Risk stratification for healthcare planning in women with gestational diabetes mellitus

BACKGROUND

To identify relevant factors predicting the need for insulin therapy in women with gestational diabetes mellitus (GDM) and secondly to determine a potential 'low- risk' diet-treated group who are likely to have good pregnancy outcomes.

METHODS

A retrospective analysis between 2011-2014. Multivariable backward stepwise logistic regression was used to identify the predictors of the need for insulin therapy. To identify a 'low-risk' diet-treated group, the group was stratified according to pregnancy complications. Diet-treated women with indications for induction in secondary care were excluded.

RESULTS

A total of 820 GDM women were included, 360 (44%) women required additional insulin therapy. The factors predicting the need for insulin therapy were: previous GDM, family history of diabetes, a previous infant weighing ≥ 4500 gram, Middle-East/North-African descent, multiparity, pre-gestational BMI ≥ 30 kg/m2, and an increased fasting glucose level ≥ 5.5 mmol/l (OR 6.03;CI 3.56-10.22) and two-hour glucose level ≥ 9.4 mmol/l after a 75-gram oral glucose tolerance test at GDM diagnosis. In total 125 (54%) women treated with diet only had pregnancy complications. Primiparity and higher weight gain during pregnancy were the best predictors for complications (predictive probability 0.586 and 0.603).

CONCLUSION

In this GDM population we found various relevant factors predicting the need for insulin therapy. A fasting glucose level ≥ 5.5 mmol/l at GDM diagnosis was by far the strongest predictor. Women with GDM who had good glycaemic control on diet only with a higher parity and less weight gain had a lower risk for pregnancy complications.

Economic analysis of use of pessary to prevent preterm birth in women with multiple pregnancy (ProTWIN trial)

OBJECTIVE

To assess the cost-effectiveness of a cervical pessary to prevent preterm delivery in women with a multiple pregnancy.

METHODS

The study design comprised an economic analysis of data from a randomized clinical trial evaluating cervical pessaries (ProTWIN). Women with a multiple pregnancy were included and an economic evaluation was performed from a societal perspective. Costs were estimated between the time of randomization and 6 weeks postpartum. The prespecified subgroup of women with a cervical length (CL) < 25(th) centile (< 38 mm) was analyzed separately. The primary endpoint was poor perinatal outcome occurring up to 6 weeks postpartum. Direct medical costs and health outcomes were estimated and incremental cost-effectiveness ratios for costs to prevent one poor outcome were calculated.

RESULTS

Mean costs in the pessary group (n = 401) were € 21,783 vs € 21,877 in the group in which no pessary was used (n = 407) (difference, -€ 94; 95% CI, -€ 5975 to € 5609). In the prespecified subgroup of women with a CL < 38 mm we demonstrated a significant reduction in poor perinatal outcome (12% vs 29%; RR, 0.40; 95% CI, 0.19-0.83). Mean costs in the pessary group (n = 78) were € 25,141 vs € 30,577 in the no-pessary group (n = 55) (difference, -€ 5436 (95% CI, -€ 11,001 to € 1456). In women with a CL < 38 mm, pessary treatment was the dominant strategy (more effective and less costly) with a probability of 94%.

CONCLUSION

Cervical pessaries in women with a multiple pregnancy involve costs comparable to those in women without pessary treatment. However, in women with a CL < 38 mm, treatment with a cervical pessary appears to be highly cost-effective.

Prediction of neonatal outcome in women with gestational hypertension or mild preeclampsia after 36 weeks of gestation

BACKGROUND

There is little knowledge about neonatal complications in GH and PE and induction at term, we aim to assess whether they can be predicted from clinical data.

METHODS

We used data of the HYPITAT trial and evaluated whether adverse neonatal outcome (Apgar score < 7, pH < 7.05, NICU admission) could be predicted from clinical data. Logistic regression, ROC analysis and calibration were used to identify predictors and evaluate the predictive capacity in an antepartum and intrapartum model.

