Survival rates of extremely preterm infants (gestational age <26 weeks) in Switzerland: impact of the Swiss guidelines for the care of infants born at the limit of viability

BACKGROUND

Because ethical decision making in the care of extremely preterm infants varies widely across Europe, the Swiss Society of Neonatology decided to publish its own guidelines on the care of infants born at the limit of viability in 2002.

OBJECTIVE

To examine the potential impact of the guidelines on survival rates, short-term complication rates and centre-to-centre outcome differences of extremely preterm infants (22-25 completed weeks).

DESIGN

Population-based, retrospective cohort study.

SETTING

All nine level III neonatal intensive care units (NICU) and affiliated paediatric hospitals in Switzerland.

PATIENTS

516 extremely preterm infants born alive between 1 January 2000 and 31 December 2004.

MAIN OUTCOME MEASURES

Delivery room and NICU mortality rates, survival to hospital discharge and incidence of short-term complications in survivors were assessed. To study the impact of the guidelines, two cohorts from two different time periods were compared (years 2000/2001, n = 220; years 2003/2004, n = 204) whereas patients born in the year of the publication (2002, n = 92) were excluded. For centre-to-centre comparisons, the entire population (n = 516) was analysed.

RESULTS

There was a significant increase in survival rates of extremely preterm infants from 31% to 40% (RR 1.24, 95% CI 1.02, 1.50) after the publication of the Swiss guidelines. This improvement was largely explained by significantly improved survival from 42% to 60% (p = 0.01) among infants born at 25 completed weeks because of decreased NICU mortality. Improved survival was not associated with statistically significant changes in the incidence of short-term complications. Despite national guidelines, considerable centre-to-centre outcome differences have persisted.

CONCLUSIONS

The publication of the Swiss guidelines was followed by significantly improved survival of extremely preterm infants but had no impact on centre-to-centre differences.

A phase I study of tumor treating fields (TTFields) in combination with pemetrexed for pretreated advanced non-small cell lung cancer

e18500

Background: TTFields (tumor treating fields) are low intensity, intermediate frequency, alternating electric fields which slow the growth of solid tumors in-vivo, and have shown promise in pilot clinical trials in patients with advanced solid tumors. TTFields are a regional treatment which acts both by interfering with microtubules polymerization and by physical disruption of the cell structure during cytokinesis. It has been shown previously that TTFields sensitize non-small cell lung cultures to Pemetrexed. In-Vivo, TTFields did not increase pemetrexed related toxicity. Methods: A prospective trial was performed in 14, pretreated, stage IIIb-IV, NSCLC patients. Patients with brain metastases were excluded, as were patients with abnormal marrow, kidney, liver or cardiac functions. Patients with history of clinically significant arrhythmias or those having pacemakers were excluded as well. Patients received Pemetrexed 500mg/m2 IV q3w together with daily TTFields (12 h/day) using a portable medical device (NovoTTF-100L). The device generated 2 direction (AP and Lat), 150 kHz TTFields. Patients were followed every three weeks and had a lung CT every 9 weeks. The primary endpoint was the safety and tolerability of the NovoTTF-100L device in combination with pemetrexed. Results: The 14 patients received an average of 4 courses of pemetrexed (Range 1–9) and a cumulative TTFields treatment time of 182 weeks. The device was well tolerated as indicated in the device log files which showed an average daily use of 11±1 hours. There were no device-related, nor pemetrexed-related SAEs. In addition, no unexpected abnormalities were evident in the lab tests or EKGs, done every 3 weeks for all patients. There were no reports of arrhythmias. The only device related AE seen in all patients was dermatitis under the electrodes. This improved with meticulous skin care, topical steroid use and in extreme cases oral steroids. One patient (7.6%) had a CR, 1 a PR (7.6%), 9 SD (69.2%) and 3 PD (23%). 77% of patients were progression free at 12 weeks and the 6 month survival was 89%. Conclusions: TTFields are well tolerated when given together with pemetrexed. The excellent safety profile and initial efficacy results reported here justify further clinical testing.

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Carboplatin-Induced Bilateral Papilledema: A Case Report

We report on a patient with carboplatin-induced bilateral papilledema, as it was described in the 1970s for cisplatin. Loss of visual accuracy up to full blindness, often loss of color vision and scotomas can be seen as a result of cortical blindness, macula degeneration, retrobulbar neuritis and papilledema. These symptoms are mostly unilateral and initially mild, so that more chemotherapy is given before the diagnosis is made. The symptoms are usually reversible within weeks to months after cessation of the platinum treatment. The therapeutic strategy is stopping the platinum treatment. In addition the empiric use of corticosteroids is suggested.

Tumor patients in psychodynamic psychotherapy including daydreaming: can imagery enhance primary process and positive emotions?

