α-actinin accounts for the bioactivity of actin preparations in inducing STAT target genes in Drosophila melanogaster

Damage-associated molecular patterns (DAMPs) are molecules exposed or released by dead cells that trigger or modulate immunity and tissue repair. In vertebrates, the cytoskeletal component F-actin is a DAMP specifically recognised by DNGR-1, an innate immune receptor. Previously we suggested that actin is also a DAMP in Drosophila melanogaster by inducing STAT-dependent genes (<xref ref-type="bibr" rid="bib10">Srinivasan et al., 2016</xref>). Here, we revise that conclusion and report that α-actinin is far more potent than actin at inducing the same STAT response and can be found in trace amounts in actin preparations. Recombinant expression of actin or α-actinin in bacteria demonstrated that only α-actinin could drive the expression of STAT target genes in Drosophila. The response to injected α-actinin required the same signalling cascade that we had identified in our previous work using actin preparations. Taken together, these data indicate that α-actinin rather than actin drives STAT activation when injected into Drosophila.

Actin is an evolutionarily-conserved damage-associated molecular pattern that signals tissue injury in Drosophila melanogaster

Damage-associated molecular patterns (DAMPs) are molecules released by dead cells that trigger sterile inflammation and, in vertebrates, adaptive immunity. Actin is a DAMP detected in mammals by the receptor, DNGR-1, expressed by dendritic cells (DCs). DNGR-1 is phosphorylated by Src-family kinases and recruits the tyrosine kinase Syk to promote DC cross-presentation of dead cell-associated antigens. Here we report that actin is also a DAMP in invertebrates that lack DCs and adaptive immunity. Administration of actin to Drosophila melanogaster triggers a response characterised by selective induction of STAT target genes in the fat body through the cytokine Upd3 and its JAK/STAT-coupled receptor, Domeless. Notably, this response requires signalling via Shark, the Drosophila orthologue of Syk, and Src42A, a Drosophila Src-family kinase, and is dependent on Nox activity. Thus, extracellular actin detection via a Src-family kinase-dependent cascade is an ancient means of detecting cell injury that precedes the evolution of adaptive immunity.

Structure of the Complex of F-Actin and DNGR-1, a C-Type Lectin Receptor Involved in Dendritic Cell Cross-Presentation of Dead Cell-Associated Antigens

DNGR-1 is a C-type lectin receptor that binds F-actin exposed by dying cells and facilitates cross-presentation of dead cell-associated antigens by dendritic cells. Here we present the structure of DNGR-1 bound to F-actin at 7.7 Å resolution. Unusually for F-actin binding proteins, the DNGR-1 ligand binding domain contacts three actin subunits helically arranged in the actin filament, bridging over two protofilaments, as well as two neighboring actin subunits along one protofilament. Mutation of residues predicted to mediate ligand binding led to loss of DNGR-1-dependent cross-presentation of dead cell-associated antigens, formally demonstrating that the latter depends on F-actin recognition. Notably, DNGR-1 has relatively modest affinity for F-actin but multivalent interactions allow a marked increase in binding strength. Our findings shed light on modes of actin binding by cellular proteins and reveal how extracellular detection of cytoskeletal components by dedicated receptors allows immune monitoring of loss of cellular integrity.

[Incidence and prevalence of type 2 diabetes mellitus in Germany: an analysis based on 5.43 million patients]

BACKGROUND AND OBJECTIVE

Based on claims-data of 5.43 million members of a large German statutory health insurance fund in 2008 (Techniker Krankenkasse), the aim of this contribution is to update and more precisely quantify age- and gender-specific prevalence and incidence of type 2 diabetes mellitus (T2DM) in a German setting.

METHODS

A patient was classified as T2DM prevalent if he or she had received at least two outpatient diagnoses of T2DM in two different quarters of the year and/or had received at least one T2DM diagnosis during inpatient treatment between 01/01/2006 and 12/31/2008. A patient was considered to have had new onset T2DM in 2008 under one of three conditions: 1. no diagnosis of T2DM in 2006 and 2007, 2. no presripction of oral antidiabetics in 2006 and 2007, 3. either one inpatient or two outpatient diagnoses of T2DM conducted in two different quarters of 2008 or one outpatient T2DM diagnosis in 2006/07 when the second diagnosis was made in 2008.

RESULTS

A total of 254,524 patients had T2DM. Compared to the total membership of the medical insurance fund, the prevalence of T2DM was 4.69 %. The average age was 64.8 years, and 66.37 % were male. The incidence of T2DM in our sample was 2.814 cases per 1,000 person-years in men and 1.690 cases in 1,000 person-years in women. Based on our sample and on official population data, 4,704,585 patients (5.75 %) in Germany would be T2DM prevalent in 2009. The number of incident T2DM cases would amount to 215,746 patients (0.264 %).

CONCLUSIONS

T2DM is one of the most common chronic diseases in Germany. The expected demographic changes in Germany will increase the burden on the German health system caused by T2DM.

[Two-years' follow-up after lumbar disc surgery.]

INTRODUCTION

Outcome studies of lumbar disc surgery document a success rate ranging between 49% and 90%, according to the evaluation criteria used. The aim of the present study was to investigate the prognostic value of pain history and of sociodemographic, psychodiagnostic and medical factors for the long-term outcome after lumbar disc surgery.

METHODS

Between selection for and performance of operations for herniated lumbar disc, 100 patients took part in standardized interviews about their clinical and social history. During the same session they answered one questionnaire on depression and one on coping strategies in response to pain. Two years after the operation, 83 patients answered the standardized follow-up questionnaires.

RESULTS

During the follow-up period, 7 (8.4%) patients had further back surgery, and 20% of the patients reported severe back pain on the follow up. With multivariate discriminant analysis, correct prediction of at most moderate back pain or severe back pain 2 years after the operation had been possible in 94.3% of the patients. The important predictors were found to be: duration of subjectively reduced working capability, pain at other locations, consideration or application for disability pension, depression, and severe acute pain. Risk factors for further back surgery were pain at other locations, guest for social support in response to pain, absence of muscle palsy and of Laségue's sign.

CONCLUSION

Anamnestic information on the pain history and psychological factors have prognostic value for the outcome after lumbar disc surgery. If there is no absolute medical indication for disc surgery, we suggest reconsidering the treatment planned for patients with the risk factors specified.

F-actin is an evolutionarily conserved damage-associated molecular pattern recognized by DNGR-1, a receptor for dead cells

Sterile inflammation can be initiated by innate immune recognition of markers of tissue injury termed damage-associated molecular patterns (DAMPs). DAMP recognition by dendritic cells (DCs) has also been postulated to lead to T cell responses to foreign antigens in tumors or allografts. Many DAMPs represent intracellular contents that are released upon cell damage, notably after necrosis. In this regard, we have previously described DNGR-1 (CLEC9A) as a DC-restricted receptor specific for an unidentified DAMP that is exposed by necrotic cells and is necessary for efficient priming of cytotoxic T cells against dead cell-associated antigens. Here, we have shown that the DNGR-1 ligand is preserved from yeast to man and corresponds to the F-actin component of the cellular cytoskeleton. The identification of F-actin as a DNGR-1 ligand suggests that cytoskeletal exposure is a universal sign of cell damage that can be targeted by the innate immune system to initiate immunity.