RESULTS

We included 1153 pregnancies, of whom 76 (6.6%) had adverse neonatal outcome. Parity (primipara OR 2.75), BMI (OR 1.06), proteinuria (dipstick +++ OR 2.5), uric acid (OR 1.4) and creatinine (OR 1.02) were independent antepartum predictors; In the intrapartum model, meconium stained amniotic fluid (OR 2.2), temperature (OR 1.8), duration of first stage of labour (OR 1.15), proteinuria (dipstick +++ OR 2.7), creatinine (OR 1.02) and uric acid (OR 1.5) were predictors of adverse neonatal outcome. Both models showed good discrimination (AUC 0.75 and 0.78), but calibration was limited (Hosmer-Lemeshow p = 0.41, and p = 0.20).

CONCLUSIONS

In women with GH or PE at term, it is difficult to predict neonatal complications, possibly since they are rare in the term pregnancy. However, the identified individual predictors may guide physicians to anticipate requirements for neonatal care.

Should cervical favourability play a role in the decision for labour induction in gestational hypertension or mild pre-eclampsia at term? An exploratory analysis of the HYPITAT trial

OBJECTIVE

To examine whether cervical favourability (measured by cervical length and the Bishop score) should inform obstetricians' decision regarding labour induction for women with gestational hypertension or mild pre-eclampsia at term.

DESIGN

A post hoc analysis of the Hypertension and Pre-eclampsia Intervention Trial At Term (HYPITAT).

SETTING

Obstetric departments of six university and 32 teaching and district hospitals in the Netherlands.

POPULATION

A total of 756 women diagnosed with gestational hypertension or pre-eclampsia between 36 + 0 and 41 + 0 weeks of gestation randomly allocated to induction of labour or expectant management.

METHODS

Data were analysed using logistic regression modelling.

MAIN OUTCOME MEASURES

The occurrence of a high-risk maternal situation defined as either maternal complications or progression to severe disease. Secondary outcomes were caesarean delivery and adverse neonatal outcomes.

RESULTS

The superiority of labour induction in preventing high-risk situations in women with gestational hypertension or mild pre-eclampsia at term varied significantly according to cervical favourability. In women who were managed expectantly, the longer the cervix the higher the risk of developing maternal high-risk situations, whereas in women in whom labour was induced, cervical length was not associated with a higher probability of maternal high-risk situations (test of interaction P = 0.03). Similarly, the beneficial effect of labour induction on reducing the caesarean section rate was stronger in women with an unfavourable cervix.

CONCLUSION

Against widely held opinion, our exploratory analysis showed that women with gestational hypertension or mild pre-eclampsia at term who have an unfavourable cervix benefited more from labour induction than other women.

TRIAL REGISTRATION

The trial has been registered in the clinical trial register as ISRCTN08132825.

[Struma ovarii during pregnancy]

A 41-year-old pregnant woman, gravida 10, para 7, with gestational diabetes, was diagnosed with subclinical hyperthyroidism. At 16-weeks gestation a left-sided unilateral ovarian cyst was discovered. At 37 weeks of pregnancy an elective caesarean section was carried out, due to the transverse presentation caused by the cyst, followed by an adnexectomy. Histological examination showed a struma ovarii, a rare mature ovarian teratoma mainly consisting of thyroid tissue. There was no evidence of malignancy.

Lifestyle risk factors for cancer: the relationship with psychosocial work environment

BACKGROUND

Psychosocial work characteristics (job demands, control, support, job strain and iso-strain [high job strain combined with social isolation at work]) may be linked to cancer risk, by affecting cancer-related lifestyles like smoking, high alcohol consumption, low intake of fruits and vegetables and lack of physical activity.

