AB1445 SYNOVIAL FLUID ANALYSIS IN HOT SWOLLEN JOINTS – A QUALITY IMPROVEMENT PROJECT

Background

Previous studies have reported delays in the investigation and suboptimal management of hot swollen joints, particularly crystal arthritis. In our hospital, it was noted that synovial fluid was inconsistently analysed for crystals which may lead to patients receiving delayed treatment.

Objectives

The aim of this quality improvement project was to 1) identify the number of synovial fluid samples that were not checked for crystals 2) implement changes to improve this process 3) re-audit and commitment to a continuous evaluation.

Methods

Retrospective review of synovial fluid analysis requested for adult patients presenting with hot swollen joints over a six month period. Following, the implementation of changes in the hospital, another comparison of pre-post intervention was performed.

Results

A total of 106 synovial fluid samples were sent for analysis between March and August 2021, of which only 69 (65%) of the samples were analysed for crystals. All samples were analysed for microscopy and culture. Following involvement with IT and laboratory departments we have introduced an intervention to make requesting crystal analysis easier. The request for synovial fluid analysis was grouped in a bundle (reflex test) so whenever a synovial fluid is collected, two forms are generated, one for microbiology (microscopy and culture), and the other for cytology (crystal analysis). Additional interventions included education and raising awareness. Post-interventions, another three month analysis of synovial fluid showed that compliance improved to 78%.

Conclusion

There was an improvement in the synovial fluid analysis requests of patients with hot, swollen joints. By implementing these changes and raising awareness, patients with acute crystal arthritis can be treated in a timely manner. We plan to continue our work with synovial fluid analysis following re-review and will continue to generate improvements.

Disclosure of Interests

None declared

Mean-field solution of structural balance dynamics in nonzero temperature

In signed networks with simultaneous friendly and hostile interactions, there is a general tendency to a global structural balance, based on the dynamical model of links status. Although the structural balance represents a state of the network with a lack of contentious situations, there are always tensions in real networks. To study such networks, we generalize the balance dynamics in nonzero temperatures. The presented model uses elements from Boltzmann-Gibbs statistical physics to assign an energy to each type of triad, and it introduces the temperature as a measure of tension tolerance of the network. Based on the mean-field solution of the model, we find out that the model undergoes a first-order phase transition from an imbalanced random state to structural balance with a critical temperature T_{c}, where in the case of T>T_{c} there is no chance to reach the balanced state. A main feature of the first-order phase transition is the occurrence of a hysteresis loop crossing the balanced and imbalanced regimes.

Perspectives on domestic violence: case study from Karachi, Pakistan

There is no adequate profile of domestic violence in Pakistan although this issue is frequently highlighted by the media. This case study used qualitative and quantitative methods to explore the nature and forms of domestic violence, circumstances, impact and coping mechanisms amongst selected women victims in Karachi. Violence was a continuum: all the women reported verbal abuse, often escalating into physical, emotional, sexual and economic abuse. The husband was the most common perpetrator. Women suffered in silence due to sociocultural norms, misinterpretation of religious beliefs, subordinate status, economic dependence and lack of legal redress. Besides short-term local measures, public policy informed by correct interpretation of religion can bring about a change in prevailing societal norms.

Using SERVQUAL for assessing and improving patient satisfaction at a rural health facility in Pakistan

A cross-sectional study of patient satisfaction with care was conducted over a period of 1 year from March 2004 to March 2005 in a secondary-level hospital in a peri-urban area of Karachi, Pakistan. Using the SERVQUAL tool and exit interviews, data were collected quarterly from a total of 1533 patients. Results sharing and capacity-building workshops were arranged during the 4 phases of the survey to sensitize the staff of the hospital to work towards improving patient satisfaction. The level of satisfaction of the patients with the outpatient health services provided showed a gradual increase from 34.4% to 82.0% over the 1-year period.

Gender sensitization among health providers and communities through transformative learning tools: experiences from Karachi, Pakistan

CONTEXT

Pakistan lags far behind most developing countries in women's health and gender equity. Appropriateness of health care services vis-a-vis the gender specific cultural norms that influence clients' needs are not very visible and are more difficult to monitor. Programs and services need to be sensitively designed to facilitate women's access to physical and social needs. This paper narrates the experience of working with health providers from public and private sectors, community, local government representatives and community-based organizations. Through transformative learning, this endeavour focused on initiating a process of sensitization on gender related health issues for women.

APPROACH

The initiative was primarily based on the use of the following two standardized tools: 'Health Workers for Change' for working with health providers and 'Initiating Women Empowerment for Health' for interacting with the community. Both tools focus primarily on women's health and social issues affecting their health status. The research methodology used was predominantly qualitative, using focus group discussions, participatory rural appraisal and interactive workshops.

IMPLICATIONS

This approach endeavours to sensitize the health service providers to the health needs of female clients and encourages behavioural changes. Simultaneously, it creates an opportunity to raise awareness among women and the community in general regarding appropriate health-seeking behaviour and the timely use of health services. The information collected is evidence for policy makers regarding the gender-based problems faced by women who are seeking health care and it suggests how to overcome these problems.

Extended vs. limited laparoscopic pelvic lymph node dissection for prostate cancer: The value of Partin tables in selection of the need for and the extent of dissection

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Background: To determine if pelvic lymph node dissection (LND) can be omitted in prostate cancer patients at low risk of nodal metastases according to the Partin tables and to determine the yield on extended vs limited LND in patients at high risk to better define the appropriate template of dissection. Methods: A total of 577 patients with clinically localized prostate cancer underwent a laparoscopic radical prostatectomy (LRP). In the first 363 patients, a cutoff of 1% on the Partin tables’ predicted probability of lymph node invasion (PPLNI) was used to select patients for a limited LND (external iliac nodes only). In the subsequent 214 patients, all patients underwent an extended LND (external iliac, obturator and hypogastric nodes). Patients were classified into 4 groups: Group I, 186 patients with a PPLNI ≤1%, did not undergo a LND; Group II, 110 patients with PPLNI ≤ 1%, underwent an extended LND; Group III, 177 patients with PPLNI >1% underwent a limited LND and Group IV, 104 patients with PPLNI >1%, underwent an extended LND. We compared Group I and II to assess the value of the Partin tables in selecting low risk patients for nodal metastasis. Multivariate logistic regression analysis was performed to compare the node positivity rate between groups III and IV, controlling for preoperative and pathological parameters. Results: None of the patients in group II had a positive lymph node after an extended LND. On multivariate analysis, controlling for PSA, biopsy Gleason, clinical stage, pathological Gleason and stage, and seminal vesicle invasion, the extended LND independently impacted the rate of node positivity with a relative risk (RR) of 15.6 (95% CI 3.7 -66.4, p < 0.001). The median (mean) number of nodes retrieved was 9 (10) and 14 (15) after limited and extended LND respectively (p < 0.001). Conclusions: A lymph node dissection including the external iliac, obturator and hypogastric lymph node groups yields positive nodes more frequently and retrieves a higher total nodal count than the often-performed LND limited to the external iliac nodes. Decision to forgo LND in low risk patients needs to be validated by long-term biochemical recurrence data

No significant financial relationships to disclose.

