Association of protein intake with recurrence and survival following primary treatment of ovarian cancer

BACKGROUND

Malnutrition is common during treatment for ovarian cancer and one in three report multiple symptoms affecting food intake after primary treatment. Little is known about diet post-treatment in relation to ovarian cancer survival, however, general recommendations for cancer survivors are to maintain a higher level of protein intake to support recovery and minimize nutritional deficits.

OBJECTIVE

To investigate whether intake of protein and protein food sources following primary treatment for ovarian cancer is associated with recurrence and survival.

DESIGN

Intake levels of protein and protein food groups were calculated from dietary data collected about 12 months post-diagnosis using a validated food frequency questionnaire in an Australian cohort of females with invasive epithelial ovarian cancer. Disease recurrence and survival status were abstracted from medical records (median 4.9 years follow-up). Cox proportional hazards regression was used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for protein intake and progression-free and overall survival.

RESULTS

Among 591 females who were progression-free at 12-months follow-up, 329 (56%) subsequently experienced cancer recurrence and 231 (39%) died. A higher level of protein intake was associated with better progression-free survival (>1-1.5 vs. ≤1 grams per kilogram body weight (g/kg): HR_adjusted=0.69, 95% CI 0.48, 1.00; >1.5 vs. ≤1g/kg: HR_adjusted=0.61, 95% CI 0.41, 0.90; >20% vs. ≤20% total energy intake from protein: HR_adjusted=0.77, 95% CI 0.61, 0.96). There was no evidence for better progression-free survival with any particular protein food sources. There was a suggestion of better overall survival among those with higher total intakes of animal-based protein foods, particularly dairy products (HR=0.71, 95% CI 0.51, 0.99 for highest vs. lowest tertiles of total dairy intake).

CONCLUSIONS

After primary treatment for ovarian cancer, a higher level of protein intake may benefit progression-free survival. Ovarian cancer survivors should avoid dietary practices that limit intake of protein-rich foods.

A phase 2 study of anastrozole in patients with oestrogen receptor and/progesterone receptor positive recurrent/metastatic granulosa cell tumours/sex-cord stromal tumours of the ovary: The PARAGON/ANZGOG 0903 trial

BACKGROUND

Hormonal therapies are commonly prescribed to patients with metastatic granulosa cell tumours (GCT), based on high response rates in small retrospective studies. Aromatase inhibitors (AIs) are reported to have high response rates and an accepted treatment option. We report the results of a phase 2 trial of an AI in recurrent/metastatic GCTs.

METHODS

41 patients with recurrent ER/PR + ve GCT received anastrozole 1 mg daily until progression or unacceptable toxicity. The primary endpoint was clinical benefit rate (CBR) at 12 weeks, evaluated by RECIST1.1 criteria. Secondary endpoints included progression-free survival (PFS), CBR duration, quality of life and toxicity.

RESULTS

The CBR at 12 weeks in 38 evaluable patients was 78.9%, which included one (2.6%; 95% CI: 0.5-13.5%) partial response and 76.3% stable disease. Two additional patients without measurable disease were stable, based on inhibin. Median PFS was 8.6 m (95% CI 5.5-13.5 m). There were delayed responses observed after 12 weeks with a total of 4 pts. (10.5%; 95% CI 4.2%-24.1%) with a RECIST partial response; 23 (59%) patients were progression-free at 6 months. The adverse effects were predominantly low grade.

CONCLUSIONS

This is the first prospective trial of hormonal therapy in GCTs. Although there was a high CBR, the objective response rate to anastrozole was much lower than the pooled response rates of >70% to AIs reported in most retrospective series and case reports. PARAGON demonstrates the importance of prospective trials in rare cancers and the need to reconsider the role of AIs as single agents in GCTs.

A healthy lifestyle and survival among women with ovarian cancer

Ovarian cancer has a poor survival rate and, understandably, women often want to know whether there is anything they can do to improve their prognosis. Our goal was to investigate the association between a healthy lifestyle prediagnosis and postdiagnosis and survival in a cohort of Australian women with invasive epithelial ovarian cancer. We calculated a healthy lifestyle index (HLI) based on women's self-reported smoking status, height, weight, physical activity, diet and alcohol consumption before diagnosis (n = 678) and after completing primary treatment (n = 512). Clinical data and vital status for each woman were ascertained through medical records. Cox proportional hazards regression was conducted to calculate hazard ratios (HR) and 95% confidence interval (CI) for all-cause mortality. There was a suggestive association between a more healthy lifestyle before diagnosis and better survival (HR 0.79, 95% CI: 0.59-1.04), however, the association was stronger for lifestyle after diagnosis, with women in the highest tertile having significantly better survival than women in the lowest tertile (HR 0.61, 95% CI: 0.40-0.93; P-trend = .02). Current smoking, particularly postdiagnosis, was associated with higher mortality (HR 1.68, 95% CI: 1.17-2.42; HR 2.82, 95% CI: 1.29-6.14, for prediagnosis and postdiagnosis smoking, respectively), but women who quit after diagnosis had survival outcomes similar to nonsmokers (HR 0.99, 95% CI: 0.57-1.72). Higher physical activity after diagnosis was associated with better survival (HR 0.60, 95% CI: 0.39-0.92; P-trend = .02). A healthy lifestyle after diagnosis, in particular not smoking and being physically active, may help women with ovarian cancer improve their prognosis.

