The Canadian Assisted Reproductive Technologies Register (CARTR) Plus database: a validation study

STUDY QUESTION

Are data accurately documented in the Canadian Assisted Reproductive Technologies Register (CARTR) Plus database?

SUMMARY ANSWER

Measures of validity were strong for the majority of variables evaluated while those with moderate agreement were FSH levels, oocyte origin and elective single embryo transfer.

WHAT IS KNOWN ALREADY

Health databases and registries are excellent sources of data. However, as these databases are typically not established for the primary purpose of performing research, they should be evaluated prior to utilization for research both to inform the study design and to determine the extent to which key study variables, such as patient characteristics or therapies provided, are accurately documented in the database. CARTR Plus is Canada's national register for collecting extensive information on IVF and corresponding pregnancy outcomes, and it has yet to be validated.

STUDY DESIGN SIZE DURATION

This study evaluating the data translation CARTR Plus database examined IVF cycles performed in 2015 using data directly from patient charts. Six clinics across Canada were recruited to participate, using a purposive sampling strategy. Fixed random sampling was employed to select 146 patient cycles at each clinic, representing unique patients. Only a single treatment cycle record from a unique patient at each clinic was considered during chart selection.

PARTICIPANTS/MATERIALS SETTING METHODS

Twenty-five data elements (patient characteristics, treatments and outcomes) were reabstracted from patient charts, which were declared the reference standard. Data were reabstracted by two independent auditors with relevant clinical knowledge after confirming inter-rater reliability. These data elements from the chart were then compared to those in CARTR Plus. To determine the validity of these variables, we calculated kappa coefficients, sensitivity, specificity, positive predictive value and negative predictive value with 95% CI for categorical variables and calculated median differences and intraclass correlation coefficients (ICC) for continuous variables.

MAIN RESULTS AND THE ROLE OF CHANCE

Six clinics agreed to participate in this study representing five Canadian provinces. The mean age of patients was 35.5 years, which was similar between the two data sources, resulting in a near perfect level of agreement (ICC = 0.99; 95% CI: 0.99, 0.99). The agreement for FSH was moderate, ICC = 0.68 (95% CI: 0.64, 0.72). There was nearly perfect agreement for cycle type, kappa = 0.99 (95% CI: 0.98, 1.00). Over 90% of the cycles in the reabstracted charts used autologous oocytes; however, data on oocyte source were missing for 13% of cycles in CARTR Plus, resulting in a moderate degree of agreement, kappa = 0.45 (95% CI, 0.37, 0.52). Embryo transfer and number of embryos transferred had nearly perfect agreement, with kappa coefficients greater than 0.90, whereas that for elective single or double embryo transfer was much lower (kappa = 0.55; 95% CI: 0.49, 0.61). Agreement was nearly perfect for pregnancy type, and number of fetal sacs and fetal hearts on ultrasound, all with kappa coefficients greater than 0.90.

LARGE-SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

CARTR Plus contains over 200 variables, of which only 25 were assessed in this study. This foundational validation work should be extended to other CARTR Plus database variables in future studies.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides the first assessment of the quality of the data translation process of the CARTR Plus database, and we found very high quality for the majority of the variables that were analyzed. We identified key data points that are either too often lacking or inconsistent with chart data, indicating that changes in the data entry process may be required.

STUDY FUNDING/COMPETING INTERESTS

This study was funded by Canadian Institutes of Health Research (CIHR) (Grant Number FDN-148438) and by the Canadian Fertility and Andrology Society Research Seed Grant (Grant Number: N/A). The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

A systematic review of database validation studies among fertility populations

STUDY QUESTION

Are routinely collected data from fertility populations adequately validated?

SUMMARY ANSWER

Of the 19 studies included, only one validated a national fertility registry and none reported their results in accordance with recommended reporting guidelines for validation studies.

WHAT IS KNOWN ALREADY

Routinely collected data, including administrative databases and registries, are excellent sources of data, particularly for reporting, quality assurance, and research. However, these data are subject to misclassification bias due to misdiagnosis or errors in data entry and therefore need to be validated prior to using for clinical or research purposes.

STUDY DESIGN SIZE DURATION

We conducted a systematic review by searching Medline, Embase, and CINAHL from inception to 6 October 2016 to identify validation studies of databases that contain routinely collected data in an ART setting. Webpages of international ART centers were also searched.

PARTICIPANTS/MATERIALS SETTING METHODS

We included studies that compared at least two data sources to validate ART population data. Key words and MeSH terms were adapted from previous systematic reviews investigating routinely collected data (e.g. administrative databases and registries), measures of validity (including sensitivity, specificity, and predictive value), and ART (including infertility, IVF, advanced reproductive age, and diminished ovarian reserve). Only full-text studies in English were considered. Results were synthesized qualitatively. The electronic search yielded 1074 citations, of which 19 met the inclusion criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

Two studies validated a fertility database using medical records; seven studies used an IVF registry to validate vital records or maternal questionnaires, and two studies failed to adequately describe their reference standard. Four studies investigated the validity of mode of conception from birth registries; two studies validated diagnoses or treatments in a fertility database; four studies validated a linkage algorithm between a fertility registry and another administrative database; one study created an algorithm in a single database to identify a patient population. Sensitivity was the most commonly reported measure of validity (12 studies), followed by specificity (9 studies). Only three studies reported four or more measures of validation, and five studies presented CIs for their estimates. The prevalence of the variable in the target population (pre-test prevalence) was reported in seven studies; however, only four of the studies had prevalence estimates from the study population (post-test prevalence) within a 2% range of the pre-test estimate. The post-test estimate was largely discrepant from the pre-test value in two studies.

LIMITATIONS REASONS FOR CAUTION

The search strategy was limited to the studies and reports published in English, which may not capture validation studies from countries that do not speak English. Furthermore, only three specific fertility-based diagnostic variables (advanced reproductive age, diminished ovarian reserve, and chorionicity) were searched in Medline, Embase, and CINAHL. Consequently, published studies with other diagnoses or conditions relevant to infertility may not have been captured in our review.

WIDER IMPLICATIONS OF THE FINDINGS

There is a paucity of literature on validation of routinely collected data from a fertility population. Furthermore, the prevalence of the markers that have been validated are not being presented, which can lead to biased estimates. Stakeholders rely on these data for monitoring outcomes of treatments and adverse events; therefore, it is essential to ascertain the accuracy of these databases and make the reports publicly available.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by Canadian Institutes of Health Research (CIHR) (FDN-148438). There are no competing interests for any of the authors.