Health Workers for Change: a tool for promoting behaviour change among health providers

Sensitizing health providers to customers' needs and women's health remains a challenge to the Pakistani health system. The Health Workers for Change methodology has been demonstrated to improve provider-client relationships in certain African and Latin American countries. This paper describes the experience of using Health Workers for Change participatory workshops in Pakistan to sensitize male and female health providers to gender issues. Health care providers identified the unmet needs of women clients as a function of individual, household and societal factors, and, unlike the African experience with this tool, not predominantly confined to factors associated with the health facility.

Health management information system: a tool to gauge patient satisfaction and quality of care

The health management information system (HMIS) is an instrument which could be used to improve patient satisfaction with health services by tracking certain dimensions of service quality. Quality can be checked by comparing perceptions of services delivered with the expected standards. The objective of the HMIS would be to record information on health events and check the quality of services at different levels of health care. The importance of patient assessment is a part of the concept of giving importance to patient's views in improving the quality of health services. Expected benefits include enhancing patient satisfaction through improved communication; greater provider sensitivity towards patients; enhanced community awareness about the quality of services; and overall better use of services in the health system.

The district health system: a challenge that remains

The health care system in Pakistan has been confronted with problems of inequity, scarcity of resources, inefficient and untrained human resources, gender insensitivity and structural mismanagement. With the precarious health status of the people and poor indicators of health in the region, health care reforms were finally launched by the government in 2001. There are, however, numerous challenges and constraints in the system. The future health of the nation depends on this decentralization initiative. All our efforts should be concerted to support and facilitate the new system, which will mature into institutionalization of the health services at the district level. Most importantly, it will help in strengthening the primary health care services catering to the major fraction of the population. Besides political commitment, we ought to maintain attitudinal, behavioural and cultural conditions conducive to letting this system flourish

The district health system: a challenge that remains

The health care system in Pakistan has been confronted with problems of inequity, scarcity of resources, inefficient and untrained human resources, gender insensitivity and structural mismanagement. With the precarious health status of the people and poor indicators of health in the region, health care reforms were finally launched by the government in 2001. There are, however, numerous challenges and constraints in the system. The future health of the nation depends on this decentralization initiative. All our efforts should be concerted to support and facilitate the new system, which will mature into institutionalization of the health services at the district level. Most importantly, it will help in strengthening the primary health care services catering to the major fraction of the population. Besides political commitment, we ought to maintain attitudinal, behavioural and cultural conditions conducive to letting this system flourish.

Tuberculosis: do we know enough? A study of patients and their families in an out-patient hospital setting in Karachi, Pakistan

SETTING

In Pakistan approximately 5.7 million people suffer from tuberculosis, with 260 000 new cases occurring every year. This study was conducted in an outpatient hospital setting in Karachi.

OBJECTIVE

To explore the level of awareness about tuberculosis amongst patients and their families, and recommend strategies for increasing understanding of the disease.

DESIGN

Descriptive cross-sectional survey based on a structured questionnaire using convenience sampling.

RESULTS

Of the 203 patients interviewed, 131 were males. Nearly 82% knew that tuberculosis is contagious and 78% were aware that lungs are commonly affected. Almost half knew that it spreads by droplets and causes cough and that treatment is long and costly. With regard to commonly affected age and sex, however, respectively only 43% and 23% had the correct knowledge. Less than one third could identify appropriate risk factors and ways to cure and limit spread. Almost half considered tuberculosis to be a social stigma. Media emerged as the main source of information. Respondents with more than 12 years of formal education were more likely to have better knowledge.

CONCLUSIONS

Further population-based studies are recommended. Misconceptions about tuberculosis need to be removed through focused health education messages. The importance of complete and appropriate treatment needs to be emphasised.

The role of thoracotomy in managing postchemotherapy residual thoracic masses in patients with nonseminomatous germ cell tumours

OBJECTIVE

To evaluate the clinical outcome and identify prognostic variables in patients with nonseminomatous germ cell tumours undergoing postchemotherapy thoracotomy for residual masses, as the role of this procedure is controversial.

PATIENTS AND METHODS

Of 385 patients who underwent postchemotherapy retroperitoneal lymph node dissections between 1988 and 1998, 105 also had 130 thoracotomies. The clinical presentation, chemotherapy regimens, marker status, primary tumour histology, pathology of all resected masses, and clinical outcome of these 105 patients were analysed.

RESULTS

The overall discordance rate for synchronous thoracic and retroperitoneal masses was 28%; that for asynchronous thoracic and retroperitoneal masses was 57%. Independent prognostic factors for residual thoracic teratoma or cancer were teratoma (mature or immature) in the primary tumour or retroperitoneal teratoma or cancer. Although three of 12 patients with residual thoracic cancer remained with no evidence of disease, residual thoracic cancer is an independent prognostic factor (P < 0.001) against disease-free survival.

CONCLUSION

Postchemotherapy thoracotomy yields important prognostic information, and is therapeutic for most patients with teratoma and a subset with residual viable cancer. The prognostic criteria predictive of fibrosis are not sufficiently accurate to omit resection of residual thoracic masses.

Low-volume nodal metastases detected at retroperitoneal lymphadenectomy for testicular cancer: pattern and prognostic factors for relapse

PURPOSE

To determine the incidence, pattern, and predictive factors for relapse in patients with low-volume nodal metastases (stage pN1) at retroperitoneal lymphadenectomy (RPLND) and identify who may benefit from chemotherapy in the adjuvant or primary setting.

PATIENTS AND METHODS

Fifty-four patients with testicular nonseminomatous germ cell tumor had low-volume retroperitoneal metastases (pathologic stage pN1, 1997 tumor-node-metastasis classification) resected at RPLND, 50 of whom were managed expectantly without adjuvant chemotherapy. The dissection was bilateral in 12 and was a modified template in 38 patients. Retroperitoneal metastases were limited to microscopic nodal involvement in 14 patients. Follow-up ranged from 1 to 106 months (median, 31.4 months).

RESULTS

Eleven patients (22%) suffered a relapse at a median follow-up of 1.8 months (range, 0.6 to 28 months). The most frequent form of recurrence was marker elevation in nine (18%) patients. Persistent marker elevation after orchiectomy and before retroperitoneal lymphadenectomy was a significant independent predictor of relapse (relative risk, 8.0; 95% confidence interval, 2.3 to 27.8; P =.001). Four of five (80%) patients with elevated markers (alpha-fetoprotein alone in three, alpha-fetoprotein and beta human chorionic gonadotropin in one) suffered a relapse, compared with seven of 45 (15.6%) patients with normal markers.

CONCLUSION

Clinical stage I and IIA patients with normal markers who have low-volume nodal metastases have a low incidence of relapse and can be managed by observation only if compliance can be assured. In contrast, patients with elevated markers before retroperitoneal lymphadenectomy have a high rate of relapse and should be considered for primary chemotherapy.

