Reference change value of global longitudinal strain in clinical practice: A test-rest quality implementation project

BACKGROUND

Reference change value (RCV) is used to assess the significance of the difference between two measurements after accounting for pre-analytic, analytic, and within-subject variability. The objective of the current study was to define the RCV for global longitudinal strain (GLS) using different semi-automated software in standard clinical practice.

METHODS

Using a test-retest study design, we quantified the median coefficient of variation (CV) for GLS using AutoStrain and Automated Cardiac Motion Quantification (aCMQ) by Philips. Triplane left-ventricular ejection fraction (LVEF) was measured for comparison. Multivariable regression analysis was performed to determine factors influencing test-retest CV including image quality and the presence of segmental wall motion abnormalities (WMA). RCV was reported using a standard formula assuming two standard deviations for repeated measurements; results were also translated into Bayesian probability. Total measurement variation was described in terms of its three different components: pre-analytic (acquisition), analytic (measuring variation), and within-subject (biological) variation.

RESULT

Of the 44 individuals who were screened, 41 had adequate quality for strain quantification. The mean age of the cohort was 56.4 ± 16.8 years, 41% female, LVEF was 55.8 ± 9.8% and the median and interquartile range for LV GLS was -17.2 [-19.3 to -14.8]%. Autostrain was more time efficient (80% less analysis time) and had a lower total median CV than aCMQ (CV = 7.4% vs. 17.6%, p < .001). The total CV was higher in patients with WMA (6.4% vs. 13.2%, p = .035). In non-segmental disease, the CV translates to a RCV of 15% (corresponding to a probability of real change of 80%). Assuming a within-subject variability of 4.0%, the component analysis identified that inter-reader variability accounts for 3.7% of the CV, while acquisition variability accounts for 4.0%.

CONCLUSION

Using test-retest analysis and CVs, we find that an RCV of 15% for GLS represents an optimistic estimate in routine clinical practice. Based on our results, a higher RCV of 17%-21% is needed in order to provide a high probability of clinically meaningful change in GLS in all comers. The methodology presented here for determining measurement reproducibility and RCVs is easily translatable into clinical practice for any imaging parameter.

Risk factors for tail lesions in undocked fattening pigs reared on Swiss farms

INTRODUCTION

Tail lesions caused by tail biting are a major welfare and economic concern in fattening pigs. The aims of this study were to describe the prevalence and incidence of tail lesions in undocked pigs on individual animal level during the fattening period, to elucidate potential risk factors associated with tail lesions, and to describe the stockpersons' attitudes towards tail biting on Swiss farms. Thirty-eight farms were visited three times during the fattening period (beginning, mid-point, end). During each farm visit, tail lesions were scored on 30-126 individually marked pigs per farm (total: 2209 pigs), information on potential risk factors for tail lesions was recorded, and a standardized interview with the farmer was conducted to explore his/her opinion on tail biting. Potential risk factors were defined by indices when adequate, and their influence on the occurrence of tail lesions was analyzed using mixed effects logistic regression models. During the first and the second half of the fattening period, on average 14,1 and 15,4 pigs, respectively, out of 100 developed new tail lesions or aggravation of old lesions. The risk for new or aggravated tail lesions increased with higher scores for a «disease index» and with increasing group size, and it decreased with higher space allowances and with restrictive compared with ad libitum feeding. The prevalence of tail lesions on arrival was not associated with the incidence of tail lesions in the first and the second half of the fattening period, neither at farm level nor at pen level. In the interviews, farmers expressed their interest in getting professional advice on how to reduce tail biting on their farms. In conclusion, our study identified several risk factors for tail lesions in undocked fattening pigs indicating that the incidence of tail lesions could be reduced by improving animal health and housing conditions.

Terahertz-Driven Nonlinear Spin Response of Antiferromagnetic Nickel Oxide

Terahertz magnetic fields with amplitudes of up to 0.4 Tesla drive magnon resonances in nickel oxide while the induced dynamics is recorded by femtosecond magneto-optical probing. We observe distinct spin-mediated optical nonlinearities, including oscillations at the second harmonic of the 1 THz magnon mode. The latter originate from coherent dynamics of the longitudinal component of the antiferromagnetic order parameter, which are probed by magneto-optical effects of second order in the spin deflection. These observations allow us to dynamically disentangle electronic from lattice-related contributions to magnetic linear birefringence and dichroism-information so far only accessible by ultrafast THz spin control. The nonlinearities discussed here foreshadow physics that will become essential in future subcycle spin switching.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Pulse synthesis in the single-cycle regime from independent mode-locked lasers using attosecond-precision feedback

We report the synthesis of a nearly single-cycle (3.7 fs), ultrafast optical pulse train at 78 MHz from the coherent combination of a passively mode-locked Ti:sapphire laser (6 fs pulses) and a fiber supercontinuum (1-1.4 μm, with 8 fs pulses). The coherent combination is achieved via orthogonal, attosecond-precision synchronization of both pulse envelope timing and carrier envelope phase using balanced optical cross-correlation and balanced homodyne detection, respectively. The resulting pulse envelope, which is only 1.1 optical cycles in duration, is retrieved with two-dimensional spectral shearing interferometry (2DSI). To our knowledge, this work represents the first stable synthesis of few-cycle pulses from independent laser sources.

