The considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study.

BACKGROUND: Treatment decision-making by family members on behalf of patients with major stroke can be challenging because of the shock of the diagnosis and lack of knowledge of the patient's treatment preferences. We aimed to understand how, and why, family members made certain treatment decisions, and explored their information and support needs. METHOD: Semi-structured interviews with family members (n = 24) of patients with major stroke, within 2 weeks of hospital admission. Data were analysed thematically. RESULTS: Families' approach to treatment decision-making lay on a spectrum according to the patient's state of health pre-stroke (i.e. patient's prior experience of illness and functional status) and any views expressed about treatment preferences in the event of life-threatening illness. Support and information needs varied according to where they were on this spectrum. At one extreme, family members described deciding not to initiate life-extending treatments from the outset because of the patients' deteriorating health and preferences expressed pre-stroke. Information from doctors about poor prognosis was merely used to confirm this decision. In the middle of the spectrum were family members of patients who had been moderately independent pre-stroke. They described the initial shock of the diagnosis and how they had initially wanted all treatments to continue. However, once they overcame their shock, and had gathered relevant information, including information about poor prognosis from doctors, they decided that life-extending treatments were no longer appropriate. Many reported this process to be upsetting and expressed a need for psychological support. At the other end of the spectrum were family members of previously independent patients whose preferences pre-stroke had not been known. Family members described feeling extremely distressed at such an unexpected situation and wanting all treatments to continue. They described needing psychological support and hope that the patient would survive. CONCLUSION: The knowledge that family members' treatment decision-making approaches lay on a spectrum depending on the patient's state of health and stated preferences pre-stroke may allow doctors to better prepare for discussions regarding the patient's prognosis. This may enable doctors to provide information and support that is tailored towards family members' needs.

Exploring adults' experiences of sedentary behaviour and participation in non-workplace interventions designed to reduce sedentary behaviour: a thematic synthesis of qualitative studies.

BACKGROUND: Sedentary behaviour is any waking behaviour characterised by an energy expenditure of ≤1.5 metabolic equivalent of task while in a sitting or reclining posture. Prolonged bouts of sedentary behaviour have been associated with negative health outcomes in all age groups. We examined qualitative research investigating perceptions and experiences of sedentary behaviour and of participation in non-workplace interventions designed to reduce sedentary behaviour in adult populations. METHOD: A systematic search of seven databases (MEDLINE, AMED, Cochrane, PsychINFO, SPORTDiscus, CINAHL and Web of Science) was conducted in September 2017. Studies were assessed for methodological quality and a thematic synthesis was conducted. Prospero database ID: CRD42017083436. RESULTS: Thirty individual studies capturing the experiences of 918 individuals were included. Eleven studies examined experiences and/or perceptions of sedentary behaviour in older adults (typically ≥60 years); ten studies focused on sedentary behaviour in people experiencing a clinical condition, four explored influences on sedentary behaviour in adults living in socio-economically disadvantaged communities, two examined university students' experiences of sedentary behaviour, two on those of working-age adults, and one focused on cultural influences on sedentary behaviour. Three analytical themes were identified: 1) the impact of different life stages on sedentary behaviour 2) lifestyle factors influencing sedentary behaviour and 3) barriers and facilitators to changing sedentary behaviour. CONCLUSIONS: Sedentary behaviour is multifaceted and influenced by a complex interaction between individual, environmental and socio-cultural factors. Micro and macro pressures are experienced at different life stages and in the context of illness; these shape individuals' beliefs and behaviour related to sedentariness. Knowledge of sedentary behaviour and the associated health consequences appears limited in adult populations, therefore there is a need for provision of accessible information about ways in which sedentary behaviour reduction can be integrated in people's daily lives. Interventions targeting a reduction in sedentary behaviour need to consider the multiple influences on sedentariness when designing and implementing interventions.

Serum total hCGß level is an independent prognostic factor in transitional cell carcinoma of the urothelial tract.

