Nonfunctioning pituitary macroadenomas : treatment and long-term follow-up
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(2) 1UALITY OF LIFE IN TREATED ADULT CRANIOPHARYNGIOMA PATIENTS. /- $EKKERS
(3) .2 "IERMASZ
(4) *7! 3MIT
(5) ,% 'ROOT
(6) & 2OELFSEMA
(7) *! 2OMIJN
(8) AND !- 0EREIRA $EPARTMENT OF %NDOCRINOLOGY AND -ETABOLIC $ISEASES
(9) ,EIDEN 5NIVERSITY -EDICAL #ENTER
(10) ,EIDEN
(11) 4HE .ETHERLANDS %UROPEAN *OURNAL OF %NDOCRINOLOGY . $)"15&3.
(12) 46.."3: /BJECTIVE 1UALITY OF ,IFE 1O, HAS BECOME INCREASINGLY IMPORTANT IN THE EVALUATION OF TREATMENT OF PITUITARY AND HORMONAL DISEASES ! REDUCED 1O, HAS BEEN REPORTED IN CHILD HOOD ONSET CRANIOPHARYNGIOMA HOWEVER
(13) REPORTS OF 1O, IN ADULT CRANIOPHARYNGIOMA PATIENTS ARE SCARCE )N THE PRESENT STUDY
(14) WE ASSESSED 1O, IN ADULT PATIENTS SUCCESSFULLY TREATED FOR CRANIOPHARYNGIOMA IN OUR CENTRE $ESIGN #ASE CONTROL STUDY -ETHODS )N THIS STUDY WE ASSESSED 1O, IN ADULT PATIENTS IN REMISSION DURING LONG TERM FOLLOW UP AFTER TREATMENT FOR CRANIOPHARYNGIOMA &OUR VALIDATED HEALTH RELATED QUESTIONNAIRES (!$3
(15) -&)
(16) .(0
(17) 3& WERE USED
(18) COVERING MULTIPLE ASPECTS OF PHYSICAL
(19) PSYCHOLOGICAL AND SOCIAL FUNCTIONING 0ATIENT OUTCOMES WERE COMPARED TO CON TROLS N AND TO AGE ADJUSTED REFERENCE VALUES DERIVED FROM LITERATURE 2ESULTS 'ENERAL FATIGUE
(20) PHYSICAL FATIGUE
(21) ENERGY
(22) PHYSICAL CONDITION AND PHYSICAL MO BILITY WERE SIGNIlCANTLY IMPAIRED
(23) COMPARED TO CONTROLS 4HE MAIN INDEPENDENT PREDIC TORS FOR A DECREASED 1O, WERE VISUAL lELD DEFECTS DEPRESSION
(24) TOTAL (!$3 SCORE
(25) ACTIVITY
(26) MOTIVATION AND ENERGY
(27) FEMALE GENDER DEPRESSION
(28) MOTIVATION AND PAIN
(29) AND
(30) TO A LESSER $IBQUFS. EXTENT
(31) REPEAT SURGERY ROLE LIMITATIONS DUE TO EMOTIONAL PROBLEMS
(32) AND RADIOTHERAPY . . MENTAL FATIGUE #ONCLUSION !DULT PATIENTS TREATED FOR CRANIOPHARYNGIOMA SHOW PERSISTENT IMPAIRMENT IN 1UALITY OF ,IFE
(33) ESPECIALLY IN THE PHYSICAL SUBSCALES .
(34) 2VBMJUZPGMJGFJOUSFBUFEBEVMUDSBOJPQIBSZOHJPNBQBUJFOUT. */530%6$5*0/ #RANIOPHARYNGIOMAS ARE HISTOLOGICALLY BENIGN BRAIN TUMOURS ARISING FROM THE REMNANTS OF 2ATHKES POUCH $ESPITE THEIR BENIGN APPEARANCE
(35) THEIR CLINICAL BEHAVIOUR IS AGGRESSIVE
(36) CAUSING SERIOUS MORBIDITY BY DAMAGING THE OPTIC CHIASM
(37) THE PITUITARY
(38) AND HYPOTHALAMIC AREA #URRENTLY
(39) CRANIOPHARYNGIOMA IS TREATED PRIMARILY BY TRANSSPHENOIDAL OR TRANSCRANIAL SURGERY
(40) WHEREAS POST SURGICAL RADIOTHERAPY IS NOT ROUTINELY APPLIED IN ALL PATIENTS 2ECURRENT DISEASE IS TREATED BY REPEAT SURGERY ANDOR RADIOTHERAPY )N ADULTS
(41) TREATMENT OF CRANIOPHARYNGIOMA IS ASSOCIATED WITH EXCESSIVE MULTI SYSTEM MORBIDITY AND INCREASED MORTALITY DURING LONG TERM FOLLOW UP DESPITE A HIGH CURE RATE 4HERE IS A HIGH INCIDENCE OF PITUITARY INSUFlCIENCIES
(42) AND VISUAL lELD DEFECTS MAY PERSIST IN SOME PATIENTS &INALLY
(43) THERE IS A HIGH INCIDENCE OF CARDIOVASCULAR RISK FACTORS IN THESE PATIENTS 0ITUITARY DISEASES IN GENERAL ARE ASSOCIATED WITH DECREASED QUALITY OF LIFE 1O, AND COGNITIVE DYSFUNCTION
(44) DESPITE OPTIMAL REPLACEMENT STRATEGIES FOR PITUITARY INSUFlCIENCY
(45) AND LONG TERM CURE OF HORMONE EXCESS SYNDROMES SUCH AS #USHINGS DISEASE AND ACRO MEGALY (YPOPITUITARISM AND RADIOTHERAPY ARE IMPORTANT FACTORS FOR IMPAIRED 1O, 2EDUCED 1O, HAS BEEN REPORTED IN CHILDHOOD ONSET CRANIOPHARYNGIOMA 4O OUR KNOWLEDGE
(46) 1O, IN ADULT CRANIOPHARYNGIOMA PATIENTS HAS BEEN REPORTED IN ONLY ONE STUDY )N THIS STUDY
(47) 1O, WAS MARKEDLY REDUCED
(48) AS ASSESSED BY TWO QUESTIONNAIRES .(0 AND 1O, !'($!
