Long-Term Noninvasive Ventilation in Chronic Stable Hypercapnic Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: Noninvasive ventilation (NIV) is used for patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnia. However, evidence for clinical efficacy and optimal management of therapy is limited.

Target Audience: Patients with COPD, clinicians who care for them, and policy makers.

Methods: We summarized evidence addressing five PICO (patients, intervention, comparator, and outcome) questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to evaluate the certainty in evidence and generate actionable recommendations. Recommendations were formulated by a panel of pulmonary and sleep physicians, respiratory therapists, and methodologists using the Evidence-to-Decision framework.

Recommendations:1) We suggest the use of nocturnal NIV in addition to usual care for patients with chronic stable hypercapnic COPD (conditional recommendation, moderate certainty); 2) we suggest that patients with chronic stable hypercapnic COPD undergo screening for obstructive sleep apnea before initiation of long-term NIV (conditional recommendation, very low certainty); 3) we suggest not initiating long-term NIV during an admission for acute-on-chronic hypercapnic respiratory failure, favoring instead reassessment for NIV at 2–4 weeks after resolution (conditional recommendation, low certainty); 4) we suggest not using an in-laboratory overnight polysomnogram to titrate NIV in patients with chronic stable hypercapnic COPD who are initiating NIV (conditional recommendation, very low certainty); and 5) we suggest NIV with targeted normalization of Pa_CO2 in patients with hypercapnic COPD on long-term NIV (conditional recommendation, low certainty).

Conclusions: This expert panel provides evidence-based recommendations addressing the use of NIV in patients with COPD and chronic stable hypercapnic respiratory failure.

Invasive central nervous system aspergillosis: cure with liposomal amphotericin B, itraconazole, and radical surgery--case report and review of the literature

Invasive aspergillosis of the central nervous system is a rare but well-described disease. There have been only a few reported survivors, and mortality exceeds 95% in the immunosuppressed host. We present a 2-year-old boy with acute lymphatic leukemia and multiple Aspergillus brain abscesses who was successfully treated with liposomal amphotericin B, itraconazole, and surgical excision of the abscesses. Liposomal amphotericin B is a new preparation that safely allows the attainment of significantly higher tissue levels with less toxicity than standard amphotericin B. The treatment of patients with invasive central nervous system aspergillosis is reviewed.

Identifying lung overdistention during mechanical ventilation by using volume-pressure loops

We measured the pulmonary mechanics of 23 mechanically ventilated neonates. Airway pressures, inspiratory and expiratory flows were simultaneously measured. Values for respiratory system mechanics were then derived from these data by using a personal computer and a special software program. Volume-pressure (V-P) loops and respiratory system compliance values were determined for representative mechanical breaths. Twelve infants had normal-appearing V-P loops. Eleven had V-P loops characteristic of lung overdistention, showing decreasing changes in volume with progressive increases in pressure. To quantify this visual observation, we determined the change in compliance during the last 20% of inspiration (C20). We then compared this value to the total compliance value for the entire breath (C) using the ratio C20/C. Mean values for C, C20, and C20/C were compared for the two patient groups. Total respiratory system compliance values were similar. C20 values were decreased in those patients with V-P loops showing overdistention. C20/C values were significantly decreased in those patients with V-P loop evidence of overdistention. Patients with V-P loop evidence of overdistention all had C20/C values less than 0.8. Those with normal-appearing V-P loops all had C20/C values greater than 1.0. The C20/C ratio appears to effectively quantitate visual V-P loop evidence of lung overdistention during mechanical ventilation.

Respiratory instability of term and near-term healthy newborn infants in car safety seats

OBJECTIVE

Premature infants who are discharged from intensive care nurseries are known to be at increased risk for apnea, bradycardia, and oxygen desaturation while in the upright position. These small infants also do not fit securely in standard infant car seats. Because of these problems, the American Academy of Pediatrics recommends a period of observation in a car seat for all infants who are born at <37 weeks' gestation. It is not clear whether this recommendation should apply to the minimally preterm infants (born at 35-36 weeks' gestation) who are healthy at birth and are hospitalized in the normal newborn nursery. The objective of this study was to evaluate the respiratory stability and safety requirements of healthy, minimally preterm infants in car seats compared with term infants.