BACKGROUND: Serum total human chorionic gonadotrophin ß subunit (hCGß) level might have prognostic value in urothelial transitional cell carcinoma (TCC) but has not been investigated for independence from other prognostic variables. METHODS: We utilised a clinical database of patients receiving chemotherapy between 2005 and 2011 for urothelial TCC and an independent cohort of radical cystectomy patients for validation purposes. Prognostic variables were tested by univariate Kaplan-Meier analyses and log-rank tests. Statistically significant variables were then assessed by multivariate Cox regression. Total hCGß level was dichotomised at < vs ≥2 IU l(-1). RESULTS: A total of 235 chemotherapy patients were eligible. For neoadjuvant chemotherapy, established prognostic factors including low ECOG performance status, normal haemoglobin, lower T stage and suitability for cisplatin-based chemotherapy were associated with favourable survival in univariate analyses. In addition, low hCGß level was favourable when assessed either before (median survival not reached vs 1.86 years, P=0.001) or on completion of chemotherapy (4.27 vs 0.42 years, P=0.000002). This was confirmed in multivariate analyses and in patients receiving first- and second-line palliative chemotherapy, and in a radical cystectomy validation set. CONCLUSIONS: Serum total hCGß level is an independent prognostic factor in patients receiving chemotherapy for urothelial TCC in both curative and palliative settings.

Relevant risk of carboplatin underdosing in cancer patients with normal renal function using estimated GFR: lessons from a stage I seminoma cohort.

BACKGROUND: Seminoma stage I is the most frequent testis cancer and single-dose carboplatin (AUC7) is an effective and widely used adjuvant treatment. Underdosing of carboplatin by 10% has been shown to almost double the rate of relapse and hence correct dosing based on accurate GFR measurement is crucial. The gold standard of GFR measurement with a radiolabelled isotope is expensive and not readily available. In many institutions, it is replaced by GFR estimation with the Cockcroft-Gault formula, which might lead to significant carboplatin underdosing and potentially inferior clinical outcome. METHODS: Retrospective analysis of all patients with stage I seminoma treated with adjuvant carboplatin between 1999 and 2012. All patients had serum creatinine measured and underwent GFR measurement with a radioisotope ((51)Cr EDTA or (99m)Tc DTPA), which was compared with seven standard GFR estimation formulae (Cockcroft-Gault, CKD-EPI, Jelliffe, Martin, Mayo, MDRD, Wright) and a flat dosing strategy. Bias, precision, rates of under- and overdosing of GFR estimates were compared with measured GFR. Bland-Altman plots were done. RESULTS: A total of 426 consecutive Caucasian male patients were included: median age 39 years (range 19-60 years), median measured GFR 118 ml/min (51-209), median administered carboplatin dose 1000 mg (532-1638). In comparison to isotopic GFR measurement, a relevant proportion of patients would have received ≤ 90% of carboplatin dose through the use of GFR estimation formulae: 4% using Mayo, 9% Martin, 18% Cockcroft-Gault, 24% Wright, 63% Jelliffe, 49% MDRD and 41% using CKD-EPI. The flat dosing strategy, Wright and Cockcroft-Gault formulae, showed the smallest bias with mean percentage error of +1.9, +0.4 and +2.1, respectively. CONCLUSIONS: Using Cockcroft-Gault or any other formula for GFR estimation leads to underdosing of adjuvant carboplatin in a relevant number of patients with Seminoma stage I and should not be regarded as standard of care.

Biological correlates of post-stroke fatigue: a systematic review.

