The influence of parotid gland sparing on radiation damages of dental hard tissues.

OBJECTIVE: The aim of the present study was to evaluate whether radiation damage on dental hard tissue depends on the mean irradiation dose the spared parotid gland is subjected to or on stimulated whole salivary flow rate. MATERIAL AND METHODS: Between June 2002 and October 2008, 70 patients with neck and cancer curatively irradiated were included in this study. All patients underwent dental treatment referring to the guidelines and recommendations of the German Society of Dental, Oral and Craniomandibular Sciences prior, during, and after radiotherapy (RT). During the follow-up period of 24 months, damages on dental hard tissues were classified according to the RTOG/EORTC guidelines. The mean doses (D(mean)) during spared parotid gland RT were determined. Stimulated whole saliva secretion flow rates (SFR) were measured before RT and 1, 6, 12, 24 months after RT. RESULTS: Thirty patients showed no carious lesions (group A), 18 patients developed sporadic carious lesions (group B), and 22 patients developed general carious lesions (group C). Group A patients received a D mean of 21.2 ± 11.04 Gy. Group B patients received a D(mean) of 26.5 ± 11.59 Gy and group C patients received a D(mean) of 33.9 ± 9.93 Gy, respectively. The D(mean) of group A was significantly lower than the D(mean) of group C (p < 0.001). Additionally, the mean SFR 6 months after RT of group A was significantly higher than the mean SFR of group C (p < 0.01). CONCLUSIONS: Irradiation damage on dental hard tissue correlates with increased mean irradiation doses as well as decreased salivary flow rates. CLINICAL RELEVANCE: Parotid gland sparing resulting in a dose below 20 Gy reduces radiation damage on dental hard tissues, and therefore, the dose may act as a predictor for the damage to be expected.

Prospective evaluation of quality of life effects in patients undergoing palliative radiotherapy for brain metastases.

BACKGROUND: Recently published results of quality of life (QoL) studies indicated different outcomes of palliative radiotherapy for brain metastases. This prospective multi-center QoL study of patients with brain metastases was designed to investigate which QoL domains improve or worsen after palliative radiotherapy and which might provide prognostic information. METHODS: From 01/2007-01/2009, n=151 patients with previously untreated brain metastases were recruited at 14 centers in Germany and Austria. Most patients (82 %) received whole-brain radiotherapy. QoL was measured with the EORTC-QLQ-C15-PAL and brain module BN20 before the start of radiotherapy and after 3 months. RESULTS: At 3 months, 88/142 (62 %) survived. Nine patients were not able to be followed up. 62 patients (70.5 % of 3-month survivors) completed the second set of questionnaires. Three months after the start of radiotherapy QoL deteriorated significantly in the areas of global QoL, physical function, fatigue, nausea, pain, appetite loss, hair loss, drowsiness, motor dysfunction, communication deficit and weakness of legs. Although the use of corticosteroid at 3 months could be reduced compared to pre-treatment (63 % vs. 37 %), the score for headaches remained stable. Initial QoL at the start of treatment was better in those alive than in those deceased at 3 months, significantly for physical function, motor dysfunction and the symptom scales fatigue, pain, appetite loss and weakness of legs. In a multivariate model, lower Karnofsky performance score, higher age and higher pain ratings before radiotherapy were prognostic of 3-month survival. CONCLUSIONS: Moderate deterioration in several QoL domains was predominantly observed three months after start of palliative radiotherapy for brain metastases. Future studies will need to address the individual subjective benefit or burden from such treatment. Baseline QoL scores before palliative radiotherapy for brain metastases may contain prognostic information.

Cluster headache and neuropsychological functioning.

BACKGROUND: Despite significant advances in unravelling the pathophysiology of cluster headache (CH), little is known about neuropsychological functioning. Apart from neuroimaging studies indicating involvement of posterior hypothalamic and other areas frequently involved in nociception, some studies suggest involvement of prefrontal areas. Among others, these mediate executive functioning (EF). METHODS: Therefore, three neuropsychological tests (Trail Making Test (TMT), Go/Nogo Task and Stroop Task) were completed by four headache patient samples (chronic CH, episodic CH in the active or inactive period, and migraine patients) and compared to healthy controls. RESULTS: Analyses revealed that patients especially with chronic and active episodic CH were particularly impaired in tests relying more on intact EF (i.e. TMT-B, Stroop interference) than on basal cognitive processes (i.e. TMT-A, Stroop naming). Within the CH groups performance decreased linearly with increasing severity. DISCUSSION: These findings are in line with a recently proposed involvement of prefrontal structures in CH pathophysiology as patients performed worse on neuropsychological tasks relying on these structures. Impaired EF could also result from medication and sleep disturbances due to active CH. Because the decreased performance was also present outside the attacks it may hint at generally altered brain functions, but do not necessarily reflect clinically relevant behaviour.