Behind the counter: pharmacies and dispensing patterns of pharmacy attendants in Karachi

BACKGROUND

There is little literature available on dispensing patterns and unsupervised sale of medicines from pharmacies in developing countries.

OBJECTIVE

This study obtained background information on pharmacies, assessed the level of training, knowledge and dispensing patterns of pharmacy attendants in Karachi.

METHODOLOGY

This is a descriptive cross sectional study with convenient sampling. A structured questionnaire was used to interview pharmacy attendants.

RESULTS

Of the 219 pharmacies surveyed, 62% reported more than 50 customers daily and 20% also sold items of general provision. Mean operating hours were 13. Only 24 (11%) had a visible license. On an average 3 attendants were employed per pharmacy. We interviewed one in each. Amongst the 219 interviewed, 77 (35%) were intermediate qualified and only 26 (12%) pharmacologically trained. Correct frequency of ORS administration was not known by 167 (76%) and 21% incorrectly suggested an anti-diarrhoeal preparation for viral diarrhoea in children. The knowledge of those with pharmacological training was significantly better. For respiratory tract infection in children approximately 60% did not know the correct dose of Paracetamol and Amoxicillin. Only 13 (6%) knew that Propanalol was contraindicated in hypertensive asthamatics. For Cotrimoxazole, metronidazole and lomotil only 40%, 21% and 15% respectively, were aware that these could not be dispensed without prescription.

CONCLUSION

In the absence of trained pharmacists existing pharmacy attendants should be trained to improve drug-dispensing patterns.

Upper-tract tumors after an initial diagnosis of bladder cancer: argument for long-term surveillance

PURPOSE

To determine the relative risk (RR) of upper-tract tumors (UTT) after bladder cancer, stratified by bladder tumor characteristics, demographic factors, and follow-up duration, in order to develop an improved risk-based surveillance strategy.

PATIENTS AND METHODS

The 1973 to 1996 Surveillance, Epidemiology, and End Results (SEER) database was used to determine the observed and expected number of UTT after bladder cancer. The RR with 95% confidence intervals (CI) were calculated, stratifying by race, sex, stage, grade, histology, and follow-up duration. The tumor characteristics and clinical outcome were compared in patients with UTT after bladder cancer and those with de novo UTT.

RESULTS

A total of 94,591 patients had a first diagnosis of bladder cancer, of whom 91,245 had follow-up (median, 4.1 years), with no antecedent or synchronous UTT. UTT developed subsequently in 657 of 91,245 (0.7%), with 12.80 expected cases (RR = 51.3; 95% CI, 47.5 to 55.4). The respective RRs for UTT for white men and women were 64.2 (95% CI, 55.1 to 74.3) and 75.4 (95% CI, 57.7 to 96.9) at less than 2 years, 44.3 (95% CI, 36.7 to 53.0) and 40.5 (95% CI, 27.9 to 56.8) at 2 to 5 years, 50.8 (95% CI, 42.2 to 60.7) and 42.1 (95% CI, 28.8 to 59.4) at 5 to 10 years, and 43.2 (95% CI, 32.6 to 56.1) and 22.2 (95% CI, 10.1 to 42.2) at >or= 10 years. Similar RRs were seen among different strata of race, stage, grade, and histology. Patients with UTT after bladder cancer had lower stage and improved disease-specific survival compared with those with de novo UTT.

CONCLUSION

The incidence of UTT is stable on long-term follow-up, with no significant risk factors identified. These findings suggest that upper-tract surveillance remain rigorous on extended follow-up of bladder cancer patients.

Factors predicting recovery of erections after radical prostatectomy

PURPOSE

Because preservation of functioning penile erections is a major concern for many patients considering treatment for localized prostate cancer, we analyzed various factors determined before and after radical retropubic prostatectomy to identify those significantly associated with recovery of erectile function.

MATERIALS AND METHODS

Our prospective database of patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy was used to determine factors predictive of erection recovery after radical prostatectomy. The study included 314 consecutive men with prostate cancer treated with radical retropubic prostatectomy between November 1993 and December 1996. Preoperative potency satisfactory for intercourse and degree of neurovascular bundle preservation during the operation were documented.

RESULTS

Patient age, preoperative potency status and extent of neurovascular bundle preservation but not pathological stage were predictive of potency recovery after radical prostatectomy. At 3 years after the operation 76% of men younger than age 60 years with full erections preoperatively who had bilateral neurovascular bundle preservation would be expected to regain erections sufficient for intercourse. Compared to the younger men, those 60 to 65 years old were only 56% (95% confidence interval [CI] 37 to 84) and those older than 65 years were 47% (95% CI 30 to 73) as likely to recover potency. Patients with recently diminished erections were only 63% (95% CI 38 to 100) as likely to recover potency as men with full erections preoperatively, and those with partial erections were only 47% (95% CI 23 to 96) as likely to recover potency. Resection of 1 neurovascular bundle reduced the chance of recovery to 25% (95% CI 10 to 61) compared to preserving both nerves.

CONCLUSIONS

Knowledge of preoperative erectile function and patient age before the operation and the degree of neurovascular bundle preservation afterward may aid in patient counseling regarding potency recovery after radical prostatectomy.

Clinical spectrum of systemic lupus erythematosus at the Aga Khan University Hospital

BACKGROUND

Systemic lupus erythematosus is a disease of unknown etiology, which at onest may involve only one organ system or be multisystemic. The aim of our study is to determine the clinical presentation of SLE patients presenting to AKUH to establish whether guidelines laid down about this disease are in agreement with our experience.

METHODS

A retrospective log review was carried out at AKUH, based on data obtained from 165 files of individuals admitted to the hospital over a period of 12 years with a confirmed diagnosis of SLE.

RESULTS

From the sample size of 165, 143 (86.7%) were females and 22 (13.3%) males. The mean age of diagnosis was 30.9 years. Frequency of symptomatology was observed to be in the following order: systemic 78.8%, musculoskeletal 63% and hematological 60.6%. Oninvestigation ANA levels were positive in 112 patients.

CONCLUSION

Our result lead us to conclude that the classification set forth by the American Rheumatological Association is applicable to patients presenting with SLE in our setting.

The minds of mothers: maternal mental health in an urban squatter settlement of Karachi

BACKGROUND

Community-based information on maternal mental health in developing countries is meager and nearly non-existent in Pakistan.

OBJECTIVE

To determine the proportion of probable cases of women with mental disorders and examine the associated conditions and risk factors which contribute to maternal mental ill-health.

METHODS

With convenient sampling 260 mothers in an urban squatter settlement of Karachi were interviewed. The tools consisted of a household questionnaire collecting information on basic demographic and other characteristics and the Aga Khan University Anxiety and Depression Scale (AKUADS), an instrument to assess psychiatric morbidity.