Ultrashort pulse characterization with a terahertz streak camera

A phase-locked terahertz transient is exploited as an ultrafast phase gate for femtosecond optical pulses. We directly map out the group delay dispersion of a low-power near-infrared pulse by measuring the electro-optically induced polarization rotation as a function of wavelength. Our experiment covers the spectral window from 1.0 to 1.4 μm and reaches a temporal precision better than 1 fs. A quantitative analysis of the detector response confirms that this streaking technique requires no reconstruction algorithm and is also well suited for the characterization of pulses spanning more than one optical octave.

Single-cycle multiterahertz transients with peak fields above 10 MV/cm

Phase-locked single-cycle transients with frequency components between 1 and 60THz and peak fields of up to 12MV/cm are generated as the idler wave of a parametric amplifier. To achieve broadband conversion in GaSe nonlinear crystals, we match the group velocities of signal and idler components. The influence of group-velocity dispersion is minimized by long-wavelength pumping at 1.18mum. Free-space electro-optic sampling monitors the multiterahertz waveforms with direct field resolution.

Spinal 2-chloroprocaine: effective dose for ambulatory surgery

BACKGROUND

There is an interest in finding a safe, short-acting spinal anaesthetic, suitable for ambulatory surgery. In this prospective study, we evaluated the effective dose of plain 2-chloroprocaine (2-CP) for lower limb surgery, including knee arthroscopy and saphenectomy.

METHODS

Sixty-four ASA physical status I-III patients undergoing elective lower limb surgery were randomly allocated to one of the four local anaesthetic groups for spinal anaesthesia in a double-blind manner. The patients (n=16 patients in each group) received 35, 40, 45 or 50 mg of 10 mg/ml isobaric 2-CP.

RESULTS

In all patients, anaesthesia was sufficient for the planned surgery. The median peak block height (T9) was similar in all four groups (P=0.66). Time to complete sensory block regression was faster in the 35 mg group (111 min, mean) and in the 40 mg group (108 min) than in the 50 mg group (134 min, P=0.005). No differences in time to complete motor block regression were observed (P=0.3). Home discharge time was faster in the 35 mg group (123 min) and in the 40 mg group (122 min) than in the 50 mg group (165 min, P=0.001). No complications related to spinal anaesthesia were observed and no transient neurologic symptoms (TNS) were reported at the 3-day follow-up.

CONCLUSION

Spinal 2-CP, 10 mg/ml 35, 40, 45 and 50 mg provide reliable sensory and motor block for ambulatory surgery, while reducing the dose of 2-CP to 35 and 40 mg resulted in a spinal block of faster ambulation.

Isobaric bupivacaine via spinal catheter for hip replacement surgery: ED50 and ED95 dose determination

BACKGROUND

Continuous spinal anaesthesia with spinal catheters allows incremental dosing of the local anaesthetic and, consequently, less haemodynamic change. However, little is known about the required doses. Therefore, we designed a study to assess the local anaesthetic doses of isobaric bupivacaine which were effective in 50% (ED50) and 95% (ED95) of patients undergoing hip replacement surgery.

METHODS

Forty-eight patients undergoing hip replacement surgery were randomly allocated to one of six possible groups of eight patients to receive 6, 7, 8, 9, 10 or 12 mg of isobaric bupivacaine in a double-blind manner. The ED50 and ED95 values were calculated by a logistic regression model. The position of the spinal catheter tip was confirmed by X-rays.

RESULTS

The ED50 and ED95 values were 7.1 mg (95% confidence interval, 6.0-8.4) and 12.3 mg (95% confidence interval, 8.9-15.7), respectively. The location of the tip of the intrathecal catheter had no effect on local anaesthetic requirements. Eight patients required ephedrine after anaesthesia induction and a further 11 patients required ephedrine for correction of hypotension during surgery.

CONCLUSION

The observed ED50 and ED95 values may guide us to use small doses of isobaric bupivacaine for hip replacement surgery. Hypotension is still possible even if low doses of isobaric bupivacaine are used.

Minimum effective local anaesthetic dose of isobaric levobupivacaine and ropivacaine administered via a spinal catheter for hip replacement surgery

BACKGROUND

Continuous spinal anaesthesia with spinal catheters allows incremental dosing of local anaesthetic and, consequently, less haemodynamic changes. However, little is known about the required doses. Therefore, we designed a study to assess the minimum effective local anaesthetic dose (MLAD) of levobupivacaine and ropivacaine in this context.

