Initial surveillance in men with marker negative clinical stage IIA non-seminomatous germ cell tumours

OBJECTIVES

To assess whether extended surveillance with repeated computed tomography (CT) scans for patients with clinical stage IIA (CS IIA; <2 cm abdominal node involvement) and negative markers (Mk-) non-seminomatous germ cell tumours (NSGCTs) can identify those with true CS I. To assess the rate of benign lymph nodes, teratoma, and viable cancer in retroperitoneal lymph node dissection (RPLND) histopathology for patients with CS IIA Mk- NSGCT.

PATIENTS AND METHODS

Observational prospective population-based study of patients diagnosed 2008-2019 with CS IIA Mk- NSGCT in the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) registry. Patients were managed with surveillance, with CT scans, and tumour markers every sixth week for a maximum of 18 weeks. Patients with radiological regression were treated as CS I, if progression with chemotherapy, and remaining CS IIA Mk- disease with RPLND. The end-point was the number and percentage of patients down-staged to CS I on surveillance and rate of RPLND histopathology presented as benign, teratoma, or viable cancer.

RESULTS

Overall, 126 patients with CS IIA Mk- NSGCT were included but 41 received therapy upfront. After surveillance for a median (range) of 6 (6-18) weeks, 23/85 (27%) patients were in true CS I and four (5%) progressed. Of the remaining 58 patients with lasting CS IIA Mk- NSGCT, 16 received chemotherapy and 42 underwent RPLND. The RPLND histopathology revealed benign lymph nodes in 11 (26%), teratoma in two (6%), and viable cancer in 29 (70%) patients.

CONCLUSIONS

Surveillance with repeated CT scans can identify patients in true CS I, thus avoiding overtreatment. The RPLND histopathology in patients with CS IIA Mk- NSGCT had a high rate of cancer and a low rate of teratoma.

Validation of a prediction model for post-chemotherapy fibrosis in nonseminoma patients

OBJECTIVE

To validate Vergouwe's prediction model using the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) RETROP database and to define its clinical utility.

MATERIALS AND METHODS

Vergouwe's prediction model for benign histopathology in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) uses the following variables: presence of teratoma in orchiectomy specimen; pre-chemotherapy level of alpha-fetoprotein; β-Human chorionic gonadotropin and lactate dehydrogenase; and lymph node size pre- and post-chemotherapy. Our validation cohort consisted of patients included in RETROP, a prospective population-based database of patients in Sweden and Norway with metastatic nonseminoma, who underwent PC-RPLND in the period 2007-2014. Discrimination and calibration analyses were used to validate Vergouwe's prediction model results. Calibration plots were created and a Hosmer-Lemeshow test was calculated. Clinical utility, expressed as opt-out net benefit (NBopt-out ), was analysed using decision curve analysis.

RESULTS

Overall, 284 patients were included in the analysis, of whom 130 (46%) had benign histology after PC-RPLND. Discrimination analysis showed good reproducibility, with an area under the receiver-operating characteristic curve (AUC) of 0.82 (95% confidence interval 0.77-0.87) compared to Vergouwe's prediction model (AUC between 0.77 and 0.84). Calibration was acceptable with no recalibration. Using a prediction threshold of 70% for benign histopathology, NBopt-out was 0.098. Using the model and this threshold, 61 patients would have been spared surgery. However, only 51 of 61 were correctly classified as benign.

CONCLUSIONS

The model was externally validated with good reproducibility. In a clinical setting, the model may identify patients with a high chance of benign histopathology, thereby sparing patients of surgery. However, meticulous follow-up is required.

Unilateral or Bilateral Retroperitoneal Lymph Node Dissection in Nonseminoma Patients with Postchemotherapy Residual Tumour? Results from RETROP, a Population-based Mapping Study by the Swedish Norwegian Testicular Cancer Group

BACKGROUND

The distribution of retroperitoneal lymph node metastases for patients with nonseminoma and a residual tumour of 10-49 mm in a population-based setting is unknown. This information is needed to justify selection of patients for a unilateral template resection.