The hidden burden of anxiety and depression in ovarian cancer: A prospective study from diagnosis

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Background: Women with ovarian cancer (OC) report high rates of anxiety (A) and depression (D), but most studies have used a cross-sectional design at a single time-point, not considered prior history and not included affected women who are symptom-free due to medication. Our goals were to quantify (i) the total burden of A and D among women with newly diagnosed OC; the proportions who (ii) experience symptoms only after their OC diagnosis and (iii) with persistent symptoms; and (iv) use of appropriate medication/services by those affected. Methods: The OPAL (Ovarian Cancer Prognosis & Lifestyle) Study is a prospective study of Australian women diagnosed with OC from 2012-15 who agreed to complete questionnaires at baseline, 3, 6, 9, 12, 24, 36 & 48 months after diagnosis. At baseline, they were asked if they had ever been diagnosed with A or D and if they took medication for this in the year before their OC diagnosis. At follow-up they completed the Hospital Anxiety and Depression Scale (HADS) and were asked about current medication use. Results: Of 893 women with data for ≥1 time point, 216 (24%) reported clinical levels (HADS > 10) of anxiety (18%) and/or depression (15%) on at least one occasion during the first 3 years after diagnosis, with another 157 (18%) reporting use of anxiolytic or antidepressant medications. A further 167 (19%) reported subclinical (HADS 8-10) A or D. Of those with clinical levels of A/D and/or taking medication, 225 (60%) reported this at ≥3 time-points, 216 (58%) reported no prior history of A or D, and 271 (73%) reported no use of anxiolytic/antidepressant medication in the year before diagnosis. When women reported clinical levels of A or D, only 45% reported taking medication (37%) and/or seeing a psychiatrist or psychologist (19%). Conclusions: More than 40% of women with OC experienced clinical levels of A or D during treatment or the first 3 years of follow-up, for 25% this persisted. For 24% this was their first experience of distress and > 50% of those affected did not receive appropriate medication or psychological support. The hidden burden of anxiety and depression in this population is much greater than previously reported but is amenable to effective intervention if recognized.

The Ovarian cancer Prognosis And Lifestyle (OPAL) study

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Background: Five-year survival after a diagnosis of ovarian cancer (OC) is < 45% and women often ask what they can do, beyond following the recommended treatment, to improve their chance of survival. The OPAL Study addresses the question of whether lifestyle choices during or after treatment could positively impact quality of life (QoL) and, ultimately, survival. Methods: OPAL is a prospective study of Australian women newly diagnosed with primary OC from 2012-15 who agreed to complete questionnaires at baseline, 3, 6, 9, 12, 24, 36 & 48 months after diagnosis. Baseline data include sociodemographic, reproductive & hormonal, medical & family history, and lifestyle (diet, alcohol, smoking, physical activity, sitting time) information. At follow-up, women are asked about their current lifestyle, medication and complementary therapy use, and a range of patient-reported outcomes including the Hospital Anxiety and Depression Scale, Insomnia Severity Index and FACT instruments for ovarian cancer, neurotoxicity and fatigue. 85% also provided a blood sample at recruitment and/or 12 months after diagnosis. Detailed treatment and outcome data are collected annually from medical records. Results: Of 1451 eligible women identified, 219 were excluded and 274 declined leaving a cohort of 958; 72% have high-grade serous and 72% advanced stage disease. Follow-up is now close to 36 months with questionnaire response rates of 85-95% among active participants. At October 2017, we had received 734, 751, 636, 434 and 225 questionnaires at 6, 12, 24, 36 and 48 months, respectively; women have completed a mean of 5 questionnaires (range 1-8). A total of 558 (58%) have experienced disease progression or recurrence, 332 (35%) have died and 300 are still active in the study. The proportion of women reporting clinical levels of anxiety ranges from 6-9% at each time-point, depression from 5-7%, insomnia from 9-14% and fatigue from 30-57%. Conclusions: This is the first prospective study to collect detailed lifestyle, QoL, clinical and outcome information from a large population-based cohort of women newly diagnosed with OC. It provides a valuable resource to identify relationships between potentially modifiable aspects of lifestyle and outcomes (QoL & survival) in women with OC.

When will I feel normal again? Quality of life trajectories after first-line chemotherapy for ovarian cancer

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Background: Patients often ask if/when they will feel normal again following treatment for ovarian cancer (OC). There is a paucity of data on the trajectories of quality of life (QoL), physical (PWB), social (SWB), emotional (EWB) and functional (FWB) wellbeing over time following chemotherapy and especially regarding those who have persistent problems. Our aim was to quantify the proportion of women with significantly lower QoL/wellbeing than the general population at the end of treatment and determine if/when they return to normal. Methods: The OPAL (Ovarian cancer Prognosis & Lifestyle) Study is a prospective study of Australian women diagnosed with invasive OC from 2012-15 who agreed to complete regular questionnaires after diagnosis. 580 participants who received ≥3 cycles of platinum-based chemotherapy as primary treatment and completed a questionnaire while on or < 6 weeks after completing chemotherapy (baseline) were included. FACT-G data came from questionnaires at baseline and ~3, 6, 9 & 18 months post-baseline. Group-based trajectory models were used to identify groups with distinct patterns of QoL/wellbeing over time. Results: Overall, 44% (254) of women had QoL scores significantly lower than the general population at baseline; 35% (88) returned to normal by 3 months after treatment, 73% by 6 months and 27% (69) had not returned to normal by 18 months. The Table shows the comparable figures for the wellbeing subscales. Conclusions: While > 50% of women with OC can expect similar QoL, FWB and EWB to the general population at the end of chemotherapy, PWB was compromised in 3 of 4 women. For most, wellbeing recovered within 6 months but a substantial proportion reported ongoing deficits. A particularly prolonged impact was seen for those with poor EWB at baseline, warranting early intervention in this subset. [Table: see text]

