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PubMed2003

Pott's paraplegia in patients with severely deformed dorsal or dorsolumbar spines: treatment and prognosis.

STUDY DESIGN: Pott's paraplegic patients with severe spinal deformity were reviewed retrospectively after being treated with chemotherapy and/or decompressive surgery. OBJECTIVES: To determine the most appropriate treatment protocol and to predict the prognosis for Pott's paraplegics with severe spinal deformity. SETTING: Catholic University of Korea Medical Center and Moon-Kim's Institute of Orthopedic Research, Seoul, Korea from 1971 to 1996. METHOD: In this study, there were 33 patients (eight children and 25 adults), ranging from 13 to 56 years of age. They developed spinal tuberculosis at the age of 9 years (range, 2-29 years), and remained neurologically symptom free from an average of 16 years (range, 4-27 years). Four adults who responded well to treatment initially suffered relapses of paraplegia. Only six patients had previously received a full course of triple chemotherapy. Seven (two children, five adults) had healed disease, and 26 (six children, 20 adults) had active disease. Eleven cases had frequent drainage from the sinuses. Kyphoscoliosis was found in 11 patients: four children and seven adults. The remaining patients had kyphosis only. Among the 26 patients with active tuberculosis, 10 had triple chemotherapy itself and the rest had additional decompression surgery (10 anterior and six posterior). All seven patients with healed tuberculosis were subjected only to surgery (two anterior and five posterior). RESULTS: In seven patients with healed tuberculosis, surgery did not improve neurologically except in one child patient. In four patients, the severity of paralysis remained unchanged and two patients, deteriorated neurologically after surgery. In six children with active tuberculosis, there were remarkable neurological recoveries by either conservative treatment or surgical decompression. Seven adults with active tuberculosis recovered slowly, improving by one or two Frankel grades (three Frankel C, three D, one E). In 11 out of 13 surgically treated adults with active disease, paralysis that had persisted for less than 3 months gradually improved by one or two Frankel grades. One Frankel A and one Frankel B paraplegic patients who had paralysis that had lasted through 6 months did not recover after surgery. CONCLUSION: The neurological recovery of Pott's paraplegics with severe spinal deformity resulted in three different outcomes: (1) severe deformity is different from moderate and mild deformities; (2) patients with healed tuberculosis had poorer prognosis than patients with active tuberculosis; (3) children had better prognosis than adults. Furthermore, patients with paralysis persisting over 6 months did not recover neurologically after surgery.

Adolescent↗
PubMed2003

Results of therapy and changing prognosis of multiple myeloma during the last 40 years in the region of North and Middle Moravia: group of 562 patients.

INTRODUCTION: The aim of this study was the retrospective assessment of therapy results and the changing prognosis of multiple myeloma (MM) patients from the Middle and North Moravia region of the Czech Republic during the last 40 years. PATIENTS AND METHODS: The analyzed group of 562 patients was gathered in the years 1959-2000, mean age 63 (28-91) years, M/F ratio 1.1 : 1.0. Overall survival (OS) curves were plotted according to the method of Kaplan and Meier and compared using the log rank test (P<0.05). RESULTS: During the long assessed period, a significant change in prognosis and therapy response was achieved (P=0.0000). The 'first turning point' (1963-1975) characterized by unsystematic melphalan and prednisone therapy (MP), led to significant improvement of OS (8-19 months, P=0.0031) in comparison with the period of plain symptomatic therapy (1959-1963) and the increase in 3-year survival rate from 4 to 23% of patients. The 'second turning point' (1976-1980), characterized by introduction of the systematic conventional polychemotherapy (VMP, VMCP, VBAP, VCAP) and complex supportive treatment, was associated with subsequent improvement of therapeutic response (OS 40 months, P=0.0000; 3- or 10-year survival was seen in 55 and 5.5% of patients). Nevertheless, the results of the next 20 years (regimens VB(C)MCP, VAD, Cy-VAD and CIDEX) are a little disappointing with insignificant progress. In the whole group of 295 patients from the years 1976 to 1995, divided into 5-year periods, remission (R< or =25% of the initial M-protein level) was achieved in 10-24% of cases, the OS median was 32-44 months, and 5 (respectively 10)-year survival improved from 25 to 36% and from 5.5 to 16.5% of patients. The 'third turning point' represented years 1996-2000 marked with the introduction of high dose (HD)-therapy with ASCT support leading in a group of 31 patients (< or =65 years) to remission in 71%, to complete remission in 32% and to significant improvement of OS (P=0.0037) and 5-year survival in 91% of the patients. The improvement of therapy results in this 'third turning point' was demonstrated in comparison with the 1976-1995 group with conventional therapy with a group of patients from 1996 to 2000 (both conventional and HD therapy with ASCT), characterized by 36% of remissions and 5-year survival of 57% of the patients (P=0.030). HD therapy with ASCT achieved in the years 1996-2000 had better therapy results (R-71%, 5-year survival 91%) than that achieved in two comparable groups of patients (1991-1995 and 1996-2000), fulfilling all criteria of HD therapy with ASCT but treated with conventional therapy only (R - 24 and 32%, 5-year survival 46 and 68% of the patients). CONCLUSION: The retrospective analysis showed that the meaningful change in overall prognosis of MM patients achieved in Moravia is in accord with worldwide trends in the course of 1959-2000 years, which was achieved due to the gradual application of the modern innovated systems of complex therapy.