METHODS

Cross-sectional data obtained from 3309 respondents participating in an ongoing prospective cohort study in the Netherlands on psychosocial factors and cancer risk were used to study the association between psychosocial job characteristics and lifestyle. Information on job characteristics and risk factor prevalence was collected from 20-65-year-old men and women, through self-administered questionnaires. Multiple logistic and linear regression analyses were undertaken by gender, with adjustment for age and education.

RESULTS

No differences in the prevalence of lifestyle risk factors for cancer were found amongst the psychosocial work characteristics studied. Moreover, little evidence was found for a relation between job (or iso-) strain and cancer-related lifestyles in multivariate analyses.

CONCLUSIONS

The present study found no support for the hypothesis that job strain or iso-strain are associated with a cancer-related lifestyle. Further research on the role of other psychosocial factors-like personality or social support outside work-in mediating associations between job characteristics and lifestyle, is warranted.

[Serous retinal detachment in preeclampsia]

A 31-year-old woman with severe pre-eclampsia developed bilateral serous retinal detachment on the second day post partum. After a few days there was spontaneous resorption of the subretinal fluid and the visual acuity improved. Ophthalmic examination showed no signs of hypertensive retinopathy. Some changes of the retinal pigment epithelium thought to represent healed infarcts of the choriocapillaris remained. Spontaneous retinal detachment is an uncommon complication of (pre)eclampsia, occurring both ante partum and post partum. Retinal and choroidal vascular damage have been implicated in the pathogenesis. Fluorescein angiographic observations lend support to the hypothesis that retinal detachment is secondary to choroidal vascular damage. The management of retinal detachment as a complication in obstetrics is conservative and the prognosis is good. Retinal detachment in (pre)eclampsia may be an indication for termination of pregnancy.

[Pregnancy after liver transplantation in Groningen: benign course for mothers and children]

OBJECTIVE

Analysing the course and outcome of pregnancies in liver transplant recipients.

DESIGN

Retrospective and descriptive.

METHOD

Since 1979 liver transplantations have been performed in the University Hospital Groningen, the Netherlands. Seven female patients conceived 12 times after transplantation. These pregnancies were managed by a team of liver transplantation specialists and obstetricians. Hypertensive disorders, foetal growth, liver function tests and infective disorders were monitored specially. The course and outcome of the pregnancies were determined.

RESULTS

The incidence of complications was much lower than in published patient series. The differences in premature deliveries (9 versus 40%) and caesarean births (18 versus 57%) are largely explained by the difference of incidence of hypertensive disorders (18 versus 35%). One woman developed a liver function disorder during pregnancy (9 versus 38%). In the long term the function of the donor liver appeared not to be disturbed; this finding is in accordance with data from other reports. Ten of the 12 pregnancies resulted in the birth of a healthy child. All children were born in good condition and all of them were alive at the completion of the study (minimal follow-up: 10 months).

CONCLUSION

After liver transplantation there is no need to advise against pregnancy.

Cervical carcinoma during pregnancy: outcome of planned delay in treatment

OBJECTIVE

To assess maternal mortality after delayed treatment for invasive carcinoma of the uterine cervix during pregnancy and to improve fetal outcome.

STUDY DESIGN

Invasive cervical cancer was diagnosed in 12 pregnant women between 1 January 1977 and 1 January 1996. The medical records were examined retrospectively, and a literature survey was performed.

RESULTS

The incidence of cervical carcinoma in our population was 1.1 per 10000 pregnancies. Ten patients had FIGO (International Federation of Gynaecology and Obstetrics) stage IB lesions, two patients stage IIA/B. Eight patients had squamous cell carcinoma, four adenocarcinoma. In six patients with a gestation of >20 weeks and stage IB/IIA we postponed treatment for 2 to 10 weeks to optimize fetal outcome. In six patients with a gestation of <20 weeks and stage IB/IIB we recommended immediate radical hysterectomy. Fetal outcome in the delayed-treatment group was excellent. Two patients, one in each group, died after a relapse. The remaining five patients of the delayed-treatment group are disease-free after a median follow-up of 82 months.

