Impact of fetal growth restriction on pregnancy outcome in women undergoing expectant management for preterm pre-eclampsia

OBJECTIVES

To assess whether coexisting fetal growth restriction (FGR) influences pregnancy latency among women with preterm pre-eclampsia undergoing expectant management. Secondary outcomes assessed were indication for delivery, mode of delivery and rate of serious adverse maternal and perinatal outcomes.

METHODS

We conducted a secondary analysis of the Pre-eclampsia Intervention (PIE) and the Pre-eclampsia Intervention 2 (PI2) trial data. These randomized controlled trials evaluated whether esomeprazole and metformin could prolong gestation of women diagnosed with pre-eclampsia between 26 and 32 weeks of gestation undergoing expectant management. Delivery indications were deteriorating maternal or fetal status, or reaching 34 weeks' gestation. FGR (defined by Delphi consensus) at the time of pre-eclampsia diagnosis was examined as a predictor of outcome. Only placebo data from PI2 were included, as the trial showed that metformin use was associated with prolonged gestation. All outcome data were collected prospectively from diagnosis of pre-eclampsia to 6 weeks after the expected due date.

RESULTS

Of the 202 women included, 92 (45.5%) had FGR at the time of pre-eclampsia diagnosis. Median pregnancy latency was 6.8 days in the FGR group and 15.3 days in the control group (difference 8.5 days; adjusted 0.49-fold change (95% CI, 0.33-0.74); P < 0.001). FGR pregnancies were less likely to reach 34 weeks' gestation (12.0% vs 30.9%; adjusted relative risk (aRR), 0.44 (95% CI, 0.23-0.83)) and more likely to be delivered for suspected fetal compromise (64.1% vs 36.4%; aRR, 1.84 (95% CI, 1.36-2.47)). More women with FGR underwent a prelabor emergency Cesarean section (66.3% vs 43.6%; aRR, 1.56 (95% CI, 1.20-2.03)) and were less likely to have a successful induction of labor (4.3% vs 14.5%; aRR, 0.32 (95% CI, 0.10-1.00)), compared to those without FGR. The rate of maternal complications did not differ significantly between the two groups. FGR was associated with a higher rate of infant death (14.1% vs 4.5%; aRR, 3.26 (95% CI, 1.08-9.81)) and need for intubation and mechanical ventilation (15.2% vs 5.5%; aRR, 2.97 (95% CI, 1.11-7.90)).

CONCLUSION

FGR is commonly present in women with early preterm pre-eclampsia and outcome is poorer. FGR is associated with shorter pregnancy latency, more emergency Cesarean deliveries, fewer successful inductions and increased rates of neonatal morbidity and mortality. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Health literacy and e-health literacy among Arabic speaking migrants in Sweden

Background

Health inequities arise when the public cannot access and understand health information in an easy, accessible, and understandable way, which may be partly due to limited health literacy (HL). Migrants may have limited HL. A subgroup that may have limited HL is migrants. This study explored comprehensive health literacy (CHL) and electronic health literacy (eHL) among Arabic-speaking migrants in Sweden.

Methods

A cross-sectional observational study conducted in Sweden year 2019. Data was collected among Swedish and Arabic speakers through the Health Literacy Survey European Questionnaire (HLS-EU-Q16), the eHealth Literacy Scale (eHEALS), and questions about self-perceived health and Internet use. Arabic speakers CHL and eHL was compared with native Swedish speakers. Various statistical analyses were performed to determine the associations and predictors for limited CHL and eHL.

Results

A total of 681 respondents were included in the analysis. CHL and eHL differed between the native Arabic-speaking migrants and the native Swedish speakers. The Arabic speaking migrants had significantly lower CHL and eHL mean sum scores. Predictors for limited CHL and eHL were being Arabic speaking, less Internet use, and not finding the Internet to be important or useful. Time spent in Sweden was associated with higher levels of both CHL and eHL.

Conclusions

CHL and eHL differ between Arabic-speaking migrants and native Swedish speakers, but difference in eHL was smaller than difference in CHL and there was a difference in both CHL and eHL related to time spent in Sweden. Internet can therefore be seen as an appropriate channel for disseminating health information to Arabic-speaking migrants in Sweden.

Key messages

Internet can be considered an appropriate channel to distribute health information to Arabic-speaking migrants in Sweden. Time spent in Sweden is associated with higher eHL and CHL levels among Arabic-Speaking migrants.

Accuracy of the combination of commercially available biomarkers and cervical length measurement to predict preterm birth in symptomatic women: A systematic review

An accurate prognostic method for preterm birth (PTB) could avoid unnecessary treatment(s) with potentially negative effects. The objective was to explore the prognostic accuracy of commercially available bedside cervicovaginal biomarker tests in combination with cervical length (CL) compared to CL measurement alone and/or a biomarker test alone, for PTB within 7 days after testing symptomatic women at 22-34 weeks. The MEDLINE, Cochrane, Embase and Web of Science databases were searched from inception to August 28th, 2019. Seven hundred and eight articles were identified and screened using Rayyan. Studies reporting on the predictive accuracy of combined tests compared to CL or biomarker alone for the prediction of PTB within 7 days of testing in symptomatic women with intact membranes were included. A piloted data extraction form was used. Direct comparisons of the prognostic accuracy of the combination test with CL measurement or a biomarker alone were done, as well as comparisons of prognostic accuracy of the included combination tests (indirect comparisons). Twelve articles were included (seven on fetal fibronectin, four on phosphorylated insulin-like growth factor binding protein-1, one comparing both). A variety of CL cut-offs was reported. The results could not demonstrate superiority of a combination method compared to single methods. Due to data scarcity and quality, the superiority of either predictive test for PTB, either combination or single, cannot be demonstrated with this systematic review. We recommend further research to compare available biomarkers.

