences in their associations to the light side of character, the Dark Triad seems to be a dyad rather than a triad.

Self-regulatory mode (locomotion and assessment), well-being (subjective and psychological), and exercise behavior (frequency and intensity) in relation to high school pupils' academic achievement

Background. Self-regulation is the procedure implemented by an individual striving to reach a goal and consists of two inter-related strategies: assessment and locomotion. Moreover, both subjective and psychological well-being along exercise behaviour might also play a role on adolescents academic achievement.

Method. Participants were 160 Swedish high school pupils (111 boys and 49 girls) with an age mean of 17.74 (sd = 1.29). We used the Regulatory Mode Questionnaire to measure self-regulation strategies (i.e., locomotion and assessment). Well-being was measured using Ryff’s Psychological Well-Being Scales short version, the Temporal Satisfaction with Life Scale, and the Positive Affect and Negative Affect Schedule. Exercise behaviour was self-reported using questions pertaining to frequency and intensity of exercise compliance. Academic achievement was operationalized through the pupils’ mean value of final grades in Swedish, Mathematics, English, and Physical Education. Both correlation and regressions analyses were conducted.

Results. Academic achievement was positively related to assessment, well-being, and frequent/intensive exercise behaviour. Assessment was, however, negatively related to well-being. Locomotion on the other hand was positively associated to well-being and also to exercise behaviour.

Conclusions. The results suggest a dual (in)direct model to increase pupils’ academic achievement and well-being—assessment being directly related to higher academic achievement, while locomotion is related to frequently exercising and well-being, which in turn, increase academic achievement.

Familial testicular germ cell tumors (FTGCT) - overview of a multidisciplinary etiologic study

This Review summarizes the cumulative results of the National Cancer Institute Clinical Genetics Branch Multidisciplinary Etiologic Study of Familial Testicular Germ Cell Tumors (FTGCT). Initiated 12 years ago, this protocol enrolled 724 subjects from 147 unrelated families with either ≥2 affected men (n = 90) with TGCT or a proband with bilateral TGCT and a negative family history for this cancer (n = 57). Data were collected directly from 162 subjects evaluated at the NIH Clinical Center, and 562 subjects provided information from their home communities (Field Cohort). The primary study aims included (i) ascertaining, enrolling eligible FTGCT kindred, (ii) characterizing the clinical phenotype of multiple-case families, (iii) identifying the underlying genetic mechanism for TGCT susceptibility in families, (iv) evaluating counseling, psychosocial, and behavioral issues resulting from membership in an FTGCT family, and (v) creating an annotated biospecimen repository to permit subsequent translational research studies. Noteworthy findings include (i) documenting the epidemiologic similarities between familial and sporadic TGCT, (ii) demonstrating significantly younger age-at-diagnosis for familial vs. sporadic TGCT, (iii) absence of a dysmorphic phenotype in affected family members, (iv) shifting the focus of gene discovery from a search for rare, highly penetrant susceptibility variants to the hypothesis that multiple, more common, lower penetrance genes underlie TGCT genetic risk, (v) implicating testicular microlithiasis in FTGCT risk, and (vi) observing that aberrant methylation may contribute to FTGCT risk. A clinically based, biospecimen-intensive, multidisciplinary research strategy has provided novel, valuable insights into the etiology of FTGCT, and created a research resource which will support FTGCT clinical and laboratory studies for years to come.

