Validation and practical implementation of a multidisciplinary cancer distress screening questionnaire.

BACKGROUND: In order to identify cancer patients with psychosocial needs during radiotherapy, a routine screening questionnaire is widely recommended in the literature. Several tools focusing mainly on psychological issues have been developed during the past decade. However, problems with their implementation into clinical routine have been repeatedly reported, due to a lack of practicability for clinicians and nurses. This study reports the compilation of a multidisciplinary screening questionnaire and an analysis of the effectiveness of its implementation into clinical routine at the Department of Radiotherapy, Medical University of Vienna. MATERIALS AND METHODS: The screening questionnaire is based on a compilation of several subscales from established and validated assessment tools. It focuses on comprehensive information with high a clinical relevance for all professions. In a pilot study, patients' acceptance was assessed qualitatively. Analysis of missing screening data in consecutively admitted patients reflects the effectiveness of implementation and representativity of the data. A validation analysis of the psychological subscales was performed using external criteria and its internal consistency was tested with Cronbachs' α. RESULTS: Qualitative patient acceptance of the screening questionnaire is good. The overall response rate in the screening procedure was 75 %. Missing patient screening data sets arose randomly-mainly due to organizational problems-and did not result in systematic errors. The psychological subscales identify highly distressed patients with a sensitivity of 89 and 78 %, and an internal consistency of 0.843 and 0.617. CONCLUSION: The multidisciplinary screening questionnaire compiled in this study has a high patient acceptance, provides reliable and representative data and identifies highly distressed patients with excellent sensitivity. Although requiring additional personnel resources, it can be implemented successfully in clinical routine with benefits for both the patient and the professional team.

Teleradiotherapy of joints in rheumatoid arthritis: lack of efficacy.

BACKGROUND: Low dose radiotherapy is commonly used for painful rheumatic conditions in clinical practice. Teleradiotherapy may be a cheap, painless procedure which is applicable to many joints at a time. OBJECTIVE: To determine if the local application of x rays to inflamed joints in rheumatoid arthritis (RA) affects the signs and symptoms of inflammation. METHODS: In a randomised, controlled, double blind study, roentgen irradiation was administered in a total dose of 20 Gy during 2 weeks to single joints in six patients with RA who were receiving constant and stable pharmacological treatment with DMARDs and NSAIDs. Single inflamed joints on the contralateral side of the body were used as controls and received sham irradiation. Swelling and tenderness was assessed by blinded investigators before and until 3 months after the irradiation; general disease activity and pain scales were included in the assessment. RESULTS: No change in the scores for tenderness, swelling, pain, or disease activity was seen. The trial was stopped for ethical reasons. CONCLUSION: Local roentgen treatment of RA at a substantial dose of 20 Gy was ineffective in this pilot trial.

[Influence of interaural time- and level differences on the binaural interaction components in normal adults]. / Binaurale Differenzpotenziale: Normalwertebestimmung und Einfluss einer interauralen Zeit- und Pegeldifferenz.

BACKGROUND: Binaural interaction components of auditory brainstem responses have long been studied and its beta-wave has been shown to be correlated with directional hearing ability. As patients with auditory processing disorders such as patients with some sorts of learning disabilities frequently have difficulties with binaural processing it seems sensible to use binaural interaction components in the diagnosis of these disorders. METHODS: In order to obtain normal values and to investigate the influence of interaural time (ITD) and level differences (ILD) binaural interaction components were measured in 21 adults. Interaural time differences varied between 0 and 1.2 ms and interaural level differences between 0 and 30 dB. RESULTS: beta-latencies increased significantly as interaural time differences increased while beta-amplitudes did not change significantly. In measurements with higher interaural time differences detection of the beta-wave was only rarely possible. The effect of interaural level differences on beta-latencies was less pronounced and not significant as well as the influence of interaural level differences on beta-amplitudes. CONCLUSIONS: In the present study it could be shown that the beta-wave of the binaural interaction waveform is present in almost every normal hearing subject. As amplitudes show a considerable variation beta-latencies seem to be of higher diagnostic value than amplitudes.

Costs of standard and conformal photon radiotherapy in Austria.

BACKGROUND: The increasing shortage of health care resources necessitates a more rational use of the funds available. New treatment strategies in radiotherapy generate additional expenses. In this study, the expenses incurred for standard radiotherapy in patients with prostate and lung cancer were compared with those for conformal photon therapy. MATERIAL AND METHODS: To itemize the direct costs, a distinction was made between pretreatment measures (independent of the tumor entity) and treatment measures proper. The cost analysis was based on a break-down by personnel, material and equipment depreciation costs. Overheads were not considered. RESULTS: Conformal photon therapy was found to be over 60% more expensive than standard radiotherapy for prostate cancer and over 100% for lung cancer. The additional expenses were attributable to the more expensive linear accelerator equipment and the additional time needed for CT localization and planning as well as for patient positioning and verification during daily therapy. CONCLUSION: Conformal photon therapy should be examined for its clinical usefulness in dedicated studies and allocated an adequate place in the reimbursement schemes for radiotherapy. If it should be found to produce higher cure rates, other costing procedures, e.g. cost--benefit analyses, should be used for establishing the costs of treatment strategies.