Measurements of cesium in Arctic beluga and caribou before and after the Fukushima accident of 2011

Concern from northern communities following the Fukushima Daiichi nuclear accident of March 2011 has prompted a reassessment of the safety of their traditional foods with respect to radioactivity levels. To this end, a study was conducted to measure the levels of radionuclides in Arctic caribou (Rangifer tarandus) and beluga (Delphinapterus leucas). The main radionuclide of concern is cesium-137, which is easily transferred through the lichen-caribou food chain. Previous studies have been conducted on the cesium-137 levels in Canadian caribou herds from 1958 to 2000, allowing researchers to determine the amount of cesium-137 in caribou specifically attributable to atmospheric weapons testing and the Chernobyl nuclear accident in 1986. In this study, samples of lichens, mushrooms, caribou, beluga and beluga prey collected before and after the Fukushima accident were analyzed for radioactivity levels. Samples were processed and measured using gamma ray spectroscopy to identify the radionuclides present and determine the radioactivity concentration. Both calibration standards and Monte Carlo simulations were used to determine the efficiency of the detectors for the samples, taking into account differences in individual sample sizes as well as matrices. In particular, a careful analysis of the atomic composition of lichens and mushrooms was performed to ensure the efficiencies for these sample types were correct. A comparison of the concentrations from before and after the accident indicated that there was no increase in radioactivity as a result of the atmospheric plume from the Fukushima accident. Some cesium-137, likely attributable to fallout from atmospheric weapons testing of the 1950s and 1960s (since there was no cesium-134 measured in the samples), was measured in the post Fukushima caribou and beluga whale samples; however, this amount was determined to be insignificant for any radiological concern (9.1 ± 1.8 and 0.63 ± 0.23 Bq kg^-1 ww respectively). The activity concentrations of cesium-137 was about 200 times smaller than that of natural radioactive potassium in the beluga samples. Both the caribou and beluga results showed that these foods continue to be a healthy food choice for northern Canadians with respect to radioactivity, and this result has been communicated to the nearby northern communities and stakeholders.

Cellular recognition and macropinocytosis-like internalization of nanoparticles targeted to integrin α2β1

Targeting nanoparticles to desired intracellular compartments is a major challenge. Integrin-type adhesion receptors are connected to different endocytosis routes in a receptor-specific manner. According to our previous observations, the internalization of an α2β1-integrin-echovirus-1 complex takes place via a macropinocytosis-like mechanism, suggesting that the receptor could be used to target nanoparticles to this specific entry route. Here, silica-based nanoparticles, carrying monoclonal antibodies against the α2β1 integrin as address labels, were synthesized. Studies with flow cytometry, atomic force microscopy and confocal microscopy showed the particles to attach to the cell surface via the α2β1 integrin. Furthermore, quantitative analysis of nanoparticle trafficking inside the cell performed with the BioImageXD software indicated that the particles enter cells via a macropinocytosis-like process and end up in caveolin-1 positive structures. Thus, we suggest that different integrins can guide particles to distinct endocytosis routes and, subsequently, also to specific intracellular compartments. In addition, we show that with the BioImageXD software it is possible to conduct sensitive and complex analyses of the behavior of small fluorescent particles inside cells, using basic confocal microscopy images.

Active targeting of mesoporous silica drug carriers enhances γ-secretase inhibitor efficacy in an in vivo model for breast cancer

Aim: In this article, we use an alternative cancer model for the evaluation of nanotherapy, and assess the impact of surface functionalization and active targeting of mesoporous silica nanoparticles (MSNPs) on therapeutic efficacy in vivo. Materials & methods: We used the chorioallantoic membrane xenograft assay to investigate the biodistribution and therapeutic efficacy of folate versus polyethyleneimine-functionalized γ-secretase inhibitor-loaded MSNPs in breast and prostate tumor models. Results: γ-secretase inhibitor-loaded MSNPs inhibited tumor growth in breast and prostate cancer xenografts. Folate conjugation improved the therapeutic outcome in folic acid receptor-positive breast cancer, but not in prostate cancer lacking the receptor. Conclusion: The results demonstrate that therapeutic efficacy is linked to cellular uptake of MSNPs as opposed to tumor accumulation, and show that MSNP-based delivery of γ-secretase inhibitors is therapeutically effective in both breast and prostate cancer. In this article, we present a model system for a medium-to-high throughput, cost-effective, quantitative evaluation of nanoparticulate drug carriers.

Original submitted 12 November 2012; Revised submitted 8 February 2013

Microstructure evolution and photoluminescence in nanocrystalline Mg(x)Zn(1 - x)O thin films

The effects of Mg concentration and annealing temperature on the characteristics of nanocrystalline Mg(x)Zn(1 - x)O thin films (where x = 0-0.4) were studied using electron microscopy and photoluminescence. The films were prepared by a sol-gel method. The solid solubility limit of MgO in ZnO for the sol-gel-derived Mg(x)Zn(1 - x)O films in the present study was determined to be ∼ 20 at.%. Microstructural characterization of the films showed that the wurtzite crystallites decrease in size with increase in Mg concentration up to the solubility limit. Increasing Mg concentration beyond the solubility limit resulted in a decrease in crystallinity of the films. The bandgap energy was found to increase with Mg concentration whereas the linewidth first increased and then decreased when the Mg concentration was increased beyond the solubility limit. Photoluminescence properties have been correlated to the microstructure of the films. A growth mechanism for Mg(x)Zn(1 - x)O nanocrystalline films under the present processing conditions has also been proposed.

Time trends in the incidence of conjunctival melanoma in Sweden

AIM

To study time trends in the incidence of conjunctival melanoma in Sweden.