OBJECTIVE

To describe the location of retroperitoneal metastases and recurrences in patients with nonseminoma germ cell tumour (NSGCT) with a residual tumour of 10-49 mm.

DESIGN, SETTING, AND PARTICIPANTS

RETROP is a population-based prospective observational mapping study of 213 patients in Sweden and Norway with a retroperitoneal residual tumour of 10-49 mm who underwent postchemotherapy retroperitoneal lymph node dissection for metastatic NSGCT during 2007-2014 with median follow-up of 100 mo. Patients were classified according to the testis primary tumour and the distribution of unilateral or bilateral lymph node metastases (with reference to the aorta) present on pre- and/or postchemotherapy computed tomography (CT) scans.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The distribution and rate of teratoma or cancer in unilateral or bilateral retroperitoneal fields and the location and rate of retroperitoneal recurrence were measured.

RESULTS AND LIMITATIONS

In total, 65% of the patients had unilateral retroperitoneal lymph node metastases (RLNMs) on CT scans. Patients with unilateral RLNMs had a low risk of contralateral teratoma or cancer (1.6% for right- and 2.6% for left-sided NSGCT) or retroperitoneal recurrence (0% for right- and 4% for left-sided NSGCT). A weakness of the study is that the pathology specimen could not be fully designated to one specific area for some of the patients.

CONCLUSIONS

Men with postchemotherapy residual disease of 10-49 mm and unilateral metastases on pre- and postchemotherapy CT scans have a low risk of contralateral disease and should be considered for a unilateral template resection.

PATIENT SUMMARY

The surgeon can use computed tomography (CT) scans in deciding on the extent of lymph node dissection in patients with testicular cancer.

Robotic retroperitoneal lymph node dissection for testicular cancer at a national referral centre

Objectives

We aim to determine if robot‐assisted retroperitoneal lymph node dissection (R‐RPLND) can be performed as a safe option to open RPLND in selected patients with metastatic germ cell cancer.

Patients and methods

This population‐based prospective study was performed at a one of two national referral centres for RPLND in Sweden. All patients referred during January 2017–March 2021 were screened for possible inclusion. R‐RPLND was performed using the Da Vinci Xi surgical system. Perioperative parameters, postoperative complications (Clavien–Dindo), final pathology, preservation of antegrade ejaculation and relapse rates were evaluated. Classifiers for selecting patients to open versus robotic RPLND were analysed by logistic regression modelling. The median follow‐up was 23 months.

Results

Of 87 patients referred, 29 were selected for R‐RPLND, 19 in a post‐chemotherapy setting. In median, retroperitoneal tumour diameter was 18 mm, BMI 24 kg/m², operative time 433 min, estimated blood loss 50 ml and length of stay 3 days. One patient underwent open conversion due to failure to progress. Four patients had Clavien–Dindo grade 3 complications, of which three were chylous‐related. No in‐field recurrences occurred during follow‐up.

Conclusion

This population‐based study suggests that R‐RPLND can be safely performed in at least one third of patients referred for an RPLND. A relatively high rate of lymph‐leakage may represent a potential drawback. Tumour size may be the most important discriminator when deciding on robotic versus open RPLND. Further studies with longer follow‐up are needed to validate the results.

Surgical Complications in Postchemotherapy Retroperitoneal Lymph Node Dissection for Nonseminoma Germ Cell Tumour: A Population-based Study from the Swedish Norwegian Testicular Cancer Group

BACKGROUND

Reports on perioperative complications after postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for nonseminoma germ cell tumour (NSGCT) are from experienced single centres, with a lack of population-based studies.

OBJECTIVE

To assess the complications of bilateral and unilateral PC-RPLND.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, population-based, observational multicentre study included all patients with NSGCT who underwent PC-RPLND in Norway and Sweden during 2007-2014. Of a total of 318 patients, 87 underwent bilateral PC-RPLND and 231 underwent unilateral PC-RPLND. The median follow-up was 6 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Bilateral and unilateral PC-RPLND were compared for the outcomes of intra- and postoperative complications (graded by Clavien-Dindo) and retrograde ejaculation (with or without nerve-sparing surgery). Complications were reported as absolute counts and percentages. The χ² test was used for comparisons.