METHODS

Forty-one patients undergoing hip replacement surgery were randomly allocated to one of the two local anaesthetic groups in a double-blind manner. The initial dose of local anaesthetic was determined by the response of the previous patient: the effective dose resulted in a 1 mg decrease in the dose of levobupivacaine or ropivacaine, and an ineffective dose resulted in a 1 mg increase. The MLAD was calculated by the Dixon up-and-down method.

RESULTS

The MLAD of levobupivacaine was 11.7 mg (95% CI, 11.1-12.4) and that of ropivacaine 12.8 mg (95% CI, 12.2-13.4).

CONCLUSIONS

These doses are significantly smaller than doses reported before for single-shot spinal anaesthesia. Continuous spinal anaesthesia allows the use of relatively small doses of local anaesthetic.

[The development of radiotherapy in Denmark through 100 years. From radiology to oncology]

A short review is given of the development of radiotherapy from its early beginning in 1896 to the establishment of the first three radium centres in 1913/14 which caused strong protest from the surgeons. The Radium Foundation was established on private initiative and was, via money collections, able to finance purchase of radium and in the 1930s erection of new buildings for the three centres. Radiotherapy became a basic specialty from 1950. In the beginning of the 1960s megavoltage therapy was introduced and at the same time chemotherapy was becoming interesting for therapy of solid tumours. This caused a centralisation of the patients to the centres for non-surgical therapy resulting in need for building of two centres (Aalborg and Herlev), and a gradual closing down of the decentral treatment with low voltage equipment in the counties. After 1970 the counties became responsible for the health care including running of the hospitals. This caused a return of some of the patients to decentral treatment facilities, usually the biggest hospital in the county and predominantly for adjuvant or palliative chemotherapy. The speciality has changed name to oncology in 1987.

Hypoxic upregulation of tyrosine hydroxylase gene expression is paralleled, but not induced, by increased generation of reactive oxygen species in PC12 cells

Oxygen sensing was investigated in rat pheochromocytoma PC12 cells. They respond to hypoxia with an increased intracellular generation of reactive oxygen species (ROS), measured by oxidation of dihydrorhodamine 123. This increase is abolished by intracellular superoxide scavenging by Mn(III)-tetrakis(1-methyl-4-pyridyl)-porphyrin, and reduced or absent in the presence of the flavoprotein/complex I inhibitors, diphenyl-eneiodonium and rotenone. The same inhibitors, but neither intra- nor extracellular (superoxide dismutase) superoxide scavenging, abolish the hypoxia-induced increase in tyrosine hydroxylase (TH) gene expression. Thus, ROS production increases in PC12 cells during hypoxia, but this is not the cause of hypoxic TH mRNA upregulation that involves a flavoprotein.

Selectively enhanced cellular signaling by Gi proteins in essential hypertension. G alpha i2, G alpha i3, G beta 1, and G beta 2 are not mutated

Recent studies have shown an enhanced signaling capacity of receptors coupled to pertussis toxin (PTX)-sensitive guanine nucleotide-binding proteins (G proteins) in immortalized B lymphoblasts from patients with essential hypertension. In the present study, we analyzed (1) whether such alterations would also be expressed in nontransformed cells of these individuals and (2) whether other G protein-mediated signaling pathways were also altered. Therefore, we established primary cultures of skin fibroblasts from previously characterized normotensive and hypertensive individuals (NT and HT cells, respectively). [Ca2+]i rises induced by lyso-phosphatidic acid (LPA), thrombin, and sphingosine-1-phosphate as well as the formation of inositol 1,4,5-trisphosphate and [3H]thymidine incorporation evoked by LPA were PTX sensitive and enhanced twofold in HT fibroblasts. In contrast, cellular responses induced by bradykinin, endothelin-1, and angiotensin II (all PTX insensitive) were similar in NT and HT cells. Formation of cAMP induced by stimulation of Gs with isoproterenol was identical in NT and HT cells. Western blot analysis yielded no evidence for an overexpression of G alpha i2, G alpha i3, G beta 2, and G beta 4. Furthermore, sequencing of cDNAs encoding for the ubiquitously expressed PTX-sensitive G protein subunits G alpha i2, G alpha i3, G beta 1, and G beta 2 from NT and HT cell lines yielded no evidence for mutations in these genes. Although the molecular mechanisms remain to be defined, these data support the concept of a selective enhancement of signal transduction via PTX-sensitive G proteins in essential hypertension.

