MANAGEMENT OF SEMINOMA OF THE TESTIS: RECOMMENDATIONS BASED ON TREATMENT RESULTS

Background : The results of management of seminoma of the testis at the Department of Radiation Oncology St Vincent's Hospital, Sydney were evaluated retrospectively to: (i) establish that outcomes were in keeping with published results from centres in Australia and overseas; (ii) assess the impact of chemotherapy on management; and (iii) to determine ‘best practice’ management protocols based on our results and a review of the relevant literature. Methods : (i) Assessment of treatment results for stage I and II seminoma of the testis treated by post-orchidectomy radiotherapy and/or chemotherapy at St Vincent's Hospital between 1979 and 1993; (ii) literature review of published data from Australian and overseas centres on the management of seminoma of the testis, and in particular the use of surveillance or chemotherapy either alone, at time of relapse or combined with radiotherapy; and (iii) development of recommendations for use as management protocols in our department. Results : Our data and a review of the literature suggest that post-orchidectomy radiotherapy with chemotherapy for relapse in stage I and IIA disease results in long-term cure rates approaching 100%. Treatment with chemotherapy either routinely or selectively or using a surveillance policy is unlikely to show any improvement in outcome and may be less cost-effective and/or produce increased morbidity and the risk of secondary leukaemia. For stage IIB disease (5–10 cm) the use of initial combination chemotherapy with or without subsequent radiotherapy did not appear to give better outcomes than initial radical radiotherapy alone, reserving chemotherapy or further radiotherapy for relapse. For bulkier stage IIB disease (> 10cm). the use of initial chemotherapy plus consolidation radiotherapy appeared to be an appropriate treatment. Conclusions : Management protocols for seminoma of the testis at St Vincent's Hospital, Sydney Department of Radiation Oncology currently are (i) stage I, IA and IIB (5–10 cm): post-orchidectomy radiotherapy alone with chemotherapy or further radiotherapy for relapse; and (ii) stage IIB (> 10 cm) disease: initial chemotherapy post-orchidectomy followed by radiotherapy to sites of initial disease involvement.     

The future of hypnosis through the remainder of the decade: a Delphi poll.

We predicted the future of hypnosis for the next 10 years using the Delphi method--the best available forecasting tool. A panel of 89 experts in the field of hypnosis completed a 44-item questionnaire that addressed future developments in these areas: (1) training and preparation, (2) general applications of hypnosis, (3) theory, and (4) research. Also predicted was the likelihood of occurrence of certain cogent events in the field. Results indicated probable increases in emphasis in nearly all areas surveyed. We also solicited nominations for major contributors to the field of hypnosis, major books on hypnosis, and journals most likely to publish articles on hypnosis.     

The Use of Stent Grafts for the Treatment of Aneurysms and Dissections of the Thoracic Aorta: A Single Centre Experience

OBJECTIVE: To review the results of stent graft treatment for diseases of the thoracic aorta. DESIGN: A retrospective study of the results of thoracic stent graft procedures in a single centre. METHODS: The results of 30 procedures performed in 24 patients were analysed. Eleven patients had aneurysmal dilatation of the descending thoracic aorta (>5.5 cm), nine patients had complicated type B dissection, three had penetrating ulcers and one had a traumatic pseudoaneurysm. Imaging follow-up consisted of CT scans performed at one, three, six and 12 months following the procedure and annually thereafter. RESULTS: One technical failure occurred due to a ruptured external iliac artery. There were no other immediate failures. The primary technical success rate was 83%. The 30-day procedural and patient mortality rates were 7 and 8%, respectively. No neurological complications occurred. Seven patients had the subclavian artery covered without complications. Secondary intervention was required in 21%. During the follow-up period (mean 11 months, range 1-48 months.) there were five deaths, two of which were related to stent graft infection. CONCLUSION: Thoracic stent grafts offer a realistic alternative to surgery.     

Carotid stenosis in lacunar stroke.

The prevalence of extracranial carotid stenosis in patients with a clinical syndrome of lacunar stroke has not been extensively studied using noninvasive methods. We performed carotid duplex sonography on 168 patients referred to the neurosonology laboratory with a diagnosis of ischemic stroke. Strokes were independently classified as lacunar or nonlacunar hemispheric infarction without knowledge of the ultrasound results. We excluded patients with infarcts that were clearly vertebrobasilar, presumed to be cardioembolic, or had occurred greater than 1 year earlier, and patients for whom classification of the nature and location of the event was not possible. Fifty-five patients had lacunar and 54 had nonlacunar stroke. No differences in age, sex, distribution, or prevalence of hypertension, diabetes, prior ischemia, or Hispanic surname existed between the two groups. Tobacco use was more frequent in the nonlacunar group (p less than 0.01). The prevalence of important extracranial carotid stenosis (greater than or equal to 50% diameter reduction) in the lacunar stroke group was 13% (seven of 55) in the ipsilateral and 4% (two of 55) in the contralateral carotid artery. Of the 54 patients with nonlacunar hemispheric stroke, 41% (22) had ipsilateral (p less than 0.01) and 26% (14) had contralateral (p less than 0.01) carotid stenosis. This study suggests that important carotid stenosis is infrequent among patients presenting with a clinical syndrome of lacunar stroke. These data impact on decisions regarding cerebrovascular work-up in such patients.     

Novel C3 nephritic factor activity in the glomerulonephritis of staphylococcal endocarditis

A case of glomerulonephritis complicating staphylococcal endocarditis is presented. Hypocomplementaemia and a C3-activating factor in the serum suggested that the patient might have mesangiocapillary glomerulonephritis in association with C3-nephritic factor. Renal biopsy showed that this was not so and further examination of the serum factor showed that it differed from classical C3-nephritic factor because it was not an immunoglobulin. It is postulated that complement activation and glomerulonephritis in staphylococcal endocarditis may be the direct result of a bacterial product. A substance in the serum which activates C3 should be confirmed to be an immunoglobulin before the presence of classical C3-nephritic factor is assumed.