CONCLUSION

Delayed treatment to achieve greater fetal maturity is a reasonable option for patients with cervix carcinoma of <stage IIB, non-bulky tumours and a gestation of >20 weeks.

Intake of nitrate and nitrite and the risk of gastric cancer: a prospective cohort study

The association between the intake of nitrate or nitrite and gastric cancer risk was investigated in a prospective cohort study started in 1986 in the Netherlands, of 120,852 men and women aged 55-69 years. At baseline, data on dietary intake, smoking habits and other covariates were collected by means of a self-administered questionnaire. For data analysis, a case-cohort approach was used, in which the person-years at risk were estimated from a randomly selected subcohort (1688 men and 1812 women). After 6.3 years of follow-up, 282 microscopically confirmed incident cases of stomach cancer were detected: 219 men and 63 women. We did not find a higher risk of gastric cancer among people with a higher nitrate intake from food [rate ratio (RR) highest/lowest quintile = 0.80, 95% CI 0.47-1.37, trend-P = 0.18], a higher nitrate intake from drinking water (RR highest/lowest quintile = 0.88, 95% CI 0.59-1.32, trend-P = 0.39) or a higher intake of nitrite (RR highest/lowest quintile = 1.44, 95% CI 0.95-2.18, trend-P = 0.24). Rate ratios for gastric cancer were also computed for each tertile of nitrate intake from foods within tertiles of vitamin C intake and intake of beta-carotene, but no consistent pattern was found. Therefore, our study does not support a positive association between the intake of nitrate or nitrite and gastric cancer risk.

Socioeconomic status and stomach cancer incidence in men: results from The Netherlands Cohort Study

STUDY OBJECTIVE

To study the association between socioeconomic status (SES) and stomach cancer incidence (cardia and non-cardia) and the role of lifestyle factors in explaining this association.

DESIGN

Prospective cohort study on diet and cancer that started in 1986. Data were collected by means of a self administered questionnaire.

SETTING

Population originating from 204 municipalities in the Netherlands.

PARTICIPANTS

58,279 men aged 55-69 years. After 4.3 years of follow up, 162 incident stomach cancer cases were detected (49 cardia and 113 non-cardia cases).

MAIN RESULTS AND CONCLUSIONS

After adjustment for age, a lower overall stomach cancer risk was found for men with the highest attained level of education (RR highest/lowest level = 0.54, 95% CI 0.33, 0.89, trend, p = 0.02). This association became less strong after additional adjustment for smoking, intake of vitamin C, beta carotene, alcohol and coffee, family history of stomach cancer, and history of stomach disorders (RR = 0.61, 95% CI 0.34, 1.07, trend, p = 0.11). No clear association was found between occupation based SES indicators and stomach cancer risk. Analyses per subsite of stomach cancer revealed that for people with the highest level of education the age adjusted rate ratio for cardia cancer changed from 0.37 (95% CI = 0.13, 1.00) to 0.60 (95% CI = 0.19, 1.87) after additional adjustment for lifestyle variables, whereas the rate ratio for non-cardia cancer (RR = 0.59, 95% CI 0.33, 1.05) did not change after additional adjustment.

Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term

BACKGROUND

Pelvimetry is widely used in women with breech presentation at term to select those for whom planned vaginal delivery is appropriate. However, its clinical value has never been established. We evaluated pelvimetry in a randomised controlled trial. The main outcome measures were the elective and emergency caesarean-section rates and the early condition of the neonate.

METHODS

Magnetic-resonance (MR) pelvimetry was done on 235 women. The women were then randomly assigned to two groups--for the study group (n = 118), the pelvimetry results were reported to the responsible obstetricians, who used them as the basis for decisions on whether to schedule elective caesarean or trial of labour; for the control group (n = 117), the pelvimetry results were not disclosed until 8 weeks post partum, and decisions about obstetric management were made on the basis of clinical factors only.