A happier and less sinister past, a more hedonistic and less fatalistic present and a more structured future: time perspective and well-being

Background. Previous studies have established a link between how people relate to their past, present, and future (i.e., time perspective) and subjective well-being (i.e., life satisfaction, positive and negative affect). Time perspective comprises five dimensions: Past Positive, Past Negative, Present Hedonistic, Present Fatalistic, and Future. Life satisfaction can also be evaluated in relation to different time frames. Moreover, approach related positive affect is associated to a different concept of well-being labeled psychological well-being. In the present study we extend previous findings by investigating the effect of time perspective on the time frame of evaluations of life satisfaction (past, present, future) and by investigating the relationship between time perspective and psychological well-being. Method. Questionnaires on time perspective (Zimbardo's Time Perspective Inventory), temporal life satisfaction (Temporal Satisfaction with Life Scale), affect (Positive Affect and Negative Affect Schedule), and psychological well-being (Scales of Psychological Well-Being-short version) were answered by 453 individuals. Two different structural equation models were tested, one of the relationship between time perspective and temporal life satisfaction, and the other of the relationship between time perspective, affect and psychological well-being. Results. Time perspective affected life satisfaction depending on the time scale on which it was evaluated-memory of a negative past influenced life satisfaction in all time frames, and a positive view of the past influenced both past and future life satisfaction. Moreover, less rumination about past negative events (i.e., low score on Past Negative), the tendency to take risks in the present to achieve happy feelings and/or avoid boredom (i.e., high scores on Present Hedonistic), and a less hopeless and pessimistic view about the present (low scores on Present Fatalistic) were associated with higher levels of psychological well-being and positive affect. These same time perspective dimensions were associated with lower levels of negative affect. The Future time perspective dimension (i.e., approaching life with self-control, punctuality, and planning for the future) was associated with both psychological well-being and positive affect. Conclusions. High levels of both subjective and psychological well-being are related to a happier and a less sinister past, a more hedonistic and less fatalistic present, as well as to a more structured future.

The affective profiles in the USA: happiness, depression, life satisfaction, and happiness-increasing strategies

Background. The affective profiles model categorizes individuals as self-fulfilling (high positive affect, low negative affect), high affective (high positive affect, high negative affect), low affective (low positive affect, low negative affect), and self-destructive (low positive affect, high negative affect). The model has been used extensively among Swedes to discern differences between profiles regarding happiness, depression, and also life satisfaction. The aim of the present study was to investigate such differences in a sample of residents of the USA. The study also investigated differences between profiles with regard to happiness-increasing strategies.

Methods. In Study I, 900 participants reported affect (Positive Affect Negative Affect Schedule; PANAS) and happiness (Happiness-Depression Scale). In Study II, 500 participants self-reported affect (PANAS), life satisfaction (Satisfaction With Life Scale), and how often they used specific strategies to increase their own happiness (Happiness-Increasing Strategies Scales).

Results. The results showed that, compared to the other profiles, self-fulfilling individuals were less depressed, happier, and more satisfied with their lives. Nevertheless, self-destructive individuals were more depressed, unhappier, and less satisfied than all other profiles. The self-fulfilling individuals tended to use strategies related to agentic (e.g., instrumental goal-pursuit), communal (e.g., social affiliation), and spiritual (e.g., religion) values when pursuing happiness.

Conclusion. These differences suggest that promoting positive emotions can positively influence a depressive-to-happy state as well as increasing life satisfaction. Moreover, the present study shows that pursuing happiness through strategies guided by agency, communion, and spirituality is related to a self-fulfilling experience described as high positive affect and low negative affect.

The difference between living biblically and just imagining it: A study on experiential-based learning among Swedish adolescents

As an assignment in their course on worldwide religions, a group of Swedish High School pupils followed 12 biblical rules for two weeks, while another group from the same school just imagined the experience. Groups were asked to reflect and write down either how it was (experience) or how it would have been (imagine) to follow the rules. By applying a semantic test, based on a Latent Semantic Analysis generated representation of the statements, we first found that the semantic representations of the written reflections differed between the experience and imagine groups, and between gender. Analysis of word frequency count suggests that the group that followed the rules were more likely to use words related to their task in their reflections, while the group that imagined the experience generated words related to themself and problems. The results suggest that the consequences of learning by experience might culminate in greater student engagement.

