Depression and quality of life in old age: a closer look

Depressive disorders are among the most widespread mental disorders in old age, with negative consequences for quality of life (QOL). Understanding QOL as a multidimensional construct, in this article we have a closer look on what specific aspects are affected by depression. We used a representative sample of the German population (n = 805) and one of individuals diagnosed with depression (n = 106) to compare QOL using the WHOQOL-BREF and the WHOQOL-OLD. Multivariate analysis showed that individuals diagnosed with depression exhibited lower QOL with regard to WHOQOL-BREF-dimensions physical health, psychological, social relationships and global QOL and with regard to WHOQOL-OLD-facets sensory abilities, past, present, and future activities and social participation. In addition, in the regression analysis, there were no significant differences between individuals with and without depression with regard to environment (WHOQOL-BREF), autonomy, death and dying, intimacy and overall (WHOQOL-OLD). Associations between depression and QOL in older age are selective in terms of which aspects of QOL are affected. From a methodological perspective, a multidimensional approach to QOL is recommended. From a clinical perspective, our research highlights those areas of QOL that are relevant for health professionals working with older people and that could be the focus of interventions.     

Teaching and training in laparoscopic inguinal hernia repair (TAPP): impact of the learning curve on patient outcome

Background

On the basis of lower incidence of postoperative pain and faster recovery compared with open techniques, the laparoscopic transabdominal preperitoneal patch plastic (TAPP) technique was established as a leading mode of inguinal hernia repair. In contrast to open hernia repairs, which are well integrated in the training of young surgeons, TAPP is still considered a more difficult surgical procedure, raising the questions of how to include this technique in trainee programs and how to provide appropriate training.

Methods

Out of 15,101 TAPP procedures performed in our department between 1993 and 2007, we analyzed 254 operations that occurred from April 2004 to February 2007 by young trainees (between the second and fourth years of surgical training). The analysis compared the trainees’ TAPP operations with 3,200 TAPP procedures performed by experienced surgeons in the same time period, and with the first 254 TAPP operations in our department performed by pioneers who introduced this technique in 1993.

Results

In the 254 operations performed by young trainees, the mean operation time was 59 min, the morbidity rate was 3.2 %, and the recurrence rate was 0.4 %. Compared to experienced surgeons, we found no significant difference in recurrence rate and morbidity. For operation time, however, the young trainees demonstrated a learning curve with continuous improvement until the end of the study period approaching expert level. Pioneers also demonstrated a clear learning curve in operation time and additionally also regarding morbidity and recurrence rate.

Conclusions

Our study demonstrates that the TAPP learning curve of young trainees is only related to operation time. Therefore, TAPP is a safe and reproducible technique when performed by young trainees under the supervision of experienced laparoscopic surgeons. With an adequate program, the technique can be learned quickly, skillfully, and safely when a standardized technique is used. It should be included as a fundamental part of state-of-the-art trainee programs.     

Impact of radiotherapy on microsurgical reconstruction of the head and neck

Purpose

To examine tissue oxygenation and perfusion of free microvascular grafts after primary reconstruction, regarding outcome for patients received adjuvant radiotherapy and different types of grafts.

Patients and methods

Free microvascular grafts (n?=?48) after primary reconstruction of the head and neck were examined for tissue oxygenation and perfusion over a period of 6?months. 28 patients received adjuvant radiotherapy. Using a laser doppler flowmetry combined with tissue spectroscopy of the Oxygen-to-see^?—equipment (LEA Medizintechnik, Giessen), we were able to determine oxygen saturation, hemoglobin concentration, blood flow and blood flow velocity in the graft in each of two tissue depths (2, 8?mm). Different types of graft were compared.

Result

Comparison of irradiated and non-irradiated grafts showed significant differences in tissue perfusion and oxygenation. Results for all radiated radial and fibula flaps showed no significant (p?>?0.05) differences for all reviewed parameters. However, it showed no dose-volume effect with impaired functionality was found for irradiated grafts.

Conclusion

Mircovascular free tissue grafts show an increased perfusion and oxygenation after radiation compared to non-irradiated grafts.     

Overexpression of Twinkle-helicase protects cardiomyocytes from genotoxic stress caused by reactive oxygen species