This therapy process study investigates the use of guided affective imagery for tumor patients. The therapeutic access to tumor patients is generally described as complex and challenging because of a disturbed emotion regulation and a defensive focus on reality. After autologous blood stem cell transplantation, 29 patients were treated with psychotherapy, including two daydreaming imagery sessions. Three text-analytical measures--Affective Dictionary Ulm, Regressive Imagery Dictionary, and Computerized Referential Activity for verbatim session transcripts--as well as the Quality of Life Questionnaire and the Karnofsky Performance Status were administered. Results show that guided affective imagery was able to enhance the psychotherapeutic process in tumor patients by activating the primary process, decreasing anxiety, and increasing referential activity. The positive emotional shift during imagery was achieved by the patients irrespective of their oncological severity status. Study limitations and future directions for research are discussed.

Monitoring of PCDD/Fs in a mountain forest by means of active and passive sampling

Polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/F) are sampled and investigated in a forested area in Middle-Europe. The campaigns, consisting in active and passive samplings, were conducted in the Bavarian and Bohemian Forest at four sites chosen for their similar soil and forest stand characteristics. Passive sampling was conducted using both semi-permeable membrane devices (SPMDs) and needles of well-exposed dominant spruce trees. Active air sampling was also performed at one site with a low volume air sampler. Correlations were performed to identify relationships and trends of PCDD/F. Lower chlorinated PCDD/F are accumulated in SPMDs, needles collected all compounds among homologues and their PCDD/F pattern is close to that of active sampling. Results of the analysed compounds obtained with the different sampling methods served as a basis for the establishment of advantages and disadvantages of the sampling tools applied and their possible optimisation.

Körpergewichts-Telemetrie bei Hämodialysepatienten - vorläufige Daten

BACKGROUND AND OBJECTIVE

Non-adherence to fluid intake restrictions is one of the leading problems in hemodialysis patients. The consequences of chronic volume overload and massive hypotensive episodes resulting from enhanced ultrafiltration lead to an increased mortality and incidence of vascular events. Telemetric body weight monitoring (TBWM) suggests itself as a successful way to reduce daily fluid intake

PATIENTS AND METHODS

This monocentric, prospective, randomized open study includes 120 patients with end-stage renal failure undergoing chronic hemodialysis (for at least two months) three times a week. The mean interdialytic weight gain (IWG) was more than 1.5 kg/2 days over the four weeks immediately before start of the study. The effect of daily body weight telemonitoring on IWG, blood pressure, haemoglobin variability, hospital stay, vascular events and mortality were observed for three months. All monitored patients (group 1, n = 60) received a weekly report of their weight changes, the number of alarms (automatically sent by email to the study center when daily IWG was greater than 0.75 kg/d) and of the interventions by phone (conducted by the responsible nephrologist when IWG was > 2 kg/day). Hemodynamics (each hemodialysis procedure) and weekly laboratory data were recorded for all patients.

RESULTS

Preliminary data of 44 patients showed a significant reduction of daily IWG (weekly average, p = 0.0187) and a smaller number of alarm reports after the whole study period in group 1. Blood pressure monitoring during hemodialysis showed less hyper- and hypotensive episodes in patients with an IWG of less than 1.5 kg/2 days. In the control group there have so far been no changes of the analysed parameters.

CONCLUSIONS

TBWM seems to be an effective method for optimizing adherence to fluid intake restrictions in patients on hemodialysis. Hemoglobin variability, mortality rates and the number of vascular events will still have to be analysed in detail for all patients once the entire study period has been completed.

Patients? health beliefs and coping prior to autologous peripheral stem cell transplantation

The aim of this study was to determine the associations between health locus of control (LoC), causal attributions and coping in tumour patients prior to autologous peripheral blood stem cell transplantation. Patients completed the Questionnaire of Health Related Control Expectancies, the Questionnaire of Personal Illness Causes (QPIC), and the Freiburg Questionnaire of Coping with Illness. A total of 126 patients (45% women; 54% suffering from a multiple myeloma, 29% from non-Hodgkin lymphomas, and 17% from other malignancies) participated in the study. Cluster analysis yielded four LoC clusters: 'fatalistic external', 'powerful others', 'yeah-sayer' and 'double external'. Self-blaming QPIC items were positively correlated with depressive coping, and 'fate or destiny' attributions with religious coping (P<0.001). The highest scores were found for 'active coping' in the LoC clusters 'powerful others' and 'yeah-sayer'. External LoC and an active coping style prevail before undergoing autologous peripheral blood stem cell transplantation, whereas the depressive coping is less frequent, associated with self-blaming causal attributions. Health beliefs include causal and control attributions, which can improve or impair the patient's adjustment. A mixture between internal and external attributions seems to be most adaptive.