METHODS

Fifty healthy, nonmonitored, preterm infants (mean gestational age: 35.8 +/- 0.6 weeks) and 50 term infants (mean gestational age: 39.5 +/- 1.4 weeks) were recruited from a level I newborn nursery in a community hospital. Appropriateness of car seat fit was documented for each infant. Heart rate, respiratory rate, and pulse oximetry were evaluated while infants were supine and in their car seats. Apneic and bradycardic events were recorded in addition to a continuous recording of oxygen saturation values.

RESULTS

Twenty-four percent of preterm and 4% of term newborn infants did not fit securely into suitable car seats despite the use of blanket rolls. Mean oxygen saturation values declined significantly in both preterm and term infants from 97% in the supine position (range: 92%-100%) to 94% after 60 minutes in their car seats (range: 87%-100%). Seven infants (3 preterm and 4 term) had oxygen saturation values of <90% for longer than 20 minutes in their car seats. Twelve percent of the preterm infants (95% confidence interval: 4.5%-24.3%) but no term infants had apneic or bradycardic events in their car seats.

CONCLUSIONS

Our data support the current American Academy of Pediatrics recommendations that all infants who are born at <37 weeks' gestation, including those who are admitted to level I community hospitals, be observed for respiratory instability and secure fit in their car seats before hospital discharge. Because lowering of oxygen saturation values was seen uniformly in all newborn infants, car seats should be used only for travel, and travel should be minimized during the first months of life.

Epithelial eotaxin-2 and eotaxin-3 expression: relation to asthma severity, luminal eosinophilia and age at onset

BACKGROUND

Eosinophilic inflammation is implicated in asthma. Eotaxin 1-3 regulate eosinophil trafficking into the airways along with other chemotactic factors. However, the epithelial and bronchoalveolar lavage (BAL) cell expression of these chemokines in relation to asthma severity and eosinophilic phenotypes has not been addressed.

OBJECTIVE

To measure the expression of the three eotaxin isoforms in bronchoscopically obtained samples and compare them with clinically relevant parameters between normal subjects and patients with asthma.

METHODS

Normal subjects and patients with asthma of varying severity recruited through the Severe Asthma Research Program underwent clinical assessment and bronchoscopy with airway brushing and BAL. Eotaxin 1-3 mRNA/protein were measured in epithelial and BAL cells and compared with asthma severity, control and eosinophilic inflammation.

RESULTS

Eotaxin-2 and eotaxin-3 mRNA and eotaxin-2 protein were increased in airway epithelial brushings from patients with asthma and were highest in cases of severe asthma (p values 0.0155, 0.0033 and 0.0006, respectively), with eotaxin-2 protein increased with age at onset. BAL cells normally expressed high levels of eotaxin-2 mRNA/protein but BAL fluid levels of eotaxin-2 were lowest in severe asthma. Epithelial eotaxin-2 and eotaxin-3 mRNA/protein was associated with sputum eosinophilia, lower forced expiratory volume in 1 s and more asthma exacerbations. Airway epithelial cell eotaxin-2 protein differed by asthma severity only in those with late onset disease, and tended to be highest in those with late onset eosinophilic asthma.

CONCLUSIONS

Epithelial eotaxin-2 and 3 are increased in asthma and severe asthma. Their expression may contribute to luminal migration of eosinophils, especially in later onset disease, asthma control and severity.

The relationship between previous fluoroquinolone use and levofloxacin resistance in Helicobacter pylori infection

The relationship between prior fluoroquinolone use and levofloxacin resistance in Helicobacter pylori infection is unknown. Among 125 enrolled patients, 8.8% had H. pylori isolates that were resistant to levofloxacin. Levofloxacin resistance was associated with any prior fluoroquinolone use over the previous 10 years and with the total number of fluoroquinolone courses prescribed (P<.001).

Necrotizing tracheobronchitis: a complication of high-frequency ventilation

The tracheobronchial histopathologic findings in eight neonates who died after treatment with high-frequency jet ventilation (HFJV) were compared with those in eight similar infants who died after treatment with conventional mechanical ventilation. The HFJV and conventionally treated groups were matched as closely as possible for birth weight, gestational age, and duration of mechanical ventilation. A 4-point, nine-variable histologic scoring system was used to grade tissue changes in the trachea, carina, and mainstem bronchi. The patients who received HFJV had significantly more histologic damage in their tracheas, carinas, and right and left mainstem bronchi. At all levels of the airway examined, HFJV was associated with more inflammation, greater losses of ciliated epithelium, and more mucus within the lumen of the airway than was conventional mechanical ventilation.

