Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Diagnostic work-up and systemic treatment for advanced non-squamous non-small-cell lung cancer in four Southeast Asian countries

BACKGROUND

Lung cancer is the second most common cancer and leading cause of cancer mortality worldwide. Recent advances in molecular testing and targeted therapy have improved survival among patients with metastatic non-small-cell lung cancer (NSCLC). We sought to quantify and describe molecular testing among metastatic non-squamous NSCLC cases in selected Southeast Asian countries and describe first-line therapy chosen.

PATIENTS AND METHODS

A retrospective study was conducted based on incident lung cancer cases diagnosed between 2017 and 2019 in Lampang (Thailand), Penang (Malaysia), Singapore and Yogyakarta (Indonesia). Cases (n = 3413) were defined using the International Classification of Diseases for Oncology third edition. In Singapore, a clinical series obtained from the National Cancer Centre was used to identify patients, while corresponding population-based cancer registries were used elsewhere. Tumor and clinical information were abstracted by chart review according to a predefined study protocol. Molecular testing of epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK) gene rearrangement, ROS1 gene rearrangement and BRAF V600 mutation was recorded.

RESULTS

Among 2962 cases with a specified pathological diagnosis (86.8%), most patients had non-squamous NSCLC (75.8%). For cases with staging information (92.1%), the majority presented with metastatic disease (71.3%). Overall, molecular testing rates in the 1528 patients with stage IV non-squamous NSCLC were 67.0% for EGFR, 42.3% for ALK, 39.1% for ROS1, 7.8% for BRAF and 36.1% for PD-L1. Among these patients, first-line systemic treatment included chemotherapy (25.9%), targeted therapy (35.6%) and immunotherapy (5.9%), with 31% of patients having no record of antitumor treatment. Molecular testing and the proportion of patients receiving treatment were highly heterogenous between the regions.

CONCLUSIONS

This first analysis of data from a clinically annotated registry for lung cancer from four settings in Southeast Asia has demonstrated the feasibility of integrating clinical data within population-based cancer registries. Our study results identify areas where further development could improve patient access to optimal treatment.

Skin conductance as a pain assessment tool during chest tube removal: An observational study

BACKGROUND

Skin conductance variability to assess pain has shown varying results. Skin conductance responses per second (SCR) during a standardized painful stimulus in awake adults may give further understanding of the method's validity. The purpose of this study was to validate the SCR with the visual analogue scale (VAS) for pain (P-VAS) and anxiety (A-VAS) during chest tube removal (CTR).

METHODS

Ninety-five patients receiving epidural or non-epidural treatment, scheduled for CTR, were studied. Pain or anxiety was considered when VAS > 30 mm; the SCR cut-off value reflecting pain was ≥0.2 SCR.

RESULTS

SCR values could not be recorded in eight cases before CTR, six cases during CTR and seven cases after CTR. CTR induced increases in SCR, P-VAS and A-VAS (p < 0.001). Seventy-seven percent of all pairs of P-VAS and SCR values were well-classified; P-VAS ≤ 30 mm and SCR < 0.2 or P-VAS > 30 mm and SCR ≥ 0.2. SCR obtained before CTR differentiates between patients with and without pain during CTR in all patients (p = 0.04) and in the subgroup of non-anxious patients (p = 0.02), but not in the subgroup of anxious patients. SCR obtained during CTR had similar values in patients with and without pain in all patients and in the subgroup of anxious patients, but in the subgroup of non-anxious patients SCR during CTR differentiates patients with and without pain (p = 0.009).

CONCLUSIONS

SCR increases during painful procedures. Preprocedural SCR may help predict reported pain in patients exposed to painful procedures. SCR during CTR differentiates between patients with and without pain only in non-anxious patients.

SIGNIFICANCE

Preprocedural SCR may help predict reported pain in patients exposed to painful procedures. Procedural SCR accuracy improves in a subgroup of non-anxious patients. P-VAS is influenced by anxiety different from SCR.

Survival in patients with primary liver cancer, gallbladder and extrahepatic biliary tract cancer and pancreatic cancer in Europe 1999-2007: Results of EUROCARE-5

BACKGROUND

The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival.

METHODS

This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers ("biliary tract cancers"), and pancreatic cancer diagnosed in 2000-2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999-2007 were also analysed using the period approach.

RESULTS

The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999-2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999-2001 and 2005-2007 for liver cancer and biliary tract cancers.