[Pharmacoeconomic studies - usability for reimbursement decisions]

BACKGROUND AND OBJECTIVE

In Germany, cost-benefit-assessments are incorporated by law since April 2007. In this study it is examined whether published international pharmacoeconomic studies correspond to the methodological recommendations of the Institute for Quality and Efficiency in Health Care (IQWiG) and international guidelines, and whether they are usable for reimbursement decisions.

METHODS

Pharmacoeconomic studies were identified by a systematic literature review and compared with the requirements of the IQWiG and 15 other international institutions. In hypothetical selection processes it was examined which and how many studies could be considered as basis for reimbursement decisions.

RESULTS

130 out of 1,982 pharmacoeconomic studies were identified as relevant and analyzed. Most frequently, the USA was mentioned as reference country (41 %) prior to UK (15 %), Canada (6 %) as well as Japan and Germany (each 4 %). In 63 % standard therapy was chosen as comparator. In 60 % of studies the payer's perspective was chosen primarily, in 22 % the societal perspective. Two thirds of the studies were modeled in most parts. Only two studies performed a comparison with standard therapy from the perspective of the statutory health insurance and could have been considered for reimbursement decisions of the G-BA. Only one German study examined the real-life effectiveness and compared it to standard therapy.

CONCLUSIONS

The study revealed a congruence between the methods of iqwig and other similar international institutions. However, hitherto existing pharmacoeconomic studies do not follow international and German guidelines in many points. In consequence IQWiG will have to perform the analyses itself and the assessment process will be time-consuming and tedious so that in the short and medium term no relevant cost savings can be expected.

Almond (Prunus dulcis L.) protein quality

Three marketing varieties of almonds; Carmel, Mission, and Nonpareil; were analyzed for proximate composition and protein nutritive quality. Moisture, lipids, protein, ash, sugars, and tannins ranges were 3.05-4.33%, 43.37-47.50%, 20.68-23.30%, 3.74-4.56%, 5.35-7.45%, and 0.12-0.18%, respectively. No detectable hemagglutinating and trypsin inhibitory activities were present in Carmel, Mission, and Nonpareil almonds. Amino acid analyses indicated the sulfur amino acids (methionine + cysteine), lysine, and threonine to be the first, second, and third limiting amino acids in almonds when compared to the recommended amino acid pattern for children 2-5-year old. However, compared to the recommended amino acid pattern for adults, sulfur amino acids were the only limiting amino acids in almonds tested. True Protein Digestibility (% TPD) values for Carmel, Mission, and Nonpareil were 88.55 +/- 1.26, 92.25 +/- 1.05, and 82.62 +/- 1.47, respectively. Protein Digestibility Corrected Amino Acid Scoring (PDCAAS) values suggested almond proteins to be of poor nutritional quality.

Mathematical-statistical concepts for modelling and prediction of longterm follow-up

Newer statistical methods for modeling and prediction of long-term follow-up in schizophrenia are presented. These include the extended Cox model, the Generalized Estimating Equations (GEE) method and the Artificial Neural Networks (ANN) approach.

Population-based genetic alterations in Ewing's tumors from Japanese and European Caucasian patients

BACKGROUND

The incidence of Ewing's tumors (ETs) is lower in Asians or African-Americans than in Caucasians.

PATIENTS AND METHODS

Japanese ETs were available for analysis of chromosomal aberrations by comparative genomic hybridization (n = 16) and for expression of chimeric EWS transcripts by reverse-transcriptase polymerase chain reaction (n = 11). These results in Japanese patients were compared with those of 62 ETs in European Caucasian patients registered in the European Intergroup Cooperative Ewing's Sarcoma Study.

RESULTS

Japanese patients with ET had lower overall survival (P = 0.0446) and relapse-free survival (P = 0.0371) compared with European Caucasian patients. Ten of 11 Japanese ETs and 31 of 62 European Caucasian ETs had type I (EWS exon 7 to FLI1 exon 6) fusion transcripts. In Japanese ETs, the median numbers of chromosomal aberrations were 2.0 and 6.0 in 11 primary tumors and five relapsed tumors, respectively. In European Caucasian ETs, the median number of changes were 2.5 and 5.0 in 52 primary and 10 relapsed tumors, respectively. Frequent gains were 8q (38%), 8p (31%) and 12q (25%) in Japanese ETs and 8q (52%), 8p (48%) and 12q (19%) in European Caucasian ETs. Frequent losses were 19q (44%), 19p (38%) and 17p (25%) in Japanese ETs and 16q (21%), 19q (18%) and 17p (15%) in European Caucasian ETs. The incidence of losses of 19p (P = 0.0215) and 19q (P = 0.0277) were significantly higher in Japanese ETs than in European Caucasian ETs. An amplification (1p33-p34) was observed in only one Japanese ET.

CONCLUSIONS

Japanese patients with ET in this study had a worse prognosis than European Caucasian patients. In molecular genetic analyses, Japanese ETs had a higher frequency of loss of chromosome 19 than European Caucasian ETs. Different genetic aberrations may explain the different incidences and prognoses of ET between Caucasian and Japanese patients.

Second malignancies after ewing tumor treatment in 690 patients from a cooperative German/Austrian/Dutch study

BACKGROUND

Ewing tumor treatment involves high cumulative doses of alkylating agents and topoisomerase inhibitors, drugs capable of inducing second cancers. We analyzed the second cancer risk in a large cohort of consistently treated patients.

PATIENTS AND METHODS

Six hundred ninety Ewing tumor patients were treated between 1992 and 1999 with local therapy and vincristine. doxorubicin, ifosfamide and/or cyclophosphamide, and antinomycin D, with or without etoposide as a randomized question. Second cancer incidences were estimated by competing risk analyses; standardized incidence ratios (SIR) in comparison to registry data were compiled.

RESULTS

After a median observation time of 56 months (32 months for survivors), 6 of 690 patients had developed second cancers: MDS/AML, two, ALL/NHL, two, squamous cell carcinoma, one, liposarcoma, one. SIR were increased 20-30 fold in comparison to the general population. The cumulative second cancer risk five years after diagnosis of the Ewing tumor was 0.0093 for the total group, zero for patients without etoposide, and 0.0118 with etoposide. Additional phase II high-dose therapy increased the risk to 0.0398 after five years.

CONCLUSIONS

The second cancder risk observed was in the range to be expected in cancer survivors. High-dose therapy, and less markedly, etoposide, may contribute to the overall second cancer risk.