FINDINGS

35 women (15 [13%] study group, 20 [17%] control group) had abnormalities on pelvimetry. The overall caesarean-section rates did not differ significantly between the study and control groups (50 [42%] vs 59 [50%], p = 0.24) but the emergency caesarean-section rate was significantly lower in the study group than in the control group (22 [19%] vs 41 [35%], p = 0.0052). The mean 1 min Apgar scores in the study and control groups were 8.1 and 8.0 (p = 0.93) and the mean 3 min scores 9.5 and 9.4, respectively (p = 0.28). There were no significant differences in the early neonatal outcome for infants born vaginally, by emergency caesarean section, or by elective caesarean section in the two groups, except for a significantly lower Apgar score in the six infants born vaginally to control-group women who had pelvic abnormalities.

INTERPRETATION

The use of MR pelvimetry in breech presentation at term did not significantly reduce the overall caesarean-section rate. However, it allowed better selection of the delivery route, with a significantly lower emergency caesarean-section rate. Neonatal outcome was not compromised by use of the pelvimetry data.

Spontaneous motility in preterm, small-for-gestational age infants. II. Qualitative aspects

In order to document in detail the developmental course of qualitative aspects of early spontaneous motility in intrauterine growth-retarded infants, sequential videotape recordings were made in 19 preterm infants with a birth weight below the 5th percentile. The quality of general movements (GMs) was studied longitudinally during the preterm and postterm period until approximately 20 weeks corrected age, using Prechtl's method of quality assessment. An abnormal quality of GMs was present in 15 out of 19 infants. Compared to a low-risk group, consisting of appropriate-for-gestational age preterm infants, the proportion of infants with normal findings on brain scans who had an abnormal quality of GMs was high. The presence of 'abrupt chaotic' GMs was related to late fetal heart-rate decelerations and ischaemic alterations of the placenta. The quality of GMs normalized before or during the third month postterm in most infants with abnormal GMs. In four infants, the GMs did not normalize during the study period. The quality of fidgety movements was, in particular, a marker for neurological outcome at 24 months. This study demonstrates that intrauterine growth retardation may cause prolonged, but in most cases transient brain dysfunction; the qualitative assessment of GMs may help to identify infants at increased risk for neurodevelopmental abnormalities.

Spontaneous motility in preterm, small-for-gestational age infants. I. Quantitative aspects

The developmental course of the quantitative aspects of early spontaneous motility was studied longitudinally in fourteen intrauterine growth-retarded infants, with a birth weight below the 5th percentile, in relation to perinatal variables, brain ultrasound findings and neurological outcome. Quantitative motility was studied during the preterm period until term age, from 1 h videotape recordings, using Prechtl's classification of different spontaneous movement patterns. Comparison to a low-risk reference group, consisting of preterm, appropriate-for-gestational age infants, showed that significant differences were inconsistent and obviously by chance, with the possible exception of a decreased rate of startles from the 2nd to the 6th postnatal weeks. A trend of increasing duration of GMs was present with increasing postnatal age. There were hardly any correlations between perinatal variables and quantitative motility, and if present the correlations were weak. Such correlations were found between the reduction of heart-rate variability on cardiotocography and the rate of startles and twitches during the first week and furthermore between the neonatal blood glucose level and the rate of isolated arm movements and total motility during the first week. This study demonstrates that intrauterine growth retardation has little or no influence on the quantitative aspects of spontaneous motility postnatally during the preterm period.

Occupational exposure to carcinogens and risk of lung cancer: results from The Netherlands cohort study

OBJECTIVES

To investigate risk of lung cancers associated with common established carcinogenic occupational exposures (asbestos, paint dust, polycyclic aromatic hydrocarbons, and welding fumes) in a prospective cohort study among the general population, and to estimate the proportion of lung cancer cases attributable to these occupational exposures.