RESULTS AND LIMITATIONS

The incidence of intraoperative complications was higher for bilateral PC-RPLND than for unilateral PC-RPLND (14% vs 4.3%, p = 0.003), with ureteral injury as the most frequent reported complication (2% of the patients). Postoperative complications were more common after bilateral than after unilateral PC-RPLND (45% vs 25%, p = 0.001) with Clavien ≥3b reported in 8.3% and 2.2%, respectively (p = 0.009). Lymphatic leakage was the most common complication occurring in 11% of the patients. Retrograde ejaculation occurred more frequently after bilateral than after unilateral surgery (59% vs 32%, p < 0.001). Limitations of the study include reporting of retrograde ejaculation, which was based on a chart review.

CONCLUSIONS

Intra- and postoperative complications including retrograde ejaculation are more frequent after bilateral PC-RPLND than after unilateral PC-RPLND.

PATIENT SUMMARY

Lymph node dissection in patients with testicular cancer puts them at risk of complications. In this study, we present the complications after lymph node dissection.

Extracorporeal shock-wave lithotripsy or ureteroscopy as primary treatment for ureteric stones: a retrospective study comparing two different treatment strategies

OBJECTIVE

Our extracorporeal shock-wave lithotripsy (ESWL) lithotripter with ultrasound localization technique was replaced in 1999 by a Storz SLX-MX lithotripter with both X-ray and ultrasound detection possibilities. Before replacing our lithotripter, most ureteric stones were treated with ureteroscopy (URS); subsequently, almost all patients underwent ESWL as primary treatment. The aim of this retrospective study was to compare the results of these two treatment strategies in all consecutive patients attending our hospital in 1998 and 2000 for ureteric stone treatment.

MATERIAL AND METHODS

The medical records of all patients treated for ureteric stones in 1998 and 2000 were reviewed. In 1998, 173 ureteric stones were treated. Primary treatment was URS in 124 patients, push back/ESWL in 24, ESWL in 21 and open surgery in four. In 2000, 176 ureteric stones were treated: 158 with ESWL and 18 with URS. ESWL or URS monotherapy was defined as ESWL or URS, respectively as the only stone-treatment therapy, with or without the use of a ureteric catheter or nephrostomy tube. Treatment success was defined as a stone-free ureter.

RESULTS

In 1998, the success rate for URS monotherapy was 95%, with a retreatment rate (sessions per stone situation) of 1.06. Corresponding figures for ESWL monotherapy in 2000 were 90% and 1.69. All URS patients received general anaesthesia; ESWL patients received opiods. Complication rates were 6% for URS and 3% for ESWL. In the URS group, 4/8 complications were considered to be major.

CONCLUSION

ESWL should be considered the first-line treatment for ureteric stones because of its non-invasive nature, lack of a requirement for general anaesthesia and low complication rates.

Immediate versus deferred radiological investigation after acute renal colic: a prospective randomized study

OBJECTIVE

The timing of radiological assessment after acute renal colic is controversial. The aim of this study was to investigate the value of immediate versus deferred radiological imaging and to compare morbidity rates after an attack of acute renal colic.

MATERIAL AND METHODS

Between September 2001 and December 2002 all 686 patients with acute renal colic attending our university hospital were registered. Of these, 172 patients rendered pain-free after analgesic injection were randomized to either immediate or deferred radiological investigation. All patients received a questionnaire encompassing questions on consumption of analgesics, impact of symptoms on normal daily activity (including working ability), need for additional emergency department visits and hospitalization. Stone treatments were registered.