The development of radiotherapy in Denmark during 100 years. From radiology to oncology

The evolution of radiotherapy in Denmark is traced from its early inception in 1896 to the first three radium centres in 1913-1914, the establishment of which caused a roar of protests among the surgeons of that time. Private initiative pioneered the Radium Foundation which raised money for radium and financed erection of new buildings for the three centres in the 1930's. Radiotherapy became a separate speciality in 1950. The early 1960s saw the introduction of megavoltage therapy and the first promising results from chemotherapeutic management of solid tumors. The consequent referral of patients to centres for non-surgical therapy created a need for two new centres (Aalborg and Herlev) and called for a gradual closing down of decentralized low-voltage treatment at county level. However, the decentralization of health care in 1970 partly reversed this trend and some patients were therefore referred for decentralized treatment at major county hospitals. Such treatment mainly consisted of adjuvant or palliative chemotherapy, though in a few countries palliative therapy was supported by low-voltage therapy. In 1987 the medical speciality of radiotherapy was officially renamed oncology.

Deletion analysis of the m4 muscarinic acetylcholine receptor. Molecular determinants for activation of but not coupling to the Gi guanine-nucleotide-binding regulatory protein regulate receptor internalization

In order to investigate whether coupling to and/or activation of guanine-nucleotide-binding proteins (G proteins) is involved in agonist-induced internalization of m4 muscarinic acetylcholine receptors (mAChRs), a deletion mutant [des-(264-394)mAChR] was constructed that lacks a substantial portion of the putative third intracellular loop. The wild-type receptor and des-(264-394)mAChR stably expressed in Chinese hamster ovary cells in essentially comparable amounts, exhibited identical antagonist-binding affinities. Consistent with the reported importance of the third cytoplasmic loop for Gi protein activation, the des-(264-394)mAChR showed a drastically reduced potential to mediate agonist-induced inhibition of adenylyl cyclase. In contrast, the ability of the mutant receptor to couple to Gi proteins was not impaired, as demonstrated by a similar guanine-nucleotide-sensitive and pertussis-toxin-sensitive high-affinity agonist-receptor binding for both mAChRs. In contrast, des-(264-394)mAChR was hardly able to stimulate the GTPase activity of G proteins, suggesting impaired activation of Gi proteins rather than ineffective coupling to Gi proteins. Internalization of wild-type receptor and des-(264-394)mAChR was observed with similar agonist concentrations and showed similar maximal values. However, des-(264-394)mAChR displayed a significantly reduced rate of receptor internalization. A similar attenuation of wild-type mAChR internalization was obtained upon pertussis toxin treatment. In conclusion, our data provide evidence that the molecular determinants of the m4 mAChR involved in Gi-protein coupling and activation are not identical and that activation of, but not coupling to, Gi proteins regulates m4 mAChR internalization.

A randomized feasibility study evaluating the effect of radiotherapy alone or combined with 5-fluorouracil in the treatment of locally recurrent or inoperable colorectal carcinoma

The effect of radiotherapy alone or given simultaneously with 5-FU in the treatment of locally recurrent or inoperable colorectal carcinoma was investigated in a randomized feasibility trial. Twenty-nine patients were randomized to radiotherapy alone (50 Gy/5 weeks + 10-20 Gy boost), and 30 patients to the same radiotherapy with weekly 5-FU (600 mg/m2) given before treatment every Monday during the first 5 weeks. The two groups were comparable with regard to age, sex, previous treatment, symptoms, tumour size and performance status. Treatment compliance to radiotherapy was the same in both groups with 87% receiving at least 50 Gy. Drug treatment was completed in 18/30 patients. Overall the treatment resulted in a significant palliative effect in 73% of evaluable patients with a median duration of 26 months, and objective response in 32% (8 CR, 11 PR), with a median duration of 18 months. The 3-year actuarial survival rate was 9% (median 12 months). Only patients who achieved CR became long-time survivors (63% 3-year actuarial survival). Similarly, performance status had a strong association with survival. Multivariate analysis showed complete response and high performance status to be the only parameters having prognostic influence on survival. Addition of 5-FU did neither influence the objective or symptomatic response, nor the development of distant metastases. However, addition of the drug resulted in an apparent increase in the frequency of severe acute radiation complications (33% vs. 13% after irradiation alone).

Time to loco-regional recurrence after resection of Dukes' B and C colorectal cancer with or without adjuvant postoperative radiotherapy. A multivariate regression analysis