A phase 2, single-arm study of an autologous dendritic cell treatment against mucin 1 in patients with advanced epithelial ovarian cancer

BACKGROUND

Mucin 1 antigen, highly expressed by epithelial ovarian cancer (EOC), is a potential target for immunotherapy. A previous successful phase 1 trial was conducted in patients with adenocarcinoma who were injected with Cvac, autologous monocyte-derived dendritic cells (DCs) incubated with mannosylated mucin 1 protein (M-FP). The present study was a phase 2 trial of Cvac in patients with advanced EOC.

METHODS

Eligible patients had EOC with progressive disease, defined as an increase in CA125 of ≥ 25% in 1 month. The primary endpoint was CA125 response or stabilization. Peripheral blood mononuclear cells were collected by leukapheresis and cultured to generate DCs. The DC were incubated with M-FP, and after washing were prepared for injection into the patient intradermally every 4 weeks for 3 doses, then every 10 weeks for up to 12 months.

RESULTS

All 28 patients recruited were evaluable for safety and 26 for efficacy. All had undergone surgery and platinum-based chemotherapy, and 57% of patients received ≥ 3 chemotherapy regimens. There were no Grade 3 or 4 toxicities considered related to Cvac. Four patients showed CA125 response or stabilization (2 patients with major responses, 1 minor response, 1 stabilization) of median duration 10.3 months (5.3-16.3 months). An additional patient had > 25% CA125 reduction (not confirmed).

CONCLUSIONS

Cvac immunotherapy was well tolerated. Clinical activity in EOC was evident based on decline or stabilization of CA125 in some patients, supporting ongoing development of Cvac in ovarian carcinoma and planning of additional trials of patients in remission is currently underway.

Squamous cell carcinoma of the vulva with bulky positive groin nodes—nodal debulking versus full groin dissection prior to radiation therapy

Patients with clinical palpable involved groin lymph nodes and squamous cell cancer of the vulva are frequently treated by a full inguinal-femoral lymph node dissection followed by adjuvant radiotherapy to the groins and pelvis. Theoretically, less radical surgery for the groin such as nodal debulking, where only the macroscopically involved nodes are resected, allowing radiotherapy to treat any remaining microscopic disease may potentially decrease morbidity without compromising survival The objective of this retrospective study was to compare the groin recurrence rate and survival (disease specific and overall survival) of patients with clinically involved groin nodes and squamous cell carcinoma of the vulva treated either by a full inguino-femoral lymphadenectomy or by a nodal debulking followed by radiotherapy. Forty patients from three separate databases who met these criteria were identified. Patients were treated either by a full inguino-femoral lymphadenectomy or by a debulking of the clinically involved inguinal lymph nodes. All patients received adjuvant radiotherapy to the groins. In these two groups, there was no difference in groin recurrence rate expressed as groin recurrence-free survival (P= 0.247). In a univariate analysis, both overall and disease-free survival were better in the group of patients treated by nodal debulking. However, in a multivariate analysis, other variables such as extracapsular growth were independent predictors for survival while the method of surgical dissection for the groin had no independent significant impact on survival.

Secondary cytoreductive surgery for recurrent epithelial ovarian cancer

OBJECTIVE

To review our experience with secondary cytoreductive surgery for recurrent epithelial ovarian cancer with regard to its feasibility, morbidity, mortality, patient selection, and survival.

METHODS

Forty-six patients who underwent secondary cytoreductive surgery at the Royal Hospital for Women, Sydney, between July 1988 and October 1996 were retrospectively reviewed. The mean age at surgery was 50.3 years, and the median disease-free interval was 26 months. Eighty-nine percent of patients had a disease-free interval of at least 12 months. Twenty-five patients (54%) had localized disease at the time of surgery. Univariate survival outcomes were analyzed using the log rank test, and survival curves were calculated using the method of Kaplan-Meier.

RESULTS

Two patients (4%) were inoperable and 19 patients (41%) were cytoreduced to no macroscopic disease. There was one postoperative death (2%), and four patients (8.7%) had significant postoperative morbidity. With a median follow-up of 88 months, the overall median survival was 22.5 months. Patients with a disease-free interval of less than 12 months after their initial treatment had a median survival of 6 months, compared with 11 months if the disease-free interval was 12-24 months and 39 months for those with a disease-free interval of 24 months or more (P =.001, log rank). Patients who had any residual disease had a median survival of 11 months, whereas those with no residual disease had a median survival of 38 months (P =.002, log rank).

CONCLUSION

For carefully selected patients with recurrent epithelial ovarian cancer: 1) complete surgical resection is feasible more commonly than with primary cytoreduction, 2) serious morbidity and mortality are acceptable, and 3) significant survival benefit accrues when a) all macroscopic disease can be resected, or b) the disease-free interval is 24 months or more.

Low-impact falls: demands on a system of trauma management, prediction of outcome, and influence of comorbidities

BACKGROUND

Falls from a low height are an extremely common source of injury, the severity of which is often underestimated. As a result, low fall patients are usually not transferred to Level I trauma centers. There are surprisingly few systematic data relating to the demands made on systems of trauma care by patients with low falls. This study addresses this issue using information from a comprehensive national trauma database. The performance of TRISS methodology, and the factors associated with prolonged hospital stay, in low fall patients is also examined.