(49) THE LATTER BEING A DISEASE SPECIlC QUESTIONNAIRE
(50) DESIGNED TO ASSESS PHYSICAL AND PSYCHOLOGICAL DISCOMFORT IN ADULT GROWTH HORMONE DElCIENCY 'IVEN THE HIGH PREVALENCE OF ASSOCIATED MORBIDITY FOUND IN OUR ADULT CRANIOPHARYNGIOMA PA TIENTS
(51) WE WANTED TO EXTEND THESE OBSERVATIONS BY ASSESSMENT OF 1O, IN MORE DETAIL )N THE PRESENT STUDY WE ASSESSED 1O, IN ADULT PATIENTS SUCCESSFULLY TREATED FOR CRANIO PHARYNGIOMA IN OUR CENTRE 7E EVALUATED PHYSICAL
(52) PSYCHOLOGICAL
(53) AND SOCIAL ASPECTS OF 1O, IN PATIENTS AFTER LONG TERM CURE
(54) USING FOUR VALIDATED
(55) HEALTH RELATED 1O, QUESTION NAIRES 0ATIENT OUTCOMES WERE COMPARED WITH OWN CONTROL VALUES AS WELL AS TO AGE AD JUSTED REFERENCE VALUES DERIVED FROM LITERATURE. 1"5*&/54"/%.&5)0%4. 1SPUPDPM &ORTY THREE PATIENTS TREATED AND CURED FOR CRANIOPHARYNGIOMA
(56) FOLLOWED IN OUR CENTRE FROM TO
(57) WERE IDENTIlED &OUR 1O, QUESTIONNAIRES WERE SENT TO THEIR HOMES 4HEY WERE ASKED TO PARTICIPATE AND TO COMPLETE
(58) AND RETURN THE QUESTIONNAIRES IN A PREPAID ENVELOPE .ON RESPONDERS RECEIVED A REMINDER LETTER 4HEREAFTER
(59) THEY WERE CON TACTED ONCE BY TELEPHONE AND ENCOURAGED TO COMPLETE AND RETURN THE QUESTIONNAIRES . .
(60) 0ATIENTS WERE ALSO ASKED TO PROVIDE A CONTROL PERSON WITH COMPARABLE AGE AND SEX FOR EXAMPLE A RELATIVE n NOT THE PARTNER n
(61) FRIEND OR NEIGHBOUR IN ORDER TO COMPOSE A CONTROL POPULATION WITH SIMILAR SOCIO ECONOMIC STATUS DERIVED FROM THE SAME GEOGRAPHICAL AREA )N ADDITION TO THIS CONTROL GROUP
(62) WE USED LITERATURE REFERENCE DATA FROM HEALTHY SAMPLES OF THE $UTCH AND WEST %UROPEAN POPULATION FROM STUDIES REPORTING NORMAL AGE ADJUSTED VALUES 4HESE DATA ARE BASED ON LARGER STUDY POPULATIONS THAN OUR OWN CONTROLS AND ARE THEREFORE NOT AFFECTED BY A POTENTIAL POSITIVE SELECTION BY THE PATIENTS 4HE MEDICAL ETHICS COMMITTEE OF THE ,EIDEN 5NIVERSITY -EDICAL #ENTRE APPROVED THE STUDY PROTOCOL. 1BUJFOUTBOEDPOUSPMT 5BCMF. 4HIRTY THREE OF PATIENTS RETURNED THE QUESTIONNAIRES
(63) FOUR OF WHOM PREFERRED NOT TO PARTICIPATE 4HUS
(64) COMPLETED QUESTIONNAIRES WERE RECEIVED 4HE STUDY POPULATION OF PATIENTS MALES HAD A MEAN AGE WAS ¢ YEARS RANGE YR !LL PATIENTS WERE PRIMARILY TREATED BY SURGERY .INE PATIENTS RECEIVED RADIOTHERAPY
(65) FOUR OF WHOM FOR RECURRENCE 3EVEN PATIENTS HAD REPEAT SURGERY -EAN FOLLOW UP AFTER PRIMARY SURGERY WAS ¢ YEARS AND ALL PATIENTS WERE CURED OF DISEASE (YPOPITUITARISM WAS PRESENT IN $IBQUFS. OF CASES .O SIGNIlCANT DIFFERENCES IN AGE
(66) GENDER AND TUMOUR CHARACTERISTICS WERE . . FOUND BETWEEN THE STUDY POPULATION AND THE PATIENTS WHO DID NOT RETURN THE QUESTION NAIRES 4WENTY lVE CONTROLS RETURNED COMPLETED QUESTIONNAIRES 4HE CONTROL GROUP WAS EX TENDED BY CONTROLS DERIVED FROM OTHER STUDIES PERFORMED AT OUR CENTRE
(67) WHO HAD BEEN SIMILARLY APPROACHED 4HEREFORE
(68) THE TOTAL CONTROL GROUP CONSISTED OF CONTROLS FEMALES
(69) MALES
(70) WITH A MEAN AGE OF ¢ YR .O SIGNIlCANT DIFFERENCES IN 1O, MEASURES WERE PRESENT BETWEEN THE THREE CONTROL GROUPS
(71) JUSTIFYING THEIR COMBINED USE !GE AND GENDER WERE NOT SIGNIlCANTLY DIFFERENT FROM THE STUDIED CRANIOPHARYNGIOMA PATIENTS . 4UVEZQBSBNFUFST 0RIMARY STUDY PARAMETERS WERE THE RESULTS OF FOUR HEALTH RELATED 1O, QUESTIONNAIRES 4HE RESULTS WERE LINKED TO PATIENT CHARACTERISTICS AGE AND SEX
(72) APPLIED TREATMENTS SURGERY
(73) RADIOTHERAPY AND MULTIPLE SURGICAL PROCEDURES
(74) PRESENCE OF HYPOPITUITARISM AND VISUAL IMPAIRMENTS (YPOPITUITARISM WAS DElNED AS ONE OR MORE PITUITARY HORMONE DElCIEN CIES. 2VFTUJPOOBJSFT (!$3 (OSPITAL !NXIETY AND $EPRESSION 3CALE 4HE (!$3 CONSISTS OF ITEMS PER TAINING TO ANXIETY AND DEPRESSION %ACH ITEM IS MEASURED ON A POINT SCALE 4HE RANGE OF SCORES FOR THE ANXIETY AND DEPRESSION SUBSCALE IS FOR THE TOTAL SCORE ! HIGH .