Factors influencing time to loco-regional recurrence were identified in a multivariate regression analysis of data from a series of 468 radically operated patients (260 Dukes' B and 208 Dukes' C) with carcinoma of the rectum and the rectosigmoid. A number of clinical and pathological characteristics were prospectively collected and recorded. In addition, carcinoembryonic antigen (CEA) was measured within 1 week before surgery. The endpoint used was recurrence below the level of the umbilicus. All patients were followed for at least 5 years or until time of death. The two Dukes' stages B and C were analysed in two separate analyses using the Cox proportional hazards model. In patients with Dukes' B tumours, an increased risk of loco-regional recurrence was associated with perineural invasion, tumour located less than 10 cm from the anal verge, patient aged above 70 years, and small tumour size. In patients with Dukes' C tumours, the necessity to resect neighbour organs, perineural and venous invasion, tumour located less than 10 cm from the anal verge, and large tumour size were all associated with a poor loco-regional outcome. Postoperative radiotherapy was not a significant prognosticator for loco-regional control. An update of the 5-year results of the randomised study of post-operative radiotherapy (50 Gy with 2 Gy per fraction in an overall treatment time of 7 weeks) showed no survival benefit from adjuvant radiotherapy in either Dukes' category and no statistically significant improvement in the 5-year loco-regional control rate. However, when the comparison was restricted to a group of high-risk patients there was a statistically significant benefit from radiotherapy with respect to loco-regional control (P = 0.03) but not with respect to survival (P = 0.23). The potential advantage, in terms of the required number of patients, of restricting clinical trials of intensified loco-regional therapies to the high-risk patients, is illustrated.

Randomized study of whole-abdomen irradiation versus pelvic irradiation plus cyclophosphamide in treatment of early ovarian cancer

From 1 September 1981 to 1 January 1987, 118 patients with FIGO Stage IB, IC, IIA, IIB, and IIC epithelial ovarian cancer were randomized to abdominal irradiation or pelvic irradiation + cyclophosphamide. There was no difference between the regimens with respect to recurrence-free survival (55%) and 4-year overall survival (63%). At routine second-look laparotomy, 16% of patients without clinical detectable tumor showed recurrence. Twenty-five percent of the patients treated with pelvic irradiation + cyclophosphamide had hemorrhagic cystitis, probably caused by radiation damage and cyclophosphamide cystitis. Eight percent had late gastrointestinal symptoms requiring surgery.

Blood transfusion and prognosis in Dukes' B and C colorectal cancer

To evaluate the prognostic influence of blood transfusion in cancer patients, transfusion data were reviewed on 468 radically operated patients (260 Dukes' B and 208 Dukes' C) with carcinoma of the rectum and the rectosigmoid. Data on whole blood and packed red blood cell transfusions were recorded together with a number of clinical, pathological and histochemical characteristics. The endpoint used was death with cancer. All patients were followed for 2-7 years or until time of death. Univariate statistical methods revealed a highly significant trend towards worsened prognosis with increasing volume of transfusion blood. However, this effect was insignificant when multivariate statistical methods were employed: patients receiving whole blood or packed red blood cell transfusions did no worse than expected from their clinico-pathological characteristics. It is concluded that in this series the observed association between transfusion status and prognosis is adequately explained by a multivariate prognostic model including well-established prognostic factors.

[Prognosis in synchronous liver metastasis from colorectal cancer. A multicenter study of patients with cancer of the rectum and cancer of the rectosigmoid colon]

A prospective investigation of 188 patients with cancer of the rectum and rectosigmoid colon with synchronous liver metastases is described. The mean survival time for 183 patients who did not receive any treatment for the liver metastases was six months and only one survived for longer than 37 months. After extirpation of the primary tumour, the most significant prognostic factors were etrahepatic metastases, enlarged liver on account of metastases and more than three liver metastases. Serum basic phosphatases had the greatest significance among a series of laboratory tests. In the sub-groups with the best possible prognoses, the mean survival time was 12 months. 25% five-year survival has been described in the literature following resection of the liver in patients with a maximum of three metastases, no other metastases and age under 70 years. Provided this holds true, liver surgery will be a therapeutic possibility in at least 100 patients per annum in Denmark with synchronous liver metastases and 25 of these will be cured. This figure requires an improved programme for the diagnosis of synchronous liver metastases than at present and the same high frequency of extirpation of the primary colorectal cancer on a national basis which was achieved in the present material.

Preoperative measurement of cancer antigen 125 (CA 125) in the differential diagnosis of ovarian tumors

The purpose of the present study was to evaluate the information preoperative measurements of cancer antigen 125 (CA 125) may give concerning the nature of an ovarian tumor. Serum samples from 61 patients were analyzed and the results compared with regard to malignancy, FIGO-stage, and histologic type of the tumor. All patients were deemed to have a malignant tumor by clinical examination. Elevated serum levels (greater than 35 U/ml) were found in 44 patients and of these patients 38 had carcinomas, 5 had borderline tumors, and one had a benign tumor (false positive). Normal serum levels (less than or equal to 35 U/ml) were registered in 17 patients. Fourteen of these had benign tumors and 3 had malignant (false negative). The false positive sample and the 3 false negative samples observed in the present study result in a positive and negative predictive value of the CA 125 analysis of 98% (43/44) and 82% (14/17) respectively. The positive predictive value of the clinical examination was 75% (46/61). It is concluded that measurement of CA 125 is a valuable adjunct to the preoperative examination of patients with ovarian tumors.