REGISTRATION NUMBER

International Prospective Register of Systematic Reviews ID: CRD42016048466.

A comprehensive mathematical model for three-body binding equilibria

Three-component systems are often more complex than their two-component counterparts. Although the reversible association of three components in solution is critical for a vast array of chemical and biological processes, no general physical picture of such systems has emerged. Here we have developed a general, comprehensive framework for understanding ternary complex equilibria, which relates directly to familiar concepts such as EC50 and IC50 from simpler (binary complex) equilibria. Importantly, application of our model to data from the published literature has enabled us to achieve new insights into complex systems ranging from coagulation to therapeutic dosing regimens for monoclonal antibodies. We also provide an Excel spreadsheet to assist readers in both conceptualizing and applying our models. Overall, our analysis has the potential to render complex three-component systems--which have previously been characterized as "analytically intractable"--readily comprehensible to theoreticians and experimentalists alike.

The transcriptome of the arbuscular mycorrhizal fungus Glomus intraradices (DAOM 197198) reveals functional tradeoffs in an obligate symbiont

• The arbuscular mycorrhizal symbiosis is arguably the most ecologically important eukaryotic symbiosis, yet it is poorly understood at the molecular level. To provide novel insights into the molecular basis of symbiosis-associated traits, we report the first genome-wide analysis of the transcriptome from Glomus intraradices DAOM 197198. • We generated a set of 25,906 nonredundant virtual transcripts (NRVTs) transcribed in germinated spores, extraradical mycelium and symbiotic roots using Sanger and 454 sequencing. NRVTs were used to construct an oligoarray for investigating gene expression. • We identified transcripts coding for the meiotic recombination machinery, as well as meiosis-specific proteins, suggesting that the lack of a known sexual cycle in G. intraradices is not a result of major deletions of genes essential for sexual reproduction and meiosis. Induced expression of genes encoding membrane transporters and small secreted proteins in intraradical mycelium, together with the lack of expression of hydrolytic enzymes acting on plant cell wall polysaccharides, are all features of G. intraradices that are shared with ectomycorrhizal symbionts and obligate biotrophic pathogens. • Our results illuminate the genetic basis of symbiosis-related traits of the most ancient lineage of plant biotrophs, advancing future research on these agriculturally and ecologically important symbionts.

Behind the ESPEN Guidelines on parenteral nutrition in the ICU

Enteral nutrition (EN) is a well established approach to nutritional support in the ICU. Parenteral nutrition (PN) represents an additional safe approach, substituting or complementing EN when its delivery fails completely or partially. This article attempts to summarize the ESPEN guidelines of PN in the ICU based on the available literature, which is often limited due to quality and methodology heterogeneity; the recommendations are therefore largely expressed as expert opinions.

Effect of surgeon education on lymphadenectomy in colon cancer

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Background: The most important determinant of prognosis for localized colon cancer is metastatic lymph node involvement. The American Joint Commission on Cancer and the College of American Pathologists have recommended examination ≥ 12 lymph nodes to ensure adequate staging. We hypothesized that surgeon education would improve the extent of lymphadenectomy in patients being treated for colon cancer. A large community based metropolitan health care system served as a model for testing this hypothesis.

Methods: 906 patients comprising AJCC stage I (n=265), stage II (n=304), and stage III (n=337) colon cancers were evaluated. Surgical approach was either open (n=567), laparoscopic (n=310), or unknown (n=29). Lymphadenectomy results obtained from post-operative pathology reports were tracked across four separate time periods: era 1 (1/1/02-1/31/04), era 2 (1/1/05-1/31/06), and era 3 (1/1/07-1/31/07). Results were then compared against a study endpoint measurement of 2008, era four.

Results: Upon analysis and comparison of individual era results, a significant improvement in lymphadenectomy (percentage of patients with ≥12 nodes harvested) was noted for all AJCC stages (p-values compare era 4 versus era 1): I (34.2% vs. 59% vs. 65% vs. 69%, P=0.0001), II (62% vs. 76% vs. 90% vs. 91%, P=0.0004), and III (55% vs. 72% vs. 84% vs. 86%, P<0.0001; see table). Surgical approach was not a significant factor. Neither age nor sex was significant.

Conclusions: Through physician education, we were able to increase awareness of optimal staging practice for lymphadenectomy in colon cancer. This resulted in significantly improved patient outcomes within a large metropolitan health care system.

No significant financial relationships to disclose.

Tetraspanin-induced death of myeloma cell lines is autophagic and involves increased UPR signalling

Background:

Multiple myeloma (MM) therapy is hindered by the interaction of the heterogeneous malignant plasma cells with their microenvironment and evolving drug resistance. We have previously shown that the membranal tetraspanins, CD81 and CD82, are under-expressed in MM cells and that their reintroduction causes massive non-apoptotic death. In this study, we aimed to characterise the tetraspanin-induced MM death.

Methods:

Multiple myeloma cell lines were transiently transfected with eGFP–CD81N1/CD82N1 fusion proteins and assessed for death mode by flow cytometry (propidium iodide, ZVAD-fmk, 3MA), activation of unfolded protein response (UPR), and autophagy (immunoblot, RT–PCR).

Results:

Cell death induced by CD81N1 and CD82N1 in MM cell lines was autophagic and involved endoplasmic reticulum (ER)-stress manifested by activation of UPR pathways, PERK (protein kinase-like ER kinase) and IRE1 (inositol-requiring 1). We also established the relative X-box binding protein 1 baseline expression levels in a panel of MM cell lines and their general dependence on autophagy for survival. Timeline of UPR cascades and cell fate supported our results.

Interpretation:

This is the first publication implicating tetraspanins in UPR signalling pathways, autophagy, and autophagic death. Integration of our findings with published data highlights the unifying dependence of MM cells on ER–Golgi homoeostasis, and underscores the potential of tetraspanin complexes and ER-stress as leverage for MM therapy.

Subthalamic deep brain stimulation and impulse control in Parkinson's disease

BACKGROUND AND PURPOSE

Experimental studies suggest that deep brain stimulation (DBS) of the subthalamic nucleus (STN) induces impulsivity in patients with Parkinson's disease (PD). The purpose of this study was to assess various measures of impulse control in PD patients with STN DBS in comparison to patients receiving medical therapy.