River Delta Morphology: Wave Climate and the Role of the Subaqueous Profile

Application of a comprehensive wave climate program to seven major deltas indicates that deltaic configurations and coastal landform combinations depend to a considerable degree on the wave power adjacent to the shore and on the river discharge relative to wave forces. Nearshore wave power is not correlative with deepwater wave power but, owing to frictional attenuation, is a function of the subaqueous slope. The subaqueous slope, in turn, depends partially on the slope and width of the continental shelf but primarily on the rate at which the river can supply sediments to the nearshore zone. River-dominated configurations result only when the river is able to build flat offshore profiles, which reduce nearshore wave power; where the subaqueous slope is steep, waves reach the shore comparatively undiminished and wave-built forms prevail.

Preferential Generation of 15-HETE-PE Induced by IL-13 Regulates Goblet Cell Differentiation in Human Airway Epithelial Cells

Type 2-associated goblet cell hyperplasia and mucus hypersecretion are well known features of asthma. 15-Lipoxygenase-1 (15LO1) is induced by the type 2 cytokine IL-13 in human airway epithelial cells (HAECs) in vitro and is increased in fresh asthmatic HAECs ex vivo. 15LO1 generates a variety of products, including 15-hydroxyeicosatetraenoic acid (15-HETE), 15-HETE-phosphatidylethanolamine (15-HETE-PE), and 13-hydroxyoctadecadienoic acid (13-HODE). In this study, we investigated the 15LO1 metabolite profile at baseline and after IL-13 treatment, as well as its influence on goblet cell differentiation in HAECs. Primary HAECs obtained from bronchial brushings of asthmatic and healthy subjects were cultured under air-liquid interface culture supplemented with arachidonic acid and linoleic acid (10 μM each) and exposed to IL-13 for 7 days. Short interfering RNA transfection and 15LO1 inhibition were applied to suppress 15LO1 expression and activity. IL-13 stimulation induced expression of 15LO1 and preferentially generated 15-HETE-PE in vitro, both of which persisted after removal of IL-13. 15LO1 inhibition (by short interfering RNA and chemical inhibitor) decreased IL-13-induced forkhead box protein A3 (FOXA3) expression and enhanced FOXA2 expression. These changes were associated with reductions in both mucin 5AC and periostin. Exogenous 15-HETE-PE stimulation (alone) recapitulated IL-13-induced FOXA3, mucin 5AC, and periostin expression. The results of this study confirm the central importance of 15LO1 and its primary product, 15-HETE-PE, for epithelial cell remodeling in HAECs.

The effects of bedside pulmonary mechanics testing during infant mechanical ventilation: a retrospective analysis

We examined the effects of regular bedside testing of pulmonary mechanics (PM) on the outcome of 468 acutely ill, mechanically ventilated neonates. During the first of two 18-month study periods, 217 infants were mechanically ventilated without the assistance of PM measurements. During the second 18-month period, 251 infants were ventilated with the assistance of at least daily PM measurements. Using data obtained from the PM tests, we adjusted the infants' ventilators to maintain tidal volume, inspiratory time, and pressure-volume loops within predetermined limits. With the exception of the PM measurements, given the limitations of retrospective analyses, both groups of infants received identical medical and nursing care. The infants ventilated with the assistance of PM testing developed fewer pneumothoraces (4.0%; 10/251) vs. no PM testing, 10.1% (22/217); P < 0.05 by Chi-square analysis]. Infants weighing less than 1,500 g ventilated with the assistance of PM measurements had less intraventricular hemorrhage (IVH) overall, most notably, less grades I and II IVH (total IVH-PM testing, 39.1% vs. no PM testing, 65.7%; P < 0.01; Grades I-II IVH-PM testing, 30.4% vs. no PM testing, 54.9%; P < 0.01). IVH incidence was decreased independent of pneumothorax occurrence. Survival rates, incidences of bronchopulmonary dysplasia, and durations of mechanical ventilation and hospitalization were similar. This retrospective analysis suggests that PM testing during infant mechanical ventilation reduces common acute ventilator-associated complications.