Mitochondrial DNA (mtDNA) in adult human heart is characterized by complex molecular forms held together by junctional molecules of unknown biological significance. These junctions are not present in mouse hearts and emerge in humans during postnatal development, concomitant with increased demand for oxidative metabolism. To analyze the role of mtDNA organization during oxidative stress in cardiomyocytes, we used a mouse model, which recapitulates the complex mtDNA organization of human hearts by overexpression of the mitochondrial helicase, TWINKLE. Overexpression of TWINKLE rescued the oxidative damage induced replication stalling of mtDNA, reduced mtDNA point mutation load, and modified mtDNA rearrangements in heterozygous mitochondrial superoxide dismutase knockout hearts, as well as ameliorated cardiomyopathy in mice superoxide dismutase knockout in a p21-dependent manner. We conclude that mtDNA integrity influences cell survival and reason that tissue specific modes of mtDNA maintenance represent an adaptation to oxidative stress.Mammalian mitochondrial DNA (mtDNA) is a 16.5-kb circular double-stranded molecule that exists in thousands of copies per cell. It is essential for ATP production in mitochondria because it encodes 13 subunits of the protein complexes required for oxidative phosphorylation, as well as tRNAs and rRNAs necessary for mitochondrial protein biosynthesis. Mitochondria are especially abundant in the heart, the most energy demanding tissue in the mammalian body. Efficient mitochondrial activity is essential for normal heart function and embryonic development (1).The majority of O₂ in mitochondria is consumed by complex IV of the electron transport chain (ETC) during controlled reduction of O₂ to water. However, because of electron leaks at complexes I and III, some oxygen molecules are reduced to superoxide anions (O₂⁻), which, in turn, are converted to H₂O₂ by mitochondrial superoxide dismutase (SOD2) and further into water in a reaction facilitated by catalase (2, 3). Both O₂⁻ and H₂O₂ can react to form highly destructive OH· radicals, and all three are therefore commonly referred to as reactive oxygen species (ROS). Mitochondrial ROS directly damage mtDNA, oxidize disulfides in proteins, and cause peroxidation of membrane fatty acids (4, 5). Oxidative damage has been suggested to be a major source of somatic mtDNA mutations because it cross-links DNA and causes nucleotide modifications as well as single- and double-strand DNA breaks (6). The importance of ROS damage specifically to the heart is particularly evident in Sod2 knockout mice. Complete lack of SOD2 in homozygous knockout mice results in early postnatal lethality, whereas reduction of SOD2 activity in heterozygous (Sod2^+/−) mice causes dilated cardiomyopathy during aging (7, 8). Other tissues in Sod2^+/− mice are not markedly affected under physiological conditions with the exception of an increased rate of tumor formation in aged mice (9).Oxidative mtDNA damage increases during postnatal heart development in rats when mitochondrial biogenesis is up-regulated and a metabolic switch from carbohydrate metabolism to β-oxidation of fatty acids occurs (10). In rodents, the developmental increase in ROS exposure temporarily elicits mtDNA repair responses but does not lead to major changes in mtDNA topology or replication during aging (10). In contrast, human heart mtDNA topology changes considerably during postnatal development (10). Although adult human heart mtDNA is organized in complex networks and shows high levels of junctional molecules, the mtDNA organization in the hearts of newborn babies is simple, resembling the situation in rodents (11–13).Although four-way junctions and complex mtDNA molecules are not present at detectable levels in normal mouse heart, they can be induced by transgenic overexpression of the TWINKLE helicase (12). Besides being necessary for the maintenance of four-way junctions in human heart (10), TWINKLE also possesses strand-annealing activity in vitro, making it an attractive candidate conferring mitochondrial recombination activity (14).We have hypothesized previously that enhanced recombination protects human heart mtDNA from chronic ROS exposure during long lifetime (11, 15). This view is also supported by the acquisition of complex mtDNA organization in postnatal human hearts concomitant with the increase in oxidative metabolism (12, 13) and ROS-dependent activation of recombination-dependent replication (RDR) in yeast (16). To test whether the mtDNA organization seen in human hearts protects against ROS, we took advantage of TWINKLE overexpressing (Tw⁺) mice, which recapitulate the structural phenotype of human heart mtDNA and crossed them with heterozygous Sod2^+/− mice. We found that TWINKLE overexpression essentially eliminated the elevated mtDNA mutation load in Sod2^+/− mouse hearts, changed the type of mtDNA rearrangements, and rescued cardiomyopathy in Sod2^+/− mice, most likely by preventing apoptosis of cardiomyocytes via p21-dependent signaling. Our results indicate that TWINKLE maintains mtDNA integrity, hence promoting cardiomyocyte survival.     

Arc therapy for total body irradiation – A robust novel treatment technique for standard treatment rooms

Background and purpose

We developed a simple and robust total body irradiation (TBI) method for standard treatment rooms that obviates the need for patient translation devices.

Methods and materials

Two generic arcs with rectangular segments for a patient thickness of 16 and 20 cm (arc16/arc20) were generated. An analytical fit was performed to determine the weights of the arc segments depending on patient thickness and gantry angle. Stability and absolute dose for both arcs were measured using EBT3 films in a range of solid water slab phantom thicknesses. Additionally ionization chamber measurements were performed every 10 cm at a source surface distance (SSD) of ∼200 cm.

Results

The measured standard deviation for arc16 is ±3% with a flatness ?9.0%. Arc20 had a standard deviation of ±3% with a flatness ?7.3% for all measured thicknesses. The theoretical curves proved to be accurate for the prediction of the segment weightings for the two arcs. In vivo measurements for the first 22 clinical patients showed a dose deviation of less than 3%.

Conclusions

Arc therapy is a convenient and stable method for TBI. This cost-effective approach has been introduced clinically, obviating the need for field patches and to physically move the patient.     

Health effects and acceptance of a physical activity program for older long-term unemployed workers

Purpose

Long-term unemployment has negative effects on both mental and physical health. In combination with an inactive lifestyle, it often leads to functional or constitutional limitations that make reemployment in the labor market difficult especially for older adults. The presented pilot study examined a 3-month-long interventional program for improving health of older, long-term unemployed persons with regard to its effectiveness and acceptance by the target group.

Methods

The low-threshold intervention was offered by a job training center that supports reemployment and was divided into lectures for enhancing the individual health competence and a supervised physical training part in a fitness center. One hundred and nineteen long-term unemployed workers (53.7 ± 3 years) took part in a prospective investigation with 3 data collection points: before intervention (T1), after intervention (T2, n = 94), and 6 month after intervention (T3, n = 59). The spectrum of methods included the assessment of nutritional status, cardiovascular risk factors, physical fitness, chronic backache, and depression.

Results

As a result of the intervention, the physical fitness improved significantly (maximal oxygen uptake: p < 0.002). Cardiovascular risk factors like systolic and diastolic blood pressure (p < 0.016; p < 0.001) and percentage body fat (p < 0.017) decreased significantly. There were also remarkable effects in the reduction in depression (p < 0.028). Chronic backache was lowered in more than 50% of the cases.

Conclusion

The health promotion program reached people who have a desire to improve both physical and mental health. To assume responsibility for their own health may be a first step in regaining self-confidence and lowering the work placement barriers.