Serum B12 levels predict response to treatment with interferon and ribavirin in patients with chronic HCV infection

Vitamin B12 is stored in hepatocytes and inhibits hepatitis C virus (HCV) RNA translation. The implication of B12 in the setting of antiviral treatment is unknown. This study aims to retrospectively evaluate the discriminative efficacy of pretreatment B12 serum levels (s-B12) on end-of-treatment response (ETR) in patients with chronic HCV. Ninety-nine treatment naïve HCV patients, treated with interferon and ribavirin were studied. Serum B12 (s-B12) was analysed in samples collected before treatment start. Pretreatment s-B12 levels were correlated to ETR using univariate analysis. S-B12 and clinical data were evaluated in a multivariate logistic regression model. Mean pretreatment s-B12 was 331 pm in ETR and 260 pm in nonresponders (NR) (P = 0.012). In patients with s-B12 levels ≤ 360 pm, 23 (31.5%) were NR and 50 (68.5%) had ETR. In patients with s-B12 > 360 pm, one (3.8%) was NR and 25 (96.2%) had ETR (P = 0.0034). The results of the multivariate analysis were as follows: Pretreatment s-B12 > 360 vs ≤ 360 pm: OR 28.6 CI 2.31-354, P = 0.008. Fibrosis stage 3-4 vs 0-2: OR 0.29 CI 0.074-1.12, P = 0.068. Genotype 2/3 vs 1/4/5: OR 15.5 CI 2.87-83.9, P = 0.0012. Dose reduction vs no dose reduction: OR 0.21, CI 0.048-0.91 P = 0.034. Standard interferon vs pegylated-interferon: OR 0.079, CI 0.0091-0.68 P = 0.019. Age and gender were not correlated to ETR. S-B12 > 360 pm is independently correlated to ETR in HCV patients treated with interferon and ribavirin. This suggests that B12 is involved in suppression of viral replication during anti-HCV treatment.

Male Breast Cancer: A Population-Based Comparison with Female Breast Cancer

Purpose: Because of its rarity, male breast cancer is often compared to female breast cancer.Materials and Methods: To compare and contrast male and female breast cancers, we obtained case and population data from the NCI's Surveillance, Epidemiology, and End Results program for breast cancers diagnosed from 1973 through 2005. Standard descriptive epidemiology was supplemented with age-period-cohort models and breast cancer survival analyses.Results: Men with breast cancer comprised less than 1% of all breast cancers. Male compared to female breast cancers occurred later in life with higher stage, lower grade, and more estrogen receptor positive tumors. Recent breast cancer incidence and mortality rates declined over time for men and women, both overall and within each age group, but these trends were greater for women than men. Comparing cases diagnosed in 1996 through 2005 versus 1976 through 1985, and adjusting for age, stage, and grade, cause-specific hazard rates for breast cancer death declined by 28% among men (p = 0.03) and by 42% among women (p ∼ 0).Conclusion: There were three intriguing results. Age-specific incidence patterns showed that the biology of male breast cancer resembled the late-onset and hormone sensitive type of female breast cancer. Similar breast cancer incidence trends among men and women suggested that there are common breast cancer risk factors that affect both sexes, especially hormone positive breast cancer. Finally, breast cancer mortality and survival rates have improved significantly over time for male breast cancer, but progress has lagged behind for men compared to women.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2075.

Advanced glycation end product is implicated in amyloid‐related kidney complications

BACKGROUND

Kidney failure is a common complication in familial amyloidotic polyneuropathy (FAP). It has been suggested that advanced glycation end products (AGEs) play an important role in the development and pathogenesis of FAP.

MATERIAL AND METHODS

To evaluate the impact of AGEs on FAP patients' kidney dysfunction, we measured AGE in serum and urine of 28 FAP patients and 18 healthy controls by AGE-specific enzyme-linked immunosorbent assay (ELISA). Immunohistochemistry utilizing antibodies to AGE and the receptor for AGE (RAGE) were used on kidney tissue from 3 FAP patients and 3 diabetic patients to disclose a correlation between amyloid deposits and AGE-RAGE.