Adult↗
PubMed2002

Specific immunoglobulin E and immunoglobulin G antibodies to toluene diisocyanate-human serum albumin conjugate: useful markers for predicting long-term prognosis in toluene diisocyanate-induced asthma.

BACKGROUND: Our previous study reported that more than 50% of toluene diisocyanate (TDI)-induced asthma patients had persistent asthmatic symptoms even after complete avoidance. Although specific IgE (sIgE) has been detected in a portion of patients with TDI-asthma, a recent investigation suggests that the presence of serum specific IgG (sIgG), not sIgE, is more closely associated with positive bronchoprovocation test (BPT) results. OBJECTIVE: To evaluate the possible role of sIgE and sIgG in predicting long-term prognosis of TDI-asthma. MATERIALS AND METHODS: Forty-one TDI-asthma patients whose diagnosis was confirmed by TDI-BPT, and 20 unexposed healthy controls were enrolled. Both sIgE and sIgG to TDI-human serum albumin (HSA) conjugate were detected by ELISA. All patients with persistent asthmatic symptoms took anti-asthmatic medications during the follow-up period (mean: 67.5 months) and were instructed to avoid exposure to TDI. Airway hyper-responsiveness to methacholine (AHM) was monitored every year during the study period. The patients were classified into three groups according to changing patterns of AHM and asthmatic symptoms as follows: group I, no improvement with persistent asthmatic symptoms (n = 12); group II, partial improvement with persistent asthmatic symptoms (n = 13); group III, in remission (n = 16). RESULTS: Favourable prognosis was associated with a mild degree of AHM at initial diagnosis (P < 0.05). Although there were no significant differences in the prevalence of sIgE antibody to TDI-HSA conjugate among the three groups (P > 0.05), prevalence of sIgG in group I tended to be higher than in group II (0.05 < P < 0.1). However, the levels of sIgG were significantly higher in group I than in group II (P = 0.05), whereas levels of sIgE were significantly higher in group II than in group I (P = 0.014). No significant differences were noted in exposure duration, sex, age, atopic status, and total IgE level among the three groups (P > 0.05). CONCLUSION: This study confirmed that a favourable outcome is related to a mild degree of AHM and to low levels of sIgG to predict persistent asthmatic symptoms, it also suggested that the presence of high serum-specific IgE at initial diagnosis may represent a better prognosis.

Asthma↗
PubMed2002

Long-term prognosis of patients treated for erythema migrans in France.