METHODS

The study included 31,419 patients. Patients with low falls (< 2 m) were compared with those suffering high falls (> or = 2 m), motor vehicle crashes, assault, sports injuries, and a group with unclassified injuries. Probability of survival was estimated using TRISS, and its performance in different types of injury was assessed using measures of discrimination and calibration. The influence of coexistent medical conditions on mortality and length of stay was investigated using logistic regression.

RESULTS

Low falls accounted for 45.5% of all admissions, and 43.9% of the total bed days. The low fall group was older (mean age, 61.6 years), and predominantly female (62.5%) in contrast to the other groups (both p < 0.001). There were fewer severely injured patients than in all of the other groups except sports injuries. The area under the receiver operating characteristic curve for TRISS applied to low falls (0.874) was less than that for high falls (0.969), motor vehicle crashes (0.973), assaults (0.960), sports (1.000), and unclassified injuries (0.965). Also, the calibration of the TRISS model was poor for patients with low falls. A logistic regression model derived from a training set of 5,000 patients gave slightly improved discrimination and markedly improved calibration when compared with TRISS. Although there was a strong relationship between the number of coexistent medical conditions and the risk of dying after a low fall, including data on comorbidities in a predictive model did not improve performance. Prolonged stay (defined as greater than the 90th centile, 23 days) was more likely in women (p < 0.005), or with advanced age (p < 0.001) or low initial calculated probability of survival (p < 0.001). Cardiovascular and central nervous system diseases and diabetes were associated with longer hospital stay (all p < 0.001). A logistic regression model using TRISS variables and comorbidity data gave poor prediction of prolonged stay. There was considerable variation in the length of stay between institutions.

CONCLUSION

Patients with low falls make considerable demands on a system of trauma care. TRISS methodology performs less well in this group than with other types of injury. Chronic medical conditions are associated with increased mortality and more prolonged stay after a low fall. Between-institutional variation in length of stay was considerable and this, along with the poor performance of predictive models derived from routinely collected clinical data, make it unlikely that length of stay could be used as a measure of institutional performance. More robust audit measures for patients with low falls are required.

Lymphatic ascites following lymphadenectomy for gynecological malignancy

Seven patients seen between January 1995 and December 1998 developed symptomatic lymphatic ascites following either pelvic or para-aortic lymph node dissection. The incidence of symptomatic lymphatic ascites during this 4-year period was 2.7% (7 of 263 cases). The accumulation of ascites postoperatively was associated with a prolonged postoperative ileus, abdominal pain, and extended postoperative hospitalization. Once the condition was recognized, abdominal paracentesis resulted in rapid improvement of symptoms in two patients but repeated paracenteses were required for a further two patients who had significant complications as a result of these procedures. Two patients improved following spontaneous drainage of a large amount of ascites per vagina and did not require further intervention. The final patient settled with observation only. This condition can be difficult to recognize and is a potential cause of significant postoperative morbidity.

The management of elderly blunt trauma victims in Scotland: evidence of ageism?

Health services are challenged with providing trauma care to an increasingly elderly population. The objectives of this study were to determine the in-hospital mortality for injured elderly patients, and by analysing key features of their management, to ascertain whether these trauma patients were managed less aggressively than their younger counterparts. Main outcome measures included; use of resuscitation room facilities, senior medical staff involvement, admission to intensive care units, transfers to regional neurosurgical centres and mortality. Three thousand seven hundred patients initially managed in a resuscitation room were significantly younger (mean age 43) than those not treated in this area (mean age 54, 95% CI 10.7-12.4). Considering seriously injured patients with a significant head injury (who did not present in coma) those transferred to neurosurgical care were younger (mean age 44) than patients who were not transferred (mean age 49, 95% CI 1. 6-8.6). Logistic regression analysis showed that age did not have a significant independent effect on the seniority of medical response from key specialties. For the severely injured, the odds of being admitted to an intensive care unit when aged 70 in comparison to age 30 were 0.7436 (95% CI 0.5787-0.9559). Overall in-hospital mortality of the 290 elderly patients who had sustained major trauma was 42.1%. Significantly more of the elderly died than would be predicted. Age appears to be an independent factor in the process of trauma care in Scottish hospitals. We consider that outcomes for the injured elderly could be improved by a more dynamic approach to their management.

National audit of the management of injured patients in 20 Scottish hospitals

The Scottish Trauma Audit Group was established in 1991 to observe and improve the management of seriously injured patients in four Scottish teaching hospitals. There are currently 25 hospitals contributing to the national database. This prospective audit monitors the management of approximately 98% of seriously injured patients in Scotland. This report presents an analysis of the management of 23479 patients who were admitted to hospital for at least three days or who died in hospital as a result of their injuries. The audit has specifically addressed the concerns raised by the working party of the Royal College of Surgeons in 1988 and the National Audit Office in 1992. National standards were agreed and implemented by STAG in 1997. STAG has demonstrated that 73.5% of seriously injured patients presented outwith 'normal' working hours when staffing and support services are at their lowest level. Seniority of accident and emergency doctor was associated with improved outcome in injured patients. An increase in the presence of consultants in accident and emergency medicine, anaesthetics and surgery has been demonstrated and a reduction in the mortality of seriously injured patients is evident. There was no evidence of a trimodal distribution of death as a result of injury. There has been a significant increase in the survival of seriously injured patients over the last six years from 65.3% to 75.6%. In terms of survival, the management of injured patients in Scotland is significantly better than that of the rest of the UK.