METHODS

All patients with conjunctival melanoma from 1960 to 2005 in Sweden were identified through the Swedish Cancer Registry, cross-checked against hospital files, and validated by histopathological review (97.5%) or detailed hospital records (2.5%). The crude and age-standardised incidences were estimated separately for each sex and the annual change in incidence over time was estimated using a regression model with logarithmic incidence numbers. Time trends for the largest diameter, thickness and location of the tumour when diagnosed were analysed.

RESULTS

The age-standardised incidence of conjunctival melanoma increased significantly in men (n = 89) from 0.10 cases/million to 0.74 cases/million (p = 0.001) and in women (n = 81) from 0.06 cases/million to 0.45 cases/million (p = 0.007). The annual relative change in age-standardised incidence was 16.9% (95% confidence interval (CI) 12.2 to 21.6) in men and 19.5% (95% CI 9.3 to 29.7) in women. The age-specific incidence was higher in men and women > or = 65 years (1.48 and 1.39 cases/million, respectively) than in younger men and women (0.3 and 0.2 cases/million, respectively). During the period of study, tumours became smaller (p = 0.005) and thinner (p = 0.002) at the time of diagnosis and increasingly arose from parts of the conjunctiva exposed to ultraviolet radiation (p = 0.001).

CONCLUSION

The incidence of conjunctival melanoma increased in Sweden during the period 1960 to 2005.

A test of radon service providers available on the Internet

With the announcement of the Government of Canada's Radon Guideline and increased public awareness of radon risk, more and more Canadians wish to test their homes for radon. Radon service providers available on the Internet have attracted many homeowners' attention. These services provide an easy and less expensive way for homeowners to test radon levels in their homes. However, a question has frequently been asked, 'How reliable are the radon testing services available on the Internet?' To answer this question, we ordered 36 radon testing kits from 10 service providers on the Internet. The test results showed that online radon testing services could collectively meet the performance requirement. However, the quality of a few service providers needs to be improved.

PRACTICAL IMPLICATIONS

Indoor radon tests were performed with detectors ordered from 10 service providers available on the Internet. The results showed that online radon testing services could collectively meet the performance requirement. However, the quality of a few service providers needs to be improved.

Variation of soil radon concentrations in southern Ontario

Radon has been identified as the second leading cause of lung cancer after tobacco smoking. Information on indoor radon concentrations is required to assess the lung cancer burden due to radon exposure. However, radon data in highly populated southern Ontario are very limited. Since radon in soil is believed to be the main source of radon in homes, measurements of soil gas radon concentrations can be used to estimate variations in radon potential of indoor environments. This study reports a transect survey of natural background variation in soil radon levels across southern Ontario. The results indicate that radon risk could be high in some areas of southern Ontario.

A report of a national mutation testing service for the MEN1 gene: clinical presentations and implications for mutation testing

INTRODUCTION

Mutation testing for the MEN1 gene is a useful method to diagnose and predict individuals who either have or will develop multiple endocrine neoplasia type 1 (MEN 1). Clinical selection criteria to identify patients who should be tested are needed, as mutation analysis is costly and time consuming. This study is a report of an Australian national mutation testing service for the MEN1 gene from referred patients with classical MEN 1 and various MEN 1-like conditions.

RESULTS

All 55 MEN1 mutation positive patients had a family history of hyperparathyroidism, had hyperparathyroidism with one other MEN1 related tumour, or had hyperparathyroidism with multiglandular hyperplasia at a young age. We found 42 separate mutations and six recurring mutations from unrelated families, and evidence for a founder effect in five families with the same mutation.

DISCUSSION

Our results indicate that mutations in genes other than MEN1 may cause familial isolated hyperparathyroidism and familial isolated pituitary tumours.

CONCLUSIONS

We therefore suggest that routine germline MEN1 mutation testing of all cases of "classical" MEN1, familial hyperparathyroidism, and sporadic hyperparathyroidism with one other MEN1 related condition is justified by national testing services. We do not recommend routine sequencing of the promoter region between nucleotides 1234 and 1758 (Genbank accession no. U93237) as we could not detect any sequence variations within this region in any familial or sporadic cases of MEN1 related conditions lacking a MEN1 mutation. We also suggest that testing be considered for patients <30 years old with sporadic hyperparathyroidism and multigland hyperplasia.

Identification of somatic mutations of the MEN1 gene in sporadic endocrine tumours

Endocrine tumours of the pancreas, anterior pituitary or parathyroids arise either sporadically in the general population, or as a part of inherited syndromes such as multiple endocrine neoplasia type 1 (MEN 1). The mechanisms responsible for the development of sporadic endocrine lesions are not well understood, although loss of heterozygosity (LOH) of the MEN1 locus on chromosome 11q13 and somatic mutation of the MEN1 gene have been frequently associated with the development of MEN 1-type sporadic endocrine lesions. To further investigate the role of the MEN1 gene in sporadic endocrine tumorigenesis, we analysed DNA from 14 primary parathyroid lesions, 8 anterior pituitary tumours and 3 pancreatic tumours for the presence of somatic MEN1 gene mutations and LOH of seven microsatellite markers flanking the MEN1 locus. In addition, we similarly analysed 8 secondary parathyroid lesions which arose in patients with chronic renal failure. None of the patients studied had a family history of MEN 1. Three primary parathyroid lesions and one pancreatic tumour (glucagonoma) were found to have lost one allele at the MEN1 locus. Somatic mutations were identified by SSCP and sequence analysis in one of these parathyroid lesions (P320L) and in the glucagonoma (E179V). These results support previous findings that inactivation of the MEN1 tumour suppressor gene contributes to the development of sporadic MEN 1-type endocrine lesions but is not associated with the development of parathyroid hyperplasia seen in some renal failure patients.