Measurement of the ovarian cancer-associated antigen CA 125 prior to second look operation

CA 125 was measured in serum samples from 81 patients with a diagnosis of epithelial ovarian cancer. The samples were drawn prior to second look laparotomy performed in patients with complete or partial clinical remission after finishing cytostatic or radiation treatment. The positive and negative predictive value of the CA 125 measurements was 100% and 64%, respectively; the sensitivity and specificity were found to be 44% and 100%, respectively. At the second look operation no evidence of disease was observed in 40 patients, microscopic tumor was found in 10, and macroscopic tumor in 31 patients. All 81 patients had a gynecologic examination under anesthesia prior to the second look operation. Measurement of CA 125 was found superior to this examination with respect to positive and negative predictive value as well as to sensitivity and specificity. It is concluded that CA 125 values above 35 U/ml without exception announced residual tumor. Therefore, in cases with elevated CA 125 values, gynecologic examination under anesthesia or explorative laparotomy gave no further information concerning the result of treatment. CA 125 levels below 35 U/ml were without predictive value owing to a high number of false negative results.

A regression analysis of prognostic factors after resection of Dukes' B and C carcinoma of the rectum and rectosigmoid. Does post-operative radiotherapy change the prognosis?

The prognostic value of several clinical and histopathological characteristics has been evaluated in patients with Dukes' B and C carcinoma of the rectum and the rectosigmoid. Data on 260 Dukes' B and 208 Dukes' C tumours entered into a prospective, randomized clinical trial of post-operative radiotherapy (50 Gy given with 2 Gy/fraction in an overall time of 7 weeks) were analyzed by means of the Cox proportional hazards model. The Dukes' stages B and C were analyzed in two separate multivariate analyses. In patients with Dukes' B tumours, a poor prognosis was associated with age above 60, perineural and venous invasion, tumour located less than 10 cm from the anal verge and elevated pre-operative carcinoembryonic antigen (CEA) (greater than 3.2 ng ml-1). In patients with Dukes' C tumours, perineural and venous invasion, tumour located less than 10 cm from the anal verge, and elevated pre-operative CEA were associated with a poor prognosis. In addition, a large tumour diameter had a strong, negative influence on the prognosis. Males seemed to have a poorer prognosis than females among the Dukes' C patients. Resection of neighbouring organs was also associated with a poor prognosis in this stage. Post-operative radiotherapy as administered in the present series had no significant influence on prognosis. Based on the derived prognostic models patients with a hazard of death above the median in each stage were selected. A separate analysis of the survival in these high risk patients showed no survival benefit from radiotherapy. The proportional hazards model may be a useful tool in selecting patients for more aggressive adjuvant treatment.

Cyclic hormonal treatment in ovarian cancer. A phase-II trial

Twenty-nine patients with advanced epithelial ovarian cancer were included in a phase-II trial of cyclic hormonal treatment. The schedule consisted of tamoxifen 10 mg X 3 daily for 14 days followed by medroxyprogesterone acetate 400 mg X 2 daily for 14 days. No objective response was recorded in 17 evaluable patients and cyclic hormonal treatment appears to be ineffective in advanced ovarian cancer.

Orgotein in radiation treatment of bladder cancer. A report on allergic reactions and lack of radioprotective effect

The possible protective effect of orgotein (a superoxide dismutase) on radiation cystitis and proctitis was studied in patients with carcinoma of the urinary bladder. A double-blind study in 60 patients was planned but due to unacceptable side effects only 30 patients were included. Radiation treatment was given with curative intent at a dose of 63 Gy in 30 fractions. Orgotein was injected 15 min after each daily radiation treatment at a dose of 4 or 8 mg. No effect of orgotein on tumour radiation response or on the acute radiation reactions in the bladder and rectum was detected. Marked subcutaneous infiltration and redness was seen at the local injection site in 5 patients. No general symptoms were observed. Intradermal tests and antibody titration tests showed that the local reactions were due to allergic reactions to the drug itself. The lack of radioprotective effect and the high frequency of unacceptable side effects makes orgotein an unsuitable drug in clinical radiation therapy.

Major or local surgery for cure in early rectal and sigmoid carcinoma--a prospective evaluation

The results of different types of treatment for early cancer in 158 out of 1,300 patients with rectal and sigmoid cancer were evaluated in a prospective study from 1979 to 1984. Radical surgery was performed in 121 patients (mean age 66 years) with cancer Dukes' A (median diameter 3 cm), while 37 patients (mean age 71) with smaller cancers (median 2 cm) had polypectomy or local excision. Post-operative complications were significantly more frequent in the first group. No patients in any of the two groups with carcinoma in pedunculated adenomas or within the upper half of the submucosa or above 9 cm from the anal verge had recurrent cancer. CEA-measurements had no prognostic value. No difference was found in crude or cancer-related death between the two groups. The overall results support the use of local treatment in elderly patients with complicating disease, having small cancers, not penetrating the tunica muscularis externa of the rectosigmoid wall.