Photodynamic diagnosis (PDD) using 5-aminolevulinic acid-supplemented cultures of human endometrial epithelial cells

PURPOSE

The studies were aimed at monitoring 5-aminolevulinic acid (5-ALA)-dependent accumulation of endogenous protoporphyrin IX (PpIX) in epithelial cells originating from normal endometrium or endometriotic foci, as related to steroid treatment.

MATERIAL AND METHODS

Epithelial cells were cultured in presence of estradiol-17 beta (E2) and progesterone (P) in concentrations typical for the follicular stage (E2 alone, 220 pg/ml) or the luteal stage (E2 100 pg/ml and P 2 ng/ml) or in presence of progesterone alone (2 ng/ml) for a period of 24, 48 or 72 h. Effect of 5-ALA concentration on the accumulation of PpIX was defined in the cells incubated with 2.0 mmol/l 5-ALA for 2 h. PpIX fluorescence was detected using a confocal microscope.

RESULTS

After hormonal stimulation, intensity of PpIX-specific fluorescence was only slightly increased in epithelial cells originating from normal endometrium. Cultures of epithelial cells from endometriosis foci showed higher concentration of PpIX than did the cells originating from normal endometrium. The highest peak of PpIX fluorescence was noted in epithelial endometriotic cells after 48h incubation with progesterone.

CONCLUSIONS

The data on PpIX accumulation in epithelial cells in the presence of estradiol-17 beta or progesterone may provide indications as to the menstrual cycle phase(s) in which photodynamic therapy for endometriosis should be performed. It is concluded that hormonal condition of female body must be taken into account for diagnosis and treatment of endometriosis.

Concentration measurements of PCDD/F in air and spruce needles in the Bavarian Forest and Bohemian Forest (Sumava): first results

The aim of this project was to assess the concentration ranges of persistent organic pollutants (POPs) in air by means of active and passive sampling devices located in remote areas along the southern part of the German-Czech border. During the measuring program we also used spruce needles of different ages as biomonitors. The first results, which are restricted to PCDD/F measurements, indicate that the concentrations in both air and needles measured at four sites in the Bavarian Forest and Sumava crest region are lower than in many other regions of Bavaria and lower than during former measuring campaigns in adjacent regions of Austria and Bohemia. There is no apparent reason for the higher contamination by dioxins and furans in South Bohemia ecosystems, which are far from emission centers in central and northern Czech Republic. Other POPs will be investigated in the future.

Is perceived social support a predictor of survival for patients undergoing autologous peripheral blood stem cell transplantation?

PURPOSE

Previous research discussed the predictive value of psychosocial variables along with biomedical predictors for survival; such as affective functioning and quality of life. The present study addresses the following research question: does perceived social support prior to PSBCT have an impact on post-transplant survival?

SUBJECTS AND METHODS

Ninety-nine patients suffering from Multiple Myeloma (n=55), Non-Hodgkin Lymphoma (n=33), and other malignancies (n=11) completed the Illness Specific Scales of Social Support (ISSS) before undergoing PBSCT. ISSS is comprised of the subscales 'positive social support' and 'problematic social support', e.g. criticising, victimising, or avoiding interactions.

RESULTS

The mean score in the subscale 'positive social support' was 3.2 (S.D. 0.54; range 0 until 4), in the subscale 'negative social support' 0.94 (S.D. 0.53). There was no association between positive interactions and survival following PBSCT. Conversely, those patients perceiving problematic social support, showed a correspondence with poor survival following PBSCT (RR=3.649; p=0.015; Cox-regression analysis). The following variables were controlled: Karnofsky Performance Status, interferon treatment, depression and participation in psychotherapy.

CONCLUSION

Differentiating between positive and problematic interactions prior to PBSCT helps to recognise detrimental forms of social support. Future research should investigate the clinical implications and help tailor psychotherapeutic intervention.

Individual quality of life of patients undergoing autologous peripheral blood stem cell transplantation

BACKGROUND

Most quality-of-life (QoL) studies in autologous Peripheral Blood Stem Cell Transplantation (PBSCT) are descriptive and concentrate on symptom severity and functional deficits. The aim of this study is to compare individual QoL (iQoL) with health-related QoL (hrQoL) and functional status of patients before high-dosed therapy/PBSCT.

PATIENTS AND METHODS

Multiple Myeloma, non-Hodgkin's Lymphoma and other tumor patients were asked to complete the following measures before high-dosed therapy/PBSCT: the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-life Questionnaire Core 30 (QLQ-C30), and the Schedule for the Evaluation of Individual QoL-Direct Weighting (SEIQoL-DW), a patient-generated instrument which allows the patients to nominate the five most important domains (cues) for their present QoL. The SEIQoL-DW assessment generates: (1) a global QoL score (SEIQoL-INDEX), calculated as Sigma(levelsxweights); (2) the current overall QoL, rated on a visual analogue scale (VAS). Additional measures included demographic data, clinical disease status of remission and Karnofsky's index.