Identification of MEN1 gene mutations in families with MEN 1 and related disorders

Following identification of the MEN1 gene, we analysed patients from 12 MEN 1 families, 8 sporadic cases of MEN 1, and 13 patients with MEN 1-like symptoms (e.g. cases of familial isolated hyperparathyroidism (FIHPT), familial acromegaly, or atypical MEN 1 cases) for the presence of germline MEN1 mutations. The entire coding region of the MEN1 gene was sequenced, and mutations were detected in 11 MEN 1 families; one sporadic MEN 1 patient, one case of FIHPT and one MEN 1-like case. Constitutional DNA samples from individuals without MEN1 mutations were digested with several restriction enzymes, Southern blotted and probed with MEN1 cDNA to analyse for the presence of larger deletions of the MEN1 gene unable to be detected by PCR. One MEN 1 patient was found to carry such a deletion. This patient was heterozygous for the D418D polymorphism, however sequence analysis of RT-PCR products showed that only the variant allele was transcribed, thus confirming the result obtained by Southern analysis, which indicated loss of a region containing the initiation codon of one allele.

Risk and prognosis of endometrial cancer after tamoxifen for breast cancer. Comprehensive Cancer Centres' ALERT Group. Assessment of Liver and Endometrial cancer Risk following Tamoxifen

BACKGROUND

Tamoxifen increases the risk of endometrial cancer. However, few studies have produced reliable risk estimates by duration, dose, and recency of use, or addressed the prognosis of endometrial cancers in tamoxifen-treated women.

METHODS

We did a nationwide case-control study on the risk and prognosis of endometrial cancer after tamoxifen use for breast cancer. Information on tamoxifen use and other risk factors for endometrial cancer was obtained from 309 women with endometrial cancer after breast cancer (cases), and 860 matched controls with breast cancer but without endometrial cancer. For 276 cases, we obtained tissue blocks of endometrial cancer to review the diagnosis, and used immunohistochemistry to examine hormone-receptor status and overexpression of p53.

FINDINGS

Tamoxifen had been used by 108 (36.1%) of 299 cases and 245 (28.5%) controls (relative risk 1.5 [95% CI 1.1-2.0]). Risk of endometrial cancer increased with longer duration of tamoxifen use (p < 0.001), with relative risks of 2.0 (1.2-3.2) for 2-5 years and 6.9 (2.4-19.4) for at least 5 years compared with non-users. Endometrial cancers of stage III and IV occurred more frequently in long-term tamoxifen users (> or = 2 years) than in non-users (17.4% vs 5.4%, p=0.006). Long-term users were more likely than non-users to have had malignant mixed mesodermal tumours or sarcomas of the endometrium (15.4% vs 2.9%, p < or = 0.02), p53-positive tumours (31.4% vs 18.2%, p=0.05), and negative oestrogen-receptor concentrations (60.8% vs 26.2%, p < or = 0.001). 3-year endometrial-cancer-specific survival was significantly worse for long-term tamoxifen users than for non-users (76% for > or = 5 years, 85% for 2-5 years vs 94% for non-users, p=0.02).

INTERPRETATION

Long-term tamoxifen users have a worse prognosis of endometrial cancers, which seems to be due to less favourable histology and higher stage. However, the benefit of tamoxifen on breast-cancer survival far outweighs the increased mortality from endometrial cancer. Nevertheless, we seriously question widespread use of tamoxifen as a preventive agent against breast cancer in healthy women.

A 500-kb sequence-ready cosmid contig and transcript map of the MEN1 region on 11q13

We have generated a transcript map of an approximately 1.2-Mb region from human chromosome band 11q13 between the loci VEGFB and CAPN1, which flank the multiple endocrine neoplasia type 1 (MEN 1) locus. In total, we isolated 144 cosmids from this region and generated a sequence-ready cosmid contig of the approximately 500-kb region between the neurexin locus and D11S2196E. We identified 54 genes/ESTs by sample sequencing and have constructed a transcript map of this region. Genes were found to be clustered in three regions, and one of these genes was identical to the recently identified MEN1 locus. Relative to the latter, we have mapped the positions of 13 known genes, 18 genes which show homology to genes from humans or other organisms, and 22 genes/ESTs that appear novel. In addition, we have ascertained the directions of transcription of some of these genes and have determined intergenic distances between many loci. Full characterization of some of these genes, as well as the novel ESTs, will be useful in identifying candidate genes for other diseases known to map to this chromosomal region.

Characterization of the mouse Men1 gene and its expression during development

The gene responsible for multiple endocrine neoplasia type 1 (MEN1), a heritable predisposition to endocrine tumours in man, has recently been identified. Here we have characterized the murine homologue with regard to cDNA sequence, genomic structure, expression pattern and chromosomal localisation. The murine Men1 gene spans approximately 6.7 kb of genomic DNA and is comprised of 10 exons with similar genomic structure to the human locus. It was mapped to the pericentromeric region of mouse chromosome 19, which is conserved with the human 11q13 band where MEN1 is located. The predicted protein is 611 amino acids in length and overall is 97% homologous to the human orthologue. The 45 reported MEN1 mutations which alter or delete a single amino acid in human all occur at conserved residues, thereby supporting their functional significance. Two transcripts of approximately 3.2 and 2.8 kb were detected in both embryonal and adult murine tissues, resulting from alternative splicing of intron 1. By RNA in situ hybridization and Northern analysis the spatiotemporal expression pattern of Men1 was determined during mouse development. Men1 gene activity was detected already at gestational day 7. At embryonic day 14 expression was generally high throughout the embryo, while at day 17 the thymus, skeletal muscle, and CNS showed the strongest signal. In selected tissues from postnatal mouse Men1 was detected in all tissues analysed and was expressed at high levels in cerebral cortex, hippocampus, testis, and thymus. In brain the menin protein was detected mainly in nerve cell nuclei, whereas in testis it appeared perinuclear in spermatogonia. These results show that Men1 expression is not confined to organs affected in MEN1, suggesting that Men1 has a significant function in many different cell types including the CNS and testis.