Postoperative radiotherapy in Dukes' B and C carcinoma of the rectum and rectosigmoid. A randomized multicenter study

Results obtained during the first 5 years of a randomized study of postoperative radiotherapy (50 Gy) are presented. Criteria for randomization were fulfilled in 494 of 861 patients with Dukes' B and C tumors, when the trial was closed. Severe complications from radiotherapy approximated 10%. Probability of survival without local failure within 24 months was significantly higher after radiotherapy in patients with Dukes' C tumors, and the time of local failure was delayed 1 year. Patients with Dukes' B tumors had no benefit from radiotherapy. Risks of distant metastases and death were not influenced by radiotherapy in the main groups. Plasma-CEA measurements were evaluated blindly, and radiotherapy changed the critical levels of CEA for detection of recurrent cancer. It was concluded that patients with Dukes' C tumors may benefit from radiotherapy and plasma-CEA levels are influenced by radiotherapy, which may be important, when these are used in screening for recurrent cancer.

Postoperative radiotherapy in Dukes' B and C carcinoma of the rectum and rectosigmoid. A randomized multicenter study

Results obtained during the first 5 years of a randomized study of postoperative radiotherapy (50 Gy) are presented. Criteria for randomization were fulfilled in 494 of 861 patients with Dukes' B and C tumors, when the trial was closed. Severe complications from radiotherapy approximated 10%. Probability of survival without local failure within 24 months was significantly higher after radiotherapy in patients with Dukes' C tumors, and the time of local failure was delayed 1 year. Patients with Dukes' B tumors had no benefit from radiotherapy. Risks of distant metastases and death were not influenced by radiotherapy in the main groups. Plasma-CEA measurements were evaluated blindly, and radiotherapy changed the critical levels of CEA for detection of recurrent cancer. It was concluded that patients with Dukes' C tumors may benefit from radiotherapy and plasma-CEA levels are influenced by radiotherapy, which may be important, when these are used in screening for recurrent cancer.

Carcinoma of the prostate limited to the pelvis. Treatment with curative radiation therapy

A retrospective analysis of external radiation therapy of 43 patients with carcinoma of the prostate limited to the pelvis is presented. The tumours were classified according to the UICC TNM system and in the range T2-4, Nx, 0-2, M0; 86 per cent had extracapsular disease. The 5-year crude survival rate was 52 per cent, the corrected survival 62 per cent compared with an expected survival of 81 per cent. Eight patients (18%) had clinical recurrence, all with distant metastases in bones and one with local recurrence as well. After 6 months mild side effects were found in 10 patients (23%), severe complications in none. In conclusion, external radiation therapy offers the possibility of partial or complete regression of carcinoma of the prostate limited to the pelvis and apparently improves the 5-year survival. If radical prostatectomy and lymphadenectomy is not used or impossible, external radiation therapy is recommended instead of hormone therapy with oestrogens.

Small cell anaplastic carcinoma of the lung. The Aarhus experience 1976-1981

Over a 6-year period 179 patients with small cell carcinoma of the lung (SCLC), 152 with limited disease, 25 with extensive disease, and 2 who were not staged, were treated with chest irradiation and combination chemotherapy with CCNU, adriamycin and vinblastine. For all patients the 2-year survival was 19.9 +/- 3 per cent, and the 5-year survival 11.9 +/- 3 per cent. No patients with extensive disease survived for 5 years. This type of treatment has curative potential for SCLC limited disease, which calls for further trials based on this approach.

Impact of CT-based treatment planning on radiation therapy of carcinoma of the bladder

Computed tomography (CT) has been an integrated step in the treatment planning of radiation therapy of carcinoma of the bladder in stages T1-T3 in 49 consecutive patients referred to Radiumstationen in Aarhus. The introduction of this technique has led to a considerable increase (26 +/- 4%) in the mean effective target volume of these patients compared with that of 51 conventionally simulated patients. The largest field expansions have been performed in the cranial and ventral directions. The field margins to the bladder have been correlated with the position of the tumour mass. The findings are compared with previously published results on CT-based treatment planning of patients with bladder carcinoma.

Radiumstationen in Aarhus from 1962 to 1984

An overview is given of the development at Radiumstationen in Aarhus from 1962 to 1984. Within the field of radiation therapy the period has been characterized by the transition to megavoltage units, an extended use of dosimetry and dose planning, the clinical application of radiobiologic principles and the recent introduction of CT scanning for dose planning. The past ten years have seen a growing importance of chemotherapy and an intensified collaboration with the specialized branches of surgery, which among other things has brought about a change in the structure of the Department; a change towards sub-specialization according to the site of the organs treated. The period has also been characterized by an increasing number of patients with cancer and a very intensive utilization of wards and equipment, as well as by a busily engaged staff . The present function of the Department is that of Department of Oncology at one of the 5 Danish oncologic centres serving its specific region.