METHODS

In a cross-sectional evaluation, 53 consecutively eligible patients were assessed for impulsivity with the Barratt Impulsiveness Scale, for impulse control disorders (ICDs) using the Minnesota Impulsive Disorders Interview, and for obsessive-compulsive symptoms using the Maudsley Obsessional-Compulsive Inventory.

RESULTS

Independent samples t-tests revealed that compulsivity scores were not different between DBS patients and patients without DBS. However, impulsivity scores were significantly higher in DBS patients. Additionally, ICDs were observed in 3 of 16 (19%) DBS patients and in 3 of 37 (8%) medically treated patients. No association was found between the use of dopamine agonists and impulsivity in DBS patients.

CONCLUSIONS

Our data suggest that screening for impulsivity and ICDs should be performed prior to DBS, and that patients should be monitored for these problems during follow-up. Prospective trials are needed to confirm the findings of this exploratory study and to elucidate the reasons of a possible induction of impulsivity by STN DBS.

Clinical outcome of low-grade NHL patients with bone marrow involvement

BACKGROUND

Bone marrow (BM) involvement in low-grade non-Hodgkin's lymphoma (NHL) has a clear impact on patients' survival. The standard practice is morphological examination of BM biopsy at diagnosis. The clinical significance of flow cytometry (FC) analysis of BM aspirates is largely unknown.

MATERIALS AND METHODS

The medical charts of 70 low-grade NHL patients, who underwent BM biopsy and FC analysis between 1994 and 2004, were reviewed.

RESULTS

Forty-three patients (61.4%) were BM+ by morphology, while in those without morphological involvement by lymphoma FC was positive in 9 (BM-FC+, 12.9%) and negative in 18 (BM-FC-, 25.7%). The median treatment-free period was shorter in the BM+ and BM-FC+ groups compared with the BM-FC- group (1 and 4 months vs. 31 months, respectively) (log-rank test, P = 0.0195). The median survival time was not reached for the BM-FC- patients, whereas for BM+ and BM-FC+ patients it was 129 and 89 months, respectively, with no significant difference between them [the difference between the BM-FC- and the two other groups was statistically significant (log-rank test, P = 0.029)].

CONCLUSIONS

The outcome of low grade NHL in patients who had BM involvement by FC alone or by morphology was similar. If confirmed, these findings suggest a modification in the workup and management of localized low grade NHL.

Detecting antibodies with similar reactivity patterns in the HLDA8 blind panel of flow cytometry data

The blind panel collected for the 8th Human Leucocyte Differentiation Antigens Workshop (HLDA8; ) included 49 antibodies of known CD specificities and 76 antibodies of unknown specificity. We have identified groups of antibodies showing similar patterns of reactivity that need to be investigated by biochemical methods to evaluate whether the antibodies within these groups are reacting with the same molecule. Our approach to data analysis was based on the work of Salganik et al. (in press) [Salganik, M.P., Milford E.L., Hardie D.L., Shaw, S., Wand, M.P., in press. Classifying antibodies using flow cytometry data: class prediction and class discovery. Biometrical Journal].

Fluorouracil induces apoptosis and surface molecule modulation of peripheral blood leukocytes

Little is known about the direct effect of chemotherapy on normal peripheral blood leukocytes (PBL) or its contribution to leukopenia. We examined 5'-fluorouracil's (5FU) effect on PBL apoptosis and adhesion molecules' expression in a single-drug solid-tumor model. Possible apoptosis mediators were examined. The study included 32 colorectal cancer patients; apoptosis was determined by annexin-V binding and light-scatter morphology before and after drug infusion. CD18, CD11a, CD11b, and CD63 membranal levels were assayed by flow cytometry. Apoptosis was increased post-5FU administration in neutrophils (PMN), monocytes and lymphocytes (P < 0.05). Levels of Fas receptor and activated caspase 3 did not vary indicating that the process was not mediated by caspase 3 in the timeframe studied. Reduced CD63 on monocytes and decreased CD18 expression on PMN and non-apoptotic monocytes were observed (P < or = 0.05). CD11a,b expression did not vary. Decreased CD18 and CD63 levels were demonstrated in apoptotic and non-apoptotic PBL implying a more direct association with the drug itself.

A novel treatment for constipation-predominant irritable bowel syndrome using Padma Lax, a Tibetan herbal formula

BACKGROUND AND AIMS

Padma Lax, a complex Tibetan herbal formula for constipation was evaluated for safety and effectiveness in treating constipation-predominant irritable bowel syndrome in a 3-month double-blind randomised pilot study.

METHODS

Patients were recruited from Hadassah Hospital's Gastroenterology clinic, using the Rome I Criteria for irritable bowel syndrome, and the international consensus criteria for constipation. Symptom severity was evaluated monthly by patients and gastroenterologist, using categorical and numerical rating scales. A patient diary recorded daily stool habit and trial medication.

RESULTS

In 61 patients, (34 Padma Lax, 27 placebo), significant improvement was demonstrated after 3 months in the Padma Lax group compared to placebo in constipation, severity of abdominal pain, and its effect on daily activities, incomplete evacuation, abdominal distension and flatus/flatulence. A global assessment indicated that significantly more Padma Lax patients, compared to placebo, rated the current treatment superior to previous therapies tried for irritable bowel. Laboratory parameters displayed no clinically significant changes. Side effects, primarily loose stools in 7 Padma Lax patients responded well to lowering treatment dosage from 2 to 1 capsule/day.

CONCLUSIONS

Padma Lax is a safe and effective treatment for constipation-predominant irritable bowel syndrome and may offer an alternative to the current multi drug approach.

The disconnect: infertility patients' information and the role they wish to play in decision making

OBJECTIVE

To determine the preferred role in medical decision making of women undergoing fertility treatments and to establish whether their knowledge of treatments is adequate to inform their choices.

METHODS

Self-report survey of 404 women undergoing fertility treatments in 2 university hospitals and a private fertility clinic in Canada.

RESULTS

The women had been in fertility treatment for 2.3 +/- 2.6 years; 67.8% reported taking fertility drugs. Most (61.7%) women wanted to share knowledge equally with their doctors about possible fertility treatments. However, about half wanted to decide alone or mostly by themselves about the acceptability of treatment risks and benefits (56%), what treatments should be selected (49.8%), and when to conclude treatments (54.3%). In addition, 55.1% of the women did not know their personal eventual chances of pregnancy with fertility treatment or thought it was 50% or greater. Over half of the women (57.2%) who had taken fertility drugs were unaware of a possible link between fertility drugs and increased ovarian cancer risk. The majority of women (61.8%) who knew of this possible association reported that they learned about it from the print media. Women who knew of the association had a poor understanding of the strength of the evidence or the ability to detect or treat ovarian cancer successfully, and 88.3% thought they could reduce cancer risk by following their doctors' advice.