CONCLUSIONS

The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

Uses of cancer registries for public health and clinical research in Europe: Results of the European Network of Cancer Registries survey among 161 population-based cancer registries during 2010-2012

AIM

To provide insight into cancer registration coverage, data access and use in Europe. This contributes to data and infrastructure harmonisation and will foster a more prominent role of cancer registries (CRs) within public health, clinical policy and cancer research, whether within or outside the European Research Area.

METHODS

During 2010-12 an extensive survey of cancer registration practices and data use was conducted among 161 population-based CRs across Europe. Responding registries (66%) operated in 33 countries, including 23 with national coverage.

RESULTS

Population-based oncological surveillance started during the 1940-50s in the northwest of Europe and from the 1970s to 1990s in other regions. The European Union (EU) protection regulations affected data access, especially in Germany and France, but less in the Netherlands or Belgium. Regular reports were produced by CRs on incidence rates (95%), survival (60%) and stage for selected tumours (80%). Evaluation of cancer control and quality of care remained modest except in a few dedicated CRs. Variables evaluated were support of clinical audits, monitoring adherence to clinical guidelines, improvement of cancer care and evaluation of mass cancer screening. Evaluation of diagnostic imaging tools was only occasional.

CONCLUSION

Most population-based CRs are well equipped for strengthening cancer surveillance across Europe. Data quality and intensity of use depend on the role the cancer registry plays in the politico, oncomedical and public health setting within the country. Standard registration methodology could therefore not be translated to equivalent advances in cancer prevention and mass screening, quality of care, translational research of prognosis and survivorship across Europe. Further European collaboration remains essential to ensure access to data and comparability of the results.

Cancer prevalence in United States, Nordic Countries, Italy, Australia, and France: an analysis of geographic variability

BACKGROUND

The objectives of this study were to quantitatively assess the geographic heterogeneity of cancer prevalence in selected Western Countries and to explore the associations between its determinants.

METHODS

For 20 cancer sites, 5-year cancer prevalence, incidence, and survival were observed and age standardised for the mid 2000s in the United States, Nordic European Countries, Italy, Australia, and France.

RESULTS

In Italy, 5-year crude prevalence for all cancers was 1.9% in men and 1.7% in women, while it was ∼1.5% in all other countries and sexes. After adjustment for the different age distribution of the populations, cancer prevalence in the United States was higher (20% in men and 10% in women) than elsewhere. For all cancers combined, the geographic heterogeneities were limited, though relevant for specific cancers (e.g., prostate, showing >30% higher prevalence in the United States, or lung, showing >50% higher prevalence in USA women than in other countries). For all countries, the correlations between differences of prevalence and differences of incidence were >0.9, while prevalence and survival were less consistently correlated.

CONCLUSION

Geographic differences and magnitude of crude cancer prevalence were more strongly associated with incidence rates, influenced by population ageing, than with survival rates. These estimates will be helpful in allocating appropriate resources.

Uveal and Conjunctival Malignant Melanoma in Denmark 1943–97: Observed and Relative Survival of Patients Followed Through 2002

PURPOSE

To evaluate the observed and relative survival of patients diagnosed with a malignant melanoma in the ocular region in Denmark during the period 1943-97.

METHODS

The study included 2,504 patients (1,292 men and 1,212 women) diagnosed with a melanoma in the ocular region, of which 2,434 cases could be topographically subclassified into 2,178 in the choroid/ciliary body, 141 in the iris, and 115 in the conjunctiva. The patients were followed through 2002 and the observed survival proportions and relative survival ratios were estimated.

RESULTS

For the total ocular region and the choroid/ciliary body, the observed survival did not vary statistically significantly with the year of diagnosis. A statistically insignificant higher observed survival for women than men was found for tumors in the ocular region and the subgroups choroid/ciliary body, iris, and conjunctiva. During the 55-year study period, the 5- and 10-year relative survival remained stable for the ocular region for men at 67% and 57% and for women at 71% and 60%, respectively, and stable for the choroid/ciliary body for men at 66% and 55% and for women at 69% and 57%, respectively. The 5- and 10-year relative survival for the iris was for men 90% and 85% and for women 99% and 101%, respectively, and for the conjunctiva for men 83% and 70% and for women 93% and 82%, respectively.

CONCLUSION

The observed and relative survival of patients diagnosed with a melanoma in the ocular region and choroid/ciliary body in Denmark during the period 1943-97 and followed through 2002 has remained stable. The highest observed and relative survival was found for iris melanomas, the lowest for choroid/ciliary body melanomas, and intermediate for conjunctival melanomas.