BACKGROUND: The long-term prognosis of patients treated for erythema migrans has only rarely been assessed. OBJECTIVES: To evaluate the clinical characteristics and long-term prognosis of patients treated for erythema migrans in the region of Alsace, France. METHODS: In a prospective study, 56 consecutive patients presenting with erythema migrans at the Strasbourg University Hospital between 1995 and 1999 were examined and a Borrelia burgdorferi enzyme immunoassay was performed. Patients were treated with tetracyclines or amoxycillin. Patients were re-examined 6 weeks later and a telephone interview was performed in summer 2000 to evaluate the long-term outcome. RESULTS: There were 25 women and 31 men of mean age 49 years presenting with single (n = 54) or multiple (n = 2) erythema migrans lesions. At the time of diagnosis, 30% of the patients had systemic signs, myalgias or arthralgias and only 36% of 50 patients were seroreactive against B. burgdorferi. None of the 51 patients evaluated at 6 weeks and none of the 37 patients interviewed after a median delay of 3 years had developed complications attributable to Lyme borreliosis. CONCLUSIONS: The prognosis of patients treated for Lyme borreliosis in this part of France is excellent. Therefore, a complete clinical examination is sufficient as an initial evaluation and long-term follow-up is not necessary.

Adolescent↗
PubMed2001

Technetium-99m-sestamethoxyisobutylisonitrile scan as a predictor of chemotherapy response in malignant lymphomas compared with P-glycoprotein expression, multidrug resistance-related protein expression and other prognosis factors.

The purpose of the present study was to predict the response of malignant lymphomas (MLs) to chemotherapy using technetium-99m methoxyisobutylisonitrile (Tc-MIBI) scan and to compare it with the predictive ability of P-glycoprotein (P-gp) expression, multidrug resistance-related protein (MRP) expression and other prognosis factors. Twenty-five ML patients were enrolled in this study prior to initiation of chemotherapy. Images were obtained 10 min after intravenous injection of Tc-MIBI, interpreted visually and the tumour-to-background (T/B) ratios calculated. Immunohistochemical analyses were performed on sections of the biopsy specimens to determine P-gp and MRP expression. Chemotherapy response was evaluated in the first 1-2 years after completion of chemotherapy. The mean T/B ratio of the 15 patients with a good response (3.3 +/- 0.6) was significantly higher than that of the 10 patients with a poor response (1.2 +/- 0.1). All 15 patients with a good chemotherapy response had positive Tc-MIBI scan results and negative P-gp and MRP expression. All 10 patients with a poor response had negative Tc-MIBI scan results and either positive P-gp or MRP expression. Other prognosis factors showed no significant difference in the incidence of good and poor responses. Tc-MIBI scan results represent P-gp or MRP expression more accurately than other prognosis factors and predict the chemotherapy response in ML patients.

ATP Binding Cassette Transporter, Subfamily B, Mem↗
PubMed2000

Effects of the combination of blood transfusion and postoperative infectious complications on prognosis after surgery for colorectal cancer. Danish RANX05 Colorectal Cancer Study Group.

BACKGROUND: The frequency of postoperative infectious complications is significantly increased in patients with colorectal cancer receiving perioperative blood transfusion. It is still debated, however, whether perioperative blood transfusion alters the incidence of disease recurrence or otherwise affects the prognosis. METHODS: Patient risk variables, variables related to operation technique, blood transfusion and the development of infectious complications were recorded prospectively in 740 patients undergoing elective resection for primary colorectal cancer. Endpoints were overall survival (n = 740) and time to diagnosis of recurrent disease in the subgroup of patients operated on with curative intention (n = 532). The patients were analysed in four groups divided with respect to administration or not of perioperative blood transfusion and development or non-development of postoperative infectious complications. RESULTS: Overall, 19 per cent of 288 non-transfused and 31 per cent of 452 transfused patients developed postoperative infectious complications (P< 0.001). The median observation period was 6.8 (range 5.4-7.9) years. In a multivariate analysis, risk of death was significantly increased among patients developing infection after transfusion (n = 142) compared with patients receiving neither blood transfusion nor developing infection (n = 234): hazard ratio 1.38 (95 per cent confidence interval (c.i.) 1.05-1.81). Overall survival of patients receiving blood transfusion without subsequent infection (n = 310) and patients developing infection without preceding transfusion (n = 54) was not significantly decreased. In an analysis of disease recurrence the combination of blood transfusion and subsequent development of infection (hazard ratio 1.79 (95 per cent c.i. 1.13-2.82)), localization of cancer in the rectum and Dukes classification were independent risk factors. CONCLUSION: Blood transfusion per se may not be a risk factor for poor prognosis after colorectal cancer surgery. However, the combination of perioperative blood transfusion and subsequent development of postoperative infectious complications may be associated with a poor prognosis.