RESULTS

Seventy-nine patients completed both types of questionnaires. The QoL domains nominated by the patients were assigned to groups (aggregated cues), the most frequent of which were family (89%), hobbies/pastimes (74%), health (physical, including mobility) (70%), profession/occupation (51%), social life/friends (47%) and marriage/partnership (33%). There was no correlation between the SEIQoL-DW total scores and the EORTC QLQ-C30 scale or the Karnofsky index.

CONCLUSION

Individual QoL as assessed by the SEIQoL-DW is unrelated to standard health-status measures such as the EORTC QLQ-C30 or the Karnofsky index. Patient-perceived iQoL in PBSCT seems to depend largely on areas others than health and physical functioning, with the family playing a prominent role.

Chlamydia trachomatis infection in women with CIN and invasive uterine cervix cancer. Significance of hormonal status

In women with CIN at fertile age and those over 50 years of age, EGFR expression is lower in the presence of Chlamydia trachomatis (Cht) infection. In all Cht infected women over 50 years of age expression of Ki 67 is higher; the increase is significant among women with invasive carcinoma. In these groups of women with CIN and invasive carcinoma TGF-alpha expression is insignificantly augmented. Chronic Cht infection is associated with cervical hypertrophy.

Chlamydia trachomatis infection in cervical intraepithelial neoplasia and invasive carcinoma

We analyzed 149 women (81 with cervical intraepithelial neoplasia and with invasive carcinoma of the cervix and 68--as a control group). The influence of Chlamydia trachomatis (Cht) infection into expression of EGFR, TGF-alpha, Ki 67, HPV 16 and 18 was examined. IS-PCR was used to measure the level of antibodies in the serum. We detected that chlamydial infection may cause cervical hypertrophy in women with and without cervical intraepithelial neoplasia and invasive carcinoma. Infections of both Cht and HPV correlate with high expession of Ki 67 in epithelium. Cht infection also increased the expression of HPV16 in CIN I. These results suggest that Cht infection modifies the activity of viruses. In our research we have confimed that Cht infection increases the expression of EGFR and TGF-alpha. These facts may explain variants other than the HPV-mechanism of cervical carcinogenesis.

Detection of Chlamydia trachomatis infection in women with CIN and invasive carcinoma. Controversial results of different methods

Chlamydia (Ch.) trachomatis infection as a sexually transmitted disease is highly important, but reliable methods of diagnosing it remain to be worked out. We used three methods of detection: an immunoenzymatic technique for detection of Ch. trachomatis antigen in endocervical material, in situ PCR, and enzyme-immuno assay for detection of IgG class anti-Ch. trachomatis antibodies in serum. We have compared the IS-PCR technique and method of detection of the endocervical antigen. We have not confirmed compatibility of the results obtained in these two methods. Parallel positive results obtained in patient serum and detection of chlamydial DNA by IS-PCR have been accepted to be indicative of persistent infection of Ch. Trachomatis.

Expression of the anti-dorsalizing morphogenetic protein gene in the zebrafish embryo

The BMP3 related anti-dorsalizing morphogenetic protein (ADMP) has been proposed to function in the organizer of chick and Xenopus embryos. We report here the cloning and expression pattern of a zebrafish admp gene. The gene is expressed in involuting cells of the embryonic shield, but not in the non-involuting forerunner cells. During gastrulation, admp transcripts are detected in the posterior prechordal plate, in the notochord primordium and in cells of the dorsal blastoderm margin. Expression is also detectable in the neuroectoderm overlying the posterior prechordal plate. Expression persists in the tail bud until the end of somitogenesis while expression in other areas disappears during early somitogenesis stages.

Identification of nodal signaling targets by array analysis of induced complex probes

Nodal signaling controls germ layer formation, left-right asymmetry, and patterning of the brain in the vertebrate embryo. Cellular responses to Nodal signals are complex and include changes in gene expression, cell morphology, and migratory behavior. Only little is known about the genes regulated by Nodal signaling. We designed a subtractive screening strategy by using a constitutively active Nodal receptor to identify putative target genes of Nodal signals in the early gastrula of zebrafish embryos. By quantitative analysis of macro-array hybridizations, 132 genes corresponding to 1.4% of genes on the entire macro-array were identified, which were enriched in the Nodal-induced probe pool. These genes encode components of signal transduction pathways, transcription regulators, proteins involved in protein metabolism but also cytoskeletal components and metabolic enzymes, suggesting dramatic changes of cell physiology in gastrula cells in response to Nodal signals.