Genetic imbalances revealed by comparative genomic hybridization in Ewing tumors

Ewing tumors are characterized by reciprocal translocations involving the EWS gene on 22q12 fused to ETS transcription-factor family members. Little is known about further aberrations contributing to tumor development and progression. Sixty-two frozen tumors with known EWS rearrangements (52 primary tumors, 10 relapses) of ET patients registered in the EICESS protocol were analyzed by comparative genomic hybridization (CGH). The median number of changes in 52 primary and 10 relapsed cases was 2.5 and 5.0 per tumor (P = 0.153). Frequent abnormalities included gains of chromosomes 8, 12, 20, and 1q and losses of 16q and 19q. Neither number nor type of aberration was associated with histology, tumor size, disease stage, tumor localization, or histologic tumor response to chemotherapy. Among the 52 primary tumors, 26 with Type I fusion (EWS exon 7 to FLI1 exon 6) and 26 with other fusion types had a median of 2.0 and 3.0 aberrations per tumor, respectively (P = 0.031). Combinations of gains of chromosomes 8 and 12, gains of chromosome 20, and either gains of 8q or 18q and losses of 16q and 17p frequently occurred. The cumulative overall survival (OAS) was different between 35 patients with <5 aberrations and 13 patients with > or =5 aberrations (P = 0.009). Univariate analysis showed that patients with gains of 1q, 2q, 12, and 20 or losses of 16q and 17p had significantly lower OAS than those without aberrations. By multivariate analysis, loss of 16q (relative risk [RR] = 5.3; P = 0.0006) was an independent prognostic factor.

Long-term efficacy and tolerability of rizatriptan wafers in migraine

CONTEXT

Rizatriptan is a selective 5-HT1B/1D receptor agonist for the acute treatment of migraine. It is available in a unique wafer formulation that dissolves rapidly in the mouth and can be taken without liquids, thereby offering patients a very convenient way to take treatment.

OBJECTIVE

To investigate the long-term efficacy of rizatriptan 10-mg and 5-mg wafers in migraineurs.

SETTING

19 headache clinics in 5 countries.

PATIENTS

458 patients diagnosed with migraine according to International Headache Society criteria.

DESIGN

6-month, open-label, extension, which followed a double-blind, placebo-controlled study.

INTERVENTIONS

Patients were randomly assigned to 1 of 3 treatments for moderate or severe migraines: rizatriptan 10-mg wafer, rizatriptan 5-mg wafer, or "standard care" (usual migraine treatment -- eg, nonsteroidal anti-inflammatory drugs [NSAIDs], analgesics, other triptans). Patients randomized to rizatriptan were blinded to the dose.

MAIN OUTCOME MEASURES

Headache severity (none, mild, moderate, severe) and adverse events were recorded on a diary card.

RESULTS

181 patients treated 3393 attacks with rizatriptan 10-mg wafer, 191 treated 3254 attacks with rizatriptan 5-mg wafer, and 86 treated 1582 attacks with standard care. The median number of treated attacks per patient was 16 for rizatriptan 10-mg wafer, 13 for rizatriptan 5-mg wafer, and 14 for standard care. The median patient on rizatriptan 10-mg wafer reported pain relief at 2 hours (reduction of headache from moderate or severe at baseline to mild or none) in 82% of attacks, vs 73% of attacks for standard care (odds ratio [95% confidence interval] = 1.63 [1.14, 2.34], P <.01) and 72% of attacks for rizatriptan 5-mg wafer (OR [95% CI] = 1.60 [1.23, 2.08], P <.001). The median patient on rizatriptan 10-mg wafer was pain free at 2 hours in 46% of attacks, vs 30% of attacks for standard care (OR [95% CI] = 1.50 [1.06, 2.12], P <.05) and 25% of attacks for rizatriptan 5-mg wafer (OR [95% CI] = 1.93 [1.50, 2.49], P <.001). All treatments were generally well tolerated. Compared with standard care, rizatriptan 5-mg wafer was associated with fewer specific adverse events of asthenia/fatigue, back pain, nausea, pharyngeal discomfort, upper respiratory infection, and vomiting (P values <.05), and, compared with rizatriptan 10-mg wafer, fewer overall drug-related adverse events (P <.05).

CONCLUSIONS

Rizatriptan 10-mg wafer was more effective than standard care and rizatriptan 5-mg wafer for treating intermittent moderate or severe migraine attacks occurring over periods of up to 6 months. Rizatriptan wafers were well tolerated.

Localized Ewing tumor of bone: final results of the cooperative Ewing's Sarcoma Study CESS 86

PURPOSE

Cooperative Ewing's Sarcoma Study (CESS) 86 aimed at improving event-free survival (EFS) in patients with high-risk localized Ewing tumor of bone.

PATIENTS AND METHODS

We analyzed 301 patients recruited from January 1986 to July 1991 (60% male; median age 15 years). Tumors of volume >100 mL and/or at central-axis sites qualified patients for "high risk" (HR, n = 241), and small extremity lesions for "standard risk" (SR, n = 52). Standard-risk patients received 12 courses of vincristine, cyclophosphamide, and doxorubicin alternating with actinomycin D (VACA); HR patients received ifosfamide instead of cyclophosphamide (VAIA). Tumor sites were pelvis (27%), other central axis (28%), femur (19%), or other extremity (26%). The initial tumor volume was <100 mL in 33% of cases and > or =100 mL in 67%. Local therapy was surgery (23%), surgery plus radiotherapy (49%), or radiotherapy alone (28%). Event-free survival rates were estimated by Kaplan-Meier analyses, comparisons were done by log-rank test, and risk factors were analyzed by Cox models.

RESULTS

On May 1, 1999 (median time under study, 133 months), the 10-year EFS was 0.52. Event-free survival did not differ between SR-VACA (0.52) and HR-VAIA (0.51, P =.92). Tumor volume of >200 mL (EFS, 0.36 v 0.63 for smaller tumors; P =.0001) and poor histologic response (EFS, 0.38 v 0.64 for good responders; P =.0007) had negative impacts on EFS. In multivariate analyses, small tumor volumes of <200 mL, good histologic response, and VAIA chemotherapy augured for fair outcome. Six of 301 patients (2%) died under treatment, and four patients (1.3%) developed second malignancies.

CONCLUSION

Fifty-two percent of CESS 86 patients survived after risk-adapted therapy. High-risk patients seem to have benefited from intensified treatment that incorporated ifosfamide.

Prognostic impact of tumor perfusion in MR-imaging studies in Ewing tumors

BACKGROUND

Intratumoral hypoxia is associated with poor prognosis in various solid tumors. Severe and long-lasting hypoxia results in necrosis. The presence of necrosis therefore might also be correlated with unfavorable outcome. This has been demonstrated for head and neck cancers, gliomas and adult soft tissue sarcomas. We have investigated whether or not the patterns of contrast enhancement and the presence of visible necrosis on pretreatment MR images has prognostic impact in Ewing tumors.

PATIENTS AND METHODS

From December 1993 though March 1997, 79 patients with Ewing tumors were prospectively analyzed for the presence and amount of necrosis in their tumors. The median age was 12 years (range 4-30 years). The median follow-up at the time of this analyses was 3 years. All patients were treated according to the multicentric EICESS-92 protocol with multi-agent chemotherapy (VACA or VAIA or EVAIA) and local therapy (radiotherapy with 50-60 Gy or surgery or surgery with pre- or postoperative irradiation with 45-50 Gy). For the measurement of necrosis, gadolinium contrast-enhanced T1-weighted MR images were used. Necrosis was defined as non-perfused areas in the tumor and the necrotic volume was expressed as percentage of total volume.