(75) 2VBMJUZPGMJGFJOUSFBUFEBEVMUDSBOJPQIBSZOHJPNBQBUJFOUT. SCORE POINTS TO MORE SEVERE ANXIETY AND DEPRESSION !GE RELATED $UTCH REFERENCE VALUES OF THE GENERAL POPULATION WERE DERIVED FROM THE STUDY OF 3PINHOVEN ET AL -&) -ULTIDIMENSIONAL &ATIGUE )NDEX 4HE -&) CONTAINS STATEMENTS TO ASSESS FATIGUE &IVE DIFFERENT DIMENSIONS OF FATIGUE FOUR ITEMS EACH ARE CALCULATED FROM THESE STATEMENTS GENERAL FATIGUE
(76) PHYSICAL FATIGUE
(77) REDUCED ACTIVITY
(78) RE DUCED MOTIVATION AND MENTAL FATIGUE %VERY STATEMENT IS MEASURED ON A POINT SCALE SCORES RANGE FROM TO (IGHER SCORES INDICATE HIGHER EXPERIENCED FATIGUE !GE RELATED $UTCH REFERENCE VALUES WERE DERIVED FROM 3METS ET AL .(0 .OTTINGHAM (EALTH 0ROlLE 4HE .(0 IS FREQUENTLY USED IN PATIENTS WITH PITUITARY DISEASE TO ASSESS GENERAL WELL BEING AND 1O, 4HE SURVEY CONSISTS OF YESNO QUESTIONS
(79) SUBDIVIDED INTO THE FOLLOWING SCALES ASSESSING IMPAIRMENTS PAIN ITEMS
(80) ENERGY LEVEL ITEMS
(81) SLEEP ITEMS
(82) EMOTIONAL REACTIONS ITEMS
(83) SOCIAL ISOLATION
(84) ITEMS
(85) AND DISABILITYFUNCTIONING
(86) IE PHYSICAL ABILITY ITEMS 3UBSCALE SCORES ARE CALCULATED AS A WEIGHTED MEAN OF THE ASSOCIATED ITEMS AND ARE EX PRESSED AS A VALUE BETWEEN AND 4HE TOTAL SCORE IS THE MEAN OF THE SUBSCALES (IGHER SCORES ARE RELATED TO WORSE 1O, !GE RELATED WEST %UROPEAN REFERENCE VALUES WERE DERIVED FROM THE STUDY FROM (INZ ET AL 3& 3HORT &ORM 4HE 3& QUESTIONNAIRE COMPRISES ITEMS AND RECORDS GENERAL WELL BEING DURING THE PREVIOUS DAYS 4HE ITEMS ARE FORMULATED AS STATEMENTS OR QUESTIONS TO ASSESS EIGHT HEALTH CONCEPTS PHYSICAL FUNCTIONING
(87) SOCIAL FUNCTIONING
(88) LIMITATIONS IN USUAL ROLE ACTIVITIES BECAUSE OF PHYSICAL HEALTH PROBLEMS
(89) PAIN
(90) GENERAL MENTAL HEALTH PSYCHOLOGICAL DISTRESS AND WELL BEING
(91) LIMITATIONS IN USUAL ROLE ACTIVITIES BECAUSE OF EMOTIONAL PROBLEMS
(92) VITALITY ENERGY AND FATIGUE
(93) AND GENERAL HEALTH PERCEPTIONS AND CHANGE IN HEALTH "ECAUSE THE (!$3 AND THE -&) ARE MORE SPECIlC QUESTIONNAIRES FOR MENTAL HEALTH AND FATIGUE
(94) THE VITALITY AND GENERAL MENTAL HEALTH ITEMS WERE LEFT OUT IN THIS EVALUATION 3CORES ARE EXPRESSED ON A SCALE (IGHER SCORES ARE ASSOCIATED WITH BETTER 1O, !GE RELATED WEST %UROPEAN REFERENCE VALUES WERE DERIVED FROM THE $UTCH PUBLICATIONS OF 6AN :EE ET AL . 4UBUJTUJDT 3033 FOR 7INDOWS VERSION 3033 )NC
(95) #HICAGO
(96) ), WAS USED TO PERFORM DATA ANALY SIS $ATA ARE EXPRESSED AS MEAN ¢ 3$ UNLESS OTHERWISE MENTIONED 7E USED UNPAIRED 4 TESTS TO COMPARE PATIENT AND CONTROL DATA 5SING LINEAR REGRESSION ANALYSIS
(97) WE ASSESSED INDEPENDENT VARIABLES THAT AFFECT QUALITY OF LIFE $IFFERENCES WERE CONSIDERED STATISTICALLY SIGNIlCANT AT P OR LESS. .
(98) 4ABLE #HARACTERISTICS OF THE CRANIOPHARYNGIOMA PATIENTS AND CONTROLS. "HF ZFBST. .BMF'FNBMF "HFBUEJBHOPTJT ZFBST. $IJMEIPPEPOTFU 3BEJPUIFSBQZ 3FQFBUTVSHFSZ 1FSTJTUFOUWJTVBMmFMEEFGFDUT *OUBDUQJUVJUBSZGVODUJPO 4JOHMFQJUVJUBSZEFmDJFODZ .VMUJQMFQJUVJUBSZEFmDJFODJFT 1BOIZQPQJUVJUBSJTN . $SBOJPQIBSZOHJPNBQBUJFOUT O . $POUSPMT O . ( . . . . . . . 1 /4. 1 /4. .3 DENOTES NOT SIGNIlCANT. $ElNED AS PITUITARY DElCIENCY IN MORE THAN AXIS. $ElNED AS PITUITARY DElCIENCY IN ALL FOUR AXES. 3&46-54. 1BUJFOUDIBSBDUFSJTUJDT 5BCMFBOE'JHVSF. $IBQUFS. #LINICAL CHARACTERISTICS ARE DETAILED IN 4ABLE 0RIMARY SURGERY WAS PERFORMED IN ALL . . PATIENTS .INE PATIENTS RECEIVED RADIOTHERAPY AFTER PRIMARY SURGERY
(99) AND SEVEN PATIENTS NEEDED MORE THAN ONE OPERATION 4HE DIFFERENT TREATMENT MODALITIES ARE SUMMARIZED IN &IGURE !T THE TIME OF EVALUATION IN TWO PATIENTS PITUITARY FUNCTION WAS INTACT 4HESE TWO PATIENTS WERE BOTH REOPERATED BECAUSE OF TUMOR REGROWTH AND SUFFERED BOTH FROM VISUAL lELD DEFECTS &IVE PATIENTS HAD PITUITARY DElCIENCY IN OF AXES )N THE MAJORITY OF PATIENTS
(100) PANHYPOPITUITARISM WAS PRESENT 4WELVE PATIENTS HAD PERSISTENT VISUAL IMPAIRMENTS . &IGURE 0ATIENT GROUPS
(101) STRATIlED ACCORDING TO DIFFERENT TREATMENT MODALITIES. ,QLWLDOVXUJLFDOWUHDWPHQW 7UDQVFUDQLDOO\1 7UDQVVSKHQRLGDOO\1 . 2QHVXUJLFDO SURFHGXUHQR57 1 . 57 3URSK\ODFWLF 1 )RUUHFXUUHQFH 1 . 57GHQRWHVUDGLRWKHUDS\. 5HSHDWVXUJHU\ 1 )RUUHFXUUHQFH 1 . 5HSHDWVXUJHU\ IROORZHGE\57 1 .
