SURVEILLANCE CAN BE THE STANDARD OF CARE FOR STAGE I NONSEMINOMATOUS TESTICULAR TUMORS AND EVEN HIGH RISK PATIENTS

PURPOSE: We investigate the results of a surveillance program for stage I nonseminomatous germ cell tumors to validate a surveillance policy, and furthermore improve it by analyzing diagnostic instruments and identifying prognostic factors for relapse. MATERIALS AND METHODS: From 1982 to 1994, 90 patients with stage I nonseminomatous germ cell tumors entered a surveillance protocol after orchiectomy. Patients with relapse were treated with cisplatin based chemotherapy. A statistical analysis of possible prognostic factors for relapse was performed. RESULTS: Relapse occurred in 23 (26%) patients. Disease specific survival was 98.9%, and 1 patient died of tumor. Most relapses were located in retroperitoneal lymph nodes only (78%). Tumor markers were the most important indicators of relapse. However, in 22% of patients with relapse abdominal x-ray of lymphangiographic contrast showed the first sign of relapse. Computerized tomography located all but 1 relapse. Vascular invasion (p = 0.0001), tumor size (p = 0.0341) and presence of immature teratoma (p = 0.0154) were significantly predictive of relapse with the multivariate analysis, percentage embryonal carcinoma only by univariate analysis (p = 0.032). The relapse rate was highest (52%) when vascular invasion was present. CONCLUSIONS: With surveillance for stage I nonseminomatous germ cell tumors, excellent treatment results can be achieved that are comparable to primary retroperitoneal lymph node dissection. Tumor markers and computerized tomography are highly reliable for detecting relapse. Lymphangiography is still of staging value. Pathological factors may influence the choice of adjuvant treatment. However, relapse risks of 50% to 60% are maximally achieved with presently available prognostic factors, and so sparing morbidity of adjuvant treatment by a surveillance protocol remains a feasible option even in these patients.     

Endocrine effects of 17 alpha-hydroxyprogesterone caproate during early pregnancy: a double-blind clinical trial

Summary. The clinical and endocrine effects of progestogen therapy in early pregnancy were investigated using a double-blind randomized trial in 64 patients who had a viable fetus at 6 weeks gestation and had an increased risk of miscarriage. The patients were randomly allocated to receive either 17 alpha-hydroxyprogesterone caproate or a placebo between 7 and 12 weeks gestation. Four fetal ultrasonographic variables and 17 maternal endocrine variables were studied in each woman. Only four maternal serum variables (17 alpha-hydroxyprogesterone, prolactin, thyroxin and thyroxin binding globulin) rose significantly. The serum progesterone levels in the hormone supplemented group were on average 20% higher than in the placebo group but the difference was not statistically significant. However, the relation between the progesterone levels and the fetal outcome was not clear. Therefore it is not advisable to prescribe 17-OHP-C during early pregnancy to prevent a miscarriage.     

Stressful life events and disability in early rheumatoid arthritis

The objective was to investigate the relationship of stressfullife events and disability in early rheumatoid arthritis (RA),taking into account a possible stress-buffering effect of thesocial network. As part of a European study (EURIDISS), 337early RA patients in France and The Netherlands (mean diseaseduration = 2.3 years) were interviewed for life events whichhad occurred in the past year. The social network compositionwas assessed using a standardized interview schedule and describedby network density and proximity characteristics. Disabilitywas assessed with the Health Assessment Questionnaire (HAQ)cross-culturally adapted to the French and Dutch languages.Subjects reported a median of 2 significant life events overthe past year. On average they had 20 persons in their socialnetwork. The disability was significantly higher when the numberof life events experienced was higher (r = 0.11; p<0.05)and when the number of social network members in monthly contactwith the subjects was lower (r = –0.13; p<0.05). Controllingfor country, the HAQ score increased significantly with thedisease duration, disease activity variables, number of lifeevents related to RA or to another health problem and decreasedwith the number of social network members. A significant (numberof health-related life events)x(number of social network members)cross-product term entered the model which fitted the data better(R² =0.51). Factors associated with disability are disease duration,disease activity, number of health-related life events and numberof social network members in monthly contact. The results suggesta stress-buffering effect of the social network in coping withstressful life events in early RA.     