The assessment of postoperative pain by monitoring skin conductance: results of a prospective study

The number of fluctuations of skin conductance per second correlates with postoperative pain. The aim of this prospective study was to test the cut-off value for the number of fluctuations of skin conductance per second obtained from a previous study. Seventy-five patients were asked to quantify their level of pain on a numeric rating scale (0-10) in the recovery room. The number of fluctuations of skin conductance per second was recorded simultaneously. The number of fluctuations of skin conductance per second was different between patients with no (0.07), mild (0.16), moderate (0.28) and severe pain (0.33); p < 0.001. The tested cut-off value for the number of fluctuations of skin conductance per second (0.1) distinguished a numeric rating scale </= 3 from > 3 with 88.5% sensitivity and 67.7% specificity. The number of fluctuations of skin conductance per second may be a useful means of assessing postoperative pain.

Skin conductance or entropy for detection of non-noxious stimulation during different clinical levels of sedation

BACKGROUND

State entropy (SE) measures electroencephalographic signals, whereas response entropy (RE) also includes frontal electromyographic activity. In the presence of electromyographic activity, the RE index is larger than the SE index, the difference being denoted as RE-Delta (RE-Delta= RE - SE). Skin conductance (SC) may be expressed by a slow reacting variable, the mean SC level, the derivate of the mean SC level (D-SC), the number of SC fluctuations (NSCF) or the amplitude of the SC fluctuations (ASCF), which directly shows skin sympathetic nerve activity. The goal of this study was to evaluate whether these SC and entropy variables could differentiate between the responses obtained to load sound stimuli at different sedation levels before the induction of general anaesthesia.

METHODS

Twenty women scheduled for gynaecological laparotomy were studied. The modified observer's assessment of alertness sedation (OAAS) was used to classify the patients' hypnotic levels. White sounds (98 dB) were given at OAAS level 5 without propofol, at OAAS levels 4-3 and 3-2 with propofol and at OAAS levels 3-2 and < 2 with propofol and remifentanil.

RESULTS

RE and SE showed a steady decline from OAAS level 5 to level < 2 (P < 0.01). RE-Delta did not discriminate between any of the OAAS levels (P= NS). The mean SC level discriminated between OAAS levels 4-3 to < 2 (P < 0.01). D-SC discriminated between all the different OAAS levels (P < 0.01). NSCF discriminated between OAAS levels 5 to 3-2 (P < 0.05), but did not discriminate at OAAS level 3-2 between propofol alone or combined with remifentanil, or between OAAS level 3-2 and < 2. ASCF differentiated between OAAS levels 5 and 4 (P < 0.001) and OAAS levels 3-2 and < 2 (P < 0.05) only.

CONCLUSION

RE, SE and D-SC showed a similar discrimination between sound responses at the different sedation levels.

Comparison of skin conductance with entropy during intubation, tetanic stimulation and emergence from general anaesthesia

BACKGROUND

The number of skin conductance fluctuations (NSCF) expresses sympathetic skin nerve activity. The response entropy (RE) measures electromyographic and electroencephalographic activity in the forehead. The state entropy (SE) measures mainly electroencephalographic activity. When the suppression of frontal muscular activity is complete, RE is equal to SE. RE-Delta is defined as SE minus RE. The purposes of this study were to examine whether NSCF and RE-Delta correlate with signs of clinical stress during intubation and tetanic noxious stimulation and to elucidate how rapidly and accurately entropy and NSCF react during emergence from general anaesthesia.

METHODS

Twenty women scheduled for gynaecological laparotomy were studied. During intubation in remifentanil and propofol general anaesthesia, NSCF and RE-Delta were correlated with the clinical stress score. After a wash-out period, two series of tetanic stimuli were given, the first with (R+) and the second without (R-) remifentanil infusion. The tetanic pre-stimuli periods were compared with the tetanic post-stimuli periods, and R+ was compared with R-. During emergence, the responses of entropy and skin conductance were related to the time of extubation.

RESULTS

NSCF correlated well with the clinical stress score during intubation (r(2)= 0.73, P < 0.0005). RE-Delta showed a weaker correlation (r(2)= 0.33, P= 0.007). During tetanic stimuli, the NSCF pre-stimuli level was lower than the post-stimuli level (P < 0.001), and the NSCF R+ response was lower than the NSCF R- response (P= 0.002). RE-Delta did not show similar differences. During emergence, RE reacted before NSCF and SE (P= 0.003).