(102) 2VBMJUZPGMJGFJOUSFBUFEBEVMUDSBOJPQIBSZOHJPNBQBUJFOUT. 2VBMJUZPG-JGFJODSBOJPQIBSZOHJPNBQBUJFOUTBOEDPOUSPMT 5BCMF. #OMPARED TO THE CONTROLS AND THE AGE ADJUSTED REFERENCE VALUES
(103) THE CRANIOPHARYN GIOMA PATIENTS HAD REDUCED 1O, IN EVERY QUESTIONNAIRE
(104) EXCEPT FOR THE (!$3 !CCORDING TO THE (!$3 THERE WAS NO SIGNIlCANT DIFFERENCE BETWEEN PATIENTS AND CONTROLS IN ITEMS CONCERNING ANXIETY AND DEPRESSION !LL SUBSCALES OF FATIGUE ASSESSED BY THE -&) WERE AFFECTED
(105) ESPECIALLY GENERAL AND PHYSICAL FATIGUE 2EDUCTION IN ACTIVITY AND MOTIVATION DID NOT REACH STATISTICAL SIGNIlCANCE WHEN COMPARED WITH THE AGE ADJUSTED REFERENCE VALUES 4HE SCORES OF THE PATIENTS ON THE .(0 POINTED TO REDUCED ENERGY AND PHYSICAL MOBILITY 3LEEP
(106) EMOTIONAL REACTION AND SOCIAL ISOLATION SCORES WERE NOT SIGNIlCANTLY DIFFERENT FROM THE CONTROLS (EALTH PERCEPTION
(107) AS ASSESSED BY THE 3&
(108) WAS SIGNIlCANTLY AFFECTED IN CRANIOPHARYNGIOMA PATIENTS -OREOVER
(109) PHYSICAL AND SOCIAL FUNCTIONING WAS REDUCED
(110) AS COMPARED WITH OWN CONTROLS . 'BDUPSTBõFDUJOH2VBMJUZPG-JGFJODSBOJPQIBSZOHJPNBQBUJFOUT #HILDHOOD VERSUS ADULT ONSET CRANIOPHARYNGIOMA !DULT ONSET CRANIOPHARYNGIOMA PA TIENTS PERFORMED WORSE ON THE DEPRESSION SCORE (!$3
(111) 0 THAN CHILDHOOD ONSET PATIENTS 'ENDER #OMPARED WITH MALES
(112) FEMALES REPORTED A DECREASED 1O, FOR SEVERAL ENERGY RELATED ITEMS
(113) SUCH AS GENERAL FATIGUE -&)
(114) 0
(115) REDUCED MOTIVATION -&)
(116) 0 AND ENERGY .(0
(117) 0
(118) AND ALSO FOR PAIN .(0
(119) 0
(120) SOCIAL FUNCTIONING 3&
(121) 0 AND ROLE LIMITATIONS DUE TO PHYSICAL PROBLEMS 3&
(122) 0 !GE 9OUNGER PATIENTS WERE MORE AFFECTED ON THE FOLLOWING SUBSCALES SOCIAL ISOLATION .(0
(123) 0 AND SOCIAL FUNCTIONING 3&
(124) 0 .O AGE RELATED DIFFERENCES WERE FOUND ON ITEMS CONCERNING ENERGY AND PHYSICAL FUNCTIONING 2ADIOTHERAPY /NLY MENTAL FATIGUE WAS SIGNIlCANTLY AFFECTED IN PATIENTS TREATED BY RADIOTHERAPY -&)
(125) 0 2EPEAT SURGERY 0ATIENTS WHO UNDERWENT MULTIPLE OPERATIONS PERFORMED WORSE ON GEN ERAL FATIGUE -&)
(126) 0
(127) SLEEP .(0
(128) 0 AND HEALTH CHANGE 3&
(129) 0 6ISUAL lELD DEFECTS 4HE PRESENCE OF PERSISTENT VISUAL lELD DEFECTS SIGNIlCANTLY AFFECTED THE FOLLOWING ITEMS TOTAL (!$3 SCORE 0
(130) GENERAL FATIGUE -&)
(131) 0
(132) RE DUCED ACTIVITY -&)
(133) 0
(134) REDUCED MOTIVATION -&)
(135) 0
(136) ENERGY .(0
(137) 0
(138) SOCIAL FUNCTIONING 3&
(139) 0 AND ROLE LIMITATIONS DUE TO PHYSICAL PROBLEMS 3&
(140) 0 -ULTIPLE PITUITARY DElCIENCIESPANHYPOPITUITARISM 3CORES FROM PATIENTS WITH INTACT PI TUITARY FUNCTION N INDICATED MORE REDUCED 1O, IN ALL SUBSCALES OF THE (!$3 AND THE -&)
(141) AS COMPARED WITH PATIENTS WITH MULTIPLE PITUITARY DElCIENCIESPANHYPOPITUITA RISM (OWEVER
(142) THE 3& SCORES FROM PATIENTS WITH MULTIPLE PITUITARY DElCIENCIESPAN. .