Mutation analysis of the MEN1 gene in multiple endocrine neoplasia type 1, familial acromegaly and familial isolated hyperparathyroidism

Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal dominant disease characterized by neoplasia of the parathyroid glands, the endocrine pancreas, and the anterior pituitary gland. In addition, families with isolated endocrine neoplasia, notably familial isolated hyperparathyroidism (FIHP) and familial acromegaly, have also been reported. However, whether these families constitute MEN 1 variants or separate entities remains speculative as the genetic bases for these diseases are unclear. The gene for MEN 1 has recently been cloned and characterized. Using single strand conformation analysis (SSCA) and sequencing, we performed mutation analysis in: a) a total of 55 MEN 1 families from 7 countries, b) 13 isolated MEN 1 cases without family history of the disease, c) 8 acromegaly families, and d) 4 FIHP families. Mutations were identified in 27 MEN 1 families and 9 isolated cases. The 22 different mutations spread across most of the 9 translated exons and included frameshift (11), nonsense (6), splice (2), missense mutations (2), and in-frame deletions (1). Among the 19 Finnish MEN 1 probands, a 1466del12 mutation was identified in 6 families with identical 11q13 haplotypes and in 2 isolated cases indicating a common founder. One frameshift mutation caused by 359del4 (GTCT) was found in 1 isolated case and 4 kindreds of different origin and haplotypes; this mutation therefore represents a common "warm" spot in the MEN1 gene. By analyzing the DNA of the parents of an isolated case one mutation was confirmed to be de novo. No mutation was found in any of the acromegaly and small FIHP families, suggesting that genetic defects other than the MEN1 gene might be involved and that additional such families need to be analyzed.

Analysis of loss of heterozygosity and KRAS2 mutations in ovarian neoplasms: clinicopathological correlations

The molecular events that give rise to ovarian epithelial neoplasms are not well understood. In particular, it is not known whether adenocarcinomas arise from benign or low malignant potential (LMP) precursors. We have examined a large series of benign (25) and LMP (31) ovarian tumors for loss of heterozygosity (LOH) at multiple loci on 17 chromosomes. LOH was observed in benign tumors on chromosomes 6 (14%) and 9 (5%) and on the X chromosome (33%) only. LOH on these chromosomes was also detected in a small number of LMP neoplasms, suggesting that these may derive sometimes from benign precursors. In addition, we examined LOH in 93 adenocarcinomas. Analysis of associations between LOH events showed that LOH on chromosomes 5 and 17 (P = 0.0002) and on chromosomes 17 and 18 (P = 0.00007) were associated significantly with each other, which suggests that these may represent cooperative, progressive events. No novel significant associations were identified between LOH events and stage, grade, or histology, which would indicate the existence of genetic heterogeneity in ovarian neoplasms. KRAS2 mutations were detected more often in LMP neoplasms than in malignant tumors (P = 0.004) and were detected more often in Stage I/II malignant tumors than in Stage III/IV malignant tumors (P = 0.033), suggesting that LMP tumors with KRAS2 mutations are unlikely to progress to frank malignancy. Univariate (but not multivariate) survival analysis showed that LOH of chromosomes 11 (P = 0.039) and 17 (P = 0.04) was associated with a significantly worse prognosis. Replication of these novel findings is necessary, and the identification, isolation, and characterization of the critical genes affected by LOH will determine their importance in the pathogenesis of ovarian malignancies.

Marked symptom reduction in two women with bulimia nervosa treated with the testosterone receptor antagonist flutamide

Previous reports indicate that elevated serum levels of androgens in women may contribute to the development of bulimia nervosa and other conditions characterized by impaired impulse control and/or depressed mood. This report describes the effect of treatment with the testosterone antagonist flutamide (250-500 mg daily) in two women with severe bulimia. Both subjects reported a marked improvement with respect to bulimic behaviour within a week after initiation of flutamide treatment; when the drug was withdrawn, both patients relapsed. It is concluded that further investigations of the possible efficacy of androgen antagonism in eating disorders are warranted.

Limbal sub-Tenon's administration of retrobulbar anesthesia using a blunt irrigating cannula

BACKGROUND AND OBJECTIVE

To eliminate sharp needles when administering local anesthesia to the eye in order to reduce serious complications caused by needle perforation.

PATIENTS AND METHODS

After topical anesthesia, limbal conjunctival incision, and sub-Tenon's dissection, a retrobulbar irrigation of an equal mixture of bupivacaine (5 mg/ml) and lidocaine (20 mg/ml) was given using a blunt cannula.

RESULTS

The technique was used in both vitreoretinal surgery (n = 70) and anterior segment surgery (n = 235) with good analgesic and akinetic effects. No serious adverse were noted.

CONCLUSION

This proved to be a safe and efficient technique that abandoned the use of sharp needles.

Costs of medical care after first-ever stroke in The Netherlands

BACKGROUND AND PURPOSE

Stroke causes high morbidity and mortality. The aging of the population further increases the demands on healthcare costs.

METHODS

We estimated the lifetime direct costs of care of first-ever stroke patients in the Netherlands in 1991 using epidemiological data from national and international studies. In addition, we examined the effect of an aging population on future healthcare costs.