Adjuvant small field pelvic radiation for patients with high risk, stage IB lymph node negative cervix carcinoma after radical hysterectomy and pelvic lymph node dissection. A pilot study

BACKGROUND

After radical hysterectomy and pelvic lymph node dissection, an identifiable subgroup of patients with International Federation of Gynecology and Obstetrics Stage IB lymph node negative cervix carcinoma remains at high risk of pelvic recurrence. This study attempted to determine whether postoperative small field of pelvic radiation can improve the disease free survival (DFS) of this high risk group of patients without producing significant morbidity.

METHODS

Between 1991 and 1995, after radical surgery, 25 patients with Stage IB lymph node negative cervix carcinoma were considered to be at high risk of pelvic recurrence on the basis of tumor dimension, depth of stromal invasion, and the presence of lymph-vascular space invasion. All had a score >/= 120 as determined by the Gynecologic Oncology Group (GOG) study. These patients received 50.4 gray of adjuvant radiation to a small central pelvic field and were followed prospectively. A Kaplan-Meier 5-year DFS curve was generated. A log rank analysis produced an estimated log rank P value (est P value) by comparing the 5-year DFS of the patients in the current study with the 5-year DFS of the corresponding high risk group of the GOG study (observation only). The morbidity of small field pelvic radiation was recorded.

RESULTS

Among the 25 patients who received small field pelvic radiation, the mean GOG score was 166 (range, 120-263) and the mean follow-up was 32 months (range, 12-64 months). There was 1 recurrence (4%) recorded at 16 months. The log rank analysis demonstrated a significant improvement in the 5-year DFS for the group who received adjuvant small field pelvic radiation (est P value = 0.005) when compared with the DFS of the high risk GOG patients who were observed postoperatively. Four cases of minor morbidity were recorded: lymphedema (three cases) and mild rectal incontinence (one case). No major morbidity was reported.

CONCLUSIONS

With low morbidity, adjuvant small field pelvic radiation appears to improve significantly the 5-year DFS of patients with high risk, lymph node negative Stage IB cervical carcinoma. However, this pilot study requires verification.

Prospective survey to verify the Ottawa ankle rules

OBJECTIVE

To determine if the Ottawa ankle rules are valid in the setting of an urban teaching hospital in the UK.

DESIGN

A prospective survey.

SETTING

Accident and emergency department, Western Infirmary, Glasgow from 1 April 1995 to 31 August 1995.

SUBJECTS

800 patients with an acute ankle injury.

RESULTS

800 patients were used for analysis of which 584 (73%) were radiographed; 70 (12%) had fractures, 63 (10.8%) of which were significant. Four of these patients with fractures fulfilled none of the Ottawa ankle rules criteria for plain radiography.

CONCLUSION

Application of the Ottawa ankle rules to this group of patients would have produced a sensitivity of 93.6%. Although useful, decision rules should be used with care and not replace clinical judgment and experience.

Corticosteroids in the management of bowel obstruction on a gynecological oncology unit

The development of gastrointestinal obstruction commonly occurs as a complication of advanced gynecological cancer. While surgery remains the mainstay of treatment for these patients, it is not always feasible, and when it is performed, it does not always resolve the obstruction. In this prospective study of patients presenting to a gynecologic oncology unit, 13 patients were administered 8 mg of dexamethasone subcutaneously or intravenously for a minimum of 3 days to manage the symptoms of bowel obstruction. Nine patients (69%) had a response to this therapy with decreased pain, nausea, and vomiting and improved oral intake. This response was maintained for a median of 31 days, with 7 of the 9 patients maintaining this symptomatic response until death. Mean survival of those responding was 39 days, including a subgroup of patients with extremely limited prognosis who, at their request, were discharged from the hospital in order to die at home. This subgroup had a mean survival of 20 days. The mean survival for nonresponders was 54 days. In patients for whom surgery is not contemplated, corticosteroids may provide a palliative treatment for bowel obstruction secondary to malignancy, provided there are no contraindications.

Increased survival after serious injury in patients admitted directly to critical care areas from the accident and emergency department

OBJECTIVES

We hypothesised that, in the subgroup of seriously injured patients who receive early critical care in the operating theatre or intensive care unit, there would be a greater actual survival rate than that statistically predicted using trauma scoring techniques.

METHODS

1031 seriously injured patients on a national trauma database were analysed. The numbers of survivors in 3 initial destination groups [intensive care unit (ICU), theatre and ward] were compared with the average number of survivors statistically predicted for similar groups of patients using the TRISS methodology. W statistics were then used to test for statistical significance.

RESULTS

77/122 patients admitted to an ICU survived (predicted number 66, W stat 8.8 [2.6-15.0]). 129/178 patients transferred to theatre survived (predicted number 113, W stat 8.8 [4.2-13.5]). 296/348 patients admitted to a ward survived (predicted number 292, W stat 1.3 [-1.9-4.4]).

CONCLUSIONS

The number of patients who survive after severe injury is significantly greater than the number predicted to survive by current trauma scoring methods if the patient is sent directly to theatre or are admitted directly to the ICU. Survival is as predicted if the patient is sent initially to a ward.

Initial assessment and outcome of head injured patients transferred to a regional neurosurgical service: what do we miss?