RESULTS

The proportion of probable cases of mental disorder was 28.8% (n = 75). Reviewing the gradient of responses the most frequently expressed psychiatric symptoms were "being worried" and "crying". Amongst somatic complaints the most frequently reported was headache. Study also suggests that women in the older age group (OR 2.30, CI 1.27-4.19, p = 0.0031) and those with longer duration of marriage (OR 1.80, CI 1.01-3.22, p = 0.032) are more likely to be mentally distressed. Arguments with husband (OR 5.0, CI 2.19-11.52, p = 0.00001) or in-laws (OR 2.43, CI 1.22-4.85, p = 0.0059), husband's unemployment (OR 4.1, CI 1.27-13.6, p = 0.0058), not having permanent source of income and lack of autonomy in making decisions significantly contributed towards mental illness.

CONCLUSION

Approximately 1 out of 4 women suffer from mental illness. This is alarmingly high. Besides counseling in cases of matrimonial disharmony, community-based interventions should aim to improve the socioeconomic status of households.

Second primary malignancies associated with renal cell carcinoma: influence of histologic type

OBJECTIVES

This study was performed to determine which histologic types of renal cell carcinoma have an association with a second primary malignancy.

METHODS

Seven hundred sixty-three patients underwent an operation for renal cell carcinoma between July 1989 and January 1999. The incidence of antecedent, synchronous, or subsequent second malignancies was determined. Statistical tests based on the Poisson model were used to compare the observed number of subsequent malignancies developing after a diagnosis of renal cell carcinoma with the expected number calculated using the 1973 to 1994 U.S. Surveillance, Epidemiology, and End Results age, race, gender, and calendar-year specific incidence rates.

RESULTS

Second primary malignancies were present in 209 of 763 (27.4%) patients, with prostate, breast, colon, and bladder cancer and non-Hodgkin's lymphoma being the five most common second malignancies. The other malignancies were antecedent in 118 cases (44.5%), synchronous in 104 cases (39.2%), and subsequent in 43 cases (16.2%). Patients with papillary renal cell carcinoma were at increased risk of developing bladder cancer (standardized incidence ratio [SIR] 6.5, P = 0.038). Men with papillary renal cell carcinoma were also at increased risk of developing prostate cancer (SIR 2.8, P = 0.035).

CONCLUSIONS

There is an increased risk of subsequent bladder and prostate cancer in patients with papillary renal cell carcinoma.

Mutation of cell cycle regulators and their impact on superficial bladder cancer

Early cytogenetic studies in bladder cancer identify regions of chromosomal gain or loss that can be candidate loci for oncogenes and tumor suppressor genes. Oncogenes with potential prognostic significance identified in bladder cancer the RAS family, epidermal growth factor receptor, ERBB-2, MDM2, and cyclin D1. The TP53 gene has been the most thoroughly characterized tumor suppressor gene in bladder cancer, with correlation of TP53 alterations with type of carcinogenic exposure, tumor stage and grade, as well as prognosis. Studies evaluating alterations of the retinoblastoma pathway have identified the retinoblastoma gene, RB, p161NK4A/CDKN2, and E2F-1 as tumor suppressor genes with potential prognostic significance in patients with bladder cancer. Better understanding of the genetic mechanisms underlying bladder tumor development and progression will allow better prevention, diagnosis, and treatment strategies.

Prospective evaluation of endorectal magnetic resonance imaging to detect tumor foci in men with prior negative prostastic biopsy: a pilot study

PURPOSE

Prostate cancer foci have a characteristic appearance on endorectal magnetic resonance imaging (MRI) which might be useful for prostate cancer detection. In this pilot study the ability of endorectal MRI to detect prostate cancer foci prospectively in men at risk for a malignant prostatic neoplasm is assessed.

MATERIALS AND METHODS

Endorectal MRI was performed in 33 consecutive men with 1 or more prior negative prostatic biopsies. All studies were read by 2 MRI dedicated study radiologists in consensus before and after receiving patient clinical data. Areas of interest on endorectal MRI were mapped as low, moderate or high suspicion for carcinoma on a prostate model. Directed needle biopsy cores of the prostate were obtained based on this model, and the histopathological findings were compared with MRI results.

RESULTS

Carcinoma was detected in 7 of 33 men (21.2%) on post-MRI biopsy, including 1 of 18 (5.6%) with low, 1 of 8 (12.5%) with moderate and 5 of 7 (71.4%) with high suspicion MRI. The site of positive biopsy correlated correctly with the area of suspicion on MRI in 85.7% of cases. Overall, endorectal MRI had 40% positive predictive value (moderate or high suspicion), 94.4% negative predictive value (low suspicion) and 69.7% accuracy. On multivariate analysis positive endorectal MRI was associated with an 11.3-fold risk of positive biopsy.

CONCLUSIONS

Endorectal MRI may effectively stratify patients with prior negative prostatic biopsy into low, moderate and high risk groups for a malignant prostatic neoplasm, and may improve our ability to identify prostatic tumor foci prospectively.

Effect of neoadjuvant hormonal therapy on prostatic intraepithelial neoplasia and its prognostic significance

PURPOSE

We studied the effect of neoadjuvant hormonal therapy on prostatic intraepithelial neoplasia in patients undergoing radical prostatectomy and assessed the effect of prostatic intraepithelial neoplasia on disease recurrence as measured by serum prostate specific antigen (PSA).

MATERIALS AND METHODS

A total of 278 patients with clinically localized prostate cancer were included in phase II and III studies evaluating radical prostatectomy alone versus radical prostatectomy following neoadjuvant hormonal therapy at Memorial Sloan-Kettering Cancer Center between October 1991 and August 1996. Patient data related to prostatic intraepithelial neoplasia were analyzed.

RESULTS

Of 275 evaluable patients 145 (52.7%) had prostatic intraepithelial neoplasia. Of 50 patients treated with neoadjuvant hormonal therapy (hormone group) 22 (44%) had a lower incidence of prostatic intraepithelial neoplasia compared to 69 of 80 controls (86.3%) (chi-square test p<0.0001). Of 262 patients (95.3%) with followup PSA 44 (16.8%) had PSA recurrence at a median followup of 32 months, with a median time to recurrence of 30 months. PSA recurrence was noted in 23 of 145 patients with compared to 21 of 130 without prostatic intraepithelial neoplasia (chi-square test p = 0.95), and did not significantly differ between the hormone group (25 of 142, 17.6%) and controls (19 of 130, 14.6%) (chi-square test p = 0.45).

CONCLUSIONS

While patients treated with neoadjuvant hormonal therapy had significantly lower incidence of prostatic intraepithelial neoplasia, neither prostatic intraepithelial neoplasia nor neoadjuvant hormonal therapy significantly affected PSA recurrence at a median followup of 32 months.