RESULTS

The lifetime costs for 24,007 first-ever stroke patients are estimated to be 1870 million Dutch guilders (Dfl) (1 Dfl = 0.53 US dollar, 1991). Per-person costs are higher for women (83,000 Dfl) than for men (71,000 Dfl). The major cost component of first-year costs is hospital costs (45%), while nursing home costs dominate lifetime costs (50%). An increase of the elderly population older than 65 years of 27% between 1991 and 2010 might lead to a parallel increase of total costs of 30%, or 1.5% per year.

CONCLUSIONS

Long-term care rather than acute care dominates the lifetime costs for stroke patients now and in the future.

Microscopic colitis syndrome

The colorectal biopsy specimens from 30 patients with chronic watery diarrhoea but normal endoscopic and radiographic findings were studied by light microscopy, morphometry, immunohistochemistry, and two patients with electron microscopy. The histological changes in the colorectum were originally diagnosed in six patients as lymphocytic colitis and in 24 patients as collagenous colitis. The analysis of the specimens for this study could delineate three distinct groups of microscopic colitis: lymphocytic colitis (six patients), collagenous colitis without lymphocytic attack on the surface epithelium (seven patients), and a mixed form presenting with both thickening of the collagen plate and increased number of intraepithelial lymphocytes (17 patients). No transformation was seen from one type to another during follow up of six patients for four to seven years. Increased numbers of active pericryptal myofibroblasts were found with the electron microscope in one patient with mixed microscopic colitis showing also myofibroblasts entrapped within the collagen layer. Hitherto undescribed flat mucosa of the ileum was found in one patient with lymphocytic colitis and both flat mucosa and thickening of the collagen plate in the ileum were seen in one patient with the mixed form of the disease. In another patient with mixed microscopic colitis, normalisation of the colorectal morphology occurred after temporary loop ileostomy, followed by the reappearance of both diarrhoea, inflammation, and thickening of the collagen plate after the ileostomy was reversed. No association was found between non-steroid anti-inflammatory drug (NSAID) consumption and collagenous or mixed microscopic colitis. The primary cause of microscopic colitis is probably an immunological reaction to luminal antigen/s, perhaps of ileal origin. The engagement of the pericryptal myofibroblasts in the disease process might result in the development of the various forms of microscopic colitis. An inverse relation between intraepithelial lymphocyte count and collagen thickness may indicate that microscopic colitis is a spectral disease.

Should tamoxifen be a primary treatment choice for elderly breast cancer patients with locoregional disease?

To determine the efficacy of tamoxifen as primary treatment for elderly breast cancer patients with locoregional disease, the medical records of 85 patients of 75 years and older were reviewed. The median follow-up was 28 months (range 3-97 mo). Complete remission occurred in twelve (14.1%) patients. All of these patients remained in remission until death or closing date of the study. Twenty (23.5%) patients responded with a partial remission; 5 of them subsequently developed tumor progression. Thirteen (15.3%) patients developed initial tumor progression and 39 (45.9%) had disease stabilisation. Nineteen of this latter group subsequently developed tumor progression. Out of 37 (43.5%) patients with tumor progression, 14 patients were salvaged by surgery (n = 13) or radiotherapy (n = 1). Until the closing date of the study, disease could not be controlled by secondary treatment in 12 patients who subsequently died of breast cancer. Twenty-two of the 37 patients were unfit for surgical treatment at progression, of whom 14 were operable at diagnosis. The actuarial 5-year observed survival rate was 40% for the whole patient group.

CONCLUSIONS

Although some patients (14.1%) managed to maintain a long lasting complete remission, caution should be preserved in using tamoxifen as first-line treatment, because of the high risk of treatment failures. As long as factors can not be identified to predict which subgroups of patients will respond to tamoxifen with a remission lasting for their life-time, tamoxifen may only provide an acceptable alternative for elderly breast cancer patients who are too frail or are unwilling to undergo surgery or radiotherapy. For elderly patients in good physical condition, primary treatment by (ABSTRACT TRUNCATED AT 250 WORDS)

Olsalazine versus sulphasalazine for relapse prevention in ulcerative colitis: a multicenter study

OBJECTIVE

To compare the relapse-preventing effect and the frequency of adverse events of olsalazine and sulphasalazine in sulphasalazine-tolerant patients with ulcerative colitis.

METHODS

Patients in remission, with at least two episodes of active disease during the last 5 yr, were randomized to 2 g of sulphasalazine or 1 g of olsalazine daily and were followed for 6-18 months. Relapse rates in the two groups were compared using frequency and life-table analysis. Sixty-nine patients with proctitis, 140 with left-sided colitis, and 113 with subtotal or total colitis were evaluated.

RESULTS

In the intention-to-treat analysis, the failure rate (relapses plus withdrawals) was 54.7% in the olsalazine and 47.2% in the sulphasalazine group. In the per-protocol analysis excluding withdrawals, 44.7% relapsed in the olsalazine and 39.3% in the sulphasalazine group. Remission curves did not differ significantly, although at all time intervals the frequency of remission was slightly higher in the sulphasalazine group (p = 0.19 in the intention-to-treat analysis and p = 0.42 in the per-protocol analysis estimated by the log-rank test). Twelve patients (of whom five had diarrhea) in the olsalazine group versus eight patients in the sulphasalazine group discontinued the study because of side effects.

CONCLUSION

The relapse-preventing effect of olsalazine and sulphasalazine in sulphasalazine-tolerant patients did not differ. Furthermore, the tolerability of olsalazine, particularly concerning diarrhea, appears to be better than previously reported.