CONCLUSION

NSCF was better than RE-Delta for the measurement of clinical stress during intubation, and was sensitive to tetanic stimuli at different opioid analgesic levels, by contrast with RE-Delta. Both modalities were able to predict emergence at the end of anaesthesia, but RE was more rapid.

Monitoring of skin conductance to assess postoperative pain intensity

BACKGROUND

Pain is known to alter the electrogalvanic properties of the skin. The aim of this pilot study was to investigate the influence of postoperative pain on skin conductance (SC) readings.

METHODS

After obtaining ethical approval and written informed consent, 25 postoperative patients were asked to quantify their level of pain on a numeric rating scale (NRS, 0-10) at different time points in the recovery room. As a parameter of SC, the number of fluctuations within the mean SC per second (NFSC) was recorded. Simultaneously, the NRS was obtained from patients by a different observer who was blinded to the NFSC values.

RESULTS

Data from 110 readings of 25 patients (14 female, 11 male; 21-67 yr) were included. NFSC showed a significant correlation with the NRS (r=0.625; P<0.01), whereas heart rate and blood pressure showed no or very weak correlation with the NRS. NFSC was significantly different between patients with no (NRS=0), mild (NRS=1-3), moderate (NRS=4-5) and severe (NRS=6-10) pain (no: 0.047, mild: 0.089, moderate: 0.242, severe: 0.263; P<0.0001). Post hoc, a cut-off value for NFSC (0.1) was calculated above which a pain score >3 on the NRS was predicted with sensitivity of 89% and specificity of 74%.

CONCLUSIONS

The severity of postoperative pain significantly influences SC. Using cut-off values, NFSC may prove a useful tool for pain assessment in the postoperative period.

Skin conductance monitoring compared with Bispectral Index to assess emergence from total i.v. anaesthesia using propofol and remifentanil

BACKGROUND

Arousal after sevoflurane anaesthesia has been detectable by monitoring changes in skin conductance (SC) with similar accuracy as monitoring Bispectral Index (BIS). As SC monitoring detects changes in sympathetic tone, the measurements might be confounded by the sympatholytic properties of propofol, a component of total i.v. anaesthesia (TIVA). Therefore in this study, monitoring of SC during emergence from TIVA was compared with the monitoring of BIS.

METHODS

Twenty-five patients undergoing plastic surgery were investigated. The number of fluctuations of SC per second (NFSC), BIS and haemodynamic variables [systolic blood pressure (SBP) and heart rate (HR)] were recorded simultaneously. The performance of the monitoring devices in distinguishing between the clinical states 'steady-state anaesthesia', 'first clinical reaction' and 'extubation' were compared using the method of prediction probability (Pk) calculation.

RESULTS

BIS((R)) showed the best performance in distinguishing between 'steady-state anaesthesia' and 'first reaction' (Pk BIS 0.99 vs NFSC 0.80; P<0.01), and 'steady-state anaesthesia' and 'extubation' (Pk BIS) 1.00 vs NFSC 0.91; P<0.05); the time from first change of BIS or NFSC to a first clinical reaction was significantly longer for NFSC (median BIS 135 s vs NFSC 191 s; P<0.05). BIS and NFSC performed better in distinguishing between the investigated clinical states than SBP and HR.

CONCLUSIONS

In this study, BIS was found to predict arousal with a higher probability but slower response times than NFSC in patients waking after TIVA.

Skin conductance monitoring compared with bispectral index ® monitoring to assess emergence from general anaesthesia using sevoflurane and remifentanil

BACKGROUND

Changes in skin conductance have previously been reported to correlate well with plasma levels of stress hormones and awakening stimuli. In this study, monitoring of skin conductance during emergence from general anaesthesia was compared with the monitoring of bispectral index (BIS).

METHODS

Twenty-five patients undergoing minor elective surgery were investigated. The number of fluctuations in mean skin conductance (NFSC), BIS and haemodynamic parameters were recorded simultaneously. The performance of the monitoring devices to predict and distinguish between the clinical states 'steady-state anaesthesia', 'first reaction' and 'extubation' were compared using the method of prediction probability (P(K)) calculation.

RESULTS

Both monitors showed similar performance in distinguishing between 'steady-state anaesthesia' vs 'first reaction' (P(K) NFSC 0.89; BIS 0.94) and 'steady-state anaesthesia' vs 'extubation' (P(K) NFSC 0.96; BIS 0.96). The response times of the monitors, to indicate the likelihood of 'first reaction', were not significantly different.

CONCLUSIONS

NFSC, as a parameter of skin conductance, performed similarly to BIS in patients waking after a general anaesthetic.