CONCLUSIONS

Despite these women's wishes to actively participate in fertility treatment decisions, they lacked the necessary information to do so meaningfully. Public health policymakers, professional and advocacy organizations, physicians, other healthcare providers, and women themselves must find ways to improve the general public's and patients' understanding about fertility treatment outcomes and risks.

The prognostic value of DNA ploidy in small renal cell carcinoma

The objective was to study the prognostic value of Deoxyribonucleic Acid (DNA) ploidy status in small renal cell carcinomas (RCC). The nuclear DNA content of renal cell carcinoma tissues from patients who underwent radical or partial nephrectomy has been analyzed by flow cytometry. The results of the DNA ploidy have been correlated to the size of tumors and disease progression. Of the 50 patients with RCC studied, 8 (16%) progressed. Tumors with non-diploid DNA patterns were found in 24 (48%) of the 50 patients and in 4 of the 8 patients who progressed. Overall the median tumor size in our series was 50 mm. A tumor diameter of 50 mm or less was measured in 26 patients (group I) and above 50 mm in 24 (group II). Non-diploid DNA patterns were found in 11 (42.3%) and 13 (54.2%) patients in groups I and II, respectively. This difference between the groups was not significant. Only one patient in group I (3.8%) developed metastatic disease and died 72 months after the operation. In group II, 7 patients (29.2%) presented tumor progression and 5 died of metastatic disease. The survival probability in group I was 95% at 5 and 8 years (95% CI 70% to 99%) and for group II 94% at 5 years (95% CI 67%-99%) and 67% at 8 years (95% CI 39%-83%). DNA ploidy is an inaccurate predictor of tumor behavior in patients with RCC, even in small tumors. Tumor size is a more significant predictor of outcome.

Preliminary observations of transtracheal augmented ventilation for chronic severe respiratory disease

OBJECTIVE

Evaluate the potential safety and efficacy of transtracheal augmented ventilation (TTAV), which is the transtracheal delivery of high flows of a humidified air-oxygen blend.

METHODS

The first of 2 observational studies evaluated patients before and after a 3-month intervention with the nocturnal (Noc) administration of TTAV at 10 L/min. Resting physiologic studies evaluated standard low-flow transtracheal oxygen (LFTTO), TTAV, and breathing without transtracheal flow via mouthpiece (MP). Patients also underwent nocturnal polysomnography, bronchoscopy, ventilatory drive evaluation, and treadmill exercise. The second study assessed the safety of Noc TTAV for up to 60 months. Each study evaluated 15 different transtracheal patients with severe lung disease.

RESULTS

Pleural pressure-time index and respiratory duty cycle were significantly lower (p < 0.05) when comparing MP to TTAV. TTAV contributed more (p < 0.05) than LFTTO to the total volume delivered to the lung (V(L)). Arterial blood gases and (V(L)) were unaltered by TTAV. Sleep quality and nocturnal oxygenation with TTAV were similar to LFTTO, and Noc TTAV had no effect on ventilatory drive. Bronchoscopy showed no evidence of substantial injury. Treadmill exercise tests showed a longer exercise time (p < 0.005) and greater total work (p < 0.05) following Noc TTAV. During exercise, the changes in slope for heart rate and pH were less steep (p < 0.05) following Noc TTAV. The 3-month study and a long-term evaluation showed that Noc TTAV was well-tolerated and safe, with a reported high compliance.

CONCLUSIONS

Patients with chronic hypoxemia and severe respiratory insufficiency may benefit from Noc TTAV.

The effect of storage on the expression of platelet membrane phosphatidylserine and the subsequent impacton the coagulant function of stored platelets

BACKGROUND

Platelet concentrates (PCs) derived from whole blood and stored under standard blood bank conditions undergo changes that are referred to as the platelet storage lesion. This study assesses the effect of PC preparation and storage on the distribution of phosphatidylserine (PS) in the platelet membrane and the effect that this distribution may have on the thrombogenic potential of stored PCs.

STUDY DESIGN AND METHODS

Fresh platelets and PCs donated by healthy donors were obtained. PCs derived from platelet-rich plasma were studied on Day 1, Day 3, and Day 6 of storage under blood bank conditions.

RESULTS

Platelet aggregation after exposure to the platelet agonists ADP and epinephrine singly declined progressively, but, when ADP and epinephrine in combination and collagen and thrombin in combination were used as agonists, the decline in platelet aggregation was less marked. PS expression as measured by Annexin V binding (mean and SD) was 2.02 +/- 0.93 percent in fresh platelet samples and increased to 5.39 +/- 4.2 percent on Day 1, 22. 1 +/- 7.1 percent on Day 3, and 39.5 +/- 12.1 percent on Day 6. Platelet prothrombinase activity (mean +/- SD) as measured by thrombin generation increased from 1.49 +/- 0.7 micro per mL in fresh platelet samples to 3.68 +/- 1.1 micro per mL in Day 1 platelets (p<0.001), 5.15 +/- 2.5 micro per mL in Day 3 platelets (p<0.001), and 4.65 +/- 2.48 micro per mL in Day 6 platelets (p<0. 001).

CONCLUSION

These results show that PS expression increases after preparation of PCs from platelet-rich plasma and rises progressively during platelet storage under blood bank conditions. Furthermore, the greater PS expression is associated with increased platelet- dependent thrombin-generating capacity.

The diagnostic significance of polyclonal lymphocytosis in pleural effusions

AIM

To evaluate the diagnostic contribution and clinical relevance of analysing subpopulations of lymphocytes in pleural effusions.

METHODS

Forty patients (age >60 years) with newly diagnosed, polyclonal, lymphocyte-rich pleural effusions were evaluated. The following data were collected: demographic characteristics, associated diseases, fluid type, fluid white blood cells count, differential morphology and immunephenotyping, and final diagnosis.