METHODS

A prospective cohort study on diet, other lifestyle factors, job history, and cancer risk that started in 1986 in The Netherlands on 58,279 men, aged 55-69 years. Based on information about job history obtained from a self-administered questionnaire, case by case expert assessment was carried out to assign to each study subject a cumulative probability of occupational exposure for each carcinogenic exposure. For analysis, a case-cohort approach was used, in which the person-years at risk were estimated from a randomly selected subcohort (n = 1688). After 4.3 years of follow up, 524 lung cancer cases with complete job history were available.

RESULTS

After adjustment for age, each of the other occupational exposures, and for smoking habits and intake of vitamin C, beta-carotene, and retinol, significant associations were found between risk of lung cancer and cumulative probability of occupational exposure to asbestos (relative risk (RR) highest/no exposure = 3.49, 95% confidence interval (95% CI) 1.69 to 7.18, trend P < 0.01 or paint dust (RR highest/no exposure = 2.48, 95% CI 0.88 to 6.97, trend P < 0.01). The population attributable risks (PARs) for the four exposures based on the multivariately adjusted RRs for ever exposed versus never exposed workers were calculated. The PAR of lifetime occupational exposure to asbestos was calculated to be 11.6%.

CONCLUSIONS

This prospective cohort study among the general population showed that occupational exposure to asbestos or paint dust is associated with higher RRs for lung cancer. This study shows that after adjustment for smoking and diet about 11.6% of the cases of lung cancer in men is attributable to lifetime occupational exposure to asbestos.

Socioeconomic status and lung cancer incidence in men in The Netherlands: is there a role for occupational exposure?

STUDY OBJECTIVE

To evaluate the influence of occupational exposure to carcinogens in explaining the association between socioeconomic status and lung cancer.

DESIGN

A prospective cohort study. Data on diet, other lifestyle factors, sociodemographic characteristics and job history were collected by means of a self administered questionnaire. Follow up for incident cancer was established by record linkage with a national pathology register and with regional cancer registries.

SETTING

Population originating from 204 municipalities in The Netherlands.

PARTICIPANTS

These comprised 58 279 men aged 55-69 years in September 1986. After 4.3 years of follow up there were 470 microscopically confirmed incident lung cancer cases with complete data on dietary habits and job history.

MEASUREMENTS AND MAIN RESULTS

Estimation of occupational exposure to asbestos, paint dust, polycyclic aromatic hydrocarbons, and welding fumes was carried out by two experts, using information on job history from the baseline questionnaire. Socioeconomic status was measured by means of highest attained level of education and two indicators based on occupation. In the initial multivariate analyses of socioeconomic status and lung cancer, adjustment was made for age, smoking habits, intake of vitamin C, beta-carotene and retinol, and history of chronic obstructive pulmonary disease or asthma. Additional adjustment for occupational exposure to the four carcinogens mentioned above did not change the inverse association between the level of education and lung cancer risk (initial model: RR highest/lowest level of education = 0.53; 95% CI 0.34, 0.82; additional model: RR highest/lowest level of education = 0.53; 95% CI 0.34, 0.84). Nor was the association between the two occupation based indicators of socioeconomic status and lung cancer risk influenced by occupational exposure to carcinogens. The effect of occupational exposure on the association between the level of education and lung cancer risk did not differ between ex-smokers and current smokers.

CONCLUSIONS

Occupational exposure to asbestos, paint dust, polycyclic aromatic hydrocarbons, and welding fumes could not explain the inverse association between socioeconomic status and lung cancer risk. More research which explicitly addresses possible explanations for the association between socioeconomic status and lung cancer risk is needed.