Fatigue is a common and disabling consequence of stroke. Its mechanisms are unknown. Neuroanatomical abnormalities (e.g. white matter lesions, brain atrophy), neuroendocrine dysregulation, neurotransmitter changes and inflammation are associated with fatigue in conditions other than stroke. This review sought to identify published studies describing associations between post-stroke fatigue and these biological factors. We searched Medline, EMBASE, CINAHL, PsycINFO and AMED on October 15 and PubMed on 28 December 2010 and included studies in English that recruited at least 10 patients (>18 years old) with stroke, assessed fatigue and reported its relationship with neuroanatomical abnormalities, hypothalamo-pituitary-adrenal axis dysregulation, neurotransmitter changes or inflammation. Of 4916 citations from the searches, 17 studies met our inclusion criteria. There was no association between white matter lesions, brain atrophy or pathological type of stroke and fatigue (seven studies, n = 4746). The data on relationship between lesion location and fatigue were inconclusive: four (n = 675) of 13 studies (n = 1613) showed associations between fatigue and infratentorial lesion location (brainstem in particular) or basal ganglia stroke. One study reported C-reactive protein levels and found an association with fatigue. No studies reported hypothalamo-pituitary-adrenal axis dysregulation or neurotransmitter changes and fatigue. We could not perform meta-analysis because the studies used different methods of fatigue assessment, examined different populations and had different designs. The biological mechanisms of post-stroke fatigue are uncertain. Further studies are required to determine the relationship between post-stroke fatigue and biological factors.

A pilot observational study of the association between fatigue after stroke and C-reactive protein.

BACKGROUND: The aetiology of fatigue after stroke is unknown. We explored the relationship between fatigue and C-reactive protein (CRP) as a marker of inflammation. METHODS: This cross-sectional study recruited inpatients with a stroke (onset within the previous three months) over a five-week period. Those with dysphasia or confusion severe enough to prevent informed consent and those with current infection were excluded. A semi-structured interview determined a) fulfillment of a case definition for fatigue and b) severity of fatigue (fatigue assessment scale, FAS). Venous blood was taken for CRP. A hospital anxiety and depression score (HADS) was used to screen for emotional distress. RESULTS: Of the 28 patients recruited (mean age 72.7 years, proportion men 47%), 15 (53%) fulfilled the case definition for fatigue. C-reactive protein data were logarithmically transformed for analysis. C-reactive protein levels did not differ significantly between those with and without fatigue, according to the case definition (=28, p=0.35). After exclusion of those with pre-stroke fatigue and those with high scores on the HADS (suggestive of emotional distress), the geometric mean CRP of the fatigued group was 16.04 mg/l (95% CI: 7.12-36.14) compared with 5.16 mg/l (95% CI: 2.7-9.85) in the non-fatigued group (n=21, p=0.025, unpaired t test), but the relationship between FAS and CRP was not statistically significant (r=0.37, p=0.098). CONCLUSION: This pilot study is the first to demonstrate an association between fatigue after stroke and higher CRP, after excluding patients with pre-stroke fatigue and those with probable mood disorders. If this finding is confirmed in a larger number of patients, it might provide a target for treating fatigue after stroke.

Sex cord stromal testicular tumors: a clinical series--uniformly stage I disease.

PURPOSE: Sex cord stromal testicular tumors are rare. Historically 10% of lesions are said to be malignant but to our knowledge there are no clinical or histological features that can accurately predict potential malignant behavior. Because of this, groups at some centers have advocated prophylactic retroperitoneal lymph node dissection in patients with clinical stage I disease. We reviewed our experience with these tumors to determine whether this policy is justified. MATERIALS AND METHODS: We retrospectively reviewed the records of all 38 men older than 18 years with sex cord stromal testicular tumors who were referred to the Wessex regional cancer center for treatment or pathological review during the 25-year period of 1982 to 2006. We then compared our series with a malignant sex cord stromal testicular tumor database generated from the world literature. RESULTS: All Wessex patients were treated with excision of the primary tumor alone and metastatic disease developed in none. All remained disease-free with an overall median survival of 6.8 years (range 1.4 to 25). Features in the literature favoring malignant behavior, ie metastatic disease, included larger tumors (mean 6.43 vs 1.71 cm), a high mitotic rate, tumor necrosis, angiolymphatic invasion, infiltrative margins and extratesticular extension (each p <0.0001). The malignant group had an overall median survival of 2.3 years (range 0.02 to 17.3). CONCLUSIONS: No patient had disease progression in our study, which is to our knowledge the largest reported United Kingdom series of sex cord stromal testicular tumors. Our data suggest that malignancy is uncommon and prophylactic retroperitoneal lymph node dissection is unjustified for clinical stage I disease.