RESULTS

Of the 33 patients for whom biochemical data were available, 18 had exudative effusion, while 15 had transudate. Thirty-three fluids contained mostly T cells and only one was B-cell rich. (The lymphocytes of five patients with malignant epithelial cells in the effusion were not subtyped.) Thirty-two of the 33 T-cell rich fluids contained mainly CD4+ lymphocytes. The most common causes of pleural effusion were congestive heart failure (17 patients) and epithelial malignant diseases (eight patients), while none of the patients had tuberculosis. Since most effusions were CD4+ rich, no correlation could be detected between lymphocyte subtyping and diagnosis or the biochemical type of the fluids. Congestive heart failure was significantly associated with transudates, while malignant diseases correlated with exudates.

CONCLUSIONS

Most patients with pleural polyclonal lymphocytosis, especially those with transudates, have congestive heart failure. The presence of exudative, lymphocyte-rich effusion is an indication for further evaluation, since it is most commonly associated with malignancy. The clinical value of lymphocyte subtyping is low and this procedure should not be used routinely.

Analysis of enzyme kinetics in individual living cells utilizing fluorescence intensity and polarization measurements

BACKGROUND

The Cellscan mark-S (CS-S) scanning cytometer was used for tracing enzymatic reactions in the same individual cells under various physiological conditions over periods of minutes. On-line reagent addition and changes in the experimental conditions (buffers, ions, substrates and inhibitors) were performed.

METHODS

Kinetic events were monitored by fluorescence intensity (FI) and fluorescence polarization (FP) measurements of fluorescein diacetate (FDA) and chloromethyl fluorescein diacetate (CMFDA) intracellular hydrolysis. FP measurements have been used to assess the intracellular marker's mobility restrictions.

RESULTS

Kinetic measurement along 1000 s of FDA labeled individual Jurkat T cells, indicated variation of 65% for FI(t) and approximately 10% for FP(t). While FI increased linearly with time, FP(t) decreased nonlinearly and asymptotically, reaching a constant value. The FP(t) of CMFDA-labeled cells was different from that of FDA-labeled cells. Average cellular Km of 3.9 microM was calculated from individual cell FDA hydrolysis curves.

CONCLUSIONS

(1) Analysis of the reaction kinetics of intracellular enzymes can be refined by using FP measurements of the products of fluorogenic substrates in addition to the FI measurements. (2) Subpopulations or individual cells could be classified according to their reaction rates. (3) A specific dependence of FP(t) on type of enzyme substrate is suggested.

A specific sign of pneumoperitoneum on sonography: enhancement of the peritoneal stripe

OBJECTIVE

Failure to reveal pneumoperitoneum is a recognized weakness of abdominal sonography. Our objective is to describe a reliable and reproducible sign of pneumoperitoneum that was first identified in an animal model and then confirmed in patients who had undergone laparoscopy.

SUBJECTS AND METHODS

We injected 300 ml of degassed water into the peritoneal cavity of a 15-kg anesthetized pig. Sonographic images were obtained of the anterior peritoneal area after intraperitoneal injection of a single bubble, a series of bubbles, and, subsequently, a 10-ml bolus of air. Later, abdominal sonography was performed in nine patients who had undergone laparoscopy. Close attention was paid to the anterior peritoneal area and signs of free air observed in the animal model. Ten healthy volunteers functioned as a control group.

RESULTS

In the pig, minute amounts of intraperitoneal air showed on sonography as enhancement of the peritoneal stripe. Larger volumes of intraperitoneal air showed as enhancement of the peritoneal stripe associated with dirty shadowing or distal multiple reflection artifacts. The stripe enhanced each time it appeared in the reflection artifact. Intraluminal gas was associated with a normal thin peritoneal stripe, superficial and distinct from the underlying gas artifact. The patients who had undergone laparoscopy showed findings suggestive of small and large pockets of free air, as we saw in the pig model. The control group showed findings consistent with intraluminal gas only.

CONCLUSION

On sonography, enhancement of the peritoneal stripe alone or with reflection artifacts involving the peritoneal stripe is an accurate sign of pneumoperitoneum.

Clinical observations of axillary involvement for tubular, lobular, and ductal carcinomas of the breast

BACKGROUND AND OBJECTIVES

Recently, there has been much interest in identifying primary breast cancer characteristics which have predictive value for axillary metastases. We studied breast cancer patients to determine variables associated with the incidence/extent of axillary involvement and to construct a modeled analysis.

METHODS

Patients with invasive ductal, lobular, and tubular breast cancer (group 1, n = 15,719) were analyzed by tumor size and histology for the probability/extent of axillary metastases. A subgroup of patients was analyzed separately for any association of axillary involvement and other variables (group 2).

RESULTS

In group 1, the incidence and extent (number of positive lymph nodes) of axillary metastases correlated significantly with histology and increasing tumor size of ductal and lobular histologies. Significant associations for < or = 10% axillary involvement in group 2 were age and S phase for tubular histology and differentiation for ductal histology. In a multivariate analysis, increasing tumor size was the only statistically significant correlate for axillary involvement (group 2) and for increasing number of positive nodes (group 1).

CONCLUSIONS

A multivariate model of tumor size and age combined with staging techniques can successfully confirm or assess extent of axillary metastases in breast carcinoma.

Ovarian hyperstimulation following the sole administration of agonistic analogues of gonadotrophin releasing hormone

Ovarian hyperstimulation following the sole administration of gonadotrophin-releasing hormone agonists (GnRHa) is exceedingly rare. We hereby report on two infertile patients undergoing in-vitro fertilization-embryo transfer who developed ovarian hyperstimulation under such circumstances. In both patients, GnRHa were administered using the 'long protocol' regimen. The first patient developed ovarian hyperstimulation on two occasions, with mid-luteal depot administration of triptorelin and with early follicular triptorelin, administered as daily subcutaneous injections. In both cycles, within 2 weeks of triptorelin therapy, massive ovarian multifollicular enlargement occurred, concomitant with high serum oestradiol concentrations, which resolved spontaneously following expectant management. The second patient developed ovarian hyperstimulation following daily injections of leuprolide acetate starting at the mid-luteal phase. The final stage of ovulation was triggered by human chorionic gonadotrophin (HCG) and 11 oocytes were retrieved. In-vitro fertilization resulted in embryo formation, but failed to result in pregnancy. The same phenomenon recurred in a subsequent cycle despite preventive pretreatment with an oral contraceptive. A negative GnRH test, performed just before HCG administration, suggested than an ongoing 'flare-up effect' was unlikely to cause ovarian stimulation. Ovarian hyperstimulation can occur following the sole administration of GnRHa irrespective of the preparation used and the administration protocol. Although spontaneous resolution is the rule, once this condition has developed, HCG administration and oocyte retrieval are feasible. This rare entity probably represents an exaggerated form of ovarian cyst formation following GnRHa administration, the underlying pathophysiology of which remains unresolved.