OBJECTIVE

To assess the level of missed extracranial injuries in patients transferred to a regional neurosurgical service for ongoing head injury management.

METHODS

A three year prospective study conducted under the auspices of the Scottish Trauma Audit Group. All patients were followed during their hospital stay by independent audit staff, their injuries being recorded and scored using established criteria.

RESULTS

115 head trauma patients were transferred during the study period. 15 patients died (13% mortality). Eight of a total of 87 separate, scorable extracranial injuries were missed (error rate 9%), none of which was serious. There were no missed injuries in patients who died. 77% of patients were managed by an accident and emergency doctor of at least registrar grade.

CONCLUSIONS

In contrast to other published series, this study has shown a low rate of missed extracranial injuries in a group of patients whose initial assessment is notoriously difficult. Early involvement by an experienced accident and emergency doctor may play an important part in the overall management of such patients.

A prospective study of rock climbing injuries

OBJECTIVES

To study the rate, causes, and nature of rock climbing injuries presenting to an accident and emergency (A&E) department.

METHODS

Patients presenting with rock climbing injuries to an urban A&E department were studied prospectively for one year.

RESULTS

19 rock climbers presented during the year, at a rate of one per 2774 A&E attendances. Fourteen climbers were injured on outdoor cliffs and five on the local indoor climbing wall, where the safety mats were noted to be in poor condition. Eighteen climbers had been injured during falls, 17 hitting the ground. Twelve of these climbers sustained fractures, four of which were missed on initial attendance. The remaining climber sustained the characteristic A2 pulley finger injury, which was treated conservatively with a good result.

CONCLUSIONS

The risks of rock climbing in Britain would be reduced if lead climbers arranged protection at earlier stages of climbs. Sports centres with climbing walls should regularly inspect and repair their safety equipment. It is important for staff in A&E departments to appreciate the large forces involved in any climbing fall, in order that significant injuries are not missed. Those treating injured climbers should also be aware of the specific injuries to which elite climbers are predisposed.

Paclitaxel (Taxol) as salvage therapy for relapsed ovarian cancer

Thirty-two patients with epithelial ovarian cancer received paclitaxel 175 mg/m2, by 3-hour infusion, in this prospective phase 2 study. All patients had relapsed or progressed after initial cisplatin/cyclophosphamide therapy. Thirteen patients received paclitaxel as second line therapy, 14 as third line therapy and 5 as fourth line therapy. One patient was excluded from efficacy analysis, due to a severe anaphylactic reaction to the first cycle of paclitaxel therapy. Of the 31 evaluable patients, complete remission was observed in 3 patients (9.7%) and partial remission in 11 patients (35.5%), with a total response rate of 45.2%. The median survival from diagnosis for the 31 evaluable patients was 32.5 months and the median survival following therapy with paclitaxel was 12.2 months (range 4-27 months). The 3 patients who achieved a complete response remain alive, at greater than 20 months, since commencing paclitaxel. Twelve patients (38.7%) who achieved a partial response, or had stable disease, had a median survival, after paclitaxel treatment, of greater than 18 months. This study confirms the activity of paclitaxel in relapsed ovarian cancer and demonstrates a prolonged survival benefit in greater than one third of this group of patients.

Cytology in the follow-up of cervical cancer

OBJECTIVE

To determine the value of cytology in the follow-up of cervical cancer.

STUDY DESIGN

The study group consisted of 230 patients with invasive cervical carcinoma who were followed for one to seven years. Forty-four patients developed recurrences or metastases. During this period, cytologic investigations involved 795 exfoliative smears from the cervix or vaginal vault, 10 fine needle aspirates and 5 fluids.

RESULTS

Thirty-three patients had positive or inconclusive cervical or vault smears that were histologically proven to be recurrences, and the other 11 patients had clinically obvious recurrences that were not smeared. Cytology first alerted the clinicians to recurrence in eight patients. Of 25 cervical or vault smears reported as malignant, 24 (96%) were histologically confirmed, and 1 showed radiation change on biopsy. In all 22 cases of smears reported as inconclusive, a biopsy followed, and in 9 (41%) of these, recurrence was demonstrated histologically. Inability to distinguish radiation change from recurrent malignancy was the chief cause of inconclusive smears. Five fluids and seven fine needle aspirates were diagnosed as malignant, saving patients an invasive diagnostic procedure.

CONCLUSION

Cytology is a useful, cost-effective, noninvasive and accurate investigation in the follow-up of cervical cancer.

Acute psychiatric problems in an A&E Department

A study of patients with psychiatric problems attending the Accident & Emergency Department at the Western Infirmary, Glasgow was performed over a four month period. Those requiring admission to other specialties for treatment were excluded (e.g. overdoses). Forty-seven patients presented during the study period and all were self-referred. Seventy-seven per cent had a past history of psychiatric illness. Sixty-six per cent of cases presented with self harm. Eighty-one per cent of cases presented after normal working hours. Alcohol intoxication was a contributing factor in only one quarter of patients presenting. Of all cases seen, 62% were referred to a duty psychiatrist. In this group 38% were admitted and 45% were discharged with psychiatric follow-up, three absconded and two were referred back to their general practitioners. Results indicated that the majority of patients referred to the psychiatric services from Accident & Emergency needed some form of psychiatric input. In the self harm group results showed a correlation between known risk factors for suicide and a need for admission or follow up. Due to local psychiatric referral policies, patients were referred to four different psychiatric hospitals in the area. After initial assessment by the duty psychiatrist, 52% of these patients were subsequently discharged with or without psychiatric follow up. Availability of an on site psychiatrist would alleviate many of the present delays in obtaining definitive management.