The management and clinical course of testicular seminoma: 15 years' experience at a single institution

Testicular seminoma is one of the most curable solid neoplasms, with 5-year survival rates in excess of 90%. However, controversy persists around its optimum management, particularly for Stage I disease. The outcome of 314 patients with testicular seminoma who were treated at a single institution is reported. A comparison of adjuvant radiotherapy and surveillance for Stage I is presented, and the possible prognostic influence of an elevated serum beta-human chorionic gonadotrophin (beta hCG) is assessed. The 5-year disease-free survival for all stages of presentation was 95.5%. There were more relapses in Stage I patients undergoing surveillance (14/94, 15%) than postorchidectomy radiotherapy (6/144, 4%; P = < 0.05). However, survival was identical irrespective of treatment policy, with no disease-related deaths in either group of Stage I patients. There were eight tumour-related deaths from advanced disease and 14 deaths from non-tumour causes. Three were due to cardiorespiratory disease, four to an unrelated second malignancy, two from infection and one from suicide; in four patients, the cause was unknown. Preoperative beta hCG was elevated in 29 (18%) of Stage I patients and in 24 (62%) of those presenting with Stage II disease. Patients were more likely to have advanced disease (> or = Stage II) if beta hCG was elevated (P < 0.001). Neither disease-free nor overall survival were influenced by the preoperative level of beta hCG. Surveillance appears to be a safe alternative to postorchidectomy radiotherapy for Stage I disease, provided the patient is prepared for intensive long term follow-up. An increased risk of relapse, but not of tumour death, can be expected and unnecessary treatments avoided.

Otitis media. Incidence, duration, and hearing status

The middle ear status and hearing sensitivity in 483 normal infants have been closely monitored as part of the Dallas Cooperative Project, University of Texas at Dallas, effort to assess the effect of early otitis media with effusion on speech and language development. At least one episode of otitis media with effusion occurred in 73.5% of the children between the ages of 6 and 18 months. Almost a quarter of these were discovered at "well-baby" checkups and were appropriately classified as "silent." The hearing levels, the methods of hearing assessment, and the implications of these data are described.

Knowledge Gaps in the Perioperative Management of Adults with Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome. An Official American Thoracic Society Workshop Report

The purpose of this workshop was to identify knowledge gaps in the perioperative management of obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). A single-day meeting was held at the American Thoracic Society Conference in May, 2016, with representation from many specialties, including anesthesiology, perioperative medicine, sleep, and respiratory medicine. Further research is urgently needed as we look to improve health outcomes for these patients and reduce health care costs. There is currently insufficient evidence to guide screening and optimization of OSA and OHS in the perioperative setting to achieve these objectives. Patients who are at greatest risk of respiratory or cardiac complications related to OSA and OHS are not well defined, and the effectiveness of monitoring and other interventions remains to be determined. Centers involved in sleep research need to develop collaborative networks to allow multicenter studies to address the knowledge gaps identified below.

Optimal NIV Medicare Access Promotion: Patients With Thoracic Restrictive Disorders: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society

The existing coverage criteria for noninvasive ventilation (NIV) do not recognize the benefits of early initiation of NIV for those with thoracic restrictive disorders and do not address the unique needs for daytime support as the patients progress to ventilator dependence. This document summarizes the work of the thoracic restrictive disorder Technical Expert Panel working group. The most pressing current coverage barriers identified were: (1) delays in implementing NIV treatment; (2) lack of coverage for many nonprogressive neuromuscular diseases; and (3) lack of clear policy indications for home mechanical ventilation (HMV) support in thoracic restrictive disorders. To best address these issues, we make the following key recommendations: (1) given the need to encourage early initiation of NIV with bilevel positive airway pressure devices, we recommend that symptoms be considered as a reason to initiate therapy even at mildly reduced FVCs; (2) broaden CO2 measurements to include surrogates such as transcutaneous, end-tidal, or venous blood gas; (3) expand the diagnostic category to include phrenic nerve injuries and disorders of central drive; (4) allow a bilevel positive airway pressure device to be advanced to an HMV when the vital capacity is < 30% or to address severe daytime respiratory symptoms; and (5) provide additional HMV when the patient is ventilator dependent with use > 18 h per day. Adoption of these proposed recommendations would result in the right device, at the right time, for the right type of patients with thoracic restrictive disorders.