Meropenem versus imipenem/cilastatin in the treatment of intra-abdominal infections

In order to compare the clinical and microbiological efficacy and safety of meropenem with imipenem/cilastatin, 249 patients with intra-abdominal infections participated in an open randomised comparative multicentre trial. Seventy-five men and 57 women (mean age 51 years) were enrolled in the meropenem group and 67 men and 50 women (mean age 52 years) in the imipenem/cilastatin group. The patients received either meropenem, 500 mg q 8 h, or imipenem/cilastatin, 500 mg/500 mg q 8 h by intravenous infusion for up to 17 days (mean 5 days). Ninety-seven of 99 patients (98%) receiving meropenem were clinically cured while 86 of 90 patients (96%) in the imipenem/cilastatin group were clinically cured. The microbiological response was satisfactory in 89 of 94 evaluable patients (95%) receiving meropenem and in 78 of 81 evaluable patients (96%) receiving imipenem/cilastatin. There was no significant difference in clinical and microbiological efficacy between the two treatment groups. Adverse reactions were noted in 26 patients receiving meropenem and in 36 patients receiving imipenem/cilastatin. The present study shows that meropenem is effective and well tolerated in the treatment of intra-abdominal infections.

High levels of free testosterone in women with bulimia nervosa

Women with normal-weight bulimia nervosa (n = 11) displayed significantly higher serum levels of free testosterone than age-matched controls (6.0 +/- 0.7 vs 3.9 +/- 0.8 pmol/l; P = 0.03). The possible importance of androgens, in women, for the pathophysiology of conditions characterized by an impairment in impulse control is being discussed.

Piperacillin-tazobactam versus imipenem-cilastatin for treatment of intra-abdominal infections

In order to compare the clinical and microbiological efficacies and safety of piperacillin plus tazobactam with those of imipenem plus cilastatin, 134 patients with intra-abdominal infections (73 patients with appendicitis) participated in an open randomized comparative multicenter trial. A total of 40 men and 29 women (mean age, 53 years; age range, 18 to 92 years) were enrolled in the piperacillin-tazobactam group and 40 men and 25 women (mean age, 54 years; age range, 16 to 91 years) were enrolled in the imipenem-cilastatin group. The patients received either piperacillin (4 g) and tazobactam (500 mg) every 8 h or imipenem and cilastatin (500 mg each) every 8 h. Both regimens were given by intravenous infusion. A total of 113 patients were clinically evaluable. Of 55 patients who received piperacillin-tazobactam, 50 were clinically cured, while 40 of 58 patients in the imipenem-cilastatin group were clinically cured. The differences were significant (Wilcoxon test; P = 0.005). There were 4 failures or relapses in the piperacillin-tazobactam group and 18 failures or relapses in the imipenem-cilastatin group. The microorganisms isolated were eradicated in similar proportions in the two patient groups. Adverse reactions, mainly gastrointestinal disturbances and nausea, were noted in 13 patients who received piperacillin-tazobactam and in 14 patients who received imipenem-cilastatin. Results of the present study show that piperacillin-tazobactam is effective and safe for the treatment of intra-abdominal infections.

The influence of age on treatment choice and survival of elderly breast cancer patients in south-eastern Netherlands: a population-based study

The influence of age on treatment choice and survival was studied in 2268 breast cancer patients of 55 years and older reported to the Eindhoven Cancer Registry from 1975 to 1987. Among patients of 75 years and older, stage I and II tumours occurred less often, whereas stage IIIb and undefined tumours occurred more often than among younger patients. Physicians were found to be less likely to treat women of 75 years and older with adjuvant radiotherapy after a mastectomy. Instead, these women received either surgery alone or surgery followed by hormonal therapy. Surgical procedures in the oldest age group were also less extensive. The 10-year relative survival for women over 74 years (32%) was significantly worse than that for younger patients (57%). Multivariate analyses showed that this poor outcome for the oldest age group was largely related to their unfavourable stage distribution: stage-specific survival appeared to be similar in all age groups. Age-related differences in treatment did not have an effect on survival.

Influence of age and comorbidity on treatment choice and survival in elderly patients with breast cancer

To determine the effect of age and comorbid diseases on treatment choice and survival, the medical records of 300 breast cancer patients of 55 years and older were reviewed. All patients were admitted to the Netherlands Cancer Institute (NKI) for first treatment between 1980 and 1987. Patients were classified according to severity level of comorbid diseases. Physicians were found to treat women of 75 years and older less often with adjuvant radiotherapy after a mastectomy, and more often to employ only primary endocrine treatment for local stage disease, as compared with younger patients. According to the treatment guidelines of the institute, the study sample was divided into patients who received standard vs. non-standard treatment. The treatment of 38 women (13.1%) did not correspond with the guidelines. Of these, 84% were 75 years and older and 50% had a severe comorbidity status. Logistic regression analysis indicated that advanced age, per se, was a better indicator of the risk of not being treated according to protocol than the comorbidity status. Cox multivariate analyses demonstrated that neither the severity of the comorbidity status nor the differences in treatment between younger and older patients had a significant effect on the risk of dying from breast cancer or on the risk of developing recurrences. In this analysis, age 75 years or more proved to be a significant and independent predictor of a worse overall and disease-specific survival as compared to age between 65-74 years.

The effect of age on treatment choice and survival in elderly breast cancer patients

To investigate the effect of age on treatment choice and survival in patients with breast cancer, data from the cancer registry of the Netherlands Cancer Institute (NKI, Amsterdam, The Netherlands) on 611 women have been analyzed. All patients 55 years and older admitted to the NKI for primary treatment of breast cancer between 1981 and 1986 were selected. For women 75 years and older, physicians were less likely to use treatment of adjuvant radiation therapy after a mastectomy and more often employed primary hormonal therapy only for local stage disease than for younger patients. Life-table analysis showed that disease-specific survival at 7 years for patients 65 through 74 years of age was significantly better (65%) than that of the youngest (55%) and the oldest age group (50%). In multivariate regression analysis (Cox), age older than 74 years was significantly and independently associated with a shorter disease-specific survival as compared with patients younger than 75 years. This difference in survival, however, does not seem to be the result of the difference in treatment between the age groups, but suggests an influence of age-related factors such as comorbid diseases and weak physical condition, which manifest themselves most strongly in the oldest age category and make the older woman more vulnerable to the course of malignant disease.