Involvement of the Ink4a gene (p16 and p19arf) in murine tumorigenesis

The INK4A and INK4B genes map to 9p21, with the INK4A gene encoding two products, p16 and p19ARF. Many neoplasms in which INK4A and INK4B genes are altered show deletions involving both genes. Mice carrying a targeted Ink4a deletion develop tumors at an early age. In the present study we examined the genetic alterations affecting the remaining Ink4a allele and the Ink4b gene in tumors arising in heterozygous Ink4a mice. We identified deletion of the remaining Ink4a allele in 7 of 18 (39%) tumors. We also observed deletion of the exon 1beta in 3 cases, one of them presenting this deletion as a unique alteration. In conclusion, the deletion of the remaining Ink4a allele was the alteration most frequently observed, representing the inactivation of two proteins capable of arresting the cell cycle through different pathways that involve the tumor suppressors pRB and p53.

Lack of association between renal cell carcinoma and non-Hodgkin's lymphoma

OBJECTIVES

To determine the incidence of non-Hodgkin's lymphoma (NHL) and renal cell carcinoma (RCC) after a diagnosis of the other malignancy.

METHODS

The 1973 to 1994 Surveillance, Epidemiology, and End Results (SEER) data base was used to determine the age-, sex-, race-, and calendar year-specific incidence rates for each year for RCC and NHL. The expected number of second cancers for each sex, race, and follow-up period (less than 1, 1 to 5, 5 to 10, and 10 or more years) was obtained by multiplying these incidence rates by the age-, sex-, race-, and calendar year-specific number of person-years at risk, with these products summed over the different age groups and calendar years. The standardized incidence ratio (SIR) was calculated (observed/expected number of second cancers), with statistical significance determined using the Poisson test.

RESULTS

From 1973 to 1994, 32,293 individuals in the SEER data base were diagnosed with RCC and 63,997 with NHL. NHL was diagnosed after RCC in 67 cases versus 59.8 expected (SIR 1.12, P = 0.19) and RCC after NHL in 96 cases versus 56.1 expected (SIR 1.71, P <0.0001). Only white males and females had a significantly increased risk of RCC after NHL, which was limited to the first year of follow-up. Excluding the first year of follow-up, NHL was diagnosed after RCC in 54 cases versus 49.3 expected (SIR 1.10, P = 0.27) and RCC after NHL in 54 cases versus 45.1 expected (SIR 1.20, P = 0.11).

CONCLUSIONS

When the first year of follow-up is excluded, there is no increased risk of NHL after RCC or vice versa.

Views about women's mental health: study in a squatter settlement of Karachi

OBJECTIVE

Mental health of women is globally receiving particular attention. This study assessed community's view on certain aspects of women's mental health prior to introducing an intervention.

SETTING

The study was conducted in an urban squatter settlement located in District West of Karachi in 1997 where the Aga Khan University has set up a Primary Health Care program in partnership with the communities.

METHODS

Using convenient sampling, door to door household survey was conducted by medical students.

RESULTS

Two hundred and eighty one residents were interviewed. Respondents were asked to list contributory factors which lead to mental distress in women. Two hundred and ten (75%) were able to list certain factors. The factors listed were; low family income (40%), dispute amongst spouses (30%), verbal abuse by in-laws (25%) and too many children (5%). When asked what women in the community did while they were mentally distressed 35% respondents reported that women talked to their husbands and 18% said counselling from a health provider was sought. Main channels of social support desired were; revenue generation (67%), membership of a women's group (11%) and training of local community women in counselling skills (10%).

CONCLUSION

Signs of awareness about mental health issues are present even in marginalized communities of Pakistan. In order to improve the mental health of women interventions should primarily focus on raising family income.

Prognostic significance of transcription factor E2F-1 in bladder cancer: genotypic and phenotypic characterization

BACKGROUND

We sought to identify and characterize potential alterations in E2F-1, a transcription factor that binds to the retinoblastoma protein (pRB), in bladder neoplasms and to elucidate a possible role for E2F-1 as an oncogene or a tumor suppressor gene.

METHODS

Tumor samples from 133 evaluable patients with bladder cancer were analyzed for E2F-1 gene mutations by use of polymerase chain reaction-single-strand conformational polymorphism (PCR-SSCP) analysis and DNA sequencing. In addition, tumors were studied for E2F-1 and pRB protein expression by use of immunohistochemistry. Results from the above analyses were correlated with clinicopathologic parameters and outcome. All P values are two-sided.

RESULTS

A polymorphism, consisting of a nucleotide change at amino acid codon 393 in exon 7 (GGC-->AGC [Gly-->Ser]), was identified in seven of 133 case patients, being present in both tumor and corresponding normal tissues. No bandshifts were identified in the nuclear-localization or DNA-binding domains on PCR-SSCP analysis. On immunohistochemical analysis, E2F-1 nuclear reactivity was observed in less than 5% of the cells from 53 tumors and in 5%-75% of the cells from the remaining 80 tumors. The pattern of E2F-1 protein expression was not altered in relation to the identified polymorphism. pRB nuclear reactivity greater than 20% (of tumor cells stained) was present in 66% of the samples. E2F-1 nuclear reactivity correlated inversely with the percentage of cells showing pRB reactivity (Kendall tau(b) = -0.18; P = .019). On multivariate analysis, patients with lower E2F-1 reactivity had statistically significantly increased risks of progression to metastases (P = .001) and death (P = .02).

CONCLUSIONS

E2F-1 alterations occur at the phenotypic level, rather than at the genotypic level, in bladder cancer. The adverse outcome for patients whose tumors exhibit low E2F-1 nuclear expression suggests a possible tumor suppressor role for E2F-1 in bladder cancer.

Economic development and health status among the poor in squatter settlements of Karachi

OBJECTIVE

Socioeconomic status is an important determinant of health outcome measures. This study examines and presents some of the important health outcomes amongst the higher and lower socioeconomic groups within the urban poor.

SETTING

Data analysis is based on a Health and Demographic Survey conducted in urban squatter settlements of Karachi in 1996.

METHODS

A structured questionnaire was administered to all households in the catchment area. The indicator used to assess economic status is ownership of assets.

RESULTS

Comparison between the two economic levels shows that the lower socio-economic group was more likely to experience child mortality, (CI; 1.02-1.29, p = 0.02) have lower contraceptive usage (CI; 2.11-2.64; p < 0.001) and childhood immunization rates (CI; 2.08-2.40, p < 0.001). No significant association was observed between economic levels and prevalence of diarrhea. The housing, literacy and employment status was consistently better in the higher economic stratum who were more likely to be Pushto-Punjabi speaking as compared to the Sindhi speaking population.

CONCLUSION

To have sustainable improvement in the health status of the poor, those who are most vulnerable need to be identified and programs aiming to improve health should also undertake broader development initiatives like raising family income.

Prostate specific antigen doubling time after radical prostatectomy: effect of neoadjuvant androgen deprivation therapy

PURPOSE

We determined the predictors of prostate specific antigen (PSA) doubling time in patients with relapse after radical prostatectomy as well as whether PSA doubling time is shorter in those treated versus not treated with neoadjuvant androgen deprivation therapy.