Assessment of oncolytic HSV efficacy following increased entry-receptor expression in malignant peripheral nerve sheath tumor cell lines

Limited expression and distribution of nectin-1, the major herpes simplex virus (HSV) type-1 entry-receptor, within tumors has been proposed as an impediment to oncolytic HSV (oHSV) therapy. To determine whether resistance to oHSVs in malignant peripheral nerve sheath tumors (MPNSTs) was explained by this hypothesis, nectin-1 expression and oHSV viral yields were assessed in a panel of MPNST cell lines using γ134.5-attenuated (Δγ134.5) oHSVs and a γ134.5 wild-type (wt) virus for comparison. Although there was a correlation between nectin-1 levels and viral yields with the wt virus (R=0.75, P =0.03), there was no correlation for Δγ134.5 viruses (G207, R7020 or C101) and a modest trend for the second-generation oHSV C134 (R=0.62, P=0.10). Nectin-1 overexpression in resistant MPNST cell lines did not improve Δγ134.5 oHSV output. While multistep replication assays showed that nectin-1 overexpression improved Δγ134.5 oHSV cell-to-cell spread, it did not confer a sensitive phenotype to resistant cells. Finally, oHSV yields were not improved with increased nectin-1 in vivo. We conclude that nectin-1 expression is not the primary obstacle of productive infection for Δγ134.5 oHSVs in MPNST cell lines. In contrast, viruses that are competent in their ability to counter the antiviral response may derive benefit with higher nectin-1 expression.

Antiquity of the Continental Slope Along the Middle-Atlantic Margin of the United States

A detailed high-resolution geophysical study of part of the continental slope along the mid-Atlantic margin of the United States indicates that it is an ancient, relict landscape largely unmodified by modern slope processes. The slope morphology is heavily influenced by bedrock outcrops, including joints and bedding planes, rather than by any single degradational process. A pelagic drape averaging 3 to 5 meters in thickness blankets the slope. Carbon-14 dates from eight drop cores show that the drape was deposited in late Pleistocene and Holocene times. The Holocene part of the drape, comprising the uppermost 1 meter, was deposited at a continuous rate of 10 centimeters per 1000 years. Most features on the slope predate the drape cover.

SHP-1 regulates STAT6 phosphorylation and IL-4-mediated function in a cell type-specific manner

SHP-1 has been shown to play positive and negative regulatory roles in IL-4-induced STAT6 phosphorylation and in IL-4-mediated functions. To determine whether SHP-1 can regulate STAT6 phosphorylation and IL-4-mediated functions in a cell type-specific manner in the immune system, we examined the IL-4 receptor (IL-4R) expression, STAT6 phosphorylation, and IL-4-mediated functions in CD4+ and CD8+ T cells of viable motheaten (me(v)/me(v)) and littermate control (+/-) mice. CD4+ T cells as well as CD8+ T cells from the lymph node of me(v)/me(v) and +/- mice expressed comparable levels of IL-4R. In CD4+ T cells, the loss of SHP-1 activity did not affect IL-4-induced STAT6 phosphorylation or IL-4-mediated function. In contrast, SHP-1-deficient CD8+ T cells from me(v)/me(v) mice failed to develop into IL-4-producing type-2 cytotoxic T cells (Tc2) in the presence of IL-4 despite that they showed comparable levels of STAT6 phosphorylation to that of +/- CD8+ T cells. Loss of SHP-1 activity also abolished IL-4-mediated inhibition of c-kit expression in bone marrow-derived mast cell (BMMC). Thus, our data suggest that SHP-1 may regulate IL-4-induced STAT6 phosphorylation and IL-4-mediated functions in a cell type-specific manner.

Hypercarbic ventilatory responses of infants at risk for SIDS

We examined the hypercarbic ventilatory responses (HVR) of 143 infants at risk for sudden infant death syndrome (SIDS) and 34 normal control infants. Sixty-five of the at-risk infants had experienced apparent life-threatening events (ALTE), and 78 were siblings of SIDS victims. Twenty-three (35%) of the ALTE infants experienced subsequent apnea; one died of SIDS. Seven (9%) of the SIDS siblings experienced subsequent apnea; two ultimately died of SIDS. In the HVR studies, we measured tidal volume (VT), minute ventilation (VE), frequency of breathing (f), and end-tidal PCO2 (PETCO2) at rest and while breathing 2% and 4% CO2. Mean HVR vales for the ALTE, sibling, and control groups were all similar. The mean HVR values for those at-risk infants who experienced subsequent apnea were not different from those who did not experience subsequent apnea. However, those infants experiencing subsequent apnea had higher mean VT/kg values (P less than 0.01) and lower mean PETCO2 values (P less than 0.001) than those who did not. The SIDS siblings had significantly lower resting VT/kg values than either the near-miss infants or normal controls (P less than 0.01). We did not find depressed HVR values in infants at risk for SIDS. On the contrary, those infants who experienced subsequent apnea had evidence suggesting relative hyperventilation. SIDS siblings had evidence suggesting relative hypoventilation. These findings are interesting and thought-provoking. However, HVR studies do not appear to be sensitive, specific, or appropriate for the general screening of infants at risk for SIDS.