Jupiter's Radiation Belts: Can Pioneer 10 Survive?

Model calculations of Jupiter's electron and proton radiation belts indicate that the Galilean satellites can reduce particle fluxes in certain regions of the inner magnetosphere by as much as six orders of magnitude. Average fluxes should be reduced by a factor of 100 or more along the Pioneer 10 trajectory through the heart of Jupiter's radiation belts in early December. This may be enough to prevent serious radiation damage to the spacecraft.

Ceratoscopelus maderensis: peculiar sound-scattering layer identified with this myctophid fish.

A sound-scattering layer, composed of discrete hyperbolic echosequences and apparently restricted to the Slope Water region of the western North Atlantic, has been identified from the Deep Submergence Research Vehicle Alvin with schools of the meyctophid fish Ceratoscopelus maderensis. By diving into the layer and using Alvin's echo-ranging sonar, we approached and visually identified the sound scatterers. The number of echo sequences observed with the surface echo-soutnder (1/23.76 x 10(5) cubic meters of water) checked roughly with the number of sonar targets observed from the submarine (1/7.45 x 105 cubic meters). The fish schools appeared to be 5 to 10 meters thick, 10 to 100 meters in diameter, and on centers 100 to 200 meters apart. Density within schools was estimated at 10 to 15 fish per cubic meter.

Cost-effectiveness of physical fitness training for stroke survivors.

Background Physical fitness is impaired after stroke, yet fitness training after stroke reduces disability. Several international guidelines recommend that fitness training be incorporated as part of stroke rehabilitation. However, information about cost-effectiveness is limited. Methods A decision tree model was used to estimate the cost-effectiveness of a fitness programme for stroke survivors vs. relaxation (control group). This was based on a published randomised controlled trial, from which evidence about quality of life was used to estimate Quality Adjusted Life Years. Costs were based on the cost of the provision of group fitness classes within local community centres and a cost per Quality Adjusted Life Year was calculated. Results The results of the base case analysis found an incremental cost per Quality Adjusted Life Year of £2,343. Conclusions Physical fitness sessions after stroke are a cost-effective intervention for stroke survivors. This information will help make the case for the development of new services.

The key challenges of discussing end-of-life stroke care with patients and families: a mixed-methods electronic survey of hospital and community healthcare professionals.

BACKGROUND: Communication between professionals, patients and families about palliative and end-of-life care after stroke is complex and there is a need for educational resources in this area. METHODS: To explore the key learning needs of healthcare professionals, a multidisciplinary, expert group developed a short electronic survey with open and closed questions, and then distributed it to six UK multiprofessional networks and two groups of local clinicians. RESULTS: A total of 599 healthcare professionals responded. Educational topics that were either definitely or probably needed were: ensuring consistent messages to families and patients (88%); resolving conflicts among family members (83%); handling unrealistic expectations (88%); involving families in discussions without them feeling responsible for decisions (82%); discussion of prognostic uncertainties (79%); likely mode of death (72%); and oral feeding for 'comfort' in patients at risk of aspiration (71%). The free-text responses (n = 489) and 82 'memorable' cases identified similar themes. CONCLUSION: Key topics of unmet need for education in end-of-life care in stroke have been identified and these have influenced the content of an open access, web-based educational resource.

Quantitative data analysis of perceived barriers and motivators to physical activity in stroke survivors.