RESULTS

The incidence of renal colic was 0.9/1,000 inhabitants per year. In total, 74% of all patients became pain-free after analgesic injection. Morbidity was low among the randomized patients, and did not differ between the immediate or deferred radiological investigation groups. In both groups, the duration of impairment of normal daily activities and analgesic consumption was a median of 2 days. In the immediate group, 14% needed another emergency visit and 4% were hospitalized. Corresponding figures for the deferred group were 15% and 7%. In the immediate group, 17% had stone treatment, compared with 8% in the deferred group.

CONCLUSION

For most patients with acute renal colic, parenteral analgesia resulted in complete symptom resolution. When initial medical treatment was successful, patient morbidity was low. In these patients, immediate radiological imaging did not lead to reduced morbidity compared with radiological imaging after 2-3 weeks.

Radical nephrectomy is still preferable in the treatment of localized renal cell carcinoma. A long-term follow-up study

OBJECTIVES

Due to the advances of radiological methods, an increased number of incidentally detected renal cell carcinomas is diagnosed. The reported excellent results of nephron-sparing surgery have promoted its application in patients with a normal contralateral kidney. However, the risk of local tumor recurrence and surgical complications after nephron-sparing surgery might be higher compared with radical nephrectomy.

METHODS

In 89 patients with localized renal cell carcinoma treated with radical nephrectomy, long-term renal function, morbidity, and survival were evaluated. The renal function was followed up regularly with serum creatinine measurements.

RESULTS

The cause-specific 5-year survival rate was 91.6%. There was neither local nor contralateral kidney tumor recurrence in any patient. Surgical complications were observed in 3% of the patients. Mean serum creatinine after the nephrectomy was 123 mumol/l without further increase during 10 years of follow-up.

CONCLUSIONS

Radical nephrectomy of localized renal cell carcinoma has low morbidity, excellent local tumor control, and a high survival rate. For patients with a normally functioning contralateral kidney the long-term renal function remained adequate. Based on these data, there is no convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a normally functioning contralateral kidney.

Metabolic evaluation and medical management of upper urinary tract stone disease. Guidelines from the Scandinavian Cooperative Group for Urinary Stones

A set of simple guidelines for metabolic evaluation and medical/dietary management of patients with urolithiasis is presented. The evaluation scheme is based on the documented risk factors in the Nordic area and the results of controlled clinical trials, and takes its basis in the severity of the stone disease in the individual stone patient. The initial evaluation in all patients aims at diagnosing conditions with a definitive metabolic, infectious or anatomical/functional cause of stone formation (MIAF urolithiasis). Patients with MIAF urolithiasis are treated according to the nature of the underlying disease. Having excluded/diagnosed MIAF urolithiasis, patients with idiopathic calcium nephrolithiasis remain, and in this group, which comprises approximately 85% of the total stone population in the Scandinavian region, only those with a complicated stone disease are subjected to additional evaluation, which aims at identifying underlying pathophysiological derangements for which medical therapy has been proven to be effective in controlled clinical trials.

Assessment of possible nephrotoxicity from iohexol in patients with normal and impaired renal function

PURPOSE

To evaluate the possible nephrotoxic effects of iohexol in patients with normal and impaired renal function.

MATERIAL AND METHODS

A prospective urographic study using iohexol (50 ml, 300 mg I/ml) was performed in 100 patients, 63 with impaired renal function (IRF) and 37 with normal renal function (NRF). The group included 24 patients with diabetes mellitus, 17 of them with IRF. Renal function parameters and adverse events were recorded for one week after the urography.

RESULTS

There were no significant changes in serum creatinine, creatinine clearance, or beta-2-microglobulin. The 24-h urine protein excretion showed a statistically significant increase in patients with NRF as well as in patients with IRF. Nine patients experienced adverse events but none of them required any treatment.

CONCLUSION

Iohexol was tolerated well in patients with NRF and in patients with IRF without significant overall nephrotoxic effects. Some minor adverse events were recorded.