Adenocarcinoma↗
PubMed2003

Tumor vascularity and tryptase-positive mast cells correlate with a poor prognosis in melanoma.

BACKGROUND: The importance of angiogenesis in melanoma has been controversial and is not homogeneous. Mast cell density (MCD) is highly correlated with the extent of both normal and pathological angiogenesis, such as that in chronic inflammatory diseases and tumours. METHODS: We evaluated the prognostic significance of tumour microvascular density (MVD) and MCD in 25 advanced melanoma patients after resection and a 4-5-year follow up: 48% of the patients were alive and free of metastases (good prognostic subgroup); 16% had developed regional nodal metastases (intermediate prognostic subgroup); and 36% had died (poor prognostic subgroup). Tissues samples were investigated immunohistochemically to count microvessels and mast cells with an antifactor VIII and an antitryptase antibody, respectively. RESULTS: Immunohistological staining showed a higher number of microvessels and mast cells in melanoma lesions of poor prognosis as compared with intermediate prognosis and with good prognosis, respectively. CONCLUSIONS: These data agree with those showing a close relationship between MCD and angiogenesis during tumour progression and demonstrate, for the first time, a prognostic significance of MCD in human melanoma.

Adult↗
PubMed1996

Breast cancer: two micrometastatic variants in the axilla that differ in prognosis.

Measurement of the area of the tumour deposits present in routine sections from the axillary nodes from a series of 1069 breast cancer patients showed that 138 cases had a single micrometastasis (0.2 cm2 or less), while in 29 a similar load was spread over two or more nodes. These 167 cases represent 15% of the patients in the series. Twentyfive of them had died of breast cancer within a mean follow-up of 6 years. They had smaller micrometastases than those surviving (P < 0.0025). Histological examination in the 138 with single micrometastases showed that two variants were present. In one, tumour growth was confined to the capsular lymphatics and/or the subcapsular sinus. In the other, tumour growth was present in the nodal lymphoid tissue, and, on occasion, at the other sites as well. Those with growth in the lymphoid tissue had a better prognosis than those without (P < 0.0035). Prognosis in the former was comparable to that in the node-negative cases, while in those lacking such growth it was similar to that in the node-positive. The presence of these two variants could explain divergent reports in the literature on prognosis in cases with micrometastases. While the mechanisms behind this apparent paradox remain speculative, the observation can be of diagnostic interest in routine surgical pathology.

Axilla↗
PubMed2001

Spitzoid malignant melanoma in teenagers: an entity with no better prognosis than that of other forms of melanoma.

AIMS: A rare form of melanoma in teenagers closely simulates Spitz naevus and is claimed to have a good prognosis. The aim of this study is to identify the clues for a confident diagnosis of this entity and to confirm the peculiarly good prognosis. METHODS AND RESULTS: Two cases of melanoma with Spitzoid features were compared with Spitz naevus and it was found that the major distinctive criteria are: mitoses and single cell necrosis in the deepest part of the lesion, cellular and particularly nuclear and nucleolar pleomorphism, and growth pattern in solid sheets of cells. More subtle clues were the asymmetric distribution of pigment and the thinning of the epidermis with parakeratosis and exudate in the cornified layer. Both of the lesions reached the mid-dermis. There was a fatal outcome in both patients after generalized metastatic spread. The metastatic disease in one of the cases appeared 15 years after the excision of the primary lesion. CONCLUSIONS: Spitzoid melanoma in teenagers can be distinguished from Spitz naevus if strict criteria are followed. Spitzoid melanoma does not show a better prognosis than other types of melanoma if the follow-up is prolonged enough.