Palmar skin conductance compared to a developed stress score and to noxious and awakening stimuli on patients in anaesthesia

BACKGROUND

The number of fluctuations in the skin conductance per s (NFSC) as a measure of the sympathetic nervous system may be a tool for monitoring physiological stress during surgery and general anaesthesia. The purpose of this study was to find the sensitivity and specificity of the NFSC when compared to a peroperative clinical stress score. Moreover, different patterns of skin conductance responses were compared with the BIS score to find out if the mean level of skin conductance (SC) and NFSC monitoring could differentiate between awakening and noxious stimuli.

METHODS

Fourteen patients were studied during stressful or non-stressful registration periods. During each registration period, the NFSC was compared to a five-point clinical stress score (CSS) (systolic blood pressure >130 mmHg, cough, tears, EMG in the forehead >50 or movements) and BIS score.

RESULTS

The NFSC and the CSS both indicated physiological stress at 12 registrations and no stress at 186 registrations. The NFSC indicated physiological stress without signs of clinical stress (CSS = 0) in 28 registrations, whereas signs of clinical stress (CSS > 0) were indicated on two occasions without signs of stress in the NFSC. The sensitivity of the NFSC when compared to the CSS was 86% and the specificity was 86%. Moreover, in all situations (n = 16) where NFSC indicated stress and the BIS score >50, the SC increased. This was different from situations (n = 13) where NFSC indicated stress and the BIS score <50, then the SC did not increase (P < 0.001).

CONCLUSION

The NFSC is sensitive to clinical stress during surgical stimulation. Moreover, the combined use of SC and NFSC may have a potential to differentiate between situations of stress due to inadequate hypnotic effect vs. inadequate analgesic effect.

Cosmic radiation and cancer mortality among airline pilots: results from a European cohort study (ESCAPE)

Cosmic radiation is an occupational risk factor for commercial aircrews. In this large European cohort study (ESCAPE) its association with cancer mortality was investigated on the basis of individual effective dose estimates for 19,184 male pilots. Mean annual doses were in the range of 2-5 mSv and cumulative lifetime doses did not exceed 80 mSv. All-cause and all-cancer mortality was low for all exposure categories. A significant negative risk trend for all-cause mortality was seen with increasing dose. Neither external and internal comparisons nor nested case-control analyses showed any substantially increased risks for cancer mortality due to ionizing radiation. However, the number of deaths for specific types of cancer was low and the confidence intervals of the risk estimates were rather wide. Difficulties in interpreting mortality risk estimates for time-dependent exposures are discussed.

Cancer prevalence in Northern Europe: the EUROPREVAL study

BACKGROUND

Information on cancer prevalence is of importance for health planning and resource allocation, but is not always available. In order to obtain such data in a comparable way a systematic evaluation of cancer prevalence in Europe was undertaken within the EUROPREVAL project.

PATIENTS AND METHODS

Standardised data were collected from 38 population-based registries on almost 3 million cancer patients diagnosed between 1970 and 1992. The prevalence of 11 specific cancer types was estimated at the index date of 31 December 1992. This study deals with the northern countries Denmark, Estonia, Finland, Iceland and Sweden.

RESULTS

There were large differences between these countries, Sweden having the highest prevalence rate of 3050 per 100 000 and Estonia the lowest, 1339 per 100 000. This difference is mainly due to a high proportion of cancers with favourable prognosis such as breast cancer, prostate cancer and melanoma, better survival and longer life expectancy in Sweden, whereas Estonia has a higher proportion of stomach and lung cancer with poor prognosis, worse survival and much shorter life expectancy, especially for males. For most tumour types, the Nordic countries did better than Estonia. There are indications that cancer patients in Estonia, as well as in Denmark, have a more advanced stage at diagnosis and that the Estonian health-care system is less efficient.

CONCLUSIONS

Despite many similarities and a common historical background, the northern countries in Europe that participated in the EUROPREVAL study display quite different cancer patterns and prevalence. Reasons for these variations are discussed.