[Screening of persons referred to forensic psychiatry. Many of them were in contact with psychiatric services before the offence]

Analysis of data for a sample comprising every second subject (266/533) who underwent forensic psychiatric examination in Sweden during a 12-month period (July 1995-June 1996) showed 50 per cent to have been in contact with psychiatric services during the 6-month period prior to the index offence. The study population was characterised by significantly higher than average proportions of women and of subjects suffering from psychotic disorder and/or serious psychiatric disorder as defined by the mental health act. In the subgroup who did not meet the criteria for special recommendations on medico-legal grounds (i.e., those without a serious psychiatric disorder according to forensic psychiatric examination) and in the youngest age group (< 20 years), the frequency of psychiatric contact prior to the index offence was lower than in the remainder, though the psychiatric consultation rate was nevertheless higher in both subgroups than in the general population. The findings suggest the need of increased alertness within the psychiatric sector, and of improved case management in the patient categories concerned. Further studies, particularly focused on violent and potentially violent offenders and their psychiatric contacts, are essential for the development of adequate programmes and guidelines for the treatment and care of such individuals.

Perforation of the bowel during SWL in prone position

Perforation of the small bowel during SWL is reported for the first time. The patient was treated in the prone position for a ureteral stone with 4500 shockwaves. There were no underlying or predisposing factors for the damage to the gut with the exception of the large number of shockwaves at a high energy setting. It is concluded that SWL in the prone position with shockwaves traversing the peritoneal cavity carries a risk of damage to the bowel. A reduction of the number of shockwaves and the energy level should be considered in this setting.

A new system for descriptive classification of stones in the upper urinary tract

A descriptive classification is proposed to stratify upper urinary tract stones by their number, size and location. The system considers the minimal but most important factors regarding the choice of surgical treatment and its success. Its principle is adaptable to more complex staging systems already existing. Practical use of the system has shown it to reflect clinical events, and its simplicity offers an opportunity for compliance in routine clinical study. It facilitates easy computerized stratification of stones in the upper urinary tract.

Significance of simple renal cysts and percutaneous cyst puncture on renal function

Renal function was investigated in 17 patients with simple renal cysts. Single kidney glomerular filtration rate was estimated by gamma camera renography with 99mTc-DTPA before, 5 days and 6 months after percutaneous puncture and evacuation of the cysts. Prior to the puncture and evacuation, the only negative effects on renal function noted were signs of moderate obstruction of the renal outflow in 2 patients. Percutaneous puncture with evacuation of the cystic fluid did not change the renal function significantly. It was concluded that simple renal cysts do not have any functional consequences nor does percutaneous puncture and evacuation of the cysts.

Multiple renal masses in patients with renal cell carcinoma: diagnostic pitfalls and surgical implications

Additional renal masses were found in the same or contralateral kidney in 41 of 131 patients with renal cell carcinoma. In 35 of the patients the additional renal masses were simple renal cysts situated in the kidney contralateral to the renal cell carcinoma in 16 patients, in the same kidney in 11 and bilaterally in 8 patients. Four patients had bilateral renal cell carcinomas. One patient had polycystic kidney disease as well as renal cell carcinoma and another patient had a benign tumour in the contralateral kidney. In 3 of the 30 patients with additional renal masses in the kidney contralateral to the renal cell carcinoma the radiologic examinations were insufficient to exclude malignancy. Only explorative surgery could establish a true diagnosis of these masses.

Renal cell carcinoma in a renal cyst: a case report and review of the literature

We report a case of renal cell carcinoma within a simple renal cyst in the lower pole of the right kidney. Excretory urography showed a mass and ultrasonography revealed multiple renal cysts with a solid component arising from the wall in 1. This finding also was visualized by computerized tomography. Analysis of the cystic fluid showed a high cholesterol level but negative cytological results. At operation a 7 mm. tumor arose from the wall of the cyst. Histopathological examination showed grade 3 renal cell carcinoma with an aneuploid deoxyribonucleic acid content.