Adolescent↗
PubMed2001

CD10 and Bcl10 expression in diffuse large B-cell lymphoma: CD10 is a marker of improved prognosis.

AIMS: Diffuse large B-cell lymphoma (DLBCL), the most common subtype of non-Hodgkin's lymphoma, is clinically and pathologically heterogeneous. The Bcl10 gene was recently isolated from the breakpoint region of t(1;14)(p22;q32) in mucosa-associated lymphoid tissue (MALT) lymphomas, and is considered to be an apoptosis-associated gene. CD10 is considered to be a marker of follicular centre B-cell differentiation. To assess the clinical significance and roles of CD10 and Bcl10 in DLBCL, we analysed 138 cases, using immunohistochemical methods. METHODS AND RESULTS: CD10 expression was limited to the cytoplasm, whereas Bcl10 expression was detected in the cytoplasm and/or nuclei. CD10 expression was detected in 39 of 138 cases (28.2%), cytoplasmic Bcl10 in 68 cases (49.2%), and nuclear Bcl10 in 34 cases (24.6%). Nuclear Bcl10 was detected in 14 of 28 cases (50%) of extranodal DLBCL, but only 20 of 110 cases (18.2%) of nodal DLBCL. Cytoplasmic Bcl10 was detected in 19 of 28 cases (67.8%) of extranodal DLBCL and 49 of 110 cases (44.5%) of nodal DLBCL. CD10 expression closely correlated with improved survival (68% overall survival (OS) vs. 48% OS), but not with site of disease. A high International Prognostic Index (IPI) was considered to be a poor prognostic factor associated with a shorter OS. CD10 expression was detected in 27 of 84 cases (32.1%) with low-risk IPIs, and in 12 of 54 cases (22.2%) with high-risk IPIs. In the low-risk group, cases expressing CD10 carried a better prognosis than CD10- cases (93% OS vs. 71% OS), whereas this was not the case in the high-risk group (25% vs. 20%). CONCLUSIONS: Bcl10 expression was associated with extranodal DLBCL, but not with prognosis. CD10 expression was closely associated with improved survival, but not with risk as predicted by IPI. Overall, our results suggest that CD10 expression may be useful, in combination with clinical parameters, for determining the prognosis of DLBCL.

Adaptor Proteins, Signal Transducing↗
PubMed2002

Exercise-induced symptomatic ischaemia predicts a poor long-term prognosis after acute myocardial infarction.

STUDY OBJECTIVES: To evaluate the long-term prognostic significance of symptomatic ischaemia during exercise testing performed 3 weeks after acute myocardial infarction (AMI). DESIGN: A prospective study with long-term follow-up. SETTING: A Cardiac Rehabilitation Clinic in a University Hospital. SUBJECTS: A total of 446 patients were allowed to perform exercise testing 3 weeks after AMI and followed for 72 +/- 20 months. MEASUREMENTS AND RESULTS: Patients were divided into three groups according to whether they had no ECG evidence of ischaemia during exercise testing (334 patients), silent ischaemia (90 patients) or symptomatic ischaemia (22 patients). Cardiac death was significantly more frequent in patients with symptomatic ischaemia when compared with silent ischaemia (31.8% vs. 7.8%, P < 0.01) or when compared with no ischaemia (31.8% vs. 10.2%, P < 0.01). The three groups had a low cardiac mortality during the first 48 months of follow-up. The prognosis of patients with symptomatic ischaemia worsens markedly thereafter. The results of exercise testing did not predict recurrence of myocardial infarction. Coronary revascularization was performed in 34.4% of those without ischaemia, 47.8% of those with silent ischaemia and 45.5% of those with symptomatic ischaemia (P < 0.01). CONCLUSIONS: Patients with symptomatic ischaemia have a good prognosis during the first 4 years of follow-up. Their prognosis worsens thereafter as opposed to patients with or without silent ischaemia. This high-risk group of patients with symptomatic ischaemia deserves optimal management including revascularization when appropriate.