BACKGROUND: Levels of physical activity after stroke are low, despite multiple health benefits. We explored stroke survivors' perceived barriers, motivators, self-efficacy and intention to physical activity. METHODS: Fifty independently mobile stroke survivors were recruited prior to hospital discharge. Participants rated nine possible motivators and four possible barriers based on the Mutrie Scale, as having 'no influence', 'some influence' or 'a major influence' on physical activity. Participants also rated their self-efficacy and intention to increasing walking. RESULTS: The most common motivator was 'physical activity is good for health' [34 (68%)]. The most common barrier was 'feeling too tired' [24 (48%)]. Intention and self-efficacy were high. Self-efficacy was graded as either 4 or 5 (highly confident) on a five-point scale by [34 (68%)] participants, while 42 (84%) 'strongly agreed' or 'agreed' that they intended to increase their walking. CONCLUSION: Participants felt capable of increasing physical activity but fatigue was often perceived as a barrier to physical activity. This needs to be considered when encouraging stroke survivors to be more active.

Radiotherapy versus single-dose carboplatin in adjuvant treatment of stage I seminoma: a randomised trial.

BACKGROUND: Adjuvant radiotherapy is effective treatment for stage I seminoma, but is associated with a risk of late non-germ-cell cancer and cardiovascular events. After good results in initial studies with one injection of carboplatin, we undertook a large randomised trial to compare the approaches of radiotherapy with chemotherapy in seminoma treatment. METHODS: Between 1996 and 2001, 1477 patients from 70 hospitals in 14 countries were randomly assigned to receive radiotherapy (para-aortic strip or dog-leg field; n=904) or one injection of carboplatin (n=573; dose based on the formula 7x[glomerular filtration rate+25] mg), at two trial centres in the UK and Belgium. The primary outcome measure was the relapse-free rate, with the trial powered to exclude absolute differences in 2-year rates of more than 3%. Analysis was by intention to treat and per protocol. This trial has been assigned the International Standard Randomised Controlled Trial Number ISRCTN27163214. FINDINGS: 885 and 560 patients received radiotherapy and carboplatin, respectively. With a median follow-up of 4 years (IQR 3.0-4.9), relapse-free survival rates for radiotherapy and carboplatin were similar (96.7% [95% CI 95.3-97.7] vs 97.7% [96.0-98.6] at 2 years; 95.9% [94.4-97.1] vs 94.8% [92.5-96.4] at 3 years, respectively; hazard ratio 1.28 [90% CI 0.85-1.93], p=0.32). At 2 years' follow-up, the absolute differences in relapse-free rates (radiotherapy-chemotherapy) were -1.0% (90% CI -2.5 to 0.5) by direct comparison of proportions, and 0.9% (-0.5 to 3.0) by a hazard-ratio-based approach. Patients given carboplatin were less lethargic and less likely to take time off work than those given radiotherapy. New, second primary testicular germ-cell tumours were reported in ten patients allocated irradiation (all after para-aortic strip field) and two allocated carboplatin (5-year event rate 1.96% [95% CI 1.0-3.8] vs 0.54% [0.1-2.1], p=0.04). One seminoma-related death occurred after radiotherapy and none after carboplatin. INTERPRETATION: This trial has shown the non-inferiority of carboplatin to radiotherapy in the treatment of stage I seminoma. Although the absence of disease-related deaths and preliminary data indicating fewer second primary testicular germ-cell tumours favour carboplatin use, these findings need to be confirmed beyond 4 years' follow-up.

No evidence that severity of stroke in internal carotid occlusion is related to collateral arteries.