Treatment of simple renal cysts by percutaneous puncture and instillation of bismuth-phosphate

One hundred and fifty-six patients with simple renal cysts had either a percutaneous puncture alone, percutaneous puncture combined with bismuth-phosphate instillation or no intervention at all. At follow-up, 25% of the cysts in which there was no intervention had grown and the mean size showed a slight increase. Ten per cent of the cysts which were only percutaneously punctured disappeared, while the mean size was reduced up to 24 months after puncture. Later, there was no statistically significant difference in change in mean size between punctured cysts and cysts that had no intervention. When puncture was combined with bismuth-phosphate instillation, a gradual reduction was seen in the mean size during the entire follow-up time and 44% of the cysts disappeared. Thirty-six or more months after puncture and instillation, the mean size was only 21% of the original size. It was concluded that percutaneous puncture combined with a bismuth-phosphate instillation is a meaningful treatment of simple renal cysts.

An educational program on depressive disorders for general practitioners on Gotland: background and evaluation

General practitioners are the psychiatrists' most important coworkers in the treatment of depressive disorders. A high degree of knowledge about this illness in this group of doctors is of decisive importance. However, the value of postgraduate educational programs for general practitioners has been questioned. The Swedish Committee for the Prevention and Treatment of Depression (PTD) offered an educational program on symptoms, etiology, diagnosis, prevention and treatment of depression to all general practitioners on the Swedish island of Gotland. Lectures on suicide, depressive illness in childhood and in old age and psychotherapy of depressive states were also given. In several control periods data were collected on suicides, referrals to the local psychiatric department, emergency admissions, the quantity of sick leave used and the quantity of inpatient care due to depression. Even the prescription of psychopharmacological drugs on the island was investigated. Overall, the results indicated that general practitioners gratefully accepted the educational program and achieved increasing competence and stringency in treating and preventing depressive states. The program was associated with decreases in the use of psychiatric inpatient care and the sick leave frequency of depressed patients. The possibility of preventing suicides was positively influenced.

Sedative effects of maprotiline and amitriptyline

By means of critical flicker fusion measurements and subjective estimation of drowsiness, experiments with 12 healthy subjects over periods of 8 h showed that maprotiline caused less than half the amount of sedation compared to amitriptyline, both drugs given in single doses of 50 mg. The experiments were blind, randomized and placebo controlled. Implications for clinical use are discussed.

Treatment, care, and rehabilitation of the chronic mentally ill in Sweden

For the last 20 years in Sweden, there has been a trend to integrate psychiatry with general medical services. However, mental hospitals remain the dominant resource for psychiatric care, with psychiatric units in general hospitals providing less than 20 percent of psychiatric hospital beds. The imbalance between the high number of inpatient facilities and the low rate of outpatient visits is beginning to be corrected by the newly introduced sector system, which allocates mental health care resources among geographic zones. The sector system has been criticized, however, because some believe it is fostering disintegration of existing resources and loss of research opportunities. A general spirit of improvement exists, but at the same time the public budget is being squeezed.

A comparison of radiologic methods in the diagnosis of renal mass lesions

The reliability of radiologic diagnosis was studied in 99 patients undergoing ultrasonography, computerized tomography and angiography in work up of renal mass lesions. The diagnoses were confirmed by angiography combined with percutaneous puncture or by surgery. Of the lesions, 37 were simple renal cysts and 56 were renal cell carcinomas. Eighty-eight percent were diagnosed correctly by ultrasonography, 96% by computerized tomography and 84% by angiography. The conclusion is that the radiologic evaluation of a renal mass lesion found at urography should start with ultrasonography. Percutaneous puncture is not recommended if all criteria of a simple renal cyst are strictly fulfilled at ultrasonography. In all other cases a computerized tomography is thought to be mandatory to avoid false negative diagnoses of malignant tumours or other diseases which may need therapy. In some patients a combination with angiography and percutaneous puncture is advised to establish a diagnosis prior to surgery.