Pleural effusion in patients with non-Hodgkin's lymphoma: a case-controlled study

BACKGROUND

Pleural effusion is reported in up to 20% of patients with non-Hodgkin's lymphoma (NHL), most often at presentation. However, the prognostic implications of such findings are not clear. The majority of the information in the literature is based on minor observational studies or case reports. Therefore, a case-controlled study was performed to verify the clinical significance of pleural effusion in NHL.

METHODS

Seventeen patients with pleural effusion at the time of presentation of NHL were identified. They were categorized by grade of NHL (based on the Working Formulation). Twenty-nine control patients with similar histopathologic characteristics who had Stage III/IV NHL without pleural effusion were matched to these cases by age, time of diagnosis, and treatment.

RESULTS

Ten patients with intermediate grade NHL were matched with 23 controls. No statistically significant difference in complete remission or survival rates between these groups was found (P=0.69 and P=0.7, respectively). The remission and survival rates also were similar in the subgroup of patients and controls who were treated with aggressive chemotherapy. Similarly, no difference was found in these parameters between four cases and six matched controls with low grade lymphoma. No matched controls were found for the patients with high grade lymphoma, but these patients had an unfavorable outcome. Fourteen of the 17 studied patients had an exudative type of pleural effusion. Thoracentesis yielded a positive cytologic finding in every case.

CONCLUSIONS

The presence of pleural effusion at the time of presentation of NHL does not adversely affect complete remission or survival rates.

Cytokines modulate expression of cell-membrane complement inhibitory proteins in human lung cancer cell lines

Human lung cancers overexpress several cell-membrane complement inhibitory proteins (CIP). These complement inhibitory proteins are membrane cofactor protein (CD46), decay-accelerating factor (DAF; CD55), and CD59 (protectin). These cell-membrane proteins have a wide normal tissue distribution, are known to protect normal host cells from homologous complement-mediated lysis, and are thought to facilitate tumor escape from immunosurveillance. To study whether proinflammatory cytokines that are involved in cancer growth can modulate cell-membrane CIP expression in lung cancer cells, we studied the effect of interleukin (IL)-1alpha, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma on two human lung cancer cell lines. ChaGo K-1 and NCI-H596 cell lines, undifferentiated carcinoma and lung adenosquamous carcinoma, respectively, were stimulated with different cytokines, and the effects of incubation time and cytokine concentration on cell-membrane CIP expression were studied. Cell-membrane CIP expression was evaluated using flow cytometry and cytokine effect was calculated as percent change in mean fluorescence intensity of each CIP molecule from its untreated control. We found that DAF was the lung cancer cell-membrane CIP molecule that was the most responsive to cytokine stimulation. Maximal stimulatory effect was usually noted 72 h after a cytokine was introduced. In ChaGo K-1 and NCI-H596 lung cancer cell lines, IL-1alpha and TNF-alpha increased DAF expression. IL-1alpha (100 U/ml/72 h) increased DAF expression up to a maximal mean of 45 and 48%, respectively, in comparison with untreated cells. TNF-alpha (1, 000 U/ml/72 h) increased DAF expression up to a mean of 131 and 46%, respectively. IFN-gamma (1 U/ml/72 h) increased DAF expression in NCI-H596 cells up to a mean of 100%, but had a slight inhibitory effect on DAF expression in ChaGo K-1 cells, decreasing expression by a mean of 17% in comparison with untreated cells. We conclude that cell-membrane DAF expression in the studied human lung cancer cell lines is modulated by IL-1alpha, TNF-alpha, and IFN-gamma, and speculate that cytokine-mediated modulation of cell-membrane DAF in human lung cancer cells might affect lung cancer cell biology.

Human lung cancer cell lines express cell membrane complement inhibitory proteins and are extremely resistant to complement-mediated lysis; a comparison with normal human respiratory epithelium in vitro, and an insight into mechanism(s) of resistance

Human lung cancer expresses cell membrane complement inhibitory proteins (CIP). We investigated whether human lung cancer cell lines also express cell-membrane CIP molecules and whether the biology of CIP molecules in these cell lines differs from that of CIP in normal human respiratory epithelium in culture. The cell lines ChaGo K-1 and NCI-H596 were compared with normal human nasal epithelium in primary cultures in respect to the level of cell membrane CIP expression of membrane cofactor protein (MCP; CD46), decay-accelerating factor (DAF; CD55) and CD59, in respect to the level of cell resistance to complement-mediated lysis, and in respect to the contribution of cell membrane CIP to cell resistance against complement-mediated lysis. We found, using flow cytometry, that both human lung cancer cell lines expressed MCP, DAF and CD59, as did normal nasal epithelial cells. However, normal cells showed a large subpopulation of low DAF-expressing cells (60% of all cells) and a smaller subpopulation of high DAF-expressing cells (40%), while the lung cancer cell lines showed only one cell population, of high DAF expression. In addition, both lung cancer cell lines expressed higher MCP levels, and NCI-H596 cells showed higher levels of CD59. Cell resistance to complement-mediated lysis of both lung cancer cell lines was much higher than that of normal cells. Fifty percent normal human serum, under the same concentrations of complement activators, induced lysis of less than a mean of 10% of lung cancer cells, while lysing up to a mean of 50% of nasal epithelial cells. Lung cancer cell resistance to complement was due to its ability to prevent significant activation of complement upon its cell membrane, as manifested by a failure of complement activators to increase cell membrane deposition of C3-related fragments. The exact mechanism for this resistance remains obscure. Unexpectedly, neutralizing antibodies, anti-MCP and anti-DAF were entirely ineffective and anti-CD59 was only slightly effective (18% mean cell lysis) in increasing the susceptibility of the lung cancer cell lines to complement, while the same antibodies were very effective in facilitating complement-mediated lysis of the normal nasal epithelial cells (50% mean cell lysis with CD59 MoAb). On the other hand, detachment of DAF and CD59 by phosphatidylinositol-specific phospholipase C (PIPLC) from the lung cancer cell lines abrogated their resistance to lysis. We suggest that the biology of cell membrane CIP molecules in human lung cancer cell lines is different from that of CIP in normal respiratory epithelial cells. Human lung cancer cell lines are able to prevent significant complement activation upon its cell membrane and are therefore especially resistant to complement-mediated lysis. Complement resistance may serve this common and highly lethal human cancer as an escape mechanism from the body's immunosurveillance and prevent effective immunotherapy with tumour-specific MoAbs.