Analysis of Variance↗
PubMed2003

Basal glucometabolic status has an impact on long-term prognosis following an acute myocardial infarction in non-diabetic patients.

OBJECTIVES: Patients with diabetes are known to have a worse prognosis after an acute myocardial infarction (AMI) compared with non-diabetic patients. The primary aim of this study was to investigate the effect of glucometabolic status on long-term prognosis in non-diabetic patients with an AMI. The second aim was to evaluate the extent to which blood glucose levels at admission depended on acute stress, assessed as serum cortisol, previous glucometabolic status, measured as haemoglobin A1c (HbA1c), or both. DESIGN: In a prospective study of patients with an AMI, blood glucose, HbA1c and cortisol were measured at admission. Fasting blood glucose was determined before discharge and also afterwards, if necessary, for classification. Patients were followed-up for 5.5 years. SUBJECTS: Of the 305 consecutive patients 24% were diagnosed as diabetic and 76% as non-diabetic. MAIN OUTCOME MEASURES: Death or non-fatal myocardial re-infarction. RESULTS: In non-diabetic patients, a Cox regression model was used. With death or re-infarction as endpoint, the following prognostic factors had an impact on event-free survival: age (P<0.001), HbA1c (P=0.002), cortisol (P<0.001) and thrombolytic treatment (P=0.001). There was a correlation between cortisol and blood glucose at admission (r=0.44, P<0.001). Fasting blood glucose day 5 showed no association with event-free survival. CONCLUSIONS: In non-diabetic patients with AMI, admission HbA1c and cortisol were predictors for 5.5-year survival without recurrent non-fatal myocardial infarction. The glucometabolic status of importance for prognosis was detected by HbA1c but not by fasting blood glucose or admission blood glucose, of which the latter was influenced by cortisol.

Aged↗
PubMed2001

Women's preferences for discussion of prognosis in early breast cancer.

OBJECTIVES: To determine preference for prognostic information in women with early breast cancer. DESIGN: Cross sectional survey. PARTICIPANTS: 100 women with early stage breast cancer attending six teaching hospitals in Sydney, Australia. MAIN OUTCOME MEASURES: Women's preference for prognostic information. RESULTS: This study identifies new elements to consider in the prognostic consultation. Whilst 91% of women wanted to know their prognosis prior to commencing adjuvant treatment, 63% wanted their cancer specialist to check with them first before giving it. Seventy-seven percent wanted to be asked if they would like a second opinion. Seventy-five percent wanted to know about complementary therapies. Most wanted their cancer specialist to check their understanding, provide an opportunity to ask questions, and explain medical terms (98%). The majority wanted information summarized (94%), supported by published information (88%) and written down (79%). Ninety-seven percent wanted their fears and concerns listened to and 79% wanted emotional support. In addition 80% of women wanted their cancer specialist to tell them where they could go to get additional emotional support for themselves and their families. Seventy-two percent of women wanted their cancer specialist to make sure they had a relative or friend with them. CONCLUSIONS: Data from this study suggests that a variety of techniques are needed to communicate prognosis. Whilst acknowledging individual women's preferences, and not wanting to appear prescriptive, recommendations emerge for effective discussion of prognosis with women with early stage breast cancer.

Attitude to Health↗
PubMed2000

Biologic parameters that correlate with the prognosis of human gliomas.