Grapelike leiomyoma of the uterus

A 24-year-old nulliparous woman underwent laparotomy for a large pelvic mass. Grapelike tumor extending from the uterus into the broad ligaments and peritoneal cavity was found. A diagnosis of sarcoma appeared likely, but radical surgery was avoided when frozen sections indicated a histologically benign smooth muscle tumor.

Extrauterine malignant mixed müllerian tumor of primary peritoneal origin

The case of an extrauterine heterologous malignant mixed müllerian tumor (MMMT) of primary peritoneal origin occurring in a 63 yr old woman is presented. The tumor was a 19 cm, soft, friable mass arising from the serosa of the sigmoid colon and spreading to adjacent pelvic peritoneum. The uterus, tubes and ovaries were uninvolved. It was composed of sarcomatous areas showing cartilaginous and rhabdomyoblastic differentiation and sharply demarcated carcinomatous areas showing endometrioid and serous differentiation. This is the thirteenth reported case of an extragenital MMMT. It demonstrates the pluripotentiality of female pelvic peritoneum to differentiate into tumors resembling those of the genital tract.

Decerebrate posturing in alcoholic coma

Two cases of alcoholic coma are presented where extensor responses to noxious stimuli are demonstrated. Decerebrate posturing normally indicates severe structural or functional depression of midbrain function but can be caused by depressant drugs. Blood alcohol measurements are a vital test in the comatose patient as the clinical picture may be caused, or temporarily significantly worsened, by severe alcohol intoxication. The preservation of pupillary light reflexes in the presence of deep coma with decerebrate posturing should alert the clinician to a possible metabolic cause for the coma, including alcohol. Nevertheless, a diagnosis of alcoholic coma should not be made unless the blood alcohol concentration is grossly elevated and other causes of coma have been excluded by careful physical examination, blood glucose and electrolyte measurement, skull radiography and, in the absence of a rapid improvement, computerized tomography.

The treatment of gynaecological malignancy in a general public hospital

OBJECTIVE

To assess the adequacy of treatment of gynaecological cancer in a public hospital and to determine the influence of referral patterns on patient outcome.

DESIGN

A retrospective analysis of clinical histories.

SETTING

A tertiary-level general public hospital.

PATIENTS

89 patients admitted between 1 January 1979 and 31 December 1987 for primary treatment of a gynaecological malignancy.

MAIN OUTCOME MEASURES

The primary study parameter was patient survival. During data analysis, the study parameters were altered to include the adequacy of initial surgery and survival time in relation to the involvement of the Gynaecology Unit.

RESULTS

Initial presenting symptoms had a major influence on the referral patterns of patients with a gynaecological malignancy. All patients who presented with abnormal vaginal bleeding were managed by the Gynaecology Unit. Patients with ovarian cancer who presented with non-specific abdominal symptoms and ascites were often managed by other units. There was a statistically significant difference in the adequacy of initial surgery depending on whether the patient was managed by the Gynaecology or the Surgical Unit (P < 0.05). The median survival time of patients managed by the Gynaecology Unit was 20 months; this was considerably longer than the figure of 14 months for other units (P < 0.05).

CONCLUSIONS

Patients with ovarian cancer who are managed by a specialised gynaecology unit are more likely to have adequate initial surgery and a longer median survival time. Female patients presenting with non-specific abdominal symptoms, ascites and other signs of intra-abdominal malignancy should be reviewed by a gynaecology unit before initial surgery.

Maximum effort in the management of ovarian cancer, including pelvic and para-aortic lymphadenectomy

Patients treated for ovarian cancer at the Mercy Hospital for Women, Melbourne over a 5 1/2 year period were studied with an emphasis on the need for lymphadenectomy. There were 80 patients identified with ovarian cancer. Forty patients underwent pelvic and/or para-aortic lymphadenectomy and 25 (62.5%) were found to have lymph node metastases, in 7 of the 40 women the lymphadenectomy resulting in upstaging of the disease. FIGO has adopted a surgicopathological approach to the staging of ovarian cancer and this requires lymphadenectomy to be performed. The importance of accurate staging in clinically early ovarian cancer and maximum surgical effort in advanced disease is discussed with particular regard to the place of lymphadenectomy.

The diagnosis of pelvic fractures by 'springing'

Thirty-six patients were studied prospectively to assess the benefit of 'springing' the pelvis in traumatized patients, to confirm or refute a fracture of the pelvis. None of the patients was multiply injured and half of those with fractures were elderly, sustaining their injuries in simple falls. Springing the pelvis was a poor predictor of the presence or absence of a pelvic fracture, at best it yielded a specificity of 71% and sensitivity of 59%. Its routine use in clinical examination should be abandoned.

The haemodynamic effects of sublingual nitroglycerin spray in severe left ventricular failure

The use of sublingual nitroglycerin spray has been studied in twenty patients referred to our Intensive Care Unit for further treatment of severe left ventricular failure. Within five minutes of spray administration significant falls in pulmonary artery occlusion pressure, mean arterial pressure, heart rate, right atrial pressure and systemic vascular resistance occurred. Similarly significant increases in cardiac index, stroke volume index and left ventricular stroke work index were found. These results show a considerable improvement in the haemodynamic parameters of invasively monitored patients and we believe that its administration undoubtedly "buys time" for the critically ill patient. However, we would caution against its routine use at present in view of the potential problem of hypotension, until further information is available.