Anxiety disorders: classification and diagnosis

Obsessive-Compulsive Disorder and Panic Disorder with or without agoraphobia are emphasized as specific entities that are easily accessible to pharmacological treatment, while more unspecific and heterogeneous syndromes are less predictable in their reaction to treatment. The DSM-III system, not yet official in Sweden, is described and commented on. Agoraphobia has undergone a re-evaluation and should be coupled with Panic Disorder, although the two illness components may have somewhat different genetic and biochemical mechanisms. Obsessive-Compulsive Disorder, on the other hand, should not be listed under Anxiety States, but have a place of its own. The relationship between anxiety and depression is discussed, and it is suggested that there is a clear break between specific affective disorders and specific anxiety disorders, while there may be continuity between Generalized Anxiety and Neurotic-reactive (dysthymic) depression, with mixed cases in between. Still, much work needs to be done in the classification of these disorders.

Karyometric investigations on urinary bladder carcinoma, correlated to histopathological grading

The aim of this study is to provide karyometric data which may be of value in the grading of urinary bladder tumours. For this purpose 27 biopsies were studied: four from normal bladder mucosae, eleven from grade I tumours, six from grade II tumours and another six from grade III tumours, according to a I-IV scale. After standardized fixation and plastic embedding, semithin sections were used for light microscopic stereology. Mean profile areas and mean volume densities of the nuclei tended to be higher in the more malignant cases. The nuclear volume densities were significantly higher in grade II than in grade I. The most important finding relates to the large nuclear profiles (greater than 90 microns 2), which were found almost exclusively in grade III tumours. Simple measurements of nuclear size can thus provide objective data to aid in the diagnostic procedure.

Critical flicker fusion (CFF) test for sedative effect of antidepressants

It is important to know in which direction and to what extent a drug affects cerebral arousal. Critical flicker fusion (CFF) is a most reliable method for measuring this particular quality of various drugs. A semi-automatic apparatus was used under standardized conditions, and double-blind technique was employed. Only acute experiments are described here. Dose-effect relationship can be demonstrated. The effect on cerebral arousal varies greatly from one antidepressant to another. Amitriptyline and doxepin were found to exert strong sedative effect, and amitriptyline-N-oxide an intermediate one, while imipramine and imipramine-N-oxide lacked this quality. Nomifensine in large doses has a significant stimulant action. Zimelidine in a low dose (75 mg) slightly, but significantly, lowered the CFF level, but at a dose of 150 mg no significant effect was obtained. At the doses 225 and 300 mg a slight increase was seen (about 2%). Various aspects of the findings are discussed in the paper.

A pilot study of the effect of the 5-HT-uptake inhibitor, zimelidine, on phobic anxiety

A new antidepressant, zimelidine, which is a selective inhibitor of 5-HT-uptake, was tested in an open study of 13 patients, in each of whom the principal clinical diagnosis was phobic neurosis. The dose varied from 200 to 300 mg daily. After 6 weeks of treatment, 6 patients dropped out of the study as they were not appreciably improved, but 7 patients definitely improved and completed a treatment course of at least 12 weeks. In these cases it was possible to observe subjective relief of symptoms, improved social function, increased working capacity and a reduced need for anxiolytics. The effect appeared similar to the previously described effects of clomipramine treatment. The incidence of side effects was low and those that occurred were mild. Tolerance was assessed as very good by the great majority of patients. The study suggests that zimelidine has a favourable effect on mild, moderate, and even in some severe phobic conditions. Some comparisons with MAO-inhibitors were made. The results are sufficiently encouraging to suggest a controlled study.

Preliminary clinical test of zimelidine (H 102/09), a new 5-HT uptake inhibitor

Zimelidine, a bicyclic compound, which in animal experiments causes specific inhibition of the uptake of 5-HT, was tried on 15 patients with depression of endogenous type. It produced considerable and highly significant 5-HT uptake inhibition in rat brain slices incubated in blood plasma from the patient under treatment, but no inhibition of NA uptake. Depressive symptoms were effectively relieved or entirely abolished in about two thirds of the patients. Only four patients did not react to the drug, and three of these were probably in need of NA uptake inhibitors, which on other occasions had worked well on their depressions. These three patients showed an extreme degree or retardation. During zimelidine treatment they were not just unaffected but showed signs of excitation, impatience and desperate feelings. These preliminary findings strongly indicate the true existence of depressive cases in need of an NA uptake inhibitor, but completely resistant to a specific 5-HT uptake inhibitor. The final dose of zimelidine was 75 mg b.i.d. This dose, although sufficient in most cases, was obviously somewhat low for a few of our patients. The concentration in blood plasma of zimelidine should probably reach a minimum level of 250 nmol/l and norzimelidine 500 nmol/l, and to achieve this a general dosage of 100 mg b.i.d. is recommended.