Much clinical and biologic data have been processed in the search for useful objective parameters to predict brain tumor behavior. Seventy cases of astrocytic glioma collected by a single clinical team were studied using a full complement of clinical procedures: follow up (7 years), histologic analysis, DNA content estimation, and cell kinetics by flow cytometry. Proliferating cell nuclear antigen (PCNA) was determined by immunocytochemical-coupling flow cytometry (PFC) and also by counting under light microscopy (PIHC). A statistical evaluation was carried out to establish the usefulness of several parameters for glioma prognosis. The cases were histologically classified as 14 low-grade astrocytomas, 20 anaplastic astrocytomas, and 36 glioblastomas multiforme. The survival curve showed significant differences between histologic groups. Diploid populations were more frequent in low-grade astrocytomas, and aneuploid tumors often had increased S-phase and proliferative fractions. The PCNA-labeled index (PCNA-LI) increased with malignancy and correlated with histologic grading (P = 0.01). The PCNA-LI and age segregated low- from high-grade astrocytomas (including anaplastic astrocytoma and glioblastoma multiforme), but none of the variables considered differentiated anaplastic astrocytoma from glioblastoma multiforme. The Cox regression test displayed significant values for age, histologic diagnosis, and PCNA determinations when considered in tandem. Discriminant analysis obtained a function integrating age and specifically PIHC-LI to help in the prognosis of doubtful cases. The results emphasize the importance of parameters integrating different variables in an attempt to provide an accurate prognosis, the most significant being age, histopathologic diagnosis, and the proliferative fraction determined by PCNA.

Adult↗
PubMed2003

Improved prognosis of patients with intermediate- and poor-risk nonseminomatous germ cell tumours by optimizing combined treatment.

OBJECTIVE: To assess whether the optimal use of combined treatment with chemotherapy and appropriately timed surgical intervention by a specialized team might improve the outcome for patients with poor- and intermediate-prognosis (International Germ Cell Consensus Classification, IGCCC) nonseminomatous germ cell tumours (NSGCTs). PATIENTS AND METHODS: Between 1984 and 1998, 47 patients with intermediate (16) and poor prognosis (31) NSGCT were treated; 43 had a testicular and four a retroperitoneal primary. RESULTS: Of the 47 patients only seven (15%) had a complete radiological response after primary chemotherapy; 36 (77%) required surgery after chemotherapy (29 para-aortic lymphadenectomy, 13 resection of pulmonary metastases, two each excision of supraclavicular and retrocrural lymph nodes and one resection of brain metastases; 13 required surgery at more than one site). There was no surgical mortality, with postoperative wound pain the commonest morbidity. On pathology, the resected masses were mature teratoma in 13, necrosis in 12 and malignant disease in 11 patients, the resection being complete in 30. There were microscopically positive margins in the other six patients, all but one having viable residual cancer. Of the 47 patients, 18 needed treatment for relapse, with four having surgery for growing mature teratoma, six chemotherapy plus surgery and eight salvage chemotherapy alone. Of 31 patients, 22 (71%) with a poor and 13 of 16 with an intermediate prognosis were alive at a median (range) follow-up of 94 (41-171) months; of all 47, 34 (72%) remain in complete remission. Ten patients died from disease progression. The presence of residual malignant disease at the resection margin was significantly associated with poorer survival (hazard ratio 7.21, P = 0.0016). Prognostic factors, e.g. number of involved sites, IGCCC group and viable tumour in resected masses, were not significant. The 5-year overall and relapse-free survival (95% confidence interval) was 81 (69-93)% and 57 (43-71)%, respectively. CONCLUSION: The optimal delivery and timing of chemotherapy and surgical resection by a specialist team of oncologists, urological and cardiothoracic surgeons is critical in treating poor-risk NSGCT and might be responsible for improving the outcome of these patients. The detection of residual malignant disease after chemotherapy by positron emission tomography should be investigated to identify those who might benefit from further systemic treatment before complete surgical resection.

Adult↗
PubMedDate not supplied

Bullous pemphigoid and epidermolysis bullosa acquisita: presentation, prognosis, and immunopathology in 11 children.

The immunobullous diseases bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA) are very rare in childhood. Although case studies have been detailed, there are no reports of a large series of patients documenting the effectiveness of treatment and long-term prognosis. We report the clinical presentation, immunopathologic features, disease course, and long-term prognosis of BP and EBA in a series of 11 children. The initial diagnoses based on clinical features were BP (5), EBA (3), and chronic bullous disease of childhood (CBDC) (3). These were subsequently revised from BP to EBA (2), CBDC to BP (2), and CBDC to BP or EBA (1) following the results of direct and indirect immunofluorescence and immunoblotting. Analysis of IgG subclasses in eight cases showed that the predominant subclasses were IgG1 (8) and IgG4 (6). The clinical features appeared to be highly variable, and in patients presenting with inflammatory blistering, laboratory studies were required in order to differentiate between BP and EBA. All patients improved on treatment with corticosteroids and/or sulfones, although treatment regimens showed wide variation. Their diseases tended to remit within 2 years, and their long-term prognosis was good.