RESULTS

The glomeruli of FAP patients were heavily deposited with amyloid and the glomerular size was enlarged. The space between Bowman's capsule and glomerulus was totally covered by the enlarged glomerulus. AGE and RAGE were deposited in glomeruli and tubuli and correlated with amyloid deposits. Decreased AGE levels in the liver-transplanted FAP patients' serum compared with that of non-transplanted patients were noted, and AGE concentration in serum tended to be higher in non-transplanted FAP patients compared with normal control subjects. There were no differences in the AGE urine levels in FAP patients compared with controls. No correlation could be found between AGE in urine and serum compared with serum albumin, serum creatinine and creatinine clearance.

CONCLUSIONS

The accumulation of AGE, RAGE and amyloid in the kidney of FAP patients suggests that these molecules play an important role in the origin and pathogenesis of renal failure in FAP patients.

Spatial variation in 2-methyl-4-chlorophenoxyacetic acid mineralization and sorption in a sandy soil at field level

The phenoxyacetic acid herbicide MCPA (2-methyl-4-chlorophenoxyacetic acid) is frequently detected in groundwater beneath Danish agricultural fields. We investigated spatial variation in microbial MCPA mineralization potential in a flat agricultural field of fine sandy soil (USDA classification: Humic Dystrudept) located on the Yoldia plains of Northern Jutland, Denmark. Samples for determination of MCPA mineralization and sorption were collected from the Ap and Bs horizons at 51 sampling sites located in a 200 x 220 m grid. Spatial variation in sorption was low in both horizons (distribution coefficient, 0.36-4.16 L kg(-1)). Sorption correlated strongly with soil organic carbon content in both horizons (CV, 93 and 83%, respectively) and negatively with soil pH. [Ring-(14)C]-MCPA mineralized readily in the Ap horizon, with 49 to 62% of the (14)C-MCPA being converted to (14)CO(2) during the 67-d incubation period. With the subsoil, mineralization of (14)C-MCPA varied considerably between samples (0.5-72.8%). At neither depth was there correlation between (14)C-MCPA mineralization and sorption, soil pH, organic carbon content, clay content, number of colony-forming units (CFU), pseudomonad CFU, or any of the four microbial activity parameters measured. The presence of microbial genes encoding for the TfdA enzyme was quantified using real-time polymerase chain reaction. No correlation was found between MCPA mineralization potential and the natural background number of tfdA genes present in the soil samples. The degradation kinetics suggests that the high (14)C-MCPA mineralization rate detected in soil samples was linked to growth of the MCPA-degrading soil microbial community.

Impact of basic soil parameters on pesticide disappearance investigated by multivariate partial least square regression and statistics

Dissipation time is a key parameter when studying and modeling the environmental fate of pesticides. This study was conducted to characterize the variability of pesticide disappearance in soil and to identify possible controlling parameters related to intrinsic soil properties and microbiology. Multivariate data analysis was used to study spatial variability in three horizons from 24 sandy soil profiles. The time for 50% disappearance (DT(50)) was characterized for two herbicides, metribuzin (MBZ) and MCPA, and methyltriazine amine (MTA; transformation product of metsulfuron-methyl, tribenuron-methyl, thifensulfuron-methyl, and chlorsulfuron). Normal and log-normal distributions were compared for DT(50) and soil properties and descriptive statistics were calculated. Conformity with log-transformed distributions was observed and assuming normality of the DT(50) data would cause 5 to 35% overestimation. Mean DT(50) were: MCPA 9.5, MBZ 168, and MTA 127. Significant effect of soil depth on DT(50) was shown for MCPA and MBZ, with low values in deeper horizons. Simple linear correlation for combinations of MCPA, MTA, pH, and total organic carbon (TOC) was observed. Using partial least squares regression (PLS) 71 to 85% of the total DT(50) variance was explained. A specific predictor variable could not be identified as the controlling components differed within horizons and compounds. For MCPA the overall important predictor variables were microbiology and TOC, whereas for MTA and MBZ it was inorganic variables (Al, Fe, cation exchange capacity, base saturation percent, and pH) and microbiology. The study indicates that PLS generated input data can improve pesticide fate modeling and reduce the uncertainty in dissipation estimation.

