Clinical outcome of patients 20 years after Fontan operation — effect of fenestration on late morbidity

Objective: The Fontan operation has been proposed as definitive palliation for an increasing variety of hearts with complex univentricular anatomy, but late morbidity after Fontan operation is still a matter of concern. This retrospective study evaluates the late outcome in patients with Fontan circulation. Methods: We included 121 consecutive patients that underwent Fontan operation between 1984 and 2004. Modifications of the Fontan operation included atriopulmonary anastomosis (APA; n = 28), total cavopulmonary connection (TCPC; n = 63), and fenestrated TCPC (f-TCPC; n = 30). Mean age was 5.8 ± 5.5 years. Post operative mortality, morbidity, hemodynamics, and somatic development were analyzed. Results: Actuarial survival was 87% at 20 years after Fontan operation. There were 10 early deaths, 5 late deaths, and 2 takedowns followed by successful conversion and heart transplantation. Among 108 early-survivors with Fontan circulation, 19 underwent reoperation, including 3 conversions of APA to TCPC. Freedom from reoperation was 76% at 20 years. Freedom from intervention was 34% at 20 years. Freedom from tachyarrhythmia or pacemaker implantation was 23% and 77%, respectively at 20 years. Heterotaxy and atrioventricular valve anomaly were risk factors for late failure and tachyarrhythmias. Patients with fenestrated TCPC had reduced incidence of late tachyarrhythmias, and patients with APA who developed collaterals showed low incidence of late tachyarrythmia. Postoperative sinus node dysfunction or tachyarrhythmias was associated with significantly lower cardiac index. Somatic development was gradually compensated after Fontan operation. Weight normalized completely 15 years postoperatively. Conclusions: Long-term survival after Fontan procedure is encouraging, but late morbidity remains suboptimal. During follow-up, emerging complications should be managed by surgical and interventional procedures. Fenestration in Fontan circulation provided better cardiac output and lower incidence of late tachyarrhythmias, suggesting a benefit of fenestration for late outcome.     

Assessing patient–caregiver communication in cancer—a psychometric validation of the Cancer Communication Assessment Tool (CCAT-PF) in a German sample

Purpose

The recently introduced Cancer Communication Assessment Tool (CCAT-PF) measures congruence in patient–caregiver communication and was initially validated in lung cancer patients. Contributing to a greater proportion of the variance in the conflict scores, primary caregivers were hypothesized to experience greater stress. For a detailed understanding of conflicting communication patterns of cancer-affected families, our study aimed for psychometric validation of the CCAT-PF in a sample covering heterogeneous tumor entities.

Methods

Subsequent to a cross-sectional survey of 189 pairs of cancer patients (31 % gastrointestinal, 34 % lung, and 35 % urological) and their caregivers’ exploratory factor analysis with principal component condensation and varimax rotation was conducted (response rate, 74.2 %). Reliability and construct validity were assessed calculating Cronbach’s α and Pearson correlation coefficients for CCAT-P and CCAT-F scales and related constructs, respectively.

Results

Cancer-related communication according to the CCAT-PF can be subdivided into four factors including the scales Disclosure, Limitation of treatment, Family involvement in treatment decisions, and Continuing treatment. Reliability ranged from α?=?.51–.68. The Disclosure scale, describing poor cancer-related communication of the patient, was correlated with patient’s distress (QSC-R10: r?=?.30, p?<?.0001), unmet needs in several areas (SCNS-SF-34: r?=?.25–.32, p?<?.001), and negatively with social/family well-being (FACT: r?=??0.31, p?<?.0001). Higher scores on the scale were significantly associated with considerable decrements in emotional well-being especially for caregivers perceiving patients’ disclosure as problematic.

Conclusions

The Disclosure scale originating from the CCAT-PF emerged as a short, valid, and reliable stand-alone instrument for identifying conflicting communication in patient–caregiver–dyads at risk.     

Depression,anxiety and disease-related distress in couples affected by advanced lung cancer

Objectives

Lung cancer patients and their partners are prone to high levels of depression and anxiety or severe distress related to the poor prognosis of the illness. However, there remain doubts regarding the extent to which this distress exceeds levels in the general population. This study explored levels of depression and generalized anxiety for comparison with matched data of a representative sample from the general population. Additionally, covariance of distress between the two partners, together with disease-specific components and differences were investigated.

Materials and methods

In a cross-sectional survey, 54 pairs of lung cancer patients and their partners (n = 108) were assessed for depression and anxiety, cancer-related distress, unmet needs and disclosure in communication. Comparisons between distress levels of participating couples and matched community-comparisons (n = 162) were conducted. Additionally, multilevel analysis for estimating intra-dyadic associations of anxiety and depression was computed. Components of distress, needs and aspects of communication were explored via item mean values.