Adolescent↗
PubMed1997

Measuring prognosis and case mix in hospitalized elders. The importance of functional status.

OBJECTIVE: Although physical function is believed to be an important predictor of outcomes in older people, it has seldom been used to adjust for prognosis or case mix in evaluating mortality rates or resource use. The goal of this study was to determine whether patients' activity of daily living (ADL) function on admission provided information useful in adjusting for prognosis and case mix after accounting for routine physiologic measures and comorbid diagnoses. SETTING: The general medical service of a teaching hospital. PARTICIPANTS: Medical inpatients (n = 823) over age 70 (mean age 80.7, 68% women). MEASUREMENTS: Independence in ADL function on admission was assessed by interviewing each patient's primary nurse. We determined the APACHE II Acute Physiology Score (APS) and the Charlson comorbidity score from chart review. Outcome measures were hospital and 1-year mortality, nursing home use in the 90 days following discharge, and cost of hospitalization. Patients were divided into four quartiles according to the number of ADLs in which they were dependent. MAIN RESULTS: ADL category stratified patients into groups that were at markedly different risks of mortality and higher resource use. For example, hospital mortality varied from 0.9% in patients dependent in no ADL on admission, to 17.4% in patients dependent in all ADLs. One-year mortality ranged from 17.5% to 54.9%, nursing home use from 3% to 33%, and hospital costs varied by 53%. In multivariate analyses controlling for APS. Charlson scores, and demographic characteristics, compared with patients dependent in no ADL, patients dependent in all ADLs were at greater risk of hospital mortality (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.1-58.8), 1-year mortality (OR 4.4; 2.7-7.4), and 90-day nursing home use (OR 14.9; 6.0-37.0). The DRG-adjusted hospital cost was 50% higher for patients dependent in all ADLs. ADL function also improved the discrimination of hospital and 1-year mortality models that considered APS, or Charlson scores, or both. CONCLUSIONS: ADL function contains important information about prognosis and case mix beyond that provided by routine physiologic data and comorbidities in hospitalized elders. Prognostic and case-mix adjustment methods may be improved if they include measures of function, as well as routine physiologic measures and comorbidity.

Activities of Daily Living↗
PubMed2002

Informative value of magnetic resonance imaging and EEG in the prognosis of infantile spasms.

PURPOSE: To investigate the informative value of EEG and cranial magnetic resonance imaging (cMRI) in the prognosis of infantile spasms (ISs); 86 patients with ISs were included in this study. METHODS: All cases had epileptic spasms, psychomotor retardation, and hypsarrhythmia in at least one of their EEGs. cMRIs and laboratory tests necessary for etiologic diagnosis were completed in all cases. Patients were followed up periodically both clinically and by video-EEGs for >1 year. Clinical information was categorized on the basis of four spheres as epilepsy, psychosocial development, motor development, and overall clinical condition, with each category being evaluated under three levels of involvement as good, moderate, and severe, depending on selected parameters. A similar scale was applied for the EEG results and for the cMRI findings. Clinical parameters were correlated to EEG and cMRI results, by Spearman test. Other statistical tests used were Kruskal-Wallis chi(2) and Mann-Whitney U analysis as multiple comparison by post hoc Bonferroni correction. RESULTS: A severe overall clinical course was observed in 64% of patients, whereas this incidence was 58% and 44% in the EEG follow-up and cMRI parameters, respectively. In regard to prognosis, a significant correlation was determined between the clinical and the EEG course. This relation was the most prominent in psychosocial developmental parameters and least prominent in the motor development. cMRI findings, however, were correlated only with motor development. CONCLUSIONS: cMRI and repeated EEG recordings, especially when assessed together, may provide complementary information regarding the prognosis in ISs.

Brain↗