Lung cancer after treatment for Hodgkin's disease: focus on radiation effects

Aspects of radiation-induced lung cancer were evaluated in an international study of Hodgkin's disease. The study population consisted of 227 patients with lung cancer and 455 matched controls. Unique features included dose determinations to the specific location in the lung where each cancer developed and quantitative data on both chemotherapy and tobacco use obtained from medical records. The estimated excess relative risk (ERR) per Gy was 0.15 (95% CI: 0.06-0.39), and there was little evidence of departure from linearity even though lung doses for the majority of Hodgkin's disease patients treated with radiotherapy exceeded 30 Gy. The interaction of radiation and chemotherapy that included alkylating agents was almost exactly additive, and a multiplicative relationship could be rejected (P = 0.017). Conversely, the interaction of radiation and smoking was consistent with a multiplicative relationship, but not with an additive relationship (P < 0.001). The ERR/Gy for males was about four times that for females, although the difference was not statistically significant. There was little evidence of modification of the ERR/Gy by time since exposure (after a 5-year minimum latent period), age at exposure, or attained age. Because of the very high radiation doses received by Hodgkin's disease patients and the immunodeficiency inherent to this lymphoma and that associated with chemotherapy, generalizing these findings to other populations receiving considerably lower doses of radiation should be done cautiously.

Food intake and oral sucrose in preterms prior to heel prick

To investigate the soothing effect of feeding on infants in distress, the effects of 2 mL 15% and 1 mL 25% sucrose given orally 2 min before heel prick in fasting preterms to reduce the pain response were assessed. The effects of milk intake by nasogastric tube were also assessed once during the last hour before heel prick, and the effects of milk intake by nasogastric tube once during the last hour before heel prick together with 1 mL 25% sucrose given orally 2 min before heel prick. The pain response was measured as changes in crying time, behavioural state, skin conductance and heart rate. Each group included 12 healthy preterm infants with a median gestational age of 32 wk and a median postnatal age of 14 d. These infants were randomly studied twice; one in connection with the intervention and once after being given sterilized water. Differences in the measured variables before and during heel prick showed that only the crying time was reduced when the infants received milk or 25% sucrose prior to heel prick (p < 0.05). If the infants received milk and 25% sucrose before heel prick, the crying time and the level of behavioural state were reduced (p < 0.05). The increase from before to during heel prick in skin conductance (number and amplitude of the waves) and heart rate correlated with the crying time (p < 0.01).

Enteropathy-associated T-cell lymphoma presenting with eosinophilia

Hypereosinophilia can be related to various diseases; when it occurs without an obvious cause it is called idiopathic hypereosinophilic syndrome (IHES). We describe a patient with increasing eosinophilia, which in spite of extensive diagnostic procedures initially remained unexplained. However, during follow-up it became apparent that this patient had a lethal enteropathy-associated T lymphoma (EATL) causing the hypereosinophilia.

Skin conductance and behaviour during sensory stimulation of preterm and term infants

AIM

To investigate the responses to painful and tactile stimulation in preterm and term infants in terms of changes in the plantar skin conductance activity (SCA) and behavioural state. Plantar SCA reflects activity in the sympathetic nervous system.

DESIGN

The plantar SCA and behavioural state in response to nociceptive (the heel prick for blood samples, or immunization) and tactile (routine nursery handling) simulation was recorded in four different groups of infants (n=71): Preterm and term neonatal infants (defined here as up to 1 week old), and preterm and term infants in the postneonatal period.

RESULTS

The preterm infants had significant increases in all skin conductance variables during both tactile and nociceptive stimulation (p<0.02), except for wave amplitude when newborns were heel pricked. The term infants displayed a more varied picture, but both the number and amplitude of the waves increased significantly during both procedures in the newborn groups, while the postneonatal groups only showed significant increases in wave amplitude during nociceptive stimulation (p<0.05). Tactile stimulation of the preterm newborn infants produced significantly higher increases in SCA than nociceptive stimulation (p<0.01), while the behavioural state was highest during nociceptive stimulation (p<0.05). A gradual change in this relation was seen with advancing total age.

CONCLUSION

Non-painful sensory stimulation of infants, especially the newborn and preterm ones, can produce equal or higher levels of physiological stress activation than painful stimulation. Repeated nociceptive stimulation probably sensitises the infants to pain.

Skin conductance correlates with perioperative stress

BACKGROUND

Skin conductance (SC) as a measure of emotional state or arousal may be a tool for monitoring surgical stress in anaesthesia. When an outgoing sympathetic nervous burst occurs to the skin, the palmar and plantar sweat glands are filled up, and the SC increases before the sweat is removed and the SC decreases. This creates a SC fluctuation. The purpose of this study was to measure SC during laparoscopic cholecystectomy with propofol and remifentanil anesthaesia and to evaluate whether number and amplitude of SC fluctuations correlate with perioperative stress monitoring.

METHODS

Eleven patients were studied nine times before, during and after anaesthesia. SC was compared to changes in stress measures such as blood pressure, heart rate, norepinephrine and epinephrine levels. SC was also compared to changes in Bispectral index (BIS).