BACKGROUND/AIM: The neurological effects of internal carotid artery (ICA) occlusion vary between patients. The authors investigated whether the severity of symptoms in a large group of patients with ipsilateral or/and contralateral ICA occlusion at presentation with ocular or cerebral ischaemic symptoms could be explained by patency of other extra or intracranial arteries to act as collateral pathways. METHODS: The authors prospectively identified all patients (n = 2881) with stroke, cerebral transient ischaemic attack (TIA), retinal artery occlusion (RAO), and amaurosis fugax (AFx) presenting to our hospital over five years, obtained detailed history and examination, and examined the intra and extracranial arteries with carotid and colour-power transcranial Doppler ultrasound. For this analysis, all those with intracranial haemorrhage on brain imaging and cerebral events without brain imaging were excluded. RESULTS: Among 2228/2397 patients with brain imaging (1713 ischaemic strokes, 401 cerebral TIAs, 193 AFx, and 90 RAO) who underwent carotid Doppler, 195 (9%) had ICA occlusion. Among those patients with cortical events, disease in potential collateral arteries (contralateral ICA, external carotid, ipsilateral or contralateral vertebral or intracranial arteries) was equally distributed among patients with severe and mild ischaemic presenting symptoms. CONCLUSION: The authors found no evidence that the clinical presentation associated with an ICA occlusion was related to patency of other extra or intracranial arteries to act as collateral pathways. Further work is required to investigate what determines the clinical effects of ICA occlusion.

Measurement of Campylobacter numbers on carcasses in British poultry slaughterhouses.

An assessment of the proposed new International Organization for Standardization quantitative method for Campylobacter was undertaken on poultry carcass samples collected after the chilling phase of processing. Using a critical differences method, we determined the uncertainty associated with log-transformed Campylobacter numbers by dual analyses of 346 samples collected from 22 processing plants located throughout the United Kingdom. Overall, using log-transformed Campylobacter numbers that ranged between -1 and 5 log, we calculated the expanded measurement of uncertainty (EMU) to be 3.889 for the new method. The EMU changed when ranges of bacterial numbers were grouped for analyses. For low numbers of Campylobacter (< 1 log), the EMU was calculated to be 5.622. There was less measurement error with higher bacterial numbers because the EMU was found to be 0.612 for samples containing Campylobacter numbers of 3 log or above. The draft method was used to measure numbers of Campylobacters on poultry carcasses collected from 18 United Kingdom processing plants in summer and winter. Numbers were significantly lower in winter. We conclude that, although the new method is adequate at quantifying high numbers of Campylobacter on poultry carcasses, further development is required to improve the measurement of small numbers of this causative agent of foodborne illness.

An assessment of sampling methods and microbiological hygiene indicators for process verification in poultry slaughterhouses.

Studies to determine the appropriateness of the use of populations of indicator bacteria on poultry carcasses for process verification were undertaken in commercial slaughterhouses. Samples were collected from neck skin by excision or from whole carcass rinses and were examined for a range of presumptive process hygiene indicator bacteria. Coefficients of variation were calculated for each bacterial indicator and were significantly lower in excised samples, indicating more reproducible bacterial recovery by this sampling method. Total viable counts of aerobic bacteria, Enterobacteriaceae, and Pseudomonas in samples collected by excision had the lowest coefficients of variation when compared with other indicators and were therefore used for further study. The uncertainties associated with the quantification of each bacterial indicator were calculated and were lowest overall for total viable counts of aerobic bacteria. In general, uncertainty was higher for lower bacterial numbers. Results of microbiological testing on pooled excised neck skin samples were not significantly different from the mean of individually analyzed samples. Bacterial numbers increased by 1 log unit when cultures were stored under chilled conditions typical of those used for transporting samples to external laboratories, but the increases were not significant for Pseudomonas and aerobic bacteria when storage time was less than 17 h. Weak relationships were identified between bacterial indicator numbers and duration of processing, although cleanliness of the processing environment diminished visibly during this time. In the plants visited for this study, there was a poor relationship between presumptive bacterial indicator numbers and process hygiene. Consequently, bacterial analyses for process verification purposes may be of limited value.

Impact of the treating institution on survival of patients with "poor-prognosis" metastatic nonseminoma. European Organization for Research and Treatment of Cancer Genito-Urinary Tract Cancer Collaborative Group and the Medical Research Council Testicular Cancer Working Party.