Comparison of high-frequency oscillatory ventilation and high-frequency jet ventilation in cats with normal lungs

Four adult cats received alternating high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) at equivalent proximal airway pressures. Physiologic measurements were made before and after each ventilator change. Proximal airway pressures were then adjusted as necessary to reestablish normal pH and PaCO2 values. Aortic, pulmonary artery, and central venous pressures were monitored. Cardiac outputs were measured. Pulmonary and systemic vascular resistance, intrapulmonary shunt, and alveolar-arterial oxygen gradient were determined. Following the change from HFOV to HFJV at similar proximal airway pressures, HFJV always produced higher pH values (P less than 0.0001), higher PaO2 values (P less than 0.05), lower PaCO2 values (P less than 0.0001), as well as higher cardiac outputs (P less than 0.01), lower pulmonary artery pressures (P less than 0.001), and lower pulmonary vascular resistances (P less than 0.001). Following the reciprocal crossover, from HFJV to HFOV, HFJV pH values were again higher (P less than 0.001), and PaCO2 values were again lower (P less than 0.001). A comparison of HFOV and HFJV at similar pH and PaCO2 values showed that HFOV consistently required higher peak inspiratory pressures (P less than 0.001), higher mean airway pressure (P less than 0.001), and higher pressure wave amplitudes (P less than 0.001). Under the circumstances of this study, HFJV produced better gas exchange at lower proximal airway pressures.

Correlations between the WAIS and revised Beta, Wechsler memory scale and Quick test in a vocational rehabilitation center

A correlational analysis of the Revised Beta, the Wechsler Memory Scale, and the Ammons' Quick Test (Forms 1, 2, 3) with 30 clients from a vocational rehabilitation center yielded correlations with the WAIS of .83, .80, and .84 respectively. For a retarded subgroup of 16 Ss only the Wechsler Memory Scale was significantly correlated with WAIS IQ ( R = .61). The Revised Beta correlation of .37 suggested this test may be less reliable when used with mentally retarded Ss.

The Management and Survival of Patients with Advanced Germ-Cell Tumours: Improving Outcome in Intermediate and Poor Prognosis Patients

AIMS

The survival of germ-cell tumours (GCT) was transformed after the introduction of cisplatin-based therapy. Previous trials have indicated BEP (bleomycin, etoposide and cisplatin) as the optimum treatment, although some centres including our own advocate the use of the alternating regimen POMB-ACE (cisplatin, vincristine, methotrexate, bleomycin and dactinomycin, cyclophosphamide and etoposide) for men with intermediate or poor prognosis disease. We analysed the survival and management of GCT patients treated at a specialist cancer centre in relation to internationally recognised prognostic groupings.

MATERIALS AND METHODS

We retrieved patient information using the Trent Testicular Tumour Registry and supplemented it with information from patient notes. This included all patients with Royal Marsden Hospital Stage II, III and IV disease and patients with stage I disease at diagnosis with raised markers or subsequent relapse. We compared the efficacy and toxicity of the BEP and POMB-ACE chemotherapy regimens, and assessed relapse-free and overall survival.

RESULTS

We identified 178 non-seminomatous germ cell tumours (NSGCT) and 71 seminoma patients. Overall survival was similar to the International Germ Cell Cancer Collaborative Group (IGCCCG) classification for the good (95% vs 92%) and intermediate groups (82% vs 80%). The outcome for the poor prognosis group was better than expected in our series (57% vs 48%). There was a higher proportion of both immediate and late side-effects with POMB-ACE.

CONCLUSION

Survival and disease progression rates at this single institution were at least as good as reported by the IGCCCG and somewhat better for the poor-prognosis group. This may reflect use of the POMB-ACE chemotherapy regimen as opposed to standard BEP regimen. However, a randomised comparison of BEP and POMB-ACE would be required to validate this.

ALS: Management Problems

Amyotrophic lateral sclerosis (ALS) is a fatal disease with no cure; however, symptomatic management has an impact on quality of life and survival. Symptom management is best performed in a multidisciplinary care setting, where patients are evaluated by multiple health care professionals. Respiratory failure is a significant cause of morbidity and mortality in patients with ALS. Early initiation of noninvasive ventilation can prolong survival, and adequate use of airway clearance techniques can prevent respiratory infections. Preventing and treating weight loss caused by dysphagia may slow down disease progression, and expert management of spasticity from upper motor neuron dysfunction enhances patient well-being.