Usefulness of symphysis-fundal height in predicting fetal weight in healthy term pregnant women

BACKGROUND

There are some works reporting that the measurement of the symphysis-fundal height (SFH) of a full-term uterus is a simple method for estimating the fetal weight.

AIM

Evaluating the goodness of distance between the symphysis and uterine fundus in predicting both low-weight fetuses and high-weight fetuses, comparing it with the third quarter ultrasound estimation of fetal weight and then assessing the clinical effectivity of symphysis-fundal measurement associated with third quarter echography in predicting birth weight.

METHODS

A prospective study was carried out on 96 single physiologically full-term pregnancies. The diagnostic accuracy of the SFH, echographic fetal growth estimated between the 32nd and the 35th week (expressed in percentiles), and of both was expressed as sensitivity, specificity, predictive positive and negative value, likelihood ratios and compared.

RESULTS

There was a correlation between the SFH and fetal birth weight. A SFH below 33 cm is predictive of a fetus whose weight is less than 3,100 g whereas a SFH above 34 cm is predictive of a fetus whose weight is more than or equal to 4,000 g. The diagnostic effectiveness of the SFH was not significantly higher than the ultrasound scanning evaluation of fetal weight in the third quarter and could be slightly improved if it is taken into account along with the ultrasound scanning data.

CONCLUSIONS

The measurement of the SFH at term may be helpful in foretelling the fetal birth weight and may improve the diagnostic accuracy of the third quarter echographic estimation of birth weight.

A randomized phase-III study on adjuvant treatment with radiation (RT) ± chemotherapy (CT) in early-stage high-risk endometrial cancer (NSGO-EC-9501/EORTC 55991)

5503

Background: Adjuvant therapy for early stage high-risk endometrial cancer remains controversial. Methods: Patients with surgical stage I, II, IIIA (positive peritoneal fluid cytology only), or IIIC (positive pelvic lymph nodes only) were eligible if they, according to departmental guidelines, had a sufficiently high risk for micrometastatic disease to qualify for adjuvant therapy. Most patients had two or more of the risk factors: grade 3, deep myometrial invasion, or DNA non-diploidy, while some patients had only one of these. Patients with serous, clear cell, or anaplastic carcinomas were eligible regardless of risk factors. Patients with para-aortic metastases were not eligible. Lymph node exploration at staging surgery was optional. Pelvic RT ± vaginal brachytherapy was given to a dose =44 Gy. CT was given before or after RT. Before August 2004 CT consisted of four courses of cisplatin =50 mg/m2 + doxorubicin 50 mg/m2 or epirubicin 75 mg/m2 (AP). Thereafter several CT regimens were allowed, of which AP, paclitaxel 175 mg/m2 + epirubicin 60 mg/m2 + carboplatin AUC 5, and paclitaxel 175 mg/m2 + carboplatin AUC 5–6 were used. Progression-free survival (PFS) was the primary end-point. The study was terminated before the aimed goal of 400 patients because of slow recruitment. We decided to make an early analysis since new studies on endometrial cancer are presently discussed. Results: 372 patients were entered between May 1996 and Oct 2006. Of 367 evaluable patients 190 were randomized to RT and 177 to RT+CT. Risk factors were well balanced between the randomization arms. The median follow-up time was 3.5 years. The hazard ratio for PFS was 0.58 in favor of RT+CT (95 % confidence interval (CI) 0.34 - 0.99; p=0.046). This translates to an estimated 7 % absolute difference in 5-year PFS from 75 % (95 % CI 67 % - 82 %) to 82 % (95 % CI 73 % - 88 %). Conclusion: RT+CT was better than RT alone. Next question is if RT+CT is better than CT alone.