Aggressiveness in different presentations of cluster headache: results from a controlled multicentric study.

BACKGROUND: The hypothalamus has been discussed as a pivotal structure for both cluster headache (CH) and aggressiveness, but little is known about the extent of self-reported aggressiveness in patients with CH. PATIENTS AND METHODS: Twenty-six patients with chronic, 25 with active episodic and 22 with episodic CH outside the active period were examined interictally with a validated questionnaire quantifying factors of aggression and compared with 24 migraine patients and 31 headache-free volunteers. RESULTS: The ANOVA was significant for the subscale 'self-aggression/depression' (F(4, 123) = 5.771, p < 0.001) with significant differences between chronic and episodic CH and healthy volunteers. No significant changes were found for other subscales and the sum scale (F(4, 123) < 1.421, p > 0.230). Especially in the clinically most affected group of patients (chronic CH and active episodic CH), high levels of "self-aggression/depression" correlate with higher prevalence of depressive symptoms and higher impairment measured on an emotional and functional level. DISCUSSION: Self-aggressive and depressive cognitions with highest scores in chronic CH seem to be reactive as they correlate with depressive symptoms and impairment. They should be considered as an important therapeutic target since they impair the patient's life significantly.

Impairment in episodic and chronic cluster headache.

Despite being an excruciating headache, little is known about the burden of cluster headache (CH) regarding its various subtypes. In a multicentre, prospective study, patients with chronic CH (n = 27), with episodic CH in the active (n = 26) and outside the active period (n = 22), migraine patients (n = 24) and healthy controls (n = 31) were included. Epidemiological data, the German version of the Headache Disability Inventory (HDI) and a screening for psychiatric complaints were applied. About 25% of chronic CH patients in our study received invalidity allowance due to CH. HDI scores (total and subscales emotion and function) indicated a severe headache-specific disability (one-way ANOVA: P < 0.01). Patients with chronic and active episodic CH were significantly more affected than patients with inactive CH and migraine. Healthy volunteers were significantly less affected than all headache patients. Symptoms suggestive of psychiatric co-morbidity were found predominantly in chronic CH: depressive symptoms (56%), signs of agoraphobia (33%) and suicidal tendencies (25%) were frequently reported. Patients with chronic and active episodic CH were severely impaired in non-economic and economic domains such as disability, working life and psychiatric complaints. Remarkably, psychiatric co-morbidity was highest in chronic CH. Thus, especially chronic CH warrants special medical and further supportive care.

A comparison of implicit and explicit reward learning in low risk alcohol users versus people who binge drink and people with alcohol dependence.

Chronic alcohol use leads to specific neurobiological alterations in the dopaminergic brain reward system, which probably are leading to a reward deficiency syndrome in alcohol dependence. The purpose of our study was to examine the effects of such hypothesized neurobiological alterations on the behavioral level, and more precisely on the implicit and explicit reward learning. Alcohol users were classified as dependent drinkers (using the DSM-IV criteria), binge drinkers (using criteria of the USA National Institute on Alcohol Abuse and Alcoholism) or low-risk drinkers (following recommendations of the Scientific board of trustees of the German Health Ministry). The final sample (n = 94) consisted of 36 low-risk alcohol users, 37 binge drinkers and 21 abstinent alcohol dependent patients. Participants were administered a probabilistic implicit reward learning task and an explicit reward- and punishment-based trial-and-error-learning task. Alcohol dependent patients showed a lower performance in implicit and explicit reward learning than low risk drinkers. Binge drinkers learned less than low-risk drinkers in the implicit learning task. The results support the assumption that binge drinking and alcohol dependence are related to a chronic reward deficit. Binge drinking accompanied by implicit reward learning deficits could increase the risk for the development of an alcohol dependence.

Cognitive impairment, clinical severity and MRI changes in MELAS syndrome.

OBJECTIVE: To examine clinical severity, cognitive impairment, and MRI changes in patients with MELAS syndrome. METHODS: Cognitive-mnestic functions, brain MRI (lesion load, cella media index) and clinical severity of ten patients with MELAS syndrome were examined. All patients carried the m.3243A>G mutation. RESULTS: The detailed neuropsychological assessment revealed cognitive deficits in attention, executive function, visuoperception, and -construction. There were significant correlations between these cognitive changes, lesion load in MRI, disturbances in everyday life (clinical scale), and high scores in NMDAS. CONCLUSION: Patients with MELAS syndrome showed no global neuropsychological deficit, but rather distinct cognitive deficits.