MATERIALS AND METHODS

We calculated PSA doubling time in 204 patients with PSA relapse after radical prostatectomy who were or were not treated with neoadjuvant androgen deprivation therapy. Analysis of covariance was used to determine the effect of clinical and pathological parameters on PSA doubling time, and the proportion of variability explained by these parameters.

RESULTS

Clinical stage, and combined clinical stage and margin status, clinical stage and androgen deprivation therapy status, androgen deprivation therapy status and time to PSA relapse, and androgen deprivation therapy status and pretreatment PSA were significant predictors of PSA doubling time. Any variable or combination of variables explained up to only 21% of PSA doubling time variability. When stratified by pretreatment PSA, clinical stage and biopsy grade, the difference in doubling times in patients treated with or without neoadjuvant androgen deprivation therapy was significant only for 4.1 to 10 ng./ml. PSA. In this group mean doubling time plus or minus standard deviation in patients receiving neoadjuvant androgen deprivation therapy and those treated only with radical prostatectomy was 7.6+/-1.0 and 15.4+/-2.6 months, respectively.

CONCLUSIONS

Our study indicates that it is difficult to predict PSA doubling time in an individual. The small proportion of variability in PSA doubling time explained by the interaction of androgen deprivation therapy status and other variables indicates that these factors are not clinically significant.

Site specific predictors of positive margins at radical prostatectomy: an argument for risk based modification of technique

PURPOSE

We identify patients at high risk for positive bladder neck, apical or posterior margins who may benefit from technical modifications, such as excision of the bladder neck or wide excision of the neurovascular bundles.

MATERIALS AND METHODS

We studied 242 patients with clinically localized prostate cancer undergoing radical prostatectomy with or without neoadjuvant androgen deprivation therapy between June 1992 and August 1997 who had a sextant biopsy available for review. Multivariate logistic regression analysis was used to develop models for prediction of positive bladder neck, apical, and right and left posterior margins based on clinical parameters. From these models patients at low and high risk for positive margins were identified.

RESULTS

The incidence of positive margins was 36% with 69% solitary sites. Patients with a prostate specific antigen of greater than 10 ng./ml. had a higher incidence (16%) of positive bladder neck margins. Patients with 3 or more positive cores who did not receive neoadjuvant androgen deprivation therapy had a higher incidence (24%) of positive apical margins. A nomogram incorporating pretreatment serum prostate specific antigen, number of ipsilateral positive cores and whether androgen deprivation therapy was used identified patients at high risk for positive posterior margins.

CONCLUSIONS

The nomograms presented identify patients at high risk for positive margins at various sites who may benefit from modification of surgical technique based on risk.

Multiple primary malignancies in renal cell carcinoma

PURPOSE

We determine the incidence and nature of multiple primary malignancies in patients with renal cell carcinoma, and whether these patients have an increased risk of a second primary malignancy.

MATERIALS AND METHODS

Between July 1989 and January 1997, 551 patients underwent an operation for renal cell carcinoma. The incidence of other primary malignancies was determined and classified as antecedent, synchronous or subsequent. The observed number of subsequent malignancies after diagnosis of renal cell carcinoma was compared to the expected number based on age, race and sex specific 1990 to 1994 incidence rates from the United States Surveillance, Epidemiology and End Results data using the Poisson test.

RESULTS

The number of primary malignancies, including cutaneous malignancies, was at least 1 in 148 patients (26.9%), at least 2 in 34 (6.2%), at least 3 in 6 (1.1%) and 4 in 1 (0.2%). Other malignancies were antecedent in 85 cases (45.0%), synchronous in 74 (39.4%) and subsequent in 30 (16.0%). The most common other primary malignancies were breast, prostate, colorectal and bladder cancer, and non-Hodgkin's lymphoma. Only men with renal cell carcinoma had an increased risk of bladder cancer (standardized incidence ratio 4.3, p = 0.0067).

CONCLUSIONS

Breast, prostate, colorectal and bladder cancer as well as non-Hodgkin's lymphoma were the most common other primary malignancies. Men with renal cell carcinoma have an increased risk of subsequent bladder cancer.

Trends in poorly differentiated prostate cancer 1973 to 1994: observations from the Surveillance, Epidemiology and End Results database

PURPOSE

Using the Surveillance, Epidemiology and End Results Program, we evaluated the changing demographics of poorly differentiated prostate cancer since early detection measures, such as serum prostate specific antigen screening, were introduced into clinical practice in the United States.

MATERIALS AND METHODS

Trends between 1973 and 1994 in the proportion, stage and treatment of poorly differentiated tumors (International Classification of Diseases [ICD]-O code 3, Gleason score 8, 9, 10) were assessed, and multivariate Cox proportional hazards models were used to identify independent correlates of disease specific survival.

RESULTS

The number of ICD-O grade 3 tumors increased during the study period, although these comprised a decreased proportion of all diagnosed cases (24.4% of 29,588 in 1980 to 1984 versus 21.4% of 81,932 in 1990 to 1994, chi-square p < 0.001). ICD-O grade 3 tumors were less often metastatic in 1990 to 1994 compared to 1980 to 1984 (17.4% versus 33.1%, chi-square p < 0.0001) and more often treated with radical prostatectomy or radiotherapy in 1990 to 1994 compared to 1983 to 1984 (37.5 versus 15.6%, chi-square p < 0.001). Although treatment group (radiotherapy versus radical prostatectomy) among patients with clinically confined tumors was an independent correlate of disease specific survival (hazard ratio 2.3, 1983 to 1984 and 3.3, 1990 to 1994), one must recognize potential selection biases inherent to this nonrandomized tumor registry study. The observed 12-year actuarial disease specific survival rates were 67.6% for radical prostatectomy and 46.3% for radiotherapy.

CONCLUSIONS

In the present era ICD-O grade 3 tumors are being detected in increasing number, are less likely to be metastatic at presentation and are more likely to be treated definitively with radical prostatectomy or radiotherapy. Disease specific survival rates observed with radical prostatectomy and radiotherapy in patients with clinically confined tumors support current efforts to detect and treat these highly aggressive tumors while clinically localized.

Early prostate cancer detection and potential for surgical cure in men with poorly differentiated tumors

OBJECTIVES

Long-term cure after radical prostatectomy has been reported for men with organ-confined poorly differentiated prostate cancer. However, organ-confined rates have been disappointingly low, ranging from 8% to 18% in earlier series, which have consisted primarily of patients not screened for prostate-specific antigen (PSA). Recently, it has been our impression that a greater number of patients with poorly differentiated tumors have had organ-confined disease than earlier reports would have led us to predict.

METHODS

To test this hypothesis, we reviewed the results of surgical staging in men with poorly differentiated tumors (Gleason score 8 to 10) entered into our prospective data base between August 1992 and June 1996.

RESULTS

Of 109 men undergoing operation during the study period, 64 underwent exploration for planned radical prostatectomy with no previous therapy and comprise the study cohort. In 92%, the initial presentation was an elevated PSA level (median 10.8 ng/mL). We observed an organ-confined rate of 30% and found preoperative PSA levels of 10 ng/mL or less to be a significant predictor of organ-confined disease (45% versus 17%, P = 0.016, chi-square test). On preliminary follow-up (median 31 months), 84% of men with organ-confined tumors are free of PSA relapse, similar to that seen in 233 men with organ-confined moderately differentiated tumors undergoing operation during the study period (P = 0.12, log-rank test).