RESULTS

Out of 79 tumors, 10 (13%) showed no necrosis, 30 (38%) had 1-25% necrosis, 21 (27%) had 26-50% necrosis and the remaining 18 (23%) more than 50% necrosis. There was a correlation between tumor size and necrosis (p = 0.001): the median tumor volume increased with amount of necrosis (47 cm3 in non-necrotic tumors, 59 cm3 vs 280 cm3 vs 284 cm3 for tumors with 1-25% vs 26-50% vs > 50% necrosis). Tumor site (central location vs proximal extremities vs distal extremities) had no impact on necrosis (p = 0.71). 23 out of 79 patients had metastases (M1) at the time of diagnosis. The frequency of metastatic spread increased with the amount of necrosis: 1/10 (10%) patients with non-necrotic tumors had metastases vs 7/30 (23%) vs 6/21 (28%) vs 9/18 (50%) for tumors with 1-25% vs 26-50% vs > 50% necrosis. "Unfavorable" metastatic spread (bone or multiple metastases) was only noted in patients with high amount of necrosis (> 25% necrosis) whereas even large tumors did not show unfavorable metastases if they contained no or only small amounts of necrosis. All patients with non-necrotic tumors survived event-free during the observation period. Patients with necrotic tumors had a 3-year event-free survival of 55% (p = 0.06 vs tumors without necrosis).

CONCLUSIONS

The presence of non-perfused (presumably necrotic) areas on pretreatment contrast-enhanced MR-images is associated with an increased risk of metastases, especially an unfavorable pattern of metastatic spread at diagnosis. This observation may be explained by a more aggressive biological behavior of hypoxic tumor cells. The small group of patients with non-necrotic tumors (13%) had an excellent prognosis suggesting that the absence of necrosis might be helpful in identifying a very favorable prognostic subgroup in Ewing tumors.

Allogeneic and autologous stem-cell transplantation in advanced Ewing tumors. An update after long-term follow-up from two centers of the European Intergroup study EICESS. Stem-Cell Transplant Programs at Düsseldorf University Medical Center, Germany and St. Anna Kinderspital, Vienna, Austria

BACKGROUND

An update of results from the High Risk Protocol of the Meta-EICESS Study, conducted at the Pediatric Stem-Cell Transplant Centers of Düsseldorf and Vienna. In order to evaluate a possible therapeutic benefit after allogeneic SCT in patients with advanced Ewing tumors (AET), we compared outcome after autologous and allogeneic stem-cell transplantation (SCT).

PATIENTS AND METHODS

We analyzed 36 patients treated with the myeloablative Hyper-ME protocol (hyperfractionated total body irradiation, melphalan, etoposide +/- carboplatin) between November 1986 and December 1994. Minimal follow-up for all patients was five years. All patients underwent remission induction chemotherapy and local treatment before myeloablative therapy. Seventeen of thirty-six patients had multifocal primary Ewing's tumor, eighteen of thirty-six had early, multiple or multifocal relapse, one of thirty-six patients had unifocal late relapse. Twenty-six of thirty-six were treated with autologous and ten of thirty-six with allogeneic hematopoietic stem cells. We analyzed the following risk factors, that could possibly influence the event-free survival (EFS): number of involved bones, degree of remission at time of SCT, type of graft, indication for SCT, bone marrow infiltration, bone with concomitant lung disease, age at time of diagnosis, pelvic involvement, involved compartment radiation, histopathological diagnosis.

RESULTS

EFS for the 36 patients was 0.24 (0.21) +/- 0.07. Eighteen of thirty-six patients suffered relapse or died of disease, nine of thirty-six died of treatment related toxicity (DOC). Nine of thirty-six patients are alive in CR. Age > or = 17 years at initial diagnosis (P < 0.005) significantly deteriorated outcome. According to the type of graft, EFS was 0.25 +/- 0.08 after autologous and 0.20 +/- 0.13 after allogeneic SCT. Incidence of DOC was more than twice as high after allogeneic (40%) compared to autologous (19%) SCT, even though the difference did not reach significance (P = 0.08, Fisher's exact test).

CONCLUSIONS

Because of the rather short observation period. secondary malignant neoplasms (SMN) may complicate the future clinical course of some of our patients who are currently viewed as event-free survivors. EFS in AET is not improved by allogeneic SCT due to a higher complication rate. The patient group was to small to analyze for a possible graft-versus-tumor effect.

Prognostic factors in Ewing's tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing's Sarcoma Study Group

PURPOSE

To further elaborate on prognostic factors for Ewing's sarcoma of bone and to document improvements in relapse-free survival (RFS) and trends in local therapy over the study period (1977 to 1993).

PATIENTS AND METHODS

A retrospective analysis was performed on a combined Gesellschaft Für Pädiatrische Onkologie und Hämatologie/Cooperative Ewing Sarcoma Study and United Kingdom Children's Cancer Study Group/Medical Research Council data set of 975 patients registered with the respective trial offices before the current collaborative European Intergroup Cooperative Ewing's Sarcoma Study trial. Both groups independently undertook studies with similar chemotherapy during the period.

RESULTS

The key adverse prognostic factor is metastases at diagnosis (5-year RFS, 22% of patients with metastases at diagnosis v 55% of patients without metastases at diagnosis; P: <.0001). For the group with metastases, there was a trend for better survival for those with lung involvement compared with those with bone metastases or a combination of lung and bone metastases (P: <.0001). In the group of patients with no metastases at diagnosis, multivariate analysis demonstrated that site (axial v other), age-group (< 15 v > or = 15 years), and period of diagnosis had significant influence on RFS (all P: <.005). RFS was superior in the period after 1985 compared with the period before 1985 for nonmetastatic patients (45% v 60%, respectively; P: <.0001) and for metastatic patients (16% v 30%, respectively; P: =.016). Patients who relapsed within 2 years of diagnosis had a less favorable prognosis than patients who relapsed later (5-year survival after relapse, 4% v 23%, respectively; P: <. 0001). There were other changes over the period; in particular, radiotherapy or amputation were more common in the period before 1986, whereas endoprosthetic surgery was widely used in the later period.

CONCLUSION

Survival and RFS improved over the period. Prognostic factors are metastases at diagnosis, primary site, and age.

Factors associated with tumor volume and primary metastases in Ewing tumors: results from the (EI)CESS studies

BACKGROUND

Tumor volumes of more than 100 ml and the presence of primary metastases have been identified as determinants of poor prognosis in patients with Ewing tumors. We sought to assess the prevalence of critical tumor size and primary metastases in a large national sample of patients at the time of first diagnosis and to identify factors that are associated with their occurrence.

PATIENTS

The present report is based on data of 945 German patients who were enrolled into the (EI)CESS therapy studies between 1980 and 1997. It is assumed that registration of German patients with Ewing tumors under the age of 15 years was almost complete since around 1985. Diagnoses of primary tumors were ascertained exclusively by biopsies. Analyses were restricted to patients with Ewing tumors of bone due to the few occurrences in soft tissues.

METHODS

Tumor volume data as assessed by radiography, computed tomography or nuclear magnetic imaging were available for 821 patients. The diagnosis of primary metastases was based on thoracic computed tomography or on whole body bone scans in 936 patients. Suspicious lesions had to be confirmed by bone marrow biopsies. We explored how year of first diagnosis, age at first diagnosis, sex, histological subtype and site of the primary tumor related to tumor size and presence of metastases by univariate and multivariate statistical techniques.