No significant financial relationships to disclose.

Malignant mixed müllerian tumor of the fallopian tube coincident with a primary serous carcinoma of the ovary. Case report

Malignant mixed müllerian tumors are very rare neoplasms of the fallopian tube, and treatment is not well defined. A case of malignant mixed müllerian tumor of the tube concomitant with a primary serous carcinoma of the ovary is reported. It was unclear if there were two distinct neoplasms in the same patient, or if it was a single tumor with a sarcomatous fallopian conversion of the serous component, as described for some recurrent ovarian carcinomas. Chemotherapy for ovarian carcinoma with intraperitoneal metastasis was performed, with about a three-year interval-free period of disease, as could be expected for ovarian carcinomas at the same stage. Such coexistence of these two tumors does not afford adequate staging of the malignancy. Therapy for the very rare cases similar to the one reported here needs to be improved.

Effects of cigarette smoking on serum fluoride concentrations and renal function integrity after 1 MAC-h sevoflurane anaesthesia

BACKGROUND

Tobacco smoke contains various chemicals which may affect drug metabolism. Sevoflurane is metabolized to inorganic fluoride, and elevated serum fluoride concentrations (S-F(-)) may cause deterioration of renal function. Whether smokers develop high S-F(-) and associated disturbances in renal function is not known.

METHODS

We investigated sevoflurane metabolism in 25 non-smoking and 25 smoking (> 10 cigarettes/day) generally healthy women, aged 19-68 years, undergoing gynaecological elective surgery under one minimum alveolar concentration-hour (1 MAC-h) standardized sevoflurane anaesthesia. S-F(-) was measured for 24 h. Glomerular and tubular function was assessed by measuring serum and urine tumour-associated trypsin inhibitor (TATI), beta(2)-microglobulin and serum creatinine for 48 h after sevoflurane inhalation.

RESULTS

There were no differences between the two study groups with regard to S-F(-). It increased significantly in both groups: in non-smokers, from a baseline between 1.0 and 11 micromol/l (median, 1.6 micromol/l) to a maximum between 8.2 and 40 micromol/l (26 micromol/l) (P < 0.001) and, in smokers, from a baseline between 0.5 and 5.2 micromol/l (1.7 micromol/l) to a maximum between 19 and 71 micromol/l (25 micromol/l) (P < 0.001). In both groups, S-F(-) remained elevated for the entire sampling period (P < 0.001). In all five women (one non-smoker and four smokers) with a maximum S-F(-) of 40 micromol/l or higher and an area under the serum fluoride concentration-time curve (AUC(F0-24)) of 500 micromol/h/l or higher, serum TATI increased above the pathological concentration of 3.0 nmol/l, whereas only six of the 45 patients with S-F(-) below 40 micromol/l had serum TATI above 3.0 nmol/l (P < 0.001). Beta(2)-Microglobulin increased significantly (> 1 mg/l) in two patients with high S-F(-) relative to two of the 45 patients with S-F(-) below 40 micromol/l (P= 0.005). None of the patients developed clinically detectable renal dysfunction.

CONCLUSION

Smoking did not affect S-F(-) after sevoflurane anaesthesia. Glomerular dysfunction, seen as increased serum TATI, was noted in five women with S-F(-) above 40 micromol/l. Our results suggest that the renal toxic threshold of S-F(-) seems to be lower than the earlier reported value of 50 micromol/l.

Comparison of 30 and the 100% inspired oxygen concentrations during early post-resuscitation period: a randomised controlled pilot study

OBJECTIVES

High oxygen concentration in blood may be harmful in the reperfusion phase after cardiopulmonary resuscitation. We compared the effect of 30 and 100% inspired oxygen concentrations on blood oxygenation and the level of serum markers (NSE, S-100) of neuronal injury during the early post-resuscitation period in humans.