[Liver rupture in pregnancy: a life-threatening complication of the HELLP syndrome]

A 31-year-old primigravida with pre-existent hypertension was admitted at 28.5 weeks gestation with foetal growth retardation. On the third day after admission she developed a 'haemolysis, elevated liver enzymes and low platelets' (HELLP) syndrome with severe pain in the epigastrium. Intrauterine death had occurred and abruptio placentae was suspected. Induction of labour was started with intravenous prostaglandins. The next day the haemoglobin concentration had decreased despite transfusions of red blood cell concentrates. At ultrasound examination, free fluid was detected in the abdomen and at explorative laparotomy a subcapsular liver haematoma appeared to have ruptured. An intrahepatic haematoma does not require operative treatment, unless it has ruptured. Packing of the ruptured liver with gauze and later removal of the gauze is preferable to lobectomy.

Differences in cancer incidence and mortality among socio-economic groups

OBJECTIVES

In this article studies on the association between socioeconomic status (SES) and risk for cancer at different sites are reviewed.

METHODS

The review is restricted to studies conducted in affluent societies, after 1970. Only studies using income, education and/or occupation as SES indicators are included.

RESULTS

A more or less consistent positive association between SES and cancer risk was found for colon and breast cancer. More or less consistent inverse associations were found for lung, stomach, oropharyngeal and esophageal cancer. Inconsistent associations were reported for cancer of the rectum and pancreas. Possible explanations for SES differences in cancer risk are discussed with special emphasis on lifestyle variables related to cancer risk.

CONCLUSIONS

It is concluded that it is still unclear whether the reported associations can be (partially) attributed to lifestyle related risk factors for cancer such as smoking, nutritional habits, drinking habits and reproductive factors.

Socioeconomic status and colon cancer incidence: a prospective cohort study

The association between socioeconomic status and colon cancer was investigated in a prospective cohort study that started in 1986 in The Netherlands among 120,852 men and women aged 55-69 years. At baseline, data on socioeconomic status, alcohol consumption and other dietary and non-dietary covariates were collected by means of a self-administered questionnaire. For data analysis a case-cohort approach was used, in which the person-years at risk were estimated using a randomly selected subcohort (1688 men and 1812 women). After 3.3 years of follow-up, 312 incident colon cancer cases were detected: 157 men and 155 women. After adjustment for age, we found a positive association between colon cancer risk and highest level of education (trend P = 0.13) and social standing (trend P = 0.008) for men. Also, male, upper white-collar workers had a higher colon cancer risk than blue-collar workers (RR = 1.42, 95% CI 0.95-2.11). Only the significant association between social standing and colon cancer risk persisted after additional adjustment for other risk factors for colon cancer (trend P = 0.005), but the higher risk was only found in the highest social standing category (RR highest/lowest social standing = 2.60, 95% CI 1.31-5.14). In women, there were no clear associations between the socioeconomic status indicators and colon cancer.

Lung cancer: is there an association with socioeconomic status in The Netherlands?

STUDY OBJECTIVE

To evaluate if there are differences in lung cancer incidence between socioeconomic groups in the Netherlands and if so, if smoking habits and other lifestyle characteristics could explain these differences.

DESIGN

Prospective cohort study. Baseline measurement included information on socioeconomic status, smoking habits, and other covariates by means of a self-administered questionnaire. Follow up was established by computerised record linkage to cancer registries and a pathology register.

SETTING

Population originating from 204 municipalities in The Netherlands.

PARTICIPANTS

58,279 men aged 55-69 years in September 1986. After 3.3 years of follow up 490 microscopically confirmed incident lung cancer cases were detected.

MAIN RESULTS

An inverse association between lung cancer risk and highest level of education was found, which persisted after adjustment for age, smoking, dietary intake of vitamin C, beta-carotene and retinol (rate ratio (RR) highest/lowest level of education = 0.52, 95% CI 0.33, 0.82, trend p < 0.001). Men with a lower white collar profession had a significantly lower relative rate of lung cancer compared with blue collar workers (RR = 0.66, 95% CI 0.47, 0.96), but after adjustment for smoking habits this difference was reduced (RR = 0.73, 95% CI 0.51, 1.08).