Increased expression of neutrophil and monocyte adhesion molecules LFA-1 and Mac-1 and their ligand ICAM-1 and VLA-4 throughout the acute phase of myocardial infarction: possible implications for leukocyte aggregation and microvascular plugging

OBJECTIVES

This study sought to evaluate expression of adhesion molecules on neutrophils and monocytes throughout the acute phase of myocardial infarction.

BACKGROUND

Neutrophil and monocyte counts increase within days from onset of acute myocardial infarction. Because leukocytes are recruited to the involved myocardial region, we postulated that these activated cells would display an increased expression of adhesion molecules necessary for effective endothelial transmigration.

METHODS

We measured the expression of neutrophil and monocyte lymphocyte function associated antigen-1 (LFA-1), Mac-1, very late after activation antigen-4 (VLA-4) and intercellular adhesion molecule-1 (ICAM-1) by flow cytometry throughout the acute phase of acute myocardial infarction in 25 patients and 10 age-matched control subjects.

RESULTS

Expression of Mac-1 on neutrophils increased significantly, whereas no expression of VLA-4 and ICAM-1 was detected. The expression of LFA-1, Mac-1, VLA-4 and ICAM-1 on the monocyte cell membrane in patients with an acute myocardial infarction was increased compared with that in control subjects by 22% (on day 7), 67%, 13% and 44% (all on day 4), respectively (all p < 0.001). Elevated density of monocyte-specific CD14 in the AMI versus the control group was also shown (30%, p < 0.001).

CONCLUSIONS

Increased expression of neutrophil and monocyte adhesion molecules may contribute to their adhesion to endothelium in the ischemic territory. This adhesion could feasibly precipitate vasoconstriction or add a local thrombotic effect due to tissue factor expression secondary to Mac-1 engagement. In addition, the manifestation of increased density of LFA-1 and Mac-1 by activated leukocytes with monocytes also expressing ICAM-1 suggests that leukocytes may form microaggregates that could cause microvascular plugging. This mechanism may facilitate the occurrence of the "no-reflow" phenomenon or slow coronary filling after acute myocardial infarction.

Case-based reasoning in IVF: prediction and knowledge mining

In vitro fertilization (IVF) is a medically-assisted reproduction technique, enabling infertile couples to achieve successful pregnancy. Given the unpredictability of the task, we propose to use a case-based reasoning system that exploits past experiences to suggest possible modifications to an IVF treatment plan in order to improve overall success rates. Once the system's knowledge base is populated with a sufficient number of past cases, it can be used to explore and discover interesting relationships among data, thereby achieving a form of knowledge mining. The article describes the TA3IVF system--a case-based reasoning system which relies on context-based relevance assessment to assist in knowledge visualization, interactive data exploration and discovery in this domain. The system can be used as an advisor to the physician during clinical work and during research to help determine what knowledge sources are relevant for a treatment plan.

Lymphoma with multi gene rearrangement on the level of immunoglobulin heavy chain, light chains, and T-cell receptor beta chain

A unique case with diffuse mixed malignant lymphoma was investigated for gene rearrangement on the level of T-cell receptor (TCR), heavy chain immunoglobulin (Ig), and both light chains. Cell phenotype was examined with immunofluorescence techniques using antibodies against surface immunoglobulins (SIg) and the kappa and lambda light chains. Monoclonal antibodies were used against CD3, CD4, CD5, CD8, CD10, CD19, CD22, HLA-DR, and TdT. Gene rearrangement analysis for monoclonality determination was carried out with restricted DNA (EcoR I and Hind III) hybridized with one of the following 32P-labelled probes: T-cell receptor (TCR beta), immunoglobulin heavy chain (JH), k light chain, and lambda light chain. Phenotyping of the cell population from the excised lymph node (LN) revealed the presence of 66% B-cells and 35% T-cells. Most of the B cells (94%) expressed mu heavy chain only. Expression of both light chains was negligible (k = 7% and lambda = 2%). Gene rearrangement, which indicates monoclonality, was positive on the level of TCR, Ig heavy chain, and both light chains. The data obtained suggests a neoplastic transforming event in lymphoid stem cells, which preceded the subsequent differentiation process into either B or T lymphoma.

The feasibility of assessing women's perceptions of the risks and benefits of fertility drug therapy in relation to ovarian cancer risk

OBJECTIVE

To determine the feasibility of asking women undergoing fertility treatment the maximum increased risk of ovarian cancer they would be willing to tolerate in order to take ovulation-induction drugs.

DESIGN

A prospective pilot study of women attending fertility clinics over a 2-month period.

SETTING

Two tertiary care fertility clinics in Toronto.

PATIENT(S)

Sixty-one English-speaking women were approached and 85% (n = 52) were enrolled.

INTERVENTION(S)

A self-administered questionnaire with fertility-specific questions. Thirty-eight women also were asked to complete standardized scales of anxiety and optimism.

MAIN OUTCOME MEASURE(S)

Women's report of the maximum level of lifetime risk of ovarian cancer they were willing to tolerate in order to undergo fertility treatment.

RESULT(S)

Seventy-nine percent were willing to accept an increased risk of ovarian cancer. Only 24% understood that treatment for ovarian cancer usually was not curative.

CONCLUSION(S)

A majority of patients were willing to tolerate a modest increase in their lifetime risk of ovarian cancer because of fertility treatment, most basing their estimate of acceptable risk on limited awareness of the issue.

Flow cytometric analysis of the platelet surface area and surface density of glycoprotein IIb-IIIa of unactivated human platelets of various sizes

Large (L) activated platelets exhibit greater aggregability and express more activated glycoprotein IIb-IIIa (GPIIb-IIIa) per cell and per unit surface area than small (S) activated platelets. We studied the binding of CD61 monoclonal antibody to GPIIb-IIIa on resting platelets and developed a new method for determining platelet surface area by flow cytometry. Using this method, we found that resting L platelets contain two times more GPIIb-IIIa per cell than S platelets but the same amount of GPIIb-IIIa per unit surface area. The data suggest that the greater aggregability of L platelets is likely to be due to increased activation and/ or expression of GPIIb-IIIa rather than to elevated density of unactivated GPIIb-IIIa on resting L platelets.