Pelvic radiation therapy for gynecologic malignancy in geriatric patients

Thirty-one patients, aged 75 years or older, who received pelvic radiation therapy as part of primary treatment for a gynecologic malignancy, were reviewed. Ten patients (32%) failed to complete their treatment and 4 patients (13%) died of treatment-related complications. The treatment-related complications were independent of increasing age, but did correlate closely with the patients' pretreatment ECOG performance status. Ten patients with performance levels of 2 or higher had a mortality rate of 30%, while 70% failed to complete treatment. Treatment fractions of greater than 220 cGy per day also resulted in unacceptably high complication rates. Alternative treatment formats should be considered in geriatric patients with poor initial performance levels.

The long-term follow-up of women with gestational diabetes

Four hundred and forty-seven women who had gestational diabetes have been retested at intervals from 1 to 12 years following diagnosis; 49 (11%) were found to be diabetic and 35 (7.8%) had impaired glucose tolerance using the WHO criteria. An abnormal glucose tolerance test in the puerperium and obesity at the time of retesting had significant associations with abnormal glucose tolerance at follow-up. However, the best predictive factor of the likelihood of the development of significant hyperglycaemia was the recurrence of gestational diabetes in a subsequent pregnancy, since 28% of these women were diabetic and a further 4% had impaired glucose tolerance at the time of follow-up. These findings indicate that the criteria used for the diagnosis of gestational diabetes at the Mercy Maternity Hospital, Melbourne (1-hour greater than or equal to 9 mmol/l together with a 2-hour greater than or equal to 7 mmol/l) are appropriate for an Australian population.

Gadusol, an enolic derivative of cyclohexane-1,3-dione present in the roes of cod and other marine fish. Isolation, properties and occurrence compared with ascorbic acid

Gadusol, C8H12O6, has been isolated from roes of the cod (Gadus morhua L.), i.e., ovaries that contain ripe eggs just before spawning. The concentration is about 4 g/kg dry wt. It has been identified as 1,4,5-trihydroxy-5-hydroxymethyl-2-methoxycyclo-hex-1-en-3-one and this structure was confirmed by synthesis of the anhydro tetra-acetate derivative from methyl 3,5-diacetoxy-4-methoxybenzoate. Concentrations of gadusol in the roes of other marine teleost fish examined are of the same order as in cod roes. Gadusol has some properties similar to ascorbic acid and both compounds, after oxidation, react with 2,4-dinitrophenylhydrazine in the commonly-used assay procedure for ascorbic acid. Specific assays showed that the concentrations of gadusol in the roes of marine fish are severalfold greater than those of ascorbic acid. Gadusol is structurally related to the mycosporines previously reported from a number of different organisms.

Drugs from the sea--fact or fantasy?

Drugs from the sea are as much a potential marine resource as cultivated fish, and mineral deposits. The study of the chemical structure and properties of unusual metabolic products of marine life is a subject where marine ecology and the experimental sciences of chemistry, biochemistry, pharmacology and medicine share a common and complementary interest. The development of ad hoc collaboration between specialists has advanced basic knowledge and resulted in a significant feedback to marine biology and ecology as well as in the development of some useful drugs.

A haemagglutinin in the tissue fluid of the Pacific oyster, Crassostrea gigas, with specificity for sialic acid residues in glycoproteins

An agglutinin for human red cells has a specificity for sialic acid and a high affinity for bovine salivary glycoprotein. Digestion of the glycoprotein with Pronase or neuraminidas indicated that binding of sialic acid to receptors in the agglutinin is the first step in the mechanism of formation of a stable complex between ligand and receptor.

Differences in the nature of the interaction of insulin and proinsulin with zinc

1. The reversible interaction of zinc with pig insulin and proinsulin has been studied at pH7 by equilibrium dialysis (ultrafiltration) and by sedimentation equilibrium and velocity measurements in the ultracentrifuge. Binding values calculated from equilibria, where the ratio of free to bound zinc was varied in the range 0.01:1-10:1, indicated that proinsulin and insulin each contained two main orders of zinc binding with very different affinities for the metal. 2. In equilibria containing low concentrations of free zinc (free: bound ratios of 0.01-0.1:1) both insulin and proinsulin aggregated to form soluble hexamers containing firmly bound zinc (up to 0.284g-atom/monomer) with an apparent intrinsic association constant of 1.9x10(6)m(-1). 3. Higher concentrations of zinc (free: bound ratios of 0.1-10.0:1) resulted in a progressive difference in the zinc binding, aggregation and solubility properties of the metal complexes of insulin and proinsulin. At the highest concentration of free zinc, proinsulin bound a total of more than 5.0g-atom/monomer and aggregated to form a mixture of soluble polymers (mainly 5.1S). In contrast, insulin bound a total of only 1.0g-atom/monomer and was almost completely precipitated from solution. 4. These results would indicate that the presence of the peptide segment connecting the insulin moiety in proinsulin does not prevent the firm binding of zinc to the insulin moiety and the formation of hexamers of zinc-proinsulin. At the same time although the connecting peptide contains additional sites of lower affinity for zinc, which should facilitate inter- and intra-molecular cross-linking, the general conformation of the zinc-proinsulin hexamer must preclude the formation of very large and close-packed aggregates that are insoluble in solutions at equilibrium.