Dose-response relationship for radiation therapy of recurrent, residual, and primarily inoperable colorectal cancer

One hundred and thirteen patients with advanced locoregional recurrent (77), residual (18) or primarily inoperable (18) colorectal carcinoma were treated with radiotherapy. Eighty-five patients had locoregional disease only and 28 had both local disease and distant metastases. The treatment was given with varying dose levels (23-73 Gy) in daily fractions of approximately 2 Gy in 3-8 weeks. This dose variation allowed an evaluation of the dose-response relationship for radiation treatment of this tumour. A good subjective response was obtained in 63%. This effect showed no dose-response relationship except for doses greater than or equal to 56 Gy, where all patients received relief of symptoms. Eighty-two per cent of evaluable patients achieved an objective response (PR 53%, CR 29%). The frequency and duration of the complete responses showed a marked dose-response relationship. Thus, at doses greater than or equal to 56 Gy, a 2-year actuarial complete response rate of 40% was found compared with 7, 4 and 0% at doses of 46-55 Gy, 36-45 Gy and less than or equal to 35 Gy, respectively. The dose-response relationship for local control also influenced the survival rate, although a number of patients died from distant metastases even when local control was obtained. However, with regard to locoregional disease, the 2-year survival was 53% for patients with complete tumour regression but only 8% for patients without complete tumour regression.

A case-control study of female bladder cancer

A case-control study was performed on 47 female bladder cancer patients and 94 female controls matched in age and geographic area. Twenty-five determinants of assumed importance were examined. The bivariate associations revealed a significantly increased relative risk (RR) for bladder cancer associated with use of tobacco, cheroot smoking and saccharin consumption, and some subgroups like never-smokers in combination with use of saccharin. The population attributable risk percentages were estimated. Through a multivariate logistic analysis of selected determinants cheroot consumption was the most pronounced independent variable.

Prostatic hypertrophy and venereal disease as possible risk factors in the development of bladder cancer

In three urological predictors, nocturia, prostatic surgery for prostatic hypertrophy and a previous venereal disease, a significantly increased relative risk (RR) of developing bladder cancer was detected. An epidemiological case control investigation was performed on 165 male bladder cancer patients and an equal number of male controls matched concerning age and geographical area. The sample was obtained from a predominantly rural district. The theoretical individual risk factors were calculated by the aid of a multivariate logistic analysis. Twenty-four patients versus 11 controls had a history of prostatic surgery (RR = 2.38) for benign prostatic hypertrophy, 60 patients versus 36 controls complained of nocturia at least 2 years before presenting symptoms of bladder cancer (RR = 2.05), and 16 patients versus seven controls had a history of venereal disease (RR = 2.42). The results seems to indicate that prostatic hypertrophy and previous venereal disease may at least in part be factors of importance associated with bladder cancer.

Presenting symptoms, treatment delay and survival in bladder cancer

In 212 consecutive patients with bladder tumour, relationships between symptoms, demographic factors, delay before treatment and survival rate were investigated. The presenting symptom was haematuria in 79% of the patients. The interval from onset of symptoms until treatment averaged 28 weeks (median = 15 weeks). The general practitioner delay comprised half of the total delay. Patients with cystitis as the presenting symptom and women with haematuria had the longest doctor delay. The length of delay did not influence the crude survival rate in patients with tumours in the two highest TNM stages. In T1 and T2 tumours, shorter delay tended to give a better survival rate.

An epidemiological study of bladder cancer in a predominantly rural district

A case-control study was performed on 212 bladder cancer patients (165 male + 47 female) and 259 control persons (165 male + 94 female) matched according to age and geographic area. Twenty-five determinants of assumed importance were examined. Bivariate analysis revealed a significantly increased relative risk (RR) of developing bladder cancer associated with cigarette smoking, cigarillos smoking, pipe smoking, tobacco chewing, industrial work, previous venereal disease, work with petroleum or asphalt, consumption of alcohol, work with oil or gasoline, and work with chemical materials. A multivariate logistic analysis showed that cigarette and cigarillos smoking involved the highest significant risks. An analogous logistic analysis of the negatively associated determinants revealed never smokers and farmers to be the weakest independent variables.

An epidemiological case-control study of bladder cancer in males from a predominantly rural district

A case-control study was performed on 165 male bladder cancer patients and an equal number of male control persons matched in age and geographic area. Thirty determinants of assumed importance were examined. A multivariate logistic analysis was performed. A significant increment in the relative risk (RR) for bladder cancer was associated with cigarette smoking (RR = 1.89), a history of prostatic surgery (RR = 2.38), nocturia (RR = 2.05), previous venereal disease (RR = 2.42), industrial work (RR = 1.82), work with oil or gasoline (RR = 2.71) and work with various unspecified chemical materials (RR = 1.58).