Epidemiology of low bone mineral density and fractures in children with severe cerebral palsy: a systematic review

Aim  Children with severe cerebral palsy (CP) are at risk for developing low bone mineral density (BMD) and low-impact fractures. The aim of this study was to provide a systematic literature review of the epidemiology of fractures and low BMD in children with severe CP, with an emphasis on risk factors. Gross Motor Function Classification System (GMFCS) levels IV and V were criteria for severe cerebral palsy.
Method  The literature (PubMed) was searched and eligible studies were given a level of evidence score using the Scottish Intercollegiate Guidelines Network criteria.
Results  Seven studies were found concerning epidemiology of fractures, 11 studies described epidemiology of low BMD, and 14 studies concerned risk factors. The methodological quality of most of these studies was poor. Five studies were considered well-conducted with low risk of confounding and bias. In these studies, the incidence of fractures in children with moderate to severe CP approached 4% per year, whereas the prevalence of low BMD in the femur was 77%. Limited ambulation, feeding difficulties, previous fractures, anticonvulsant use, and lower body fat mass were associated with low BMD z-scores.
Interpretation  There is only a limited amount of high-quality evidence on low BMD and fractures in children with severe CP.     

Stability of Artemisinin in Aqueous Environments: Impact on its Cytotoxic Action to Ehrlich Ascites Tumour Cells

We have recently shown artemisinin to be cytotoxic against Ehrlich ascites tumour cells. The aim of this study was to investigate the stability of this compound in the aqueous environment of the in-vitro Ehrlich ascites tumour cell system (RPMI 1640 cell culture medium supplemented with 10% foetal bovine serum (RPMI/FBS) with reference to its cytotoxic action. Literature data show that artemisinin can react with Fe²⁺ yielding reactive intermediates leaving artemisinin G as a major end-product. The current study showed that only excess addition of Fe²⁺ to artemisinin in distilled water, phosphate-buffered saline (PBS) and RPMI/FBS and incubation for 24 h led to degradation of artemisinin and yielded artemisinin G. If Fe²⁺ was not added results from HPLC analysis were indicative of complete recovery of artemisinin from distilled water and RPMI/FBS, with or without cells, at 37°C for at least 24 h. In addition, incubation of artemisinin in RPMI/FBS with or without cells at 37°C for 24 h before cytotoxicity assay did not change its cytotoxic action. On the basis of these results, we suggest that cytotoxicity to tumour cells was caused by unchanged artemisinin. This is not so for the antimalarial activity of artemisinin and derivatives, for which the presence of a pool of (haem) Fe²⁺ is a prerequisite resulting in free radicals or electrophilic intermediates or both.     

SEM and microradiographic investigation of initial enamel caries

Abstract – In this paper a combined microradiography and SEM study is presented on human enamel after a caries attack in vivo for a 4-wk period. The initial enamel caries is induced under a specially designed orthodontic band; plaque accumulation takes place under a niche in the band. The microradiography and SEM were done on the same sections. A special manipulation and breaking technique of the thin sections makes it possible to observe with the SEM, demineralized enamel areas with a mineral content known from microradiography. The results show that with a mineral content of about 50 vol. %, the observable porosity is noticeable at the prism level (interprismatically) but barely noticeable at the crystallite level. The surface morphology of the demineralized enamel is at low magnifications not very different from sound enamel. At high magnifications, however, the surface porosity becomes visible. The results indicate that the mineral in vivo losses in enamel after an initial caries attack can be explained mainly by mineral losses from interprismatic areas and from the prism peripheries.     

Differences in production between medical specialists: An inventory based on claims data to identify potential areas for quality-improvement activities

Claims data from sickness funds were used to describe practicepatterns of all physician partnerships of six medical specialtiesin a region of The Netherlands. The numbers of admissions tohospital, patient days, in-patient and out-patient procedureswere compared per 1,000 insured persons. There were large differencesamong physicians within the same specialties. The non-surgicalspecialties had more variable practice patterns. Variation inuse of specific procedures with a supposedly clear indicationversus a less-defined indication was the same. We could notidentify special areas with greater differences that shouldhave a priority for quality-improvement activities. The useof sickness fund data in monitoring and decreasing variationsin medical practice is discussed.     

Compliance after 17 years of breast cancer screening: Factors associated with reattendance for periodic breast screening

The motives and reasons for regular attendance, irregular attendanceand drop-out were studied in women who were enrolled in a biennialbreast screening programme in 1975 and who were invited to eachsubsequent screening round until 1992. Three compliance groupswere compared: ‘attended all rounds’ (group A, n=79),‘missed 1 or 2 rounds’ (group B, n=73) and ‘missedmore than 2 rounds’ (group C, n=64). The groups did notdiffer with respect to background variables such as sociodemographiccharacteristics, actual health problems or preventive healthorientations, but significant differences were found in generalattitudes to breast screening and to the organizational aspectsof screening procedures. The results suggest that during thecourse of a screening programme, for a substantial group ofnot strongly motivated women, the recurring negative aspectsof mammography (pain and anxiety) are increasingly becominga burden. ‘Circumstantial factors’ like waitingfor one's turn, the distance to the screening centre and incidentaldissatisfaction with handling by screening staff, appear totrigger the decision to skip screening rounds or to drop outof the programme. From the perspective of maintaining a regularattendance throughout the programme this is an important group.Special efforts must be made to encourage these women to stayin the programme.