Assessment of intersignal variability for discrimination of atrial fibrillation from atrial flutter.

The analysis of endocardial signals obtained from an electrode located in the right atrium enabled by new dual chamber implantable cardioverter defibrillators may be helpful to provide additional therapies such as overdrive pacing or low energy atrial cardioversion for the treatment of concomitant atrial flutter (AFL) or atrial fibrillation (AF). Algorithms for discrimination of atrial tachyarrhythmias based on rate counting are of limited efficacy. The aim of this study was to assess the intersignal variability by using fast discrete wavelet transforms (FDWT) as a new method of discrimination of AF from AFL. Patients with spontaneous episodes of AF/AFL or patients who developed AF/AFL during an electrophysiological study were studied. The endocardial signals were recorded from the high right atrium using a transvenous 5 Fr bipolar electrode catheter (interelectrode spacing: 1 cm). The signals were digitized (2 kHz, 12-bit resolution) after amplification and filtering (40-500 Hz). Within data segments of 10-second duration, 25 consecutive signals were selected and normalized and FDWT was applied. Standard deviations of the wavelet coefficients (SD) from coarse scales (scale 4-8) were calculated. A total of 94 data segments (AF: 52, AFL: 42) from 28 patients were analyzed. SD at each considered scale was higher for AF than for AFL (P < 0.001). SD at scale 8 discriminated between AF from AFL with 100% sensitivity and specificity. We conclude that assessment of intersignal variability of bipolar endocardial recordings using FDWT is an effective method for the discrimination of AF from AFL. The implementation of this tool in a discrimination algorithm of an implantable device may help provide the appropriate differential therapy for atrial tachyarrhythmias.

Discrimination of sinus rhythm, atrial flutter, and atrial fibrillation using bipolar endocardial signals.

INTRODUCTION: Analysis of endocardial signals obtained from an electrode located in the right atrium as realized in newly designed dual chamber, implantable cardioverter defibrillators might be used to provide additional therapeutic options, such as overdrive pacing or low-energy atrial cardioversion for the treatment of concomitant atrial flutter (AFL) or atrial fibrillation (AF). Therefore, we developed a computer algorithm for discrimination of normal sinus rhythm (NSR), AFL, and AF that may lead to adequate differential therapy of atrial tachyarrhythmias in an automated mode. METHODS AND RESULTS: During an electrophysiologic study, bipolar endocardial signals from the high right atrium were obtained in 28 patients during sustained AFL or AF and after restoration of NSR. A total of 286 data segments of 5-second duration were recorded (NSR: 96, AFL: 86, AF: 104). Mean atrial cycle length (MCL), standard deviation of mean atrial cycle length (SDCL), and index of irregularity (IR), defined as the ratio between MCL and SDCL, were calculated for each data segment. A cutoff of 315 msec for MCL allowed discrimination of NSR from atrial tachyarrhythmias with 100% sensitivity and specificity. For discrimination of AF from AFL by using SDCL, a cutoff value of 11.5 msec led to a sensitivity of 99% and a specificity of 90%. Best discrimination of AF from AFL was found for the criterion IR > or = 7.5%, resulting in a sensitivity of 100% with a specificity of 95% for AF detection. CONCLUSION: The investigated algorithm provides discrimination of NSR, AFL, and AF with high sensitivity and specificity. Incorporation of this algorithm in an implantable automated antitachycardia device may lead to adequate differential therapy in patients suffering from spontaneous episodes of AF and AFL.

[The disease coping of radiation cancer patients compared]. / Krankheitsbewältigung radioonkologischer Patienten im Vergleich.

Emotional well-being and physical complaints of 87 outpatients undergoing radiotherapy were compared with those of a variety of other patients. The emotional and physical status were assessed by a list of emotional symptoms (German: "Befindlichkeitsskala") [18] and a list of physical complaints (German: "Beschwerdeliste") [19]. Although they have to cope with a fair amount of physical strain, values of the "oncologic group" rank second lowest, outranked only by healthy controls. The results strengthen the hypothesis of an adaptive denial to cope with the strain of the treatment. In conclusion, concrete suggestions are made for the doctor-patient relationship.