BACKGROUND: Because metastatic nonseminomatous germ cell cancer is a rare but treatable cancer, we have explored whether there is an association between the experience of the treating institution with this disease and the long-term clinical outcome of the patients, particularly patients with a poor prognosis. METHODS: We analyzed data on 380 patients treated in one of 49 institutions participating in the European Organization for Research and Treatment of Cancer/ Medical Research Council randomized trial of four cycles of bleomycin-etoposide-cisplatin followed by two cycles of etoposide-cisplatin versus three cycles of bleomycin-vincristine-cisplatin followed by three cycles of etoposide-ifosfamide-cisplatin-bleomycin, both treatment regimens given with or without filgrastim (granulocyte colony-stimulating factor). Institutions were divided into four groups based on the total number of patients entered in the trial. The groups were compared by use of the Cox proportional hazards model stratified for treatment with filgrastim and for patient prognosis as defined by the International Germ Cell Consensus Classification Group. With the use of this classification, only 65 % of the patients had a poor prognosis. RESULTS: Patients treated in the 26 institutions that entered fewer than five patients into the trial had an overall survival that was statistically significantly worse (two-sided P = .010; hazard ratio = 1.85; 95% confidence interval = 1.16-3.03) than that of patients treated in the 23 institutions that entered five patients or more. Overall survival and failure-free survival were similar among institutions that entered at least five patients. The observed effect may be related to differences in adherence to the chemotherapy protocol and in the frequency and extent of surgery for residual masses, although only the differences in dose intensity achieved statistical significance. CONCLUSIONS: Patients treated in institutions that entered fewer than five patients into the trial appeared to have poorer survival than those treated in institutions that entered a larger number of patients with "poor-prognosis" nonseminoma.

Case series: adult testicular dermoid tumours--mature teratoma or pre-pubertal teratoma?

Adult testicular dermoid tumours are rare tumours with no reported potential for recurrent or metastatic spread. Despite this they are currently classified as mature teratoma and managed as if they have equivalent malignant potential. This report describes two cases of adult mature teratoma of dermoid type and questions the classification and pathogenesis of this disease. In one of the cases there was a clear history of a testicular lump arising pre-pubertally, raising the possibility that some adult dermoid tumours may in fact be pre-pubertal teratomas that have persisted into adulthood. Classification as a mature teratoma carries with it a follow-up regimen that includes numerous radiological investigations with their attendant radiation exposure. A positive histological diagnosis and separate classification of adult dermoid tumours would allay clinical fears of recurrence and metastasis and negate the need for repeated radiological investigations.

Intensive weekly combination chemotherapy for patients with intermediate-grade and high-grade non-Hodgkin's lymphoma.

High response and overall survival rates have been reported for second- and third-generation combination chemotherapy regimens used in the treatment of advanced intermediate- and high-grade non-Hodgkin's lymphoma (NHL). Results with methotrexate with leucovorin, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B) chemotherapy have been particularly impressive, although this regimen produces considerable toxicity. We have devised a similar regimen, which differs from previously reported weekly regimens in that it includes etoposide given at 14-day intervals. The doses of methotrexate and prednisolone were lower in our regimen than those used in MACOP-B. Alternating cycles of cyclophosphamide, doxorubicin, and etoposide (week 1) and methotrexate, bleomycin, and vincristine (week 2) were given for a total of 12 weeks, with continuous oral prednisolone and prophylactic antibiotics. We report here the first 61 patients entered onto this study. The overall response rate is 84% (57% complete remission [CR], 27% partial remission [PR]). With a median follow-up of 32 months for surviving patients, the actuarial overall survival at 3 years is 47%, and the failure-free survival is 45%. The dose-limiting toxicity of this regimen was mucositis. Five deaths occurred during chemotherapy, two of which were due to sepsis. The dose intensities of cyclophosphamide and doxorubicin in this regimen are considerably lower than those in MACOP-B. However, because of the inclusion of etoposide, the projected average relative dose intensity for our regimen is higher than that for MACOP-B. Our regimen has produced inferior results to those reported for MACOP-B. This may be because the addition of etoposide has failed to compensate for the lower doses of doxorubicin and cyclophosphamide. Alternatively, it may reflect differences in the presenting features of the patient populations.