RESULTS

Sixty-eight percent of the patients (n = 559) had a volume above 100 ml with smaller tumors being more common in childhood than in late adolescence and early adulthood. Extensive volumes were observed in almost 90% of the tumors located in femur and pelvis while they were less common in other sites (P < 0.001). On average, 26% of all patients presented with clinically apparent primary metastases. The detection rate of metastases was markedly higher in patients diagnosed after 1991 (P < 0.001). Primary metastases were also significantly more common for tumors originating in the pelvis and for peripheral neuroectodermal tumors (PNET; P < 0.01). Tumors greater than 100 ml were positively associated with metastatic disease (P < 0.001). Multivariate analyses, which included simultaneously all univariate predictors in a logistic regression model, indicated that most of the observed associations were essentially unconfounded. The adjusted odds ratios (OR) for the presence of tumor volumes > or = 100 ml were OR = 1.5 per age rise of 10 years, and OR = 5.8 for pelvis and OR = 7.1 for femur as primary tumor site (all P < 0.001). The presence of metastases was significantly associated with the year of diagnosis (OR = 1.9, after 1991 vs. before 1986), pelvis as site of the primary tumor (OR = 1.8), a PNET (OR = 1.5), and tumor size > or = 100 ml (OR = 1.6).

CONCLUSIONS

In conclusion, we find that the prevalence of established factors for an unfavorable prognosis is disturbingly high among patients diagnosed with Ewing tumors. Recent progress in imaging techniques seems to account for much of the rise in the detection rate of metastases after 1991. We identify age and, in particular pelvic and femoral site as the major determinants of local tumor extension. Occurrence of primary metastases is independently related to tumor size, pelvic site, and PNET.

[EICESS 92 (European Intergroup Cooperative Ewing's Sarcoma Study)-- preliminary results]

BACKGROUND

Ewing tumor patients' outcome is 50% to 60% with current treatment strategies. Questions concerning toxicity and secondary malignancies are of increasing importance.

PATIENTS AND METHODS

631 patients were registered with the German EICESS study center of the European Intergroup Cooperative Ewing's Sarcoma Study, 369 patients were randomized. Treatment apart from local therapy consisted of 14 courses of Vincristine, Actinomycin D, Cyclophosphamide or Ifosfamide, Adriamycin (Doxorubicin), with or without Etoposide. First results concerning event-free survival (EFS), toxicity, and the rate of secondary malignancies three years after diagnosis are presented.

RESULTS

Three year EFS was 0.66 for patients with localized tumors, 0.43 for patients with primary pulmonary/pleural metastases, and 0.29 for patients with other metastases, respectively. Large tumor volume or pelvic site, especially if inoperable, were adverse prognostic factors. Both histological and MRT-defined response were positively correlated to outcome. Up to 67% of patients experienced WHO grade IV toxicity, mostly related to bone marrow depression. The treatment related mortality was 1% (6/631). Until 15.02.1999, six of 687 patients have suffered secondary malignancies, two of six after (additional) myeloablative therapy.

CONCLUSIONS

EICESS 92 treatment is toxic, but manageable and compares favorably to international results. New strategies must be sought for certain risk groups of patients.

[Descriptive epidemiology of Ewing's tumor--analysis of German patients from (EI)CESS 1980-1997]

BACKGROUND

Due to low absolute morbidity rates a reliable descriptive epidemiology of the Ewing family of tumors (EFT) has been mainly provided by large population-based cancer registry reports. To date, only few reports on this topic have been published.

PATIENTS

The present report is based on data of 945 German patients who were enrolled into the (EI)CESS therapy studies between 1980 and 1997. It is assumed that under the age of 15 years an almost complete registration of all German patients with Ewing's sarcoma has been achieved. Diagnoses in all patients were ascertained by biopsies.

METHODS

In this analysis we looked at the associations between year of first diagnosis, age at first diagnosis, gender, the histological subtypes and the primary skeletal localisation of the tumours.

RESULTS

The majority of patients with EFT was male (60%). More than half of the patients developed the disease between age 10 and 19 (57%) while about 20% were younger and almost a quarter was diagnosed after age 20 years. The percentage of patients older than 15 years was higher in men (55%) than in women (45%). The age-standardized annual incidence before age 15 years was estimated as 3 per million, and the cumulative incidence up to that age as about 46 per million. Long bones of the lower extremities (32%, femur alone 16%) and the pelvis were the most common sites of primary localisation. While 70 to 80% of all tumours in the long bones of the extremities were composed of Ewing's sarcomas, about one third in the central skeleton and over 20% in the pelvic bones were Primitive neuroectodermal tumours (PNET). Atypical Ewing's sarcoma accounted for about 10% of tumours in all sites.

CONCLUSIONS

The large (EI)CESS database enables the meaningful and reliable description of epidemiological characteristics of the rare occurrence of the Ewing family of tumours. Further analyses of this database seem to hold great promise.

[High-dosage chemotherapy in primary metastasized and relapsed Ewing's sarcoma. (EI)CESS]

BACKGROUND

Patients (pts) with primary metastatic Ewing tumours (ET) have a poor prognosis for event free survival (EFS) compared to pts with localised disease. Following relapse the prognosis is extremely poor. Therefore these primary metastatic and relapsed pts were piloted for high dose therapy (HDT) for the last years.

PATIENTS AND METHODS

Between April 1984 and May 1997, 131 ET pts who underwent HDT were registered in the German CESS/EICESS office: 79 pts with primary metastases and 52 pts with relapsed tumours. After induction therapy, consisting of chemotherapy and local therapy, pts received high dose regimens, mainly based on melphalan and/or etoposide (92%). Stem cell rescue was applied from allogeneic bone marrow (n = 13), autologous bone marrow (n = 17), or peripheral blood stem cells (n = 95). The date of analysis was September 1st, 1998. Outcome was calculated by Kaplan-Meier-analyses.

RESULTS

The median time under study since high dose therapy was 3.7 years. 35/131 pts (26.7%) were in continuous complete remission, 80/131 pts (61.1%) had relapsed or progressed, 11/131 pts (8.4%) died of complications and 5/131 pts (3.8%) presented with secondary malignancies. For the total group of primary metastatic pts, EFS five years after diagnosis was 19% for pts with HDT and 27% for those without (p = 0.9209). The subgroup of pts with primary lung and bone metastases seemed to benefit from HDT (EFS five years after diagnosis: 34% versus 5%, p = 0.0001). Outcome of pts with an early ET relapse (< 2 years) was also improved by HDT (EFS four years after relapse: 17% versus 2%, p = 0.0001).

CONCLUSIONS

The total group of primary metastatic ET pts showed no obvious benefit from HDT, based on melphalan and/or etoposide. Pts with metastases to multiple organ systems, and early relapse seemed to benefit from HDT. The value of HDT should be assessed in prospective clinical trials.

Implementing a clinical pathway for congestive heart failure: experiences at a teaching hospital

Clinical pathways are processes of care that use a multidisciplinary team effort to move patients toward a designed outcome. This article details the challenges of a Quality Enhancement and Clinical Resource Management Team in designing and implementing a successful congestive heart failure pathway at a teaching hospital. Academic institutions have the resources as part of their research mission, to enhance the development of clinical pathways and assess their outcomes.