Attention and executive functions in remitted major depression patients.

BACKGROUND: Although deficits in attention and executive functions in patients with Major Depressive Disorder (MDD) are well confirmed [Veiel, H.O.F., 1997. A preliminary profile of neuropsychological deficits associated with major depression. Journal of Clinical and Experimental Neuropsychology 19, 587-603.]. The database regarding the relationship between impairments and the duration of disease or the number of episodes is inconsistent. Furthermore, the role of long-term cognitive impairments in MDD during remitted state is not well understood [Elliott, R., 2002. The neuropsychological profile in primary depression. Taylor and Francis, London, pp. 273-293.]. There is consequently a lack of studies accounting for different courses of illness in the euthymic state and considering the influence of possible attentional deficits on executive performance. METHODS: 40 euthymic patients with MDD diagnosis according to DSM-IV (20 patients with 1-2 episodes and 20 severe depressives with at least three episodes) as well as 20 healthy controls matched for education and age were administered three tests for attention (attentional shift, Stroop task, sustained attention) and three for executive functions (BADS, word fluency, memory span). The methods selected were theory based with regard to an involvement of frontal-subcortical networks in MDD, attention, and executive functions, respectively. RESULTS: Euthymic patients with MDD showed deficits in all tests related to attentional and executive functions compared to healthy controls. The patient groups did not differ with regard to attentional performance. Executive functions in severe depressives were more impaired than in mild depressives. LIMITATIONS: Differing performances of the patient groups in the subtests of the executive test battery (BADS) can only be interpreted to a limited extent. CONCLUSIONS: The results support the assumption that deficits in attention and executive functions in MDD show an increase in trait character and executive function during chronic course. Implications for differential diagnosis and cognitive psychotherapy are discussed.

Implicit and explicit reward learning in chronic nicotine use.

BACKGROUND: Chronic tobacco use is related to specific neurobiological alterations in the dopaminergic brain reward system that can be termed "reward deficiency syndrome" in dependent nicotine consumers. The close linkage of dopaminergic activity and reward learning led us to expect implicit and explicit reward learning deficits in dependent compared to non-smokers. Smokers who maintain a less regular, occasional use may also, to a lesser extent, show implicit reward learning deficits. The purpose of our study was to examine the behavioral effects of the neurobiological alterations on reward related learning. We also tested whether any deficits observed in an abstinent state are also present in a satiated state. METHODS: In two studies, we examined implicit and explicit reward learning in smokers. Participants were administered a probabilistic implicit reward learning task, and an explicit reward- and punishment-based trial-and-error learning task. In Study 1, we compared dependent, occasional, and non-smokers, and in Study 2 satiated and abstinent smokers. RESULTS: In Study 1, chronic and occasional smokers showed impairments in both, implicit and explicit reward learning tasks. In Study 2, satiated smokers did not perform better than abstinent smokers. CONCLUSIONS: The results support the hypothesis of reward learning deficits. These deficits are not limited to explicit but extend to implicit reward learning and cannot be explained by tobacco withdrawal.

Patient information in radiation oncology: a cross-sectional pilot study using the EORTC QLQ-INFO26 module.

BACKGROUND: The availability of alternative sources of information, e. g. the internet, may influence the quantity and quality of information cancer patients receive regarding their disease and treatment. The purpose of the present study was to assess perception of information in cancer patients during radiotherapy as well as media preferences and specifically the utilization of the internet. METHODS: In a cross-sectional, single-centre study 94 patients currently undergoing radiotherapy were asked to complete two questionnaires. The EORTC QLQ-INFO26 module was used to assess the quality and quantity of information received by patients in the areas disease, medical tests, treatment, other services, different places of care and how to help themselves, as well as qualitative aspects as helpfulness of and satisfaction with this information. The importance of different media, in particular the internet, was investigated by a nine-item questionnaire. RESULTS: The response rate was n = 72 patients (77%). Patients felt best informed concerning medical tests (mean +/- SD score 79 +/- 22, scale 0-100) followed by disease (68 +/- 21). Treatment (52 +/- 24) and different places of care and other services (30 +/- 36 and 30 +/- 30, respectively) ranked last. 37% of patients were very satisfied and 37% moderately satisfied with the amount of information received, 61% wished more information. Among eight media, brochures, television and internet were ranked as most important. 41% used the internet themselves or via friends or family, mostly for research of classic and alternative treatment options. Unavailability and the necessity of computer skills were most mentioned obstacles. CONCLUSION: In a single-center pilot study, radiotherapy patients indicated having received most information about medical tests and their disease. Patients very satisfied with their information had received the largest amount of information. Brochures, television and internet were the most important media. Individual patient needs should be considered in the development of novel information strategies.