(143) $IBQUFS. 4ABLE 1UALITY OF ,IFE (!$3
(144) -&)
(145) .(0
(146) 3& IN TREATED CRANIOPHARYNGIOMA PATIENTS COMPARED TO CONTROLS AND AGE ADJUSTED REFERENCE VALUES. . )"%4 "OYJFUZ %FQSFTTJPO 5PUBM .'* (FOFSBMGBUJHVF 1IZTJDBMGBUJHVF 3FEVDUJPOJOBDUJWJUZ 3FEVDUJPOJONPUJWBUJPO .FOUBM'BUJHVF /)1 &OFSHZ 1BJO &NPUJPOBMSFBDUJPO 4MFFQ 1IZTJDBMBCJMJUZ 4PDJBMJTPMBUJPO /)1UPUBMTDPSF 4' 1IZTJDBMGVODUJPOJOH 4PDJBMGVODUJPOJOH 3PMFMJNJUBUJPOTEVFUPQIZTJDBMQSPCMFNT 3PMFMJNJUBUJPOTEVFUPFNPUJPOBMQSPCMFNT 1BJO (FOFSBMIFBMUIQFSDFQUJPO )FBMUIDIBOHF. $SBOJPQIBSZOHJPNBQBUJFOUT O . $POUSPMT O . QWBMVFB. "HFBEKVTUFE SFGFSFODFWBMVFTC. QWBMVFD. . . OT OT OT. . OT OT OT. . . . . OT OT OT. . . OT OT OT . . OT OT OT OT. . . OT OT OT OT. . E. OT OT OT OT OT OT. $ATA SHOWN ARE THE MEAN ¢ 3$ A 0ATIENTS COMPARED WITH OWN CONTROLS BY THE UNPAIRED TWO TAILED T TEST B $ERIVED FROM REFERENCES C 0ATIENTS COMPARED WITH LITERATURE REFERENCE DATA BY THE UNPAIRED TWO TAILED T TEST D .O DATA AVAILABLE. HYPOPITUITARISM WERE LOWER
(147) INDICATING A MORE REDUCED 1O, ACCORDING TO THE .(0
(148) NO OBVIOUS DIFFERENCE IN SCORES WAS OBSERVED . -JOFBSSFHSFTTJPO 3TEPWISE
(149) UNI VARIATE
(150) LINEAR REGRESSION ANALYSIS WAS PERFORMED IN A MODEL INCLUDING GENDER
(151) AGE
(152) RADIOTHERAPY
(153) MULTIPLE PITUITARY DElCIENCIESPANHYPOPITUITARISM
(154) MULTIPLE OPERATIONS AND VISUAL DEFECTS AS INDEPENDENT VARIABLES
(155) AND THE QUESTIONNAIRE ITEMS AS DEPENDENT VARIABLES 6ISUAL lELD DEFECT WAS AN INDEPENDENT PREDICTOR FOR DEPRESSION (!$3
(156) 0
(157) TOTAL (!$3 SCORE 0
(158) REDUCED ACTIVITY -&)
(159) 0
(160) RE DUCED MOTIVATION -&)
(161) 0 AND REDUCED ENERGY .(0
(162) 0 &EMALE GENDER WAS AN INDEPENDENT PREDICTOR FOR DEPRESSION (!$3
(163) 0
(164) REDUCED MOTIVATION .
(165) 2VBMJUZPGMJGFJOUSFBUFEBEVMUDSBOJPQIBSZOHJPNBQBUJFOUT. -&)
(166) 0 AND PAIN .(0
(167) 0 2ADIOTHERAPY WAS AN INDEPENDENT PREDICTOR FOR MENTAL FATIGUE -&)
(168) 0 2EPEAT SURGERY CORRELATED TO ROLE LIMITATIONS DUE TO EMOTIONAL PROBLEMS 3&
(169) 0 -ULTIPLE PITUITARY DElCIENCIESPANHYPOPITUITARISM WAS NOT AN INDEPENDENT PREDICTOR FOR ANY OF THE QUESTIONNAIRE ITEMS. %*4$644*0/ $ESPITE LONG TERM CURE
(170) ADULT CRANIOPHARYNGIOMA PATIENTS EXPERIENCE A CONSIDERABLE DE CREASE IN 1O, 4HE DECREASE IN 1O, WAS MAINLY MANIFESTED IN THE PHYSICAL ITEMS AND
(171) TO A LESSER EXTENT
(172) IN PSYCHOSOCIAL ITEMS 1O, IN ADULT CRANIOPHARYNGIOMA PATIENTS IS MOSTLY AFFECTED BY VISUAL IMPAIRMENTS AND TO A LESSER EXTENT BY FEMALE GENDER
(173) REPEAT SURGERY AND RADIOTHERAPY 4HE SURVIVAL PROGNOSIS OF PATIENTS TREATED FOR CRANIOPHARYNGIOMA IS FAVOURABLE
(174) WITH REPORTED YEAR SURVIVAL RATES OF APPROXIMATELY IN BOTH ADULTS AND CHILDREN
(175) ALTHOUGH A LOWER SURVIVAL RATE HAS BEEN REPORTED #LINICAL SYMPTOMS MAY ARISE FROM BOTH TUMOUR MASS EFFECTS AND EFFECTS OF TREATMENT )N ADDITION TO THE WELL REC OGNIZED SIGNS AND SYMPTOMS SECONDARY TO HORMONAL DElCIENCIES AND VISUAL DElCITS
(176) PATIENTS EXPERIENCE PHYSICAL AND NEUROPSYCHOLOGICAL DElCITS
(177) SUCH AS OBESITY AND DElCITS OF HIGHER CORTICAL FUNCTION
(178) MEMORY
(179) AND BEHAVIOUR $ECREASED 1O, IN CHILDREN TREATED FOR CRANIOPHARYNGIOMA HAS BEEN REPORTED
(180) AFFECTING BOTH PHYSICAL AND PSYCHO SOCIAL HEALTH 4O DATE
(181) STRUCTURED 1O, RESEARCH IN ADULT PATIENTS TREATED FOR CRANIOPHARYNGIOMA HAS BEEN STUDIED IN ONLY ONE REPORT )N THIS STUDY
(182) USING THE .(0 AND THE 1O, !'($! QUESTIONNAIRES
(183) 1O, WAS MARKEDLY REDUCED /UR SERIES REPORTS A BROADER ASSESSMENT OF 1O,
(184) WHICH ALSO FOCUSES ON FATIGUE AND ENERGY -&)
(185) AS WELL AS ANXIETY AND DEPRESSION (!$3 7E APPLIED FOUR DIFFERENT QUESTIONNAIRES
(186) COVERING MULTIPLE ASPECTS OF PHYSICAL
(187) PSYCHOLOGICAL
(188) AS WELL AS SOCIAL FUNCTIONING )N THE PRESENT STUDY
(189) 1O, IN PATIENTS TREATED FOR CRANIOPHARYNGIOMA PROVED TO BE MORE AFFECTED IN ITEMS CONCERNING PHYSICAL PERFORMANCE THAN IN PSYCHOSOCIAL PERFOR MANCE 'ENERAL FATIGUE
(190) PHYSICAL FATIGUE
(191) ENERGY
(192) PHYSICAL CONDITION AND MOBILITY WERE SIGNIlCANTLY AFFECTED
(193) AS COMPARED WITH CONTROLS 4HIS IS IN AGREEMENT WITH THE HIGH PREVALENCE OF METABOLIC AND VISUAL MORBIDITY FOUND IN ADULT CRANIOPHARYNGIOMA
(194) WHICH IS ATTRIBUTED TO IRREVERSIBLE HYPOTHALAMIC
(195) AND OPTIC DAMAGE !CCORDINGLY
(196) THE MAIN INDEPENDENT PREDICTORS TO AFFECT 1O, WERE FOUND TO BE VISUAL lELD DEFECTS
(197) AND TO A LESSER EXTENT MULTIPLE OPERATIONS
(198) FEMALE GENDER AND RADIOTHERAPY (OWEVER
(199) BECAUSE OF THE RELATIVE SMALL NUMBER OF PATIENTS
(200) THE RESULTS OF THE LINEAR REGRESSION ANALYSIS HAVE TO BE INTERPRETED WITH CAUTION -ULTIPLE PITUITARY DElCIENCIES OR PANHYPOPITUITARISM WAS FOUND IN ALL EXCEPT TWO CRANIOPHARYNGIOMA PATIENTS "ECAUSE OF THE SMALL NUMBER OF PATIENTS WITH INTACT PITUITARY FUNCTION
(201) THE POTENTIAL CONTRIBUTION OF HYPOPITUITARISM TO THE REDUCED . .