Sequencing of combined hyperthermia and photodynamic therapy

Photodynamic therapy (PDT) and hyperthermia are two alternative tumor treatment modalities currently being investigated in clinical trials. It has been suggested that, due to the differences in cell-killing mechanisms, synergetic tumor responses may be achieved if the two modalities are combined in appropriate sequences. This hypothesis is tested in the current study by delivering graded PDT doses during a transient tumor reoxygenation period after a hyperthermia treatment, or delivering graded hyperthermia doses when the tumor becomes acidic and hypoxic after a PDT treatment. The results indicate that the latter combination sequence has a profound effect on tumor response. While treating the tumors with PDT followed by hyperthermia evokes a synergetic tumor response, reversing the sequence results only in an additive effect. Possible mechanisms associated with tissue oxygenation are discussed.

Effect of the number of core biopsies of the prostate on predicting Gleason score of prostate cancer

PURPOSE

We determined the effect of the number of core biopsies of the prostate on predicting the Gleason score of the prostatectomy specimen.

MATERIALS AND METHODS

The Gleason scores from 124 radical prostatectomy specimens were compared to those from preoperative core needle biopsies of the prostate. The number of cores obtained and tumor stage were compared regarding agreement in prostate cancer score.

RESULTS

Four to 6 core biopsies yielded the best results, with agreement within 1 Gleason score in 75% of the cases. Further increases in the number of core biopsies did not improve results. Additionally, 37% of the well differentiated tumors on core biopsy were stage C.

CONCLUSIONS

Gleason score from the core biopsy has limitations in respect to predicting prostatectomy tumor score and stage and, therefore, it is problematic for use in therapeutic decision making.

Model for outcomes assessment of antihistamine use for seasonal allergic rhinitis

BACKGROUND

Drug selection for optimal treatment of common medical conditions may be difficult and involve many diverse factors.

OBJECTIVE

The efficacy, safety, quality of life, and cost of treatment of seasonal allergic rhinitis with cetirizine, chlorpheniramine, or terfenadine were compared in a prospective, two-phase, randomized, single-blind clinical trial conducted in a managed care setting.

METHODS

In phase I, which lasted 2 weeks, patients were randomized to receive one of the study drugs. In phase II, which lasted 4 weeks, the initial treatment was continued unless patients were dissatisfied, in which case they could be randomly assigned to receive another study drug. In both phases pseudoephedrine could be taken as needed. Patients kept daily diaries of symptoms and costs, and study drugs were evaluated at the end of each phase for efficacy, safety, and effect on quality of life by means of a validated questionnaire. A multiattribute outcomes assessment model for formulary decision making was used to rank the antihistamines.

RESULTS

Physicians' and patients' assessments in phases I and II indicated that cetirizine and chlorpheniramine were significantly more effective than terfenadine (p < 0.05). Incidence of sedation in phase I and phase II was 40.5% and 16.7% for chlorpheniramine, 11.6% and 9.8% for cetirizine, and 6.7% and 5.1% for terfenadine, respectively. At the end of phase I, 28.9% of the patients treated with chlorpheniramine, 50% of the patients treated with terfenadine, and 69.4% of the patients treated with cetirizine were satisfied with their therapy and chose not to switch their medication. Quality of life scores improved most after treatment with cetirizine and least after treatment with terfenadine.

CONCLUSION

The result of this trial indicate that antihistamine selection is best made with the use of a multiattribute evaluation that includes quality of life. In this study cetirizine was favored by patients and physicians most often, followed by chlorpheniramine and then terfenadine.

Human nasal epithelium adsorbs complement C3-related fragments and expresses cell membrane complement regulatory proteins

Recent evidence suggests that complement is activated in human nasal airways in inflammatory states. Activated complement protects the nasal mucosa against microorganisms, but also has the potential to lyse the host's normal cells. Complement-mediated cell lysis depends on adsorption of complement to the cell membrane and on uninterrupted activation of the complement cascade upon the same cell membrane. In the present study, the authors investigated first whether key complement components, C3-related fragments, are adsorbed to nasal epithelial cell membrane. Second, we investigated whether nasal epithelium expresses cell membrane complement regulatory proteins that are known as interruptors of complement activation. Studies were done using fresh nasal mucosa obtained at turbinectomies from allergic rhinitis and vasomotor rhinitis patients. In addition, in order to establish an in vitro model, studies were also done using primary cell cultures of nasal epithelium. We have found that complement C3-related fragments are present on cell membranes of fresh nasal epithelium and that C3-related fragments are adsorbed to the epithelial cell membrane in nasal mucosa tissue segments and in cell cultures that were incubated with autologous serum. Adsorption of C3-related fragments to the cell membrane of cultured nasal epithelial cells was found by flow cytometry analysis to be concentration-dependent. In addition, we found that nasal epithelium in fresh tissue and in cell culture express three cell membrane complement regulatory proteins: membrane cofactor protein (MCP, CD46), decay-accelerating factor (DAF, CD55), and CD59. Our findings in fresh nasal epithelium suggest that complement activation may occur upon the nasal epithelial cell membrane during inflammation in vivo and that nasal epithelium might regulate this complement activation. Our in vitro cell culture model will allow further investigations of complement activation and regulation upon the human nasal epithelial cell membrane.

Primary ovarian carcinoid tumors

Primary ovarian carcinoid tumors were reviewed from Mayo Clinic and Colorado Tumor Registry data. A total of 17 patients with this diagnosis were identified. Histologic analysis of these carcinoid tumors revealed 9 (53%) were insular, 5 (29%) were trabecular, and 4 (26%) were strumal carcinoid with or without a mature dermoid component. There were 11 patients with stage I and 6 patients with stage III or IV disease at diagnosis. Carcinoid syndrome was found in 29% of patients. Pressure or pain with defecation was noted in 41% of cases. Recurrence of tumor occurred in 1 of 11 patients with suspected stage I disease 13 years after initial diagnosis. Overall survival was excellent in the 11 patients whose disease was confined to one ovary (100% 5-year survival), but only 1 of 6 patients survived (33% 5-year survival) if advanced stage at diagnosis. Systemic chemotherapy for advanced disease achieved a complete response in 1 patient and stable disease in another. Although rare, primary ovarian carcinoid tumors treated with surgery alone and found to be confined to the ovary can be expected to have an excellent overall outcome.