CONCLUSIONS

There is an inverse association between highest level of education and lung cancer, which is still apparent after adjustment for age, smoking, dietary intake of vitamin C, beta-carotene and retinol. The significantly lower lung cancer risk of lower white collar workers compared with the risk of blue collar workers could be partially explained by smoking habits.

Effect of extent of anterior resection and sex on disease-free survival and local recurrence in patients with rectal cancer

Results are presented following 119 curative resections for rectal cancer performed on 47 women and 72 men. Throughout the study it was policy to remove part of the female genital tract when the rectal tumour impinged on the uterus and/or the posterior vaginal wall. After a median follow-up of 7.5 years, local recurrence occurred in three of 46 women and 15 of 71 men (P = 0.03). The survival rates at 5 years were 71 per cent for women (95 per cent confidence interval 56-83 per cent) and 60 per cent for men (95 per cent confidence interval 50-71 per cent) (P < 0.05). The risk for distant metastasis was comparable, suggesting an influence of local recurrence on survival. Reduction of the local recurrence rate coincides with the higher proportion of anterior extensions of surgery in women (19 of 47) than in men (two of 72).

Non-immune hydrops fetalis and bilateral pulmonary hypoplasia in a newborn infant with extralobar pulmonary sequestration

Extralobar pulmonary sequestration was found in a newborn premature infant that presented with non-immune hydrops fetalis, massive bilateral hydrothorax and polyhydramnios in utero. The baby died of severe respiratory insufficiency 15 h after birth. Postmortem examination revealed distended lymphatic vessels in the sequestered lung tissue probably due to impeded lymph drainage. We suggest that not extralobar pulmonary sequestration itself but a subsequent massive unilateral hydrothorax due to severe obstruction of lymph drainage was the cause of the non-immune hydrops fetalis, pulmonary hypoplasia and polyhydramnios. If these symptoms are diagnosed before delivery, a search for extralobar pulmonary sequestration is indicated.

[2 patients with brain metastases who became pregnant during phenytoin administration]

Two young women taking phenytoin because of symptomatic brain metastases are described. Both patients, one with end-stage lung cancer and the other in complete remission after intensive chemotherapeutic treatment of a choriocarcinoma, became pregnant while using oral contraceptives in combination with phenytoin. One patient had the child, but died a year after the metastases became apparent, in the other the pregnancy was terminated. When prescribing phenytoin, attention should be paid to fertility--even in patients with end-stage cancer or after intensive, possibly sterilising, chemotherapeutic treatment.

Pelvimetry by magnetic resonance imaging in breech presentation

Evaluation of the pelvis by pelvimetry plays an important role in selecting patients with term breech presentation for possible vaginal delivery. X-ray pelvimetry involves the disadvantage of fetal exposure to ionizing radiation. Computed tomography reduces the amount of radiation markedly, but there is still a risk. Ten patients with breech presentation at term underwent antepartum pelvimetry with magnetic resonance imaging, following by postpartum magnetic resonance pelvimetry and x-ray pelvimetry. Measurements with magnetic resonance imaging are as reliable as those obtained with x-ray pelvimetry and the contrast of the magnetic resonance images is even better. The advantages of magnetic resonance pelvimetry are clear: no ionizing radiation and reliable pelvimetry results in cases of term breech presentation in which a normal pelvis is a prerequisite for safe vaginal delivery.

Cross-sectional versus longitudinal investigations of the diet-cancer relation

Within a prospective cohort study on diet and cancer, information was collected on cancer prevalence and baseline meat consumption. A nested case-control study on meat and cancer was conducted with 656 prevalent colorectal cases, 1,894 breast cancer cases, and 4,701 controls. When analyzed cross-sectionally, prevalence odds ratios for eating meat rarely versus regularly were 2.08 for female colorectal and 1.75 for breast cancer. In the longitudinal analysis, cases who started consuming meat rarely after diagnosis were excluded, resulting in odds ratios of 0.51 for female colorectal and 1.17 for breast cancer. These opposite findings highlight the problem of cross-sectional designs.