(202) 1O, COULD NOT STATISTICALLY BE ASSESSED (YPOPITUITARISM WAS FOUND TO BE AN INDEPENDENT PREDICTOR OF REDUCED 1O, IN PATIENTS TREATED FOR #USHINGS DISEASE AND ACROMEGALY
(203) AFFECT ING BOTH PHYSICAL AND PSYCHOSOCIAL ITEMS $ESPITE OPTIMAL SUBSTITUTION
(204) IT IS LIKELY THAT HYPOPITUITARISM IN OUR PATIENT GROUP ALSO CONTRIBUTES TO A REDUCED 1O, 3& SCORES FROM OUR CRANIOPHARYNGIOMA PATIENTS
(205) OF WHOM HAD PITUITARY DElCIENCIES IN AT LEAST THREE AXES
(206) WERE COMPARABLE TO SCORES IN PATIENTS WITH TWO OR THREE PITUITARY DElCIENCIES AFTER TREATMENT FOR NONFUNCTIONING PITUITARY ADENOMAS (OWEVER
(207) COMPARED TO SCORES FROM TREATED #USHING PATIENTS WITH HYPOPITUITARISM
(208) OUR CRANIOPHARYNGIOMA PATIENTS REPORT BETTER 1O, SCORES IN ALL FOUR QUESTIONNAIRES
(209) POINTING TO A SIGNIlCANT CONTRIBUTION OF HYPERCORTISOLISM ON REDUCED 1O, 4HE PREDISPOSITION FOR FEMALE GENDER AS AN INDEPENDENT RISK FACTOR FOR A DECREASED 1O, IN CRANIOPHARYNGIOMA IS UNCLEAR
(210) ALTHOUGH IT DOES NOT SEEM TO BE A DISEASE SPECIlC PHENOMENON )N THE GENERAL POPULATION FEMALE GENDER IS ALSO ASSOCIATED WITH HIGHER SCORES ON THE .(0
(211) INDICATING A LOWER 1O, 1O, STUDIES IN NON PITUITARY DISEASES MALIGNANCIES
(212) CORONARY HEART DISEASE
(213) INmAMMATORY BOWEL DISEASE ALSO REPORT DECREASED 1O, IN FEMALE PATIENTS AS COMPARED WITH MALE PATIENTS 4HIRTY THREE OF PATIENTS RETURNED THE QUESTIONNAIRES
(214) FOUR OF WHOM PREFERRED $IBQUFS. NOT TO PARTICIPATE BECAUSE OF PHYSICAL INVALIDATION 0ARTICIPATION OF THESE PATIENTS
(215) HOW. . EVER
(216) WOULD EVEN HAVE WORSENED 1O, SCORES
(217) BECAUSE THEY SUFFERED OF SERIOUS MORBIDITY 4HE USE OF CONTROLS CHOSEN BY THE PATIENTS MAY HAVE INTRODUCED A BIAS
(218) SINCE CONTROLS WITH A SUPPOSEDLY GOOD 1O, ARE MORE LIKELY TO BE ASKED )N ORDER TO OVERCOME THIS POS SIBLE BIAS WE ALSO USED VALIDATED REFERENCE DATA FROM LITERATURE #OMPARED WITH THOSE AGE ADJUSTED REFERENCE VALUES
(219) 1O, PARAMETERS WERE AFFECTED SIGNIlCANTLY IN FEWER SUBSCALES
(220) THAN WAS REVEALED BY THE COMPARISON WITH OUR OWN CONTROLS 4HIS SUGGESTS THAT PATIENTS HAVE CHOSEN CONTROLS WITH A SUPPOSED GOOD HEALTH STATUS .ONETHELESS
(221) THE COMPARISON WITH BOTH SOURCES OF CONTROL DATA REVEALED THE SAME PATTERN
(222) IE ADULT CRANIOPHARYNGIOMA PATIENTS HAD SERIOUSLY IMPAIRED 1O, )N CONCLUSION
(223) 1O, IN ADULT CRANIOPHARYNGIOMA PATIENTS IS SIGNIlCANTLY REDUCED COM PARED TO A HEALTHY POPULATION
(224) ESPECIALLY IN THE PHYSICAL ITEMS 4HE MAIN INDEPENDENT PREDICTOR OF A WORSE 1O, IS VISUAL lELD DEFECTS $ESPITE LONG TERM CURE
(225) TREATMENT OF CRANIOPHARYNGIOMA
(226) WITH THE AIM TO PREVENT RECURRENCE
(227) DOES NOT NORMALIZE 1UALITY OF ,IFE.
(228) 2VBMJUZPGMJGFJOUSFBUFEBEVMUDSBOJPQIBSZOHJPNBQBUJFOUT. 3&'&3&/$&4 +ARAVITAKI .