CONCLUSIONS

Early prostate cancer detection, as reflected by PSA levels of 10 ng/mL or less, is associated with a higher organ-confined rate in men with poorly differentiated tumors. On preliminary follow-up, PSA relapse rates were lower in men with pathologically confirmed, organ-confined, poorly differentiated disease.

Incidence and clinical significance of false-negative sextant prostate biopsies

PURPOSE

Since most patients do not undergo repeat sextant prostate biopsies after a biopsy is positive for prostate cancer, the true incidence of false-negative biopsies is not well defined. We assess the incidence and clinical significance of false-negative sextant prostate biopsies in patients undergoing radical prostatectomy.

MATERIALS AND METHODS

A total of 118 patients with biopsy proved prostate cancer underwent repeat sextant prostate biopsy before enrollment in a prospective randomized trial of radical prostatectomy with or without neoadjuvant hormonal therapy. Clinical parameters were assessed to determine potential sources of bias. Pathological parameters and prostate specific antigen relapse-free survival rates were compared to determine the clinical significance of false-negative biopsies.

RESULTS

Of the 118 patients 27 (23%) had a negative repeat sextant biopsy. Except for initial clinical stage, no differences were noted in the clinical or pathological parameters, or prostate specific antigen relapse rates in patients with negative versus positive repeat biopsies.

CONCLUSIONS

Our findings suggest that this 23% incidence of false-negative biopsies represents significant cancer. This relatively high incidence is important to consider in treatment modalities in which prostate biopsy may be performed to determine response to therapy.

Genotypic and phenotypic characterization of the histoblood group ABO(H) in primary bladder tumors

The ABO(H) histoblood group genes have been mapped by linkage analysis to 9q34.1-34.2, an area of common deletions in bladder cancer. Lack of ABO(H) antigen expression in bladder tumors is a frequent and well-documented event. In bladder neoplasms the loss of A and B transferase activity is due to down-regulation of the ABO gene transcripts. Our study was undertaken in order to determine the presence of structural alterations of the ABO(H) gene-encoding locus in primary bladder tumors, to estimate the extent of allelic deletions and to characterize further the pattern of histoblood group antigen expression. Fifty-three primary bladder tumors were analyzed by immuno-histochemistry (IHC) using a panel of well-characterized antibodies and fresh frozen tissue sections. Normal and tumor DNA also were analyzed by PCR coupled with restriction enzyme analysis in order to establish the ABO genotype. Results obtained from these analyses were then compared to allelotyping data at the 9q34.1-4 region by Southern blotting. IHC data showed undetectable levels of antigen expression on neoplastic cells in 59% of informative cases. PCR-based genotypic results revealed allelic losses in 27% of heterozygous cases. Four of the 16 pheno- and/or genotypically altered cases (25%) presented loss of heterozygosity at D9S10 or D9S7 loci. Our data indicate that the lack of ABO antigen expression in certain bladder tumors is due to the allelic loss of the ABO glycosyltransferase-encoding genes and that in some of these tumors the loss involves the surrounding chromosomal region at 9q34.1-4.

Predictors of pathological stage before neoadjuvant androgen withdrawal therapy and radical prostatectomy. The Canadian Urologic Oncology Group

PURPOSE

This prospective randomized trial was used to compare predictive factors for organ confined margin negative status after radical prostatectomy with and without a 3-month course of neoadjuvant androgen withdrawal therapy.

MATERIALS AND METHODS

A total of 213 patients with localized adenocarcinoma of the prostate were randomized to radical prostatectomy with or without a 3-month course of 300 mg. neoadjuvant cyproterone acetate daily. Multivariate logistic regression analysis was used to determine significant predictors of organ confined margin negative status after radical prostatectomy in both groups. Parameters evaluated included baseline prostate specific antigen (PSA 4 or less, 4.1 to 10, greater than 10 ng./ml.), clinical stage (T2c versus T2b or less), biopsy Gleason score and percentage of surface area of biopsies involved with cancer. The multivariate analysis was repeated with PSA density and the natural logarithm of PSA to optimize the model.

RESULTS

In the radical prostatectomy alone arm a model incorporating only PSA density was the best predictor of organ confined margin negative status. In the neoadjuvant androgen withdrawal therapy arm a model incorporating biopsy Gleason score, PSA density and clinical stage was the best predictor.

CONCLUSIONS

The conventional predictors of pathology at radical prostatectomy, biopsy Gleason score, PSA density and clinical stage retain significance as predictors in patients treated with a 3-month course of neoadjuvant androgen withdrawal therapy before radical prostatectomy.

Retroperitoneal lymphadenectomy for post-chemotherapy residual masses: is a modified dissection and resection of residual masses sufficient?

OBJECTIVE

To determine if post-chemotherapy retroperitoneal lymphadenectomy for residual masses can be limited to resection of the residual masses and a modified template dissection, without loss of therapeutic efficacy.

PATIENTS AND METHODS

Between 1985 and 1995, 50 patients underwent one of three types of retroperitoneal lymphadenectomy for a residual mass after cisplatin-based chemotherapy for stages II and III testicular non-seminomatous germ cell tumour. The pre-operative imaging, operative record and pathology reports were reviewed to determine the location of the residual masses and whether tumour, defined as teratoma or viable carcinoma, was within the boundaries of the modified template and/or residual masses. The median (range) follow-up was 56 (1-140) months.

RESULTS

Of 39 patients undergoing a bilateral dissection, one (2.6%) with a left testicular cancer had teratoma identified outside the boundaries of the modified template and the residual masses. The nine patients who underwent resection of residual masses and a modified-template dissection were relapse-free at a median follow-up of 55 months. One of two patients undergoing resection of residual mass alone had two recurrences arising from incomplete resection. Four of eight patients undergoing a modified dissection retained ejaculation, compared with seven of 25 (28%) undergoing a non-nerve sparing bilateral dissection.

CONCLUSION

This retrospective study suggests that in patients whose tumour markers become normal and have a residual mass after chemotherapy, residual masses can be resected with a modified-template dissection with no significant risk of leaving tumour in the retroperitoneum.

Neoadjuvant androgen deprivation therapy before radical prostatectomy: who is unlikely to benefit?

OBJECTIVE

To determine which patients undergoing radical prostatectomy for localized cancer are unlikely to benefit from neoadjuvant androgen withdrawal therapy.