Evaluation of prognostic factors in a tumor volume-adapted treatment strategy for localized Ewing sarcoma of bone: the CESS 86 experience. Cooperative Ewing Sarcoma Study

BACKGROUND

The Cooperative Ewing Sarcoma Study (CESS 86), conducted by the German Society of Pediatric Oncology and Hematology (GPOH), was planned on the basis of the results of the preceding CESS 81 study. The prognostic significance of tumor volume in localized Ewing sarcoma of bone was well documented in the CESS 81 trial. As a consequence, the treatment intensity was adapted to volume in the follow-up CESS 86 trial: the four-drug combination used in CESS 81 was amended for patients with large tumor volume (> or = 100 ml), where ifosfamide was substituted for cyclophosphamide.

PROCEDURE

From January 1986 to June 1991, 177 protocol patients with localized Ewing sarcoma of bone were registered in CESS 86. The prognostic implication of tumor volume and several covariates was evaluated using Kaplan-Meier life table analysis and Cox's proportional hazard model.

RESULTS

The estimated 5- and 8-year event-free survival (EFS) rates were both 59%. Age, gender, tumor site, and a tumor volume of 100 ml did not distinguish groups of patients with different prognosis. However, the prognosis of patients with tumors >200 ml (8-year EFS rate: 42%) was significantly inferior compared to patients with tumors both of 100 to 200 ml (70%) and of <100 ml (63%). In contrast to CESS 81, the histological response to chemotherapy was no longer a significant prognostic factor (EFS: 64% for good and 50% for poor responders, respectively).

CONCLUSIONS

Despite risk-adapted treatment intensity, tumor volume retained its prognostic significance; the cut point, however, was shifted toward larger volumes.

Pelvic Ewing sarcoma: a retrospective analysis of 241 cases

BACKGROUND

This article reports on 241 patients each with pelvic Ewing sarcoma registered for studies in Germany, Austria, and the Netherlands from January 1, 1981, until January 31, 1994. One hundred sixty-four patients had localized disease and 87 had metastases at diagnosis (PMP). Eighty-four patients with localized disease were entered on protocol (PP) and 80 were followed (FP).

METHODS

Statistics included an analysis of event free survival by the Kaplan-Meier method and a Cox regression analysis of factors influencing prognosis.

RESULTS

In the Kaplan-Meier analysis, on February 1, 1995, the event free survival (EFS) rate was 32% at 12 years for all patients, 54% for PP, 25% for FP, and 13% for PMP. Cox regression analysis showed that response to chemotherapy, initial metastases, and less intense therapy were significant prognostic factors. Among patients who had surgery for local control, the histologic response to chemotherapy was analyzed in the surgical specimen and had a significant influence on survival: EFS 69% for PP with good response compared with 47% (P = 0.11) for patients with poor response, and for FP 56% versus 13% (P = 0.002). All PP with small tumors had relapse free survival, compared with 69% of patients with medium-sized tumors and 36% of patients with tumors larger than 200 mL (P = 0.006). The initial tumor volume was a significant predictor of survival.

CONCLUSIONS

Combined modality treatment has resulted in definitive improvement of prognosis for patients with localized pelvic Ewing sarcoma. However, the results for patients with metastases at diagnosis are still discouraging, and their treatment requires new approaches. Tumor load, responsiveness to chemotherapy, and adequate surgical margins are the major factors influencing the prognosis of patients with localized Ewing sarcoma of the pelvis.

Radiotherapy in Ewing's sarcoma and PNET of the chest wall: results of the trials CESS 81, CESS 86 and EICESS 92

PURPOSE

Treatment results and the pattern of relapse were evaluated in the multimodal treatment of Ewing's sarcomas of the chest wall.

METHODS AND MATERIALS

In a retrospective analysis, 114 patients with non-metastatic Ewing's sarcoma of the chest wall were evaluated. They were treated in the CESS 81, CESS 86, or EICESS 92 studies between January 1981 and December 1993. The treatment consisted of polychemotherapy (VACA, VAIA, or EVAIA) and local therapy, either surgery alone (14 patients), radiotherapy alone (28 patients) or a combination of both (71 patients). The median follow-up was 46.6 months (range 5-170). A relapse analysis for all patients with local or combined relapses was performed.

RESULTS

Overall survival was 60% after 5 years, event-free survival was 50%. Thirty-seven patients had a systemic relapse (32.4%), 11 patients had a local relapse alone (9.6%), and 3 patients had a combined local and systemic relapse (2.6%). The risk to relapse locally after 5 years was 0% after surgery alone, 19% after radiation alone, and 19% after postoperative irradiation. None of the 8 patients with preoperative irradiation have failed locally so far. With the introduction of central radiotherapy planning in CESS 86, local control of irradiated patients improved. Ten of 14 patients with local failure could be evaluated in the relapse analysis: 3 patients had an in-field relapse, 4 patients had a marginal relapse, 2 patients had a relapse outside the radiation fields, and 1 patient failed with pleural dissemination. Six treatment deviations were observed.

CONCLUSION

Local control was best after surgery alone in a positively selected group of patients. Local control after radiation or combined radiation and surgery was good. With diligent performance of radiotherapy, it will be possible to further improve the results in the radiotherapy group.

Effects of age, gender and ear side on SOAE parameters in infancy and childhood

We investigated 267 infants and children aged 9 days to 16.8 years to study the spontaneous otoacoustic emission (SOAE) data prevalence, number per ear, level and frequency as a function of growth. Dependence on age, gender and ear side was statistically analyzed using the method of generalized estimation equations. Except in the 1st year of life, SOAE prevalence per ear and SOAE number per ear decreased significantly with increasing age. Both SOAE parameters were significantly higher in female than in male subjects, with gender difference of SOAE prevalence per ear being more distinct in the 1st year of life. Although a clear ear side effect on SOAE prevalence per ear could already be seen in ears of female children in this age group, only SOAE number per ear was significantly higher in right ears than in left ears from the 1st year of life on. Except in the first 12 months, SOAE level and SOAE frequency decreased significantly with increasing age. Neither a significant gender difference nor a significant ear side difference could be determined. Our results found in infancy and childhood are discussed within the framework of the current literature.

Ewing's tumors with primary lung metastases: survival analysis of 114 (European Intergroup) Cooperative Ewing's Sarcoma Studies patients

PURPOSE

To analyze event-free survival (EFS) and prognostic factors in patients who present with Ewing's tumors (ET) of bone and synchronous pulmonary and/or pleural metastases (ppm).

PATIENTS AND METHODS

Of 1,270 patients (pts) registered at the continental office of the German/European Intergroup Cooperative Ewing's Sarcoma Studies (CESS81, CESS86, EICESS92), 114 were diagnosed ET with ppm. Patients underwent neoadjuvant therapy and local treatment of the primary tumor. Whole-lung irradiation 15 to 18 Gy was applied to 75 ppm-pts. EFS and 95% confidence intervals (CIs) were estimated according to the Kaplan-Meier method, and prognostic factors were analyzed by log-rank tests and Cox and logistic regression procedures.

RESULTS

On November 1, 1997, at a median time under study of 5.9 years, the 5-year EFS was 0.36 (95% CI, 0.26 to 0.46) and the 10-year EFS was 0.30 (95% CI, 0.19 to 0.41). Thirty-seven of 59 (63%) first relapses involved lung and/or pleura, and the lungs were the only site of relapse in 26 of 59 (44%) ppm-pts. Risk factors identified in univariate and multivariate tests were poor response of the primary tumor toward chemotherapy, metastatic lesions in both lungs, and treatment without additional lung irradiation.