(229) "RUFANI #
(230) 7ARNER *4
(231) !DAMS #"
(232) 2ICHARDS 0
(233) !NSORGE /
(234) 3HINE "
(235) 4URNER (% 7ASS *! #RANIOPHARYNGIOMAS IN CHILDREN AND ADULTS SYSTEMATIC ANALYSIS OF CASES WITH LONG TERM FOLLOW UP #LINICAL %NDOCRINOLOGY -ERCHANT 4%
(236) +IEHNA %.
(237) 3ANFORD 2!
(238) -ULHERN 2+
(239) 4HOMPSON 3*
(240) 7ILSON -7
(241) ,USTIG 2( +UN ,% #RANIOPHARYNGIOMA THE 3T *UDE #HILDRENS 2ESEARCH (OSPITAL EXPERIENCE )NTERNATIONAL *OURNAL OF 2ADIATION
(242) /NCOLOGY
(243) "IOLOGY AND 0HYSICS +ENDALL 4AYLOR 0
(244) *ONSSON 0*
(245) !BS 2
(246) %RFURTH %-
(247) +OLTOWSKA (AGGSTROM -
(248) 0RICE $! 6ER HELST * 4HE CLINICAL
(249) METABOLIC AND ENDOCRINE FEATURES AND THE QUALITY OF LIFE IN ADULTS WITH CHILDHOOD ONSET CRANIOPHARYNGIOMA COMPARED WITH ADULT ONSET CRANIOPHARYNGIOMA %URO PEAN *OURNAL OF %NDOCRINOLOGY 0EREIRA !-
(250) 3CHMID %-
(251) 3CHUTTE 0*
(252) 6OORMOLEN *(
(253) "IERMASZ .2
(254) VAN 4HIEL 37
(255) #ORSSMIT %0
(256) 3MIT *7
(257) 2OELFSEMA & 2OMIJN *! (IGH PREVALENCE OF LONG TERM CARDIOVASCULAR
(258) NEUROLOGICAL AND PSYCHOSOCIAL MORBIDITY AFTER TREATMENT FOR CRANIOPHARYNGIOMA #LINICAL %NDOCRINOLOGY 4OMLINSON *7
(259) (OLDEN .
(260) (ILLS 2+
(261) 7HEATLEY +
(262) #LAYTON 2.
(263) "ATES !3
(264) 3HEPPARD -# 3TEWART 0- !SSOCIATION BETWEEN PREMATURE MORTALITY AND HYPOPITUITARISM 7EST -IDLANDS 0ROSPECTIVE (YPOPITUITARY 3TUDY 'ROUP ,ANCET "ULOW "
(265) !TTEWELL 2
(266) (AGMAR ,
(267) -ALMSTROM 0
(268) .ORDSTROM #( %RFURTH %- 0OSTOPERATIVE PROGNOSIS IN CRANIOPHARYNGIOMA WITH RESPECT TO CARDIOVASCULAR MORTALITY
(269) SURVIVAL
(270) AND TUMOR RECURRENCE *OURNAL OF #LINICAL %NDOCRINOLOGY AND -ETABOLISM "IERMASZ .2
(271) VAN 4HIEL 37
(272) 0EREIRA !-
(273) (OFTIJZER (#
(274) VAN (EMERT !-
(275) 3MIT *7
(276) 2OMIJN *! 2OELFSEMA & $ECREASED QUALITY OF LIFE IN PATIENTS WITH ACROMEGALY DESPITE LONG TERM CURE OF GROWTH HORMONE EXCESS *OURNAL OF #LINICAL %NDOCRINOLOGY AND -ETABOLISM *OHNSON -$
(277) 7OODBURN #* 6ANCE -, 1UALITY OF LIFE IN PATIENTS WITH A PITUITARY ADENOMA 0ITUITARY VAN !KEN -/
(278) 0EREIRA !-
(279) "IERMASZ .2
(280) VAN 4HIEL 37
(281) (OFTIJZER (#
(282) 3MIT *7
(283) 2OELFSEMA &
(284) ,AMBERTS 37 2OMIJN *! 1UALITY OF LIFE IN PATIENTS AFTER LONG TERM BIOCHEMICAL CURE OF #USHINGS DISEASE *OURNAL OF #LINICAL %NDOCRINOLOGY AND -ETABOLISM 0EACE +!
(285) /RME 3-
(286) 0ADAYATTY 3*
(287) 'ODFREY (0 "ELCHETZ 0% #OGNITIVE DYSFUNCTION IN PATIENTS WITH PITUITARY TUMOUR WHO HAVE BEEN TREATED WITH TRANSFRONTAL OR TRANSSPHENOIDAL SURGERY OR MEDICATION #LINICAL %NDOCRINOLOGY 0ORETTI !
(288) 'ROTZER -!
(289) 2IBI +
(290) 3CHONLE % "OLTSHAUSER % /UTCOME OF CRANIOPHARYNGIOMA IN CHILDREN LONG TERM COMPLICATIONS AND QUALITY OF LIFE $EVELOPMENTAL -EDICINE AND #HILD .EUROLOGY -ULLER (,
(291) "RUHNKEN '
(292) %MSER !
(293) &ALDUM !
(294) %TAVARD 'ORRIS .
(295) 'EBHARDT 5
(296) +OLB 2 3O RENSEN . ,ONGITUDINAL STUDY ON QUALITY OF LIFE IN SURVIVORS OF CHILDHOOD CRANIOPHARYN GIOMA #HILDS .ERVOUS 3YSTEM 6ILLANI 2-
(297) 4OMEI '
(298) "ELLO ,
(299) 3GANZERLA %
(300) !MBROSI "
(301) 2E 4 'IOVANELLI "- ,ONG TERM RESULTS OF TREATMENT FOR CRANIOPHARYNGIOMA IN CHILDREN #HILDS .ERVOUS 3YSTEM (INZ !
(302) +LAIBERG !
(303) 3CHUMACHER * "RAHLER % ;4HE PSYCHOMETRIC QUALITY OF THE .OTTINGHAM (EALTH 0ROlLE .(0 IN THE GENERAL POPULATION= 0SYCHOTHERAPIE
(304) 0SYCHOSOMATIK
(305) -EDIZINISCHE 0SYCHOLOGIE 3METS %-
(306) 6ISSER -2
(307) 7ILLEMS 'ROOT !&
(308) 'ARSSEN "
(309) 3CHUSTER 5ITTERHOEVE !, $E (AES *# &ATIGUE AND RADIOTHERAPY " EXPERIENCE IN PATIENTS MONTHS FOLLOWING TREATMENT "RITISH *OURNAL OF #ANCER . .