Radiation of jejunal interposition in T3-T4 upper aerodigestive tumours.

30 patients with T3 and T4 tumours of the upper aerodigestive tract had their tumours resected by pharyngolaryngectomy. This was followed by reconstruction of a gullet or creation of a siphon as a tracheohypopharyngeal shunt for voice restoration with a free jejunal autograft. All patients were treated postoperatively with 60Co gamma radiation, 6 MeV photons or 7.5 to 10 MeV electrons of a beta-tron, with a dose of 50-65 Gy in the area of the primary tumour and 50-65 Gy to the neck. 4 patients refused further treatment after a depth dose of between 16 and 32 Gy. Local recurrence occurred in 40% of cases. The survival rate was 36.6% (11/30) after a mean follow-up time of 21.5 months, although 2 patients died of intercurrent diseases without recurrence of their tumours. The results obtained justify active surgical intervention with postoperative irradiation even at an advanced stage of the tumour.

[The psychosocial care of cancer radiology patients--the requirement, subjective need and acceptance]. / Psychosoziale Betreuung radioonkologischer Patienten--Bedarf, subjektives Bedürfnis und Akzeptanz.

The topic of the investigation was the discrepancy between the documented objective need for psychosocial support of cancer patients on the one hand, and of the patient's little subjective needs on the other, the latter resulting in only low acceptance of care offered. In an empiric study the attitude of 38 radio-oncological patients (29 female, nine male) toward psychosocial support was investigated. The study revealed a tendency, independent of sex, that may be described as a social retreat (e.g. emphasis on personal independence, desire not to burden anybody, to hold back own interests and feelings, to be of help rather to others). We interpret this attitude as a specific reaction of coping with the problem, attempting at self-stabilisation.

Dose estimation in postoperative keloid irradiation with special consideration of ovarian dose.

For a long time now, surgery followed by irradiation has been the preferred therapy in the treatment of keloids. Radiation can be administered by means of X-rays (energy level less than or equal to 100 KV), electrons (energy level less than or equal to 5 MeV) or 192Ir wires. The choice of one of these methods depends on the availability of suitable facilities within a short period of time (less than 24 hours postoperatively), and the possibility of adapting the irradiation field quickly and easily to the scar. A further criterion is the dose received by underlying organs possibly, especially the ovaries of women of child-bearing age. It consists of primary and secondary (scattered) parts of radiation and was measured in two standard field sizes for the various types of radiation so as to allow a rapid evaluation. Apart from the types of radiation mentioned above, such measurements were also carried out for 125I seeds. With a field size of 20 x 1.5 cm2 and a surface dose of 10 Gy, ovaries at a depth of 10 cm in the central beam will receive a dose of between less than 1 m Gy in electron therapy to around 1 Gy in X-ray therapy (100 KV).

[The status of oncologic patients in radiotherapy--physical and psychological aspects]. / Die Situation des onkologischen Patienten in der Strahlentherapie--physische und psychische Aspekte.

UNLABELLED: This study examines the psychological strains experienced by patients undergoing radiotherapy, as well as their somatic complaints and the possible connection between these two aspects. The sample consisted of 87 cancer patients, 64 female, 23 male. We used two standardized clinical instruments, one Zerssen's list of somatic complaints ("Beschwerdeliste" in German) and Zerssen's questionnaire of wellbeing ("Befindlichkeitsskala" in German). These two research instruments were implemented four times: at the beginning, in the middle and at the end of radiation, and three months afterwards. RESULTS: Both the psychological state of well-being and somatic complaints remained at approximately the same level during the whole course of therapy. The state of well-being increased significantly after therapy, which is indicated by the decrease in the number of psychological impairments, whereas the score for somatic complaints remained the same. We observed a general tendency on the part of the patients to play down their situation. Sex differences were not observed. The discussion of the results includes their implication on the doctor-patient relationship.

[Effect of the stress coping mechanisms of oncologic patients on their physical and psychological state in radiotherapy]. / Der Einfluss von Stressverarabeitungsmechanismen onkologischer Patienten auf physisches und psychisches Befinden in der Strahlentherapie.

An empiric study was designed to investigate how patients cope with radiotherapy and its secondary effects. Subject of inquiry was the influence of variables such as age, sex and individual strategies of coping with stress on the extent of reported strain. 91 cancer patients (66 female, 25 male) undergoing radiotherapy with different diagnoses but comparable history and duration of disease were interviewed concerning physical complaints and impairment of psychic mood at four times: in the beginning, the middle and the end of a 6-week radiotherapy as well as 3 moths afterwards. Additionally general coping strategies were evaluated in the beginning. Results showed that reported impairment (only within the subgroup: women under 50) correlated significantly (p less than 0.01) with a coping behaviour that could be described as a "retreat and giving up".