METHODS

Patients resuscitated from witnessed out-of-hospital ventricular fibrillation were randomised after the return of spontaneous circulation (ROSC) to be ventilated either with 30% (group A) or 100% (group B) oxygen for 60 min. Main outcome measures were NSE and S-100 levels at 24 and 48 h after ROSC, the adequacy of oxygenation at 10 and 60 min after ROSC and, in group A, the need to raise FiO(2) to avoid hypoxaemia. Blood oxygen saturation <95% was the threshold for this intervention.

RESULTS

Thirty-two patients were randomised and 28 (14 in group A and 14 in group B) remained eligible for the final analysis. The mean PaO(2) at 10 min was 21.1 kPa in group A and 49.7 kPa in group B. The corresponding values at 60 min were 14.6 and 46.5 kPa. PaO(2) values did not fall to the hypoxaemic level in group A. In another group FiO(2) had to be raised in five cases (36%) but in two cases it was returned to 0.30 rapidly. The mean NSE at 24 and 48 h was 10.9 and 14.2 microg/l in group A and 13.0 and 18.6 microg/l in group B (ns). S-100 at corresponding time points was 0.21 and 0.23 microg/l in group A and 0.73 and 0.49 microg/l in group B (ns). In the subgroup not treated with therapeutic hypothermia in hospital NSE at 24h was higher in group B (mean 7.6 versus 13.5 microg/l, p=0.0487).

CONCLUSIONS

Most patients had acceptable arterial oxygenation when ventilated with 30% oxygen during the immediate post-resuscitation period. There was no indication that 30% oxygen with SpO(2) monitoring and oxygen backup to avoid SpO(2)<95% did worse that the group receiving 100% oxygen. The use of 100% oxygen was associated with increased level of NSE at 24h in patients not treated with therapeutic hypothermia. The clinical significance of this finding is unknown and an outcome-powered study is feasible.

Fluoride metabolism in smokers and non-smokers following enflurane anaesthesia

BACKGROUND

Inorganic fluoride is released by the metabolism of enflurane and the increased serum fluoride concentrations may impair renal function. Tobacco smoke consists of numerous reactive compounds that can either induce or inhibit drug metabolism. Studies on the interaction of smoking with anaesthetic drug metabolism and possible toxicity are warranted.

METHODS

Sixteen non-smoking and 17 smoking (>10 cigarettes day(-1)) generally healthy women undergoing elective gynaecological surgery were given 1 MAC (minimum alveolar concentration)-hour standardized anaesthesia with enflurane in oxygen-air mixture. The serum inorganic fluoride and renal function markers beta(2)-microglobulin, tumour-associated trypsin inhibitor (TATI) and serum creatinine were measured for 48 h.

RESULTS

The greatest inorganic fluoride concentration was between 8.4 and 21.0 (mean 13.8 (SD 3.4)) micromol litre(-1) in the non-smokers and between 8.6 and 38.0 (18.7 (7.0)) micromol litre(-1) in the smokers; the mean difference was 4.9 micromol litre(-1) (95% confidence interval (CI) 1.0-8.8, P<0.05). Serum beta(2)-microglobulin, TATI and creatinine were not increased. Serum inorganic fluoride concentrations were significantly greater in the smokers compared with the non- smokers 1, 2, 3 and 6 h after 1 MAC-hour inhalation with enflurane (P<0.05). Inorganic fluoride concentrations were still increased 24 h after anaesthesia in both groups. Urine beta(2)-microglobulin and TATI creatinine ratio remained at low values during the whole 48-h period in both groups.

CONCLUSIONS

Regular smoking is associated with an increase in serum inorganic fluoride concentration after anaesthesia with enflurane, but there are no signs of renal damage.