(310) $IBQUFS . 3PINHOVEN 0
(311) /RMEL *
(312) 3LOEKERS 00
(313) +EMPEN ')
(314) 3PECKENS !% VAN (EMERT !- ! VALIDATION STUDY OF THE (OSPITAL !NXIETY AND $EPRESSION 3CALE (!$3 IN DIFFERENT GROUPS OF $UTCH SUBJECTS 0SYCHOLOGICAL -EDICINE 6AN DER :EE +) 3ANDERMAN 2 (ET METEN VAN DE ALGEMENE GEZONDHEIDSTOESTAND MET DE 2!.$
(315) EEN HANDLEIDING .OORDELIJK #ENTRUM VOOR 'EZONDHEIDSVRAAGSTUKKEN
(316) 'RONINGEN
(317) 4HE .ETHERLANDS 6ANDER:EE +)
(318) 3ANDERMAN 2 (EYINK * ! COMPARISON OF TWO MULTIDIMENSIONAL MEASURES OF HEALTH STATUS THE .OTTINGHAM (EALTH 0ROlLE AND THE 2!.$ )TEM (EALTH 3URVEY 1UALITY OF ,IFE 2ESEARCH :IGMOND !3 3NAITH 20 4HE HOSPITAL ANXIETY AND DEPRESSION SCALE !CTA 0SYCHIATRICA 3CAN DINAVICA 3METS %-
(319) 'ARSSEN "
(320) "ONKE " $E (AES *# 4HE -ULTIDIMENSIONAL &ATIGUE )NVENTORY -&) PSYCHOMETRIC QUALITIES OF AN INSTRUMENT TO ASSESS FATIGUE *OURNAL OF 0SYCHOSOMATIC 2ESEARCH (UNT 3-
(321) -C+ENNA 30
(322) -C%WEN *
(323) "ACKETT %-
(324) 7ILLIAMS * 0APP % ! QUANTITATIVE APPROACH TO PERCEIVED HEALTH STATUS A VALIDATION STUDY *OURNAL OF %PIDEMIOLOGY AND #OMMUNITY (EALTH (UNT 3- -C%WEN * 4HE DEVELOPMENT OF A SUBJECTIVE HEALTH INDICATOR 3OCIOLOGY OF (EALTH )LLNESS "RAZIER *%
(325) (ARPER 2
(326) *ONES .-
(327) /#ATHAIN !
(328) 4HOMAS +*
(329) 5SHERWOOD 4 7ESTLAKE , 6ALIDAT ING THE 3& HEALTH SURVEY QUESTIONNAIRE NEW OUTCOME MEASURE FOR PRIMARY CARE "RITISH -EDICAL *OURNAL 7ARE *%
(330) *R 3HERBOURNE #$ 4HE -/3 ITEM SHORT FORM HEALTH SURVEY 3& ) #ONCEP TUAL FRAMEWORK AND ITEM SELECTION -EDICAL #ARE (ETELEKIDIS 3
(331) "ARNES 0$
(332) 4AO -,
(333) &ISCHER %'
(334) 3CHNEIDER ,
(335) 3COTT 2- 4ARBELL .* YEAR EXPERIENCE IN CHILDHOOD CRANIOPHARYNGIOMA )NTERNATIONAL *OURNAL OF 2ADIATION
(336) /NCOLOGY
(337) "IOLOGY AND 0HYSICS -ULLER (,
(338) 'EBHARDT 5
(339) %TAVARD 'ORRIS .
(340) +ORENKE %
(341) 7ARMUTH -ETZ -
(342) +OLB 2
(343) 3ORENSEN . #ALAMINUS ' 0ROGNOSIS AND SEQUELA IN PATIENTS WITH CHILDHOOD CRANIOPHARYNGIOMA n RESULTS OF ()4 %.$/ AND UPDATE ON +2!.)/0(!29.'%/- +LINISCHE 0ËDIATRIE &ISHER 0'
(344) *ENAB *
(345) 'OPLDTHWAITE 04
(346) 4IHAN 4
(347) 7HARAM -$
(348) &OER $2 "URGER 0# /UTCOMES AND FAILURE PATTERNS IN CHILDHOOD CRANIOPHARYNGIOMAS #HILDS .ERVOUS 3YSTEM !GEWALL 3
(349) "ERGLUND - (ENAREH , 2EDUCED QUALITY OF LIFE AFTER MYOCARDIAL INFARCTION IN WOMEN COMPARED WITH MEN #LINICAL #ARDIOLOGY "ERNKLEV 4
(350) *AHNSEN *
(351) !ADLAND %
(352) 3AUAR *
(353) 3CHULZ 4
(354) ,YGREN )
(355) (ENRIKSEN -
(356) 3TRAY .
(357) +JELLEVOLD /
(358) 6ATN - -OUM " (EALTH RELATED QUALITY OF LIFE IN PATIENTS WITH INmAMMATORY BOWEL DISEASE lVE YEARS AFTER THE INITIAL DIAGNOSIS 3CANDINAVIAN *OURNAL OF 'ASTROENTEROLOGY -AINIO !
(359) (AKKO (
(360) .IEMELA !
(361) +OIVUKANGAS * 2ASANEN 0 'ENDER DIFFERENCE IN RELATION TO DEPRESSION AND QUALITY OF LIFE AMONG PATIENTS WITH A PRIMARY BRAIN TUMOR %UROPEAN *OURNAL OF 0SYCHIATRY -YSTAKIDOU +
(362) 4SILIKA %
(363) 0ARPA %
(364) +ATSOUDA %
(365) 'ALANOS ! 6LAHOS , !SSESSMENT OF !NXIETY AND $EPRESSION IN !DVANCED #ANCER 0ATIENTS AND THEIR 2ELATIONSHIP WITH 1UALITY OF ,IFE 1UALITY OF ,IFE 2ESEARCH .ORRIS #-
(366) 'HALI 7!
(367) 'ALBRAITH 0$
(368) 'RAHAM --
(369) *ENSEN ,! +NUDTSON -, 7OMEN WITH CORONARY ARTERY DISEASE REPORT WORSE HEALTH RELATED QUALITY OF LIFE OUTCOMES COMPARED TO MEN (EALTH AND 1UALITY OF ,IFE /UTCOMES .
(370)
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