Radiotherapy of Morbus Gorham-Stout: the biological value of low irradiation dose.

Morbus Gorham-Stout is a very rare disease. A patient with this disease was treated at the University Clinic of Radiobiology in Vienna. The clinical and radiological findings place special emphasis on the radiotherapeutic treatment, and the biological basis of the recommended dose is discussed.

[Postoperative prevention of hypertrophic scars and keloids using radiotherapy]. / Postoperative Prophylaxe hypertropher Narben und Keloide mittels Strahlentherapie.

A group of 63 patients with keloids or hypertrophic scars were treated with excision and postoperative superficial X-ray irradiation. The cosmetic and functional results were very good in more than two-thirds of these cases. In 10% a relapse occurred, which is in keeping with the international literature. Finally, other radiotherapeutic modalities such as brachytherapy, in combination with hyperthermia are discussed.

[Sonographic localization of the kidneys for the purpose of radiation treatment of the abdomen: how accurate is this method?]. / Sonographische Nierenlokalisation im Rahmen der abdominellen Strahlenbehandlung: Wie genau ist diese Methode?

In 31 patients, the kidneys were located with ultrasonography before urography was carried out. The projection of the medial, lateral, cranial and caudal margins of the kidney were marked on the patient's back with a pellet. On X-ray film, the mean distance between the pellet and margin of the kidney varied from 0.12 to 1.13 cm; nevertheless the standard deviations were high (up to 2.63 cm). In 11 patients, more than one-third of the kidney was located outside the sonographically determined borders; on the left side this happened in 10 patients. We conclude that sonographical localization of the kidneys for protection during irradiation of the abdomen should only be used when other localization procedures cannot be carried out.

[Coping with disease and management of therapy in patients with cancer with special reference to radiotherapy. An overview]. / Krankheitsverarbeitung und Therapiebewältigung bei Krebskranken unter besonderer Berücksichtigung der Radiotherapie. Ein Uberblick.

The actual state of research is reviewed, focussing on the psychosocial aspects of cancer. The argumentation is oriented at distinguishable stages during the course of disease. Further topics are doctor-patient-relationship, compliance, coping and the evaluation of psychosocial care.

[B-mode and color-coded Doppler sonography in irradiation planning in klippel-Trenaunay syndrome with Kasabach-Merritt symptoms]. / B-Bild und farbcodierte Dopplersonographie zur Bestrahlungsplanung bei Klippel-Trenaunay-Syndrom mit Kasabach-Merritt-Symptomatik.

A patient with intravascular coagulation caused by the Klippel-Trenaunay syndrome is presented; this is a rare phenomenon. The patient was treated with fast electrons. Sonography is a suitable method for determining the extension of the haemangiomas occurring in Klippel-Trenaunay's syndrome. This is important for therapy planning. With colour-coded Doppler sonography, arteriovenous fistulas can be ruled out, this allowing to distinguish the Klippel-Trenaunay syndrome from the Parkes-Weber syndrome.

[Therapy and follow-up using TPA in radio-oncologic after-care in bladder cancer]. / Therapie- und Verlaufskontrolle mittels TPA in der radioonkologischen Nachsorge des Blasenkarzinoms.

Differentiating between a progressive carcinosis and a clinically tumour-free patient, using the data provided by a tumour-marker, is above all else important for the observation of cancer patients whose primary tumour has been surgically removed. The tumour marker TPA was observed postoperatively in 55 patients with carcinoma of the bladder throughout a period of 12 to 36 months before, during and after radiotherapy and compared to the respective clinical condition. Among these patients all stages T1 to T4 of the TNM-system were represented (19) (Tab. 1). Clinical progress remained stationary in 44 cases, whereby TPA was in 19% (n = 8) of the cases in discordance with clinical progress. In 11 cases (7 local recurrences and 4 distant metastasis) clinical progress was observed to be positive, whereby TPA was concordant in 75% (n = 5) of the local recurrences and in 90% (n = 3) of the distant metastases.

[Radiologic breast diagnosis following breast-preserving operations and radiation]. / Problematik der radiologischen Mammadiagnostik nach brusterhaltenden Operationen und Radiatio.

The postoperative and post-irradiation changes occurring in the female breast that can be recorded via mammography, were demonstrated in 74 patients with carcinoma of the breast in the T1 and T2 stages after partial resection and postoperative irradiation. 47 of these women received exclusively percutaneous treatment, whereas 27 received combined treatment both percutaneously and interstitially. The changes occurring in the cutis and in the mammary gland tissue were analysed in respect of first and follow-up examinations. Problems of differential diagnosis were discussed and demonstrated.