Axonal damage to the left musculocutaneous nerve of the left biceps muscle during laparoscopic surgery

The probable etiology of axonal damage to the left musculocutaneous nerve (motor branch) of the left biceps branchii during a laparoscopic procedure was the position in which the patient was maintained. As a result of unintentional change in the angle of the arm from 90 to approximately 120 degrees while in steep Trendelenburg position, the arm might have suffered hyperextension, resulting in pressure on and stretching of the brachial plexus nerve. This in turn might be the cause of neurologic damage. We recommend taking steps to prevent such occurrences, such as tying the patient's arms parallel to the body.

Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest

OBJECTIVE

To investigate the safety and efficacy of thrombolytic treatment for an acute myocardial infarction (AMI) immediately after resuscitation in the out-of-hospital setting.

DESIGN

Retrospective.

SETTING

A middle-sized urban city (population 540000) served by a single emergency medical system using a tiered response with physicians in field.

PATIENTS AND METHODS

Sixty-eight patients with an initial diagnosis of AMI who received thrombolytic treatment in an out-of-hospital setting after cardiac arrest and cardiopulmonary resuscitation (CPR) between January 1st 1994 and December 31st 1998. An ECG and the myocardial enzymes (CK, CK-MB, Troponin-T) were used to diagnose AMI. Myocardial reperfusion was assessed by resolution of the ST-segment elevation. Side effects and complications were studied. The quality of secondary survival was evaluated. The Utstein style was used for a uniform style of reporting the cardiac arrest data.

RESULTS

The accuracy of prehospital diagnosis was found to be excellent. Retrospective analysis revealed that thrombolytic therapy had been appropriately administered in 64 (94%) of the 68 patients actually treated. Reperfusion was achieved in 71% of the patients. Haemorrhagic complications were few, and included intracranial haemorrhage (one patient), gastrointestinal bleeding (two patients), bleeding from the puncture site (one patient) and epistaxis (one patient). The incidence of hypotension during streptokinase infusion was 22%. Sixty-three (93%) of the patients were admitted alive to the hospital, with 36 subsequently surviving to discharge.

CONCLUSIONS

Thrombolytic treatment is a safe and effective treatment in AMI even after out-of-hospital cardiopulmonary resuscitation.

Ketorolac is not nephrotoxic in connection with sevoflurane anesthesia in patients undergoing breast surgery

Ketorolac, which may cause renal vasoconstriction by cyclooxygenase inhibition, is often administered to patients anesthetized with sevoflurane that is metabolized to inorganic fluoride (F(-)), another potential nephrotoxin. We assessed this possible interaction using urine N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine (U-NAG/crea) as a marker of proximal tubular, beta2-microglobulin as a tubular, urine oxygen tension (P(u)O(2)) as a medullary, and erythropoietin as a marker of tubulointerstitial damage. Thirty women (ASA physical status I-II) undergoing breast surgery were included in our double-blinded study. They were allocated into two groups receiving either ketorolac 30 mg IM (Group K) or saline (Group C) at the time of premedication, at the end of, and 6 h after anesthesia maintained with sevoflurane. Urine output, U-NAG/crea, P(u)O(2,) serum creatinine, urea, and F(-) were assessed. Blood loss was larger in Group K (465 +/- 286 mL vs 240 +/- 149 mL, mean +/- SD, P < 0.05). The MAC-doses of sevoflurane were similar. U-NAG/crea increased during the first 2 h of anesthesia and serum F(-) peaked 2 h after the anesthesia without differences between the groups. There were no statistically significant changes in P(u)O(2), erythropoietin, beta2-microglobulin, serum creatinine, urea, or urine output during anesthesia or the recovery period in either group. Our results indicate that the kidneys are not affected by ketorolac administered in connection with sevoflurane anesthesia.

IMPLICATIONS

The different kinetics of N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine and serum inorganic fluoride during and after sevoflurane anesthesia suggest that the observed mild renal tubular function deterioration is not caused by inorganic fluoride. Administration of ketorolac IM is therefore considered safe in adequately hydrated healthy adult patients given sevoflurane anesthesia.