PATIENTS AND METHODS

Over a 5-year period, 173 patients underwent radical retropubic prostatectomy: 87 patients received no pre-operative androgen withdrawal therapy, for whom the clinical stages were T1b (17 patients), T1c (3), T2a (31) and T2b/c (36). Pre-operative prostate biopsies contained well-differentiated cancer in 43 and moderately differentiated cancer in 44 patients. Serum prostate-specific antigen (PSA) ranged from 0.4 ng/mL to 110.1 ng/mL (median 5.0). The presence of extracapsular disease, positive surgical margins and seminal vesicle involvement were correlated with pre-operative PSA, PSA density (PSAD), the natural logarithm of PSA [In(PSA)], biopsy grade, clinical stage, and sparing of neurovascular bundles.

RESULTS

Patients with a PSA < or = 4.0 ng/mL had a rate of extracapsular disease and positive margins of 8.3% and none had seminal vesicle invasion; corresponding rates for patients with a PSA > 4.0 ng/mL were 57%, 51% and 12%, respectively. Multivariate analysis revealed In(PSA) to be the best predictor of extracapsular disease (P < < 0.001), margin positivity (P < < 0.001) and seminal vesicle invasion (P = 0.0019).

CONCLUSIONS

These results suggest that in patients who have clinically localized, well or moderately differentiated prostate cancer, a PSA < or = 4.0 ng/mL is predictive for organ-confined disease. This group is unlikely to benefit from neoadjuvant androgen deprivation. Ln(PSA) may be able to improve the accuracy of mathematical multivariate models predicting the presence of extracapsular disease or margin positivity, but this will require verification in larger population-based studies.

Teratoma in primary testis tumor reduces complete response rates in the retroperitoneum after primary chemotherapy. The case for primary retroperitoneal lymph node dissection of stage IIb germ cell tumors with teratomatous elements

BACKGROUND

Recent advances in the therapy of advanced testicular nonseminomatous germ cell tumors (NSGCT) have resulted in increased attention to avoiding double therapy in cases where single modality therapy will suffice.

METHODS

Over an 8-year period, 104 patients with Stage II and III testicular NSGCT received primary chemotherapy. Seventy-nine patients had retroperitoneal lymph nodal metastases, 33 of whom had a radiologic complete response, 43 a radiologic incomplete response, and 3 were not re-evaluated after induction chemotherapy. Thirty-nine patients underwent retroperitoneal lymph node dissection (RPLND). The radiologic and pathologic response of the nodes to primary chemotherapy was correlated with tumor burden (lymph node metastasis size < or = 2 cm, 2.1-5 cm, 5.1-10 cm, and >10 cm), primary tumor pathology, and prechemotherapy marker levels.

RESULTS

Larger initial lymph node size, metastases size, the presence of teratoma in the primary tumor, and prechemotherapy alpha-fetoprotein (alpha-FP) > 80 mg/L and beta-HCG (bHCG) 10000 IU/L were found to correlate significantly with an incomplete radiologic response. Lymph node metastases size was the only independent prognostic factor on multivariable logistic regression analysis. Prechemotherapy alpha-FP > 80 mg/L and beta-HCG > 10000 IU/L were associated with the presence of teratoma or carcinoma in the retroperitoneal nodes. The presence of teratoma in the primary tumor is associated with a higher incomplete response rate and residual teratoma in the retroperitoneal lymph nodes after primary chemotherapy.

CONCLUSIONS

Predictors of need for postchemotherapy RPLND include large lymph node metastasis size and presence of teratomatous elements in the primary tumor. To reduce the need for and morbidity of double therapy, patients with low volume clinical Stage II, NSGCT and teratomatous elements in the primary tumor are arguably better served by primary RPLND.

Transition zone carcinoma of the prostate

Transition zone carinoma of the prostate can present a difficult diagnostic challenge. This entity should be considered in patients who have high prostate specific antigens (PSA) in relation to prostate volume and negative transrectal ultrasounds and ultrasound-guided biopsies. A transurethral biopsy of the prostate may be necessary to obtain the diagnosis.

The importance of breastfeeding in minimizing mortality and morbidity from diarrhoeal diseases: the Bangladesh perspective

Despite world-wide promotion of breastfeeding, there is a declining trend in breastfeeding practice in many developed as well as developing countries. In these countries, health planners are faced with the difficult task of re-educating women on the value of breastfeeding. In this context, it is useful to review the role of breastfeeding in combating infectious diseases, especially childhood diarrhoea, and in preventing deaths. Studies have shown that the duration of benefits of breastfeeding in diarrhoea can range from a few months to several years. However, breastfeeding is not consistently protective in all types of diarrhoea. For example, there is evidence of increased risk of rotavirus diarrhoea in breastfed children compared to non-breastfed children after certain age. Impairment of child growth is another controversial issue associated with prolonged breastfeeding. Is this growth-faltering, or do breastfed children follow a normal growth pattern which is below the reference growth curve? How long should mothers be advised to continue breastfeeding? This review focuses on answers to these questions and discusses benefits of breastfeeding and its controversial issues. The reasons for choosing the case study in Bangladesh are: (i) the prevalence of breastfeeding in Bangladesh is often cited as one of the highest in the world, (ii) diarrhoeal diseases are hyper endemic in this country; and (iii) issues of breastfeeding in several diarrhoeal diseases have been well documented here.

Should we reconsider the indications for ileo-obturator node dissection with localized prostate cancer?

OBJECTIVE

To evaluate the need for ileo-obturator node dissection in patients with localized prostate cancer who are undergoing radical retropubic prostatectomy.

PATIENTS AND METHODS

Over a 5-year-period, 95 patients underwent bilateral pelvic lymphadenectomy. Ninety were performed in association with planned radical prostatectomy and five were staging procedures in clinical stage T3 patients prior to radiotherapy or hormonal therapy. The patients with localized prostate cancer were stage T1a (one patient), T1b (21), T2a (30), and T2b (38). Pre-operative biopsies in the patients with localized cancer were well differentiated in 44 patients, moderately well differentiated in 45 and poorly differentiated in one. In the patients with T3 tumours, pre-operative biopsies were well differentiated in one, moderately well differentiated in two and poorly differentiated in two. Prostate-specific antigen (PSA) levels ranged from 0.4 to 110.1 ng/mL (Hybritech assay).

RESULTS

Two patients had positive lymph node dissections on fixed section. These two patients had well-differentiated T1b disease with a PSA level of 72.4 ng/mL and poorly differentiated T3 disease with a PSA level of 58.5 ng/mL. There was significant upstaging (P < 0.001) and upgrading (P < 0.001) on pathological examination. None of the 71 patients with a PSA < or = 10 ng/mL had positive lymph nodes compared with 8.3% of the 24 patients with a PSA > 10 ng/mL (P = 0.0618). Lymph node metastases were present in 1% of patients with well or moderately well-differentiated prostate cancer on pre-operative biopsy versus 33% with poorly differentiated disease (P = 0.0625). These P values strongly suggest an association, achieving significance only at the 10% level which might be the more appropriate level given the relative lack of power of the study due to the small number of patients with positive lymph nodes.

CONCLUSION

These results suggest that routine ileo-obturator node dissection in patients with well or moderately well-differentiated, localized prostate cancer and a PSA level < 10 ng/mL may be unnecessary, especially as a separate procedure.