RESULTS

The blood pressure, epinephrine levels and norepinephrine levels were positively correlated with both the number (P < 0.001) and amplitude (P < 0.01) of the SC fluctuations. Moreover, the BIS was positively correlated with the number (P < 0.001) and amplitude (P < 0.001) of the SC fluctuations. Furthermore, during tracheal intubation, the mean levels of the number of SC fluctuations from the 11 patients had the same stress response as measured in changes of the mean levels of norepinephrine. The mean BIS did not show any stress response during tracheal intubation.

CONCLUSION

Number of SC fluctuations may be a useful method for monitoring the perioperative stress.

The development of a software program for analyzing skin conductance changes in preterm infants

OBJECTIVES

Changes in palmar and plantar skin conductance (SC) are due to outgoing bursts in the postganglionic efferent sympathetic cholinergic fibres, which respond to changes in the central arousal state. An apparatus that measures SC by applying an alternating voltage is sensitive enough to measure SC changes in preterm infants. The purpose of this study was to develop a software program for analyzing SC in premature infants.

METHODS

The software program was designed to calculate the number and mean amplitude of the waves and the mean SC changes during a given period. Different pre-set values for minimum amplitude, maximum slope and minimum width of the waves were used in the program and the results were compared with manually counted waves.

RESULTS

For SC waves, the optimal minimum amplitude was found to be 0.015 microS, the maximum slope of the waves could, with the same result, be 1, 2 or 5 microS/s and the optimal width of the waves was found to be unlimited.

CONCLUSIONS

SC in preterm infants is easily analyzed by this software program.

[Evaluation of the new doctoral degree program at the Faculty of Medicine in Oslo 1993-98]

BACKGROUND

In 1993, the doctoral degree programme in the Faculty of Medicine of the University of Oslo was substantially revised to include coursework and supervision of thesis work. PhD students were expected to complete their work towards the doctorate in three years, and funding was only provided for this period.

MATERIAL AND METHODS

In spring 1999, all doctoral candidates, their supervisors and members of the adjudicating committees were invited to reply to a questionnaire with the purpose of evaluating the results of the new programme over the 1993-99 period.

RESULTS

Only a few doctoral students had been able to obtain their degrees in three years, the defined length of the programme. The mean age for new PhDs was 38; however, physicians obtained their PhD at a later age than the other life scientists enrolled in the programme, and the percentage of PhDs with a medical background declined from 71% in 1993-95 to 51% in 1996-98.

INTERPRETATION

The doctoral programme should be extended from three to four years. More physicians should go into research soon after graduating from medical school and more openings for postdocs should be created. More time for research in the university clinics is also needed.

[Multiple pathological fractures within the scope of DeToni-Debre-Fanconi syndrome after fumarate therapy in psoriasis]

We report about a rare case of a pathological fracture of the shank following earlier pathological fractures at other locations in a comparatively young female patient with no history of trauma. There were no known diseases other than psoriasis. The shank fracture was treated surgically by osteosynthesis. Osteoporosis, myeloma, or malignancy as causative factors of this fracture could be excluded. Scintigraphy showed an enhancement, especially at the extremities. Other than reactive bone growth, histological examination revealed no further aspects. Laboratory analysis indicated a massive lack of vitamin D3. After transferring the patient to the internal department of our hospital, long-term medication with fumaric acid was determined to be the reason for the osteomalacia of a Fanconi's syndrome. Three months after cessation of these medicaments and treatment with active vitamin D3 metabolites, the patient was free of complaints. The radiographs showed an essential improvement of the demineralization.

Development of emotional sweating in preterms measured by skin conductance changes

Skin conductance shows the emotional state, as reflected in changes in the sympathetic nervous system. Skin conductance changes (number and amplitude of the waves, as well as mean skin conductance level) were measured in connection with heel prick from 29 weeks gestational age. The purposes of this study were to examine the development of emotional sweating in preterm infants, and to correlate the changes in emotional sweating with the changes in behavioural state. Fifty infants' behavioural state and skin conductance changes were measured for 2 min before, 2 min during, and 2 min after heel prick. Half of the infants were between 29 and 31 weeks gestational age. They were divided into three sub-groups; 0-10, 11-20 and 21-30 days postnatal age. The other half of the infants were between 32 and 34 weeks gestational age and they were divided into three similar sub-groups. They changed their behavioural state 114 times. Infants from 29 weeks gestational age and more than 10 days old showed emotional sweating as measured by the number and amplitude of the waves that were lowest in sleep and highest during crying (p<0.05). The mean skin conductance level mirrored the behavioural state from 34 weeks gestational age (p<0.05).To conclude, skin conductance changes increased with the level of behavioural state from 29 weeks gestational age and more than 10 days postnatal age.