CONCLUSION

Chemotherapy response of the primary tumor is a prognostic factor in patients with ET with ppm. Strategies of treatment intensification warrant further evaluation.

Second malignancies after treatment for Ewing's sarcoma: a report of the CESS-studies

PURPOSE

During recent years, more intensified systemic and local treatment regimens have increased the 5-year survival figures in localized Ewing's sarcoma to more than 60%. There is, however, concern about the risk of second malignancies (SM) in long-term survivors. We have analyzed the second malignancies in patients treated in the German Ewing's Sarcoma Studies CESS 81 and CESS 86.

MATERIALS AND METHODS

From January 1981 through June 1991, 674 patients were registered in the two sequential multicentric Ewing's sarcoma trials CESS 81 (recruitment period 1981-1985) and CESS 86 (1986-1991). The systemic treatment in both studies consisted of a four-drug-regimen (VACA = vincristine, actinomycin D, cyclophosphamide, and adriamycin; or VAIA = vincristine, actinomycin D, ifosfamide, and adriamycin) and a total number of four courses, each lasting nine weeks, was recommended by the protocol. Local therapy in curative patients was either complete surgery (n = 162), surgery plus postoperative radiotherapy with 36-46Gy (n = 274), or definitive radiotherapy with 46-60Gy (n = 212). The median follow-up at the time of this analysis was 5.1 years, the maximum follow-up 16.5 years.

RESULTS

The overall survival of all patients including metastatic patients was 55% after 5 years, 48% after 10 years, and 37% after 15 years. Eight out of 674 patients (1.2%) developed a SM. Five of these were acute myelogenic leukemias (n = 4) or MDS (n = 1), and three were sarcomas. The interval between diagnosis of Ewing's sarcoma and the diagnosis of the SM was 17-78 months for the four AMLs, 96 months for the MDS and 82-136 months for the three sarcomas. The cumulative risk of an SM was 0.7% after 5 years, 2.9% after 10 years, and 4.7% after 15 years. Out of five patients with AML/MDS, three died of rapid AML-progression, and two are living with disease. Local therapy (surgery vs. surgery plus postoperative irradiation vs. definitive radiotherapy) had no impact on the frequency of AML/MDS, but local therapy did influence the risk of secondary sarcomas. All three patients with secondary sarcomas had received radiotherapy; however, all three sarcomas were salvaged by subsequent treatment and are in clinical remission with a follow-up of 1 month, 4.3 years, and 7.5 years after the diagnosis of the secondary sarcoma. Thus far, SM contributed to less than 1 % (3/328) of all deaths in the CESS-studies.

CONCLUSIONS

The risk of leukemia after treatment for Ewing's sarcoma is probably in the range of 2%. The risk of solid tumors also seems to be low within the first 10 years after treatment and remains in the range of 5 % after 15 years. In the CESS-studies, less than 1% of all deaths within the first 10 years after diagnosis were caused by SM. Effective salvage therapy for secondary sarcomas is feasible.

Primary metastatic (stage IV) Ewing tumor: survival analysis of 171 patients from the EICESS studies. European Intergroup Cooperative Ewing Sarcoma Studies

BACKGROUND

In the multicenter European Intergroup Cooperative Ewing's Sarcoma Studies, localized Ewing tumors of bone were treated by combination chemotherapy with surgery and/or radiotherapy. Patients with primary metastases (pm-pts) were treated in high risk protocols.

PATIENTS AND METHODS

One hundred seventy-seven pm-pts were registered from January 1990 to December 1995, 171 were evaluable for survival analyses. Thirty-six pm-pts received myeloablative megatherapy with stem cell rescue following conventional treatment. Bilateral whole lung irradiation (WLI) was administered in 57 pm-pts with pulmonary involvement. Event-free survival (EFS) rates were estimated by Kaplan-Meier analysis. Prognostic factors were identified by log-rank statistics, Cox procedures and logistic regression.

RESULTS

Eighty-nine deaths were recorded by 1 February 1997, EFS four years after diagnosis for all 171 pm-pts was 0.27. EFS for isolated lung metastases was 0.34, for bone/bone marrow (BM) metastases, 0.28, and for combined lung plus bone/BM metastases, 0.14 (P < 0.005). WLI improved outcome in case of isolated pulmonary involvement (0.40 vs. 0.19, P < 0.05). In pm-pts with combined pulmonary/skeletal metastases, intensification by megatherapy and/or WLI improved EFS from 0.00 to 0.27 (P = 0.0001).

CONCLUSIONS

EFS four years after diagnosis in patients with disseminated Ewing tumors is 0.27. Whole lung irradiation and megatherapy improve outcome in subgroups of patients with disseminated Ewing tumors is 0.27. Whole lung irradiation and megatherapy improve outcome in subgroups of patients with disseminated Ewing disease.

[Inpatient psychosomatic treatment--patient markers and treatment success]

All patients who were admitted to a psychosomatic clinic during the period of one year and ended the in-patient psychotherapy regularly were evaluated before the treatment, at dismissal and one year later, the 113 (68.9%) women and 51 (31.1%) men ranged in age from 17 to 71 years, with a mean age of 39.7 years. The in-patient treatment lasted at average 9 1/2 weeks. On dismissal 85% of the patients reported a reduction of complaints. One year later 75% of the patients rated their psychological and 67% their physical state of health better compared to the time before the in-patient treatment. Standardised psychodiagnostic questionnaires (FSI, GT-S, IIP-D, SCL-90-R) demonstrated significant improvements concerning different aspects which remain stable during the follow-up period. Using the anamnestic information the prediction of treatment outcome was unsatisfactory.

Predictors of bad and good outcome of lumbar spine surgery. A prospective clinical study with 2 years' follow up

STUDY DESIGN

Based on prospective assessment, patients with lumbar disc surgery were examined to determine reliable predictors for clinical outcome.

OBJECTIVES

The prognostic value of a screening checklist developed in a previous study was evaluated in a 2-year follow-up.

SUMMARY OF BACKGROUND DATA

Outcome studies of lumbar disc surgery document a success rate between 49-90%. It has been shown that a number of medical history data and sociodemographic and psychodiagnostic findings are of prognostic value for the outcome of lumbar spine surgery.

METHODS

In addition to clinical and neuroradiologic examinations, 164 patients took part in a standardized interview. Eighty-two percent participated in a follow-up performed 2 years after the operation. Preoperative findings, outcome, and prediction of three diagnostic subgroups were compared. Eighty-three (51%) patients had disc herniation only, 29 (18%) had disc herniation and other relevant back diagnoses, and 51 (31%) had no disc herniation but had other relevant back diagnoses.

RESULTS

In patients with disc herniation only, good results were observed in 53%, moderate in 19%, and bad in 28%. The accuracy of prediction of the postoperative result was 75% for the patients with good outcome and 86% for those with bad outcome. In the group of patients with diagnoses other than disc herniation, the success rate of the operation was 38% good, 28% moderate, and 41% bad, but the predictor score was not as useful as for the other groups.