Results

Lung cancer patients as well as their partners exhibited significantly higher levels of depression and anxiety when compared to community-based comparison subjects (patients: mean difference of 1.01 for depression with a relative risk (RR) of 4.5 and 0.84 for anxiety with RR = 6.1; partners: 1.17 for depression with RR = 4.6 and 1.59 for anxiety with RR = 7.6). Partial intraclass correlations between patients and partners were weak (PIC = .29 for depression; PIC = .21 for anxiety). Fear of progression emerged as main component of distress for both patients and partners, although differing stressors were described.

Conclusion

Lung cancer-affected couples exhibit levels of depression and anxiety far exceeding those of the general community. In clinical practice, patients and partners should be assessed separately for distress against the background of weak intra-dyadic associations. In cases of significant depression or anxiety, referral for psychosocial treatment is indicated and has been shown to improve quality of life.     

Zur Diagnostik der Schwangerschaft Mittels Phloridzininjektion

Ohne Zusammenfassung     

Experimental Evaluation of Functional Imaging for Radiotherapy

Strahlentherapie und Onkologie -     

Quantitative liver function tests in donors and recipients of living donor liver transplantation.

The unique ability of the liver to regenerate quickly after resection makes living donor liver transplantation (LDLT) possible. This technique uses the unique ability of the liver to regenerate to full size after partial resection. However, the quality and course of this regeneration process in humans are still widely unexplored. In the present study we investigated the quantitative liver function tests galactose elimination capacity (GEC), indocyanine green half-life (ICG), and lidocaine half-life as markers for the quality of the liver regeneration in the first 3 months after LDLT. In this study, 22 consecutive living liver donors and their corresponding recipients were analyzed at baseline and at 10 and 90 days after LDLT. Six recipients lost their grafts during the study period. We compared donors and recipients at the different time points. After LDLT, GEC decreased (-42.6%) and ICG increased (+50.6%) significantly in donors. ICG and GEC remained significantly altered over 3 months in donors with an improvement between days 10 and 90 (GEC, +59.3%; ICG, -9.1%). ICG and GEC improved significantly in recipients between days 10 and 90 (ICG, -63.7%; GEC, +16.3%). The lidocaine half-life showed no significant changes. The donors had better test results and recovered faster than the recipients. In conclusion, after LDLT the parameters for liver capacity and flow remain altered in donors and recipients despite rapid volume growth.     

Recombinant virus-like particles as a carrier of B- and T-cell epitopes of hepatitis C virus (HCV)

The major aim of the project was the development of virus-like particles (VLP) displaying B- and T-cell epitopes of hepatitis C virus (HCV) proteins. To this end, hepatitis B virus core (HBc) particles were used as a carrier of HCV epitopes. Fragments of HCV genes encoding core (aa 98) and NS3 (aa 155) proteins were fused to the 3' terminus of the truncated HBV core gene. All recombinant plasmids led to relatively high levels of expression of chimeric proteins in E. coli, which resulted in the formation of complete "mature" VLP. Chimeric HBc/HCV VLPs were purified by combination of gel filtration and sucrose gradient centrifugation, and used for immunogenicity studies in mice. All variants of hybrid particles induced high humoral and cellular responses to HBcAg. Immunization with the HBc/HCV core particles led to relatively low antibody and T-cell proliferative responses to HCV core epitopes. The HBc/HCV NS3 particles were able to induce high levels of anti-NS3 antibodies in the absence of proliferative responses to HCV epitopes. Thus, the results of the current study have demonstrated the principal possibility of using VLP on the basis of HBcAg for creation of a new type of HCV-specific immunogen.     

Rate of action ofAnemonia sulcata toxin II on sodium channels in myelinated nerve fibres

1. The effect of Anemonia sulcata toxin II (ATX II) on single myelinated nerve fibres of the frog, Rana esculenta, was investigated. 2. ATX II promptly and reversibly increased the duration of action potentials; on applying 9.5 micro M the time, t0.5, to reach half of the final effect was 2.6 s. In the presence of 10 mM tetraethylammonium the duration was very sensitive to ATX II and as little as 10 nM could be detected. 3. The underlying mechanism was a diphasic incomplete inactivation of sodium channels which, at 15 degrees C, caused a sizeable INa to persist after 15 ms depolarization (I15ms). 4. On applying 5 micro M (1.25 micro M) ATX II at ca. 15 degrees C, I15ms developed with a sigmoid time course whose t0.5 was 1.5 s (2.6 s) and on washing declined in a near-exponential fashion with tau off = 6.1 s (6.4 s). Washing after a short (1-2s) application led to a transient considerable increase in I15ms followed by a faster decline with tau'off less than tau off. 5. Cooling decreased the rate of action with a Q10 of 1/tau0.5 = 1.9 and of 1/tau off = 2.0 (between 7 and 14 degrees C). ATX I (up to 15 micro M) was ineffective and did not antagonize ATX II. 6. Both rates of diffusional access and reaction seem to contribute to the rate of action. The results suggest a superficial binding site.