The development of a software program for analyzing spontaneous and externally elicited skin conductance changes in infants and adults

OBJECTIVES

Changes in palmar and plantar skin conductance (SC) are due to outgoing bursts in the postganglionic efferent sympathetic cholinergic fibres, which responds to changes in central arousal state. The purpose of this study was designed to develop a software program for analyzing spontaneous and external elicited SC changes for infants and adults.

METHODS

The program was designed to calculate the number and mean amplitude of the waves as well as the mean basal level in a given period. Different pre-set values for the minimum amplitude, maximum slope and minimum width of the spontaneous waves were used in the analysis program, and the results were compared with manually counted waves. The program was also used to perform coherent averaging of repeated elicited SC changes. For the mean elicited skin conductance responses, the latency time, response amplitude and recovery time were calculated. The habituation pattern could be calculated semi-automatically by analyzing each response.

RESULTS

For SC waves, the minimum amplitude and the maximum slope should be, respectively, 0.02 microsiemens (microS) and 2 microS/s for infants and adults, and the width of the waves should be at least 1 s for adults, and unlimited for infants. The coherent average method was found to be a satisfactory method for revealing whether a subject responded to stimuli, and is recommended, especially for infants.

CONCLUSIONS

Spontaneous and stimulated skin conductance are easily analyzed by this software program.

Skin conductance and the stress response from heel stick in preterm infants

AIM

To evaluate whether spontaneous skin conductance activity is an objective method for measuring the stress response to painful stimuli in premature infants. The number and amplitude of the waves and the baseline increase with the activity of the sympathetic nervous system.

METHODS

In 20 preterm infants of gestational age >/= 29 weeks, behavioural state and spontaneous skin conductance activity variables were measured for three minutes before, during, and for three minutes after heel stick.

RESULTS

The number of waves (p < 0.001), the amplitude of the waves (p = 0.001), and the level of the behavioural state (p < 0.001) increased during heel stick, and then decreased to levels found before the procedure. The baseline increased both during (p < 0.001) and after heel stick (p < 0.001), compared with levels before.

CONCLUSION

Spontaneous skin conductance activity reflects the stress response to heel stick in premature infants from at least 29 weeks of gestational age.

Vitamin D(3) and vitamin K(1) supplementation of Dutch postmenopausal women with normal and low bone mineral densities: effects on serum 25-hydroxyvitamin D and carboxylated osteocalcin

OBJECTIVE

Improvement of vitamin D and K status of about 60 -y-old postmenopausal Dutch women.

DESIGN

In a randomized study postmenopausal women with normal (T-score >-1; n=96) and low (T-score< or =-1; n=45) bone mineral density (BMD) of the lumbar spine, were supplemented with 350-400 IU vitamin D(3), 80 microg vitamins K(1) vitamins K(1)+D(3), or placebo for 1 y. Serum 25-hydroxyvitamin D [25(OH)D] and percentage carboxylated osteocalcin (%carbOC) were measured at baseline and after 3, 6 and 12 months.

RESULTS

Baseline %carbOC of the entire study population was positively correlated with BMD of the lumbar spine and femoral neck. Correspondingly, women with low BMD had lower %carbOC at baseline than women with normal BMD but this difference disappeared after 1 y of supplementation with vitamin K(1) ((mean+/-s.d.) 68+/-11% (95% CI, 64. 5-71.2%) vs 72+/-6% (95% CI, 70.1-72.9%), respectively). One year of supplementation with vitamin D(3) showed maximum increases in 25(OH)D of 33+/-29% (95% CI, 24.8-41.8%) and 68+/-58% (95% CI, 50.1-84.6%) in women with normal and low BMD, respectively. During winter, however, a 29% decline in maximum 25(OH)D levels was not prevented in women with low BMD.

CONCLUSION

Daily supplementation of Dutch postmenopausal women with >400 IU vitamin D(3) is indicated to prevent a winter decline in 25(OH)D and to control serum parathyroid hormone levels. Daily supplementation with 80 microg vitamin K(1) seems to be necessary to reach premenopausal %carbOC levels. A stimulatory effect of calcium and/or vitamin D on %carbOC cannot be excluded. European Journal of Clinical Nutrition (2000) 54, 626-631.