CONCLUSION

Patients with a high risk of a bad operation outcome after lumbar discectomy could be identified preoperatively. It is suggested that those patients take part in a pain management approach instead of or in addition to surgical intervention.

[Surgery versus radiotherapy in Ewing's sarcoma with good prognosis. Analysis of the CESS-86 data]

PURPOSE

The evaluation of radiotherapy and surgery as exclusive local treatment in comparably selected subgroups of patients with Ewing's sarcoma on the basis of the CESS 86-data.

PATIENTS AND METHODS

In the German multicenter Ewing's sarcoma study CESS 86, treatment consisted of four 9-week-courses of VACA- or VAIA-chemotherapy plus local therapy. VACA (vincristine, actinomycin D, cyclophosphamide, adriamycin) was given in low-risk extremity tumors with a tumor volume below 100 cm3. High-risk patients with central lesions or a tumor volume > 100 cm3 received VAIA (ifosfamide instead of cyclophosphamide). Local therapy started after one complete chemotherapy course in week 10. Based on an individual decision in each patient, local therapy was either radical surgery or resection plus postoperative irradiation with 45 Gy or definitive radiotherapy with 60 Gy. Because of poor results with radiotherapy in a preceding study, it was intended to restrict irradiation to patients with small lesions.

RESULTS

Hundred and seventy-seven protocol patients were recruited from January 1986 through June 1991 and 176 received local therapy: 39 underwent radical surgery, 44 received definitive radiotherapy and 93 were treated with resection and postoperative irradiation. The median tumor volume was higher in patients with radiotherapy as compared to combined local treatment or radical surgery, 156 cm3 versus 140 cm3 versus 102 cm3. The overall 5-year survival after radiotherapy and surgery was nearly identical, 63% versus 67% for the whole group 75% versus 65% in tumors < 100 cm3 volume and 65% versus 67% in tumors with 100 cm3 to 600 cm3 volume, respectively.

CONCLUSIONS

With regard to tumor volume, the most important single prognostic factor in Ewing's sarcoma, irradiated patients were poorer selected than surgically treated patients despite the fact that a selection of good-risk patients for radiotherapy was intended. The nearly identical survival figures after surgery and radiotherapy suggest that radiotherapy is as effective as surgery if selection of patients is comparable.

Self-care limitations of persons after acute myocardial infarction

In this descriptive study, the self-care limitations of persons who had experienced their first myocardial infarction were identified during the first 3 months of their convalescent period. The five most frequently occurring limitations identified were patterns of personal and family living that interfere with self-care; intense emotional states, likes or dislikes, overriding interest and concerns; perceptions, meanings, and appraisals not in accord in reality; inability to attend to self with respect to changing conditions; and new, unrecognized requirements for self-care associated with changed health. Assessment of limitation is a framework that nurses might use to evaluate the needs of post myocardial infarction patients.

Coping strategies and defense mechanisms and their relevance for the recovery after discectomy

Although several empirical studies have shown that psychological and social characteristics predict recovery after lumbar discectomy, the possible significance of the psychodynamic concept of defense mechanisms has been neglected. To investigate the predictive usefulness of defense mechanisms, coping strategies, and depression, 52 consecutive admissions were assessed before their operations and again six months later (n = 48). Using three outcome criteria, 8 patients (16, 7%) were classified as having poor operation outcomes. A stepwise discriminant analysis correctly classified 87.7% of these poor outcomes. The groups with poor and good outcome differed significantly in the prominence of two defense mechanisms: "rationalization" and "regression".

[Prognosis in Ewing sarcoma patients with initial pathological fractures of the primary tumor site]

In this retrospective analysis, data of 52 patients with Ewing's sarcoma or PNET with a pathological fracture in the area of the primary tumor were evaluated. All patients were treated according to the trials CESS 81, CESS 86 P, CESS 86, CESS 91 P and EICESS 92 of the German Society of Pediatric Oncology and Haematology (GPOH). At the date of evaluation (15. September 1994) all patients had completed treatment and had been under observation for at least one year following diagnosis. The median follow-up time was 28 months. 22 patients were female, 30 male. The median age was 12 years. 75% of primary tumors had a volume of > or = 100 ml. 30 patients presented with fractures in proximal, 12 in central and 10 in distal parts of the skeleton. 10 patients had primary metastases. The histological definition was Ewing's sarcoma (including atypical Ewing's sarcoma) in 43 patients, PNET in 8 and small-cell osteosarcoma in 1 patient. For local therapy the patients underwent surgery, definitive radiotherapy or a combination of both. The percentage of primary metastases in the group of the patients with pathological fractures is comparable to the whole reference group. The present analysis focuses on those patients with pathological fractures who had no metastases at diagnosis. The relapse-free survival of patients with a pathological fracture and no primary metastases is 58%, the overall survival 65%. These rates are similar to those of the reference group of protocol patients without pathological fractures at diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of bad and good outcomes of lumbar disc surgery. A prospective clinical study with recommendations for screening to avoid bad outcomes

STUDY DESIGN

Patients were assessed by independent research teams in six different spine centers after indication for discectomy was established. Six- and twelve-month follow-ups were performed.

OBJECTIVES

Objectives of this study were to determine somatic subjective symptoms, objective signs, sociodemographic, and psychological factors that influence the outcome of lumbar disc surgery, as well as to develop a screening checklist and score of reliable predictors to distinguish bad and good responders of surgery.

METHODS

In addition to symptoms, signs, and neuroradiologic findings, sociodemographic data were obtained. A mobility questionnaire and Beck depression inventory were included in the structured interview.

RESULTS

In all, 381 patients were examined. At 6 months 89% and at 12 months, 86% of all operated patients were available for follow-up study. There was no significant difference in the outcome between the 6- and 12-month follow-ups. Of the patients, 51.5% had a good outcome, 28.4% moderate, and 20.1% bad at 12 months follow-up. The calculation of predictor score gave an overall appropriate prediction of 80%, for good outcome 76%, and for bad 79%.

CONCLUSION

In addition to clinical and radiologic examination, the Hannover Mobility Questionnaire, the Beck depression inventory, and structured interview should be included for preoperative assessment for disc surgery. If a bad outcome is predicted, it is probably more appropriate not to operate and await natural development of the disc disease or to apply conservative and psychological treatment.

Standardized teaching plans in the ambulatory laser center

The changing economic climate in health care has motivated nurses to clearly define their role and job duties. Ophthalmic nurses, in particular, have to relate to the differences between the skill level of nurses and technicians. Staff nurses asked to define their role in an ambulatory ophthalmic laser center, placed a high priority on patient education as a professional responsibility. Their view is supported by the Joint Commission Accreditation Manual for Hospitals, and is listed as a responsibility for the registered nurse by that agency. The Joint Commission Standards were reviewed, and a review of related theories of learning was conducted. Teaching standards were developed for nine ophthalmic laser procedures. The standards include teaching content and appropriate teaching aids. The goal is to inform patients specifically regarding the laser surgery, and eye health in general. The patient's knowledge base regarding laser surgery is addressed as part of the nursing assessment and documented in the progress note. Information regarding the proposed procedure is provided based on the teaching standard, and the patient's level of understanding is documented in the progress note. Theories of learning as well as individual teaching standards and tools will be presented.