Biological fate of methenamine in man. Absorption, renal excretion and passage to umbilical cord blood, amniotic fluid and breast milk

Methenamine hippurate was administered orally as tablets or granules to healthy volunteers. Plasma concentrations of methenamine reached a maximum 1--2 hours after a single dose and then declined with a half-life of about 4 hours. The apparent distribution volume was similar to that of total body water. Renal clearance of methenamine was somewhat lower than that of creatinine. In cross-over experiments over six days, methenamine recovered in the urine corresponded to about 80 per cent of the dose given per 12 hours, slightly lower values being obtained from granules than from tablets. The efficient renal elimination of methenamine was confirmed in similar studies on patients post-operatively. Methenamine hippurate was also given to healthy pregnant women during labor, a few hours before expected delivery. Methenamine was found to pass the placental barrier. The concentration of methenamine in umbilical cord plasma was low but reached the level in maternal plasma after about 4 hours. In amniotic fluid the methenamine con centration was low and varying. No correlation was obtained to the maternal or umbilical cord plasma levels. The methenamine concentration in breast milk was of the same magnitude as in maternal plasma. It is concluded that methenamine may be safely given to pregnant and lactating women with respect to the ellbeing of the child.

Degree of sedation obtained with various doses of diazepam and nitrazepam

Using critical flicker fusion (CFF) determination and estimation of drowsiness in eight healthy volunteers the sedative-hypnotic effects of diazepam and mitrazepam were studied. Three dose levels of each drug were used, so that dose-effect curves could be produced. The most reliable results were obtained with the CFF method, and significant dose-effect relations could be demonstrated. The CFF deviation after diazepam initially related well to the concentration in blood serum, but after 4--6 hours the CFF depression vanished rapidly, while the drug concentration remained high. After nitrazepam the signs of drowsiness occurred similarly, while the drug concentration in serum showed on an average a slower rise. The effects began to disappear before the nitrazepam concentration had reached a peak. A rapid tachyphylaxis at the receptor sites seems to be responsible for this incongruity. Nitrazepam exerted significantly stronger sedative effects than diazepam, particularly when the respective serum concentrations were taken into account. This confirms that nitrazepam should be a more efficient sleeping drug, although diazepam also has considerable sedative-hypnotic action.

Intrauterine death due to infection with group B Streptococci

During the 6-year period 1970-1975 5 cases of late intrauterine death caused by group B streptococcal infection were seen in two obstetrical departments in the Stockholm area. During the same period 17 638 infants were born in the two departments, and in 117 cases intrauterine death occurred. Hematogenous spread of the infection from the mother was the most likely cause in the 5 cases. This figure should be compared with a carrier rate of 15-20% in pregnant women in the Stockholm area.

Sedative properties of doxepin in comparison with diazepam

Doxepin (Quitaxon) at doses of 25, 50, and 75 mg was compared with diazepam 7.5, 15, and 22.5 mg, using as variables the percentage lowering of Critical Flicker Fusion (CFF) and the self-estimated degree of drowsiness. Single doses were given, and repeated effect determinations were made over 6 h. Clear dose-effect relations could be demonstrated. The two drugs differed in speed and duration of action and in steepness of effect increase with dose. Although there were good correlations between CFF effect and subjective drowsiness, it seemed that the two methods interrelated somewhat differently in the different types of drug. CFF was a more stable and reliable method than the subjective estimation of drowsiness. However, when comparing drugs belonging to different classes, both methods preferably should be used together.