Treatment of postoperative paralytic ileus with cisapride

The effect of cisapride on postoperative colonic motility was studied in 40 patients undergoing cholecystectomy under randomized, double-blind conditions. The patients received 10 mg of cisapride or placebo by intravenous injection starting on the day of surgery and repeated every 12 h until the 3rd postoperative day. The return of propagative motility in the colon was visualized by means of radiopaque markers and serial abdominal radiographs. Cisapride induced a significantly earlier return of propulsive motility in the right colon, as indicated by the propagation of markers from the ascending colon to the transverse colon (p less than 0.05). Radiopaque markers reached the descending colon (p less than 0.05) and the rectosigmoid colon (p less than 0.05) significantly earlier in the cisapride group than in controls. The first passage of feces occurred significantly earlier in cisapride-treated patients than in controls (p less than 0.05). The first passage of gas after surgery did not differ significantly between the groups. Our results suggest that cisapride can be used to induce earlier return of propagative motility in the colon after major abdominal surgery.

Adjuvant chemotherapy with 5-fluorouracil, vincristine and CCNU for patients with Dukes' C colorectal cancer. The Swedish Gastrointestinal Tumour Adjuvant Therapy Group

A prospective controlled randomized trial testing adjuvant postoperative combination chemotherapy (5-fluorouracil, lomustine (CCNU) and vincristine) versus no adjuvant therapy in patients operated on for Dukes' C colorectal cancer is reported. In total 334 patients aged less than 70 years were recruited: 205 patients with colonic and 99 with rectal cancer, but there were three protocol violations and these cases are excluded from further consideration. Twenty-seven patients had a limited resection of their cancer. After 5 years' follow-up there was no significant difference in the tumour-free survival rate or in the survival rate between the treated and control groups. Twenty-nine of the 147 patients who started chemotherapy discontinued this treatment because of side-effects, mainly from the gastrointestinal tract. In 30 patients treatment was discontinued because of recurrent disease. The conclusion is that systemic administration of combination chemotherapy for colorectal cancer after operation is not worthwhile in routine clinical practice.

Can villous atrophy be induced by chronic alcohol consumption?

A 43-year-old man presented with loose stools, abdominal pain and a weight loss of 15 kg. Investigations revealed a pancreatic insufficiency and an enteropathy with villous atrophy. Coeliaki was suspected. In spite of treatment with a gluten-free diet in hospital the patient did not improve and the villous atrophy remained unchanged. Other causes than coeliaki to villous atrophy were ruled out. The patient had a heavy consumption of alcohol and after prolonged abstinence the patient gained weight, the pain disappeared and the stools were normalized. The jejunal biopsy was now normal. This case report raises the possibility that enteropathy and villous atrophy may be causally related to alcohol overconsumption.

Single-dose chemoprophylaxis in elective colorectal surgery. A comparison between doxycycline plus metronidazole and doxycycline

In a prospective, randomized double-blind study either 400 mg of doxycycline + 1500 mg of metronidazole (D + M) or 400 mg of doxycycline (D) alone were given intravenously as a single preoperative dose to patients admitted for elective colorectal surgery. A comparison of the rate of postoperative septic complications was made. After excluding drop-out patients, 261 patients remained for evaluation. In 135 patients with D + M treatment there were four postoperative septic complications (3.0%). In 126 patients with D treatment 20 septic complications related to the surgical procedure occurred (15.9%). The difference is highly significant (p less than 0.005). Most postoperative infections were superficial wound infections (14 of 24 patients), and the mean hospital stay in the two treatment groups was equal. Bacteriologic studies showed a highly significant reduction in anaerobes in cultures from perioperative intra-abdominal fluid in the D + M treatment group. The study has thus showed that the addition of metronidazole, an efficient agent against anaerobic bacteria, to an antimicrobial agent against aerobic bacteria significantly reduces postoperative septic complications in elective colorectal surgery.

Posterior trans-sphincteric resection for small tumours of the lower rectum

In the period 1977-1983, 21 patients with small tumour of the lower two-thirds of the rectum were treated with local excision, using the posterior trans-sphincteric approach. The operative and postoperative course was uneventful, with no mortality, septic complications, fistula or anal incontinence. In 14 cases the tumour was an adenocarcinoma. These tumours had been preoperatively classified as carcinoma or suspected carcinoma with limited superficial growth. In 12 of them there was no invasion beyond the rectal wall. In follow-up averaging 44 months there has been no local recurrence, but liver metastasis has appeared in two patients. In our experience, local tumour excision via posterior trans-sphincteric rectotomy is a safe alternative for removal of adenoma or small, localized carcinoma of the lower two-thirds of the rectum.

Crohn's disease. A long-term study of the clinical course in 186 patients

A series of 186 patients treated for Crohn's disease during the period 1956 to 1968 has been followed up in 1970, 1975, and now in 1983. Among 173 patients operated on there were 89 recurrences (52%). After a follow-up time greater than 14 years (mean, 18 years) 'radical' resections at the first operation gave a lower recurrence rate (31%), fewer reoperations, and a better quality of life compared with non-'radical' resections (recurrence rate, 83%). The quality of life estimated for all patients alive in 1983, 152 patients, was good in 89%; 8.6% had moderate subjective symptoms, and 2.6% had pronounced subjective symptoms. With an increasing follow-up time there was no decrease in the patients' quality of life. Ileorectal anastomosis did not give very good results; proctocolectomy and ileostomy, however, gave good results. Regular investigation of all patients is of vital importance to give them a good quality of life.