Clinically relevant fatigue in cancer outpatients: the Edinburgh Cancer Centre symptom study.

BACKGROUND: Fatigue is associated with cancer and its treatment but we know little about how many and which patients suffer fatigue of clinical severity. We aimed to determine the prevalence of clinically relevant fatigue (CRF) and its associations in outpatients with various cancer diagnoses. PATIENTS AND METHODS: A survey of outpatients with colorectal, breast, gynaecological, genitourinary, sarcoma, melanoma and miscellaneous tumours at a regional cancer centre. Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) fatigue subscale and the Hospital Anxiety and Depression Scale (HADS). These self-report data were linked to demographic and clinical variables. Data were available on 2867 outpatients. RESULTS: The prevalence of CRF (EORTC fatigue subscale > or =40) was 32% (95% confidence interval 31-34%). The variables independently associated with CRF were primary cancer site, having disease present, type of cancer treatment and emotional distress (total HADS score > or =15). Emotional distress had the strongest association with fatigue but half the cases of CRF were not distressed. CONCLUSION: CRF is common in cancer outpatients and is associated with type of disease and treatment, as well as with emotional distress. The association between CRF and emotional distress is strong but they are not equivalent conditions.

The management of preterm rupture of the membranes.

Little is known about the reasons for rupture of the fetal membranes before the onset of labour. When this occurs before term, there is an increase in perinatal mortality principally due to immaturity, less commonly due to infection, and rarely due to asphyxia as a result of cord prolapse. Management consists of delaying delivery until satisfactory levels of surfactant are present in the liquor amnii or until intra-uterine infection intervenes, in which case delivery is expedited. The care of patients with preterm rupture of the membranes should be conducted in a unit equipped with intensive perinatal care facilities.

The management of preterm labour with intact membranes.

Hyaline membrane disease is a complication of preterm delivery and is a major cause of mortality and morbidity. The onset of such labour is so difficult to predict that diagnosis is often made only when labour is advanced. In practice, therefore, treatment consists of drugs which suppress uterine activity at least until concomitant steroid therapy has had time to enhance pulmonary surfactant formation; this can be determined by means of amniocentesis. If delivery of a preterm infant is inevitable, the gastric contents can be examined at birth in order to predict whether the baby will develop hyaline membrane disease and should therefore be transferred to a neonatal intensive care unit.

Incidence of preterm delivery in patients with previous preterm delivery and/or abortion.

Patients with a history of two or more pregnancies which ended spontaneously before 37 weeks' gestation had an increased risk of spontaneous labour and delivery in subsequent pregnancies. This risk was correlated with previous second trimester abortion and spontaneous preterm delivery but not with previous first trimester abortions. Patients with one or more pregnancies ending in spontaneous second trimester abortion or with preterm labour and delivery had a 38--43% risk of again delivering before term.

Incidence of hyaline membrane disease in the Cape Coloured.

Hyaline membrane disease (HMD), which carries a significant mortality and morbidity, is usually a disorder of the preterm infant. Several workers have shown that there is a lower incidence in the Black and Coloured neonate than in the White neonate. These studies have not excluded the growth-retarded baby, in whom the functional maturation of vital organs may be accelerated. This article examines the incidence of HMD among appropriately grown Cape Coloured infants and compares this with the incidence in White infants.

Induction of labour in pregnancy complicated by heart disease.

Thirty-seven patients whose pregnancies were complicated by heart disease and who required induction of labour were given 4 mg of prostaglandin E2 (PGE2) oral tablets per vaginam. Thirty-one patients (84%) went into labour and delivered within 24 hours, 28 of them vaginally. Although 3 infants had an Agpar score of less than 7 at birth, 2 having been delivered vaginally, all were discharged from hospital thriving and in good condition. No side-effects of PGE2 were observed and although these women had a wide range of functional disabilities, none developed deterioration in cardiac status. Vaginal administration of PGE2 for induction of labour is a safe and simple method of achieving elective delivery in patients with pregnancies complicated by heart disease.

Incidence of heart disease in pregnancy. A study done at Peninsula Maternity Services hospitals.

A detailed retrospective analysis was made of the records of 697 women with heart disease who were delivered between 1972 and 1976 and who accounted for 0.83% of all deliveries during this time. Rheumatic heart disease accounted for 65%, congenital lesions for 14% patients who had had cardiac surgery 12%, and miscellaneous heart conditions for 10% of cardiac lesions. The maternal mortality rate in these women was 7,17/1,000 deliveries, compared with 0.46/1,000 deliveries during this time. Cardiac disease was found to be the most important non-obstetric cause of maternal death. The perinatal mortality rate was not significantly higher than that in the total population. The high incidence of cardiac disease in pregnancy is unlikely to be significantly reduced until effective contraception is more widely practised in our community.

The association between idiopathic spontaneous preterm delivery, an infected intra-uterine environment and hyaline membrane disease.

A total of 110 preterm infants delivered as a result of the spontaneous onset of labour in the absence of obvious maternal and/or neonatal lesions and without premature rupture of the membranes was examined prospectively. Thirty per cent had more than 5 pus cells per high-power field in the gastric aspirate at birth. This finding correlated significantly with a lower incidence of hyaline membrane disease (HMD). All infants who developed HMD had negative or intermediate foam test results. There was no consistent relationship between either the pus cell count or the foam test result and the development of the wet lung syndrome. Data from our community suggest that many spontaneous deliveries occur in association with an infected itra-uterine environment.

The five-year survival rate in urban patients with ovarian carcinoma.

The 5-year survival of 253 patients with ovarian malignancy of epithelial origin is reviewed. Although this is closely related to the clinical stage at presentation, the overall survival is poor, because the majority present with disease which has spread beyond the pelvis. There are more deaths in the first 2 years after diagnosis; thereafter the survival curve gradually flattens off and becomes almost horizontal during the 4th and 5th years.

Management of heart disease in pregnancy.

Cardiac disease in pregnancy is the most important non-obstetric cause of maternal death; such patients should be assessed by a cardiologist before considering pregnancy. Once pregnant, the patient is managed by a combined cardiac and obstetric team familiar with the special risks associated with heart disease in pregnancy. Delivery should be undertaken in a hospital equipped with specialist cardiac, anaesthetic and obstetric facilities. If the patient cannot be expected to survive in good health, puerperal sterilization is advised.

A randomized controlled trial of cervical cerclage in women at high risk of spontaneous preterm delivery.

The effect of cervical suture on pregnancy outcome was studied in 194 women with a high risk (approximately 30%) of having a late abortion or a preterm delivery. The women were randomly allocated either to have a cervical suture inserted (n = 96) or to be managed without a suture (n = 98). There was no evidence that cervical cerclage either prolonged gestation or improved survival. Patients allocated to receive cerclage spent significantly longer in hospital, even when the period of admission for insertion was excluded. The patients in the cerclage group were more likely to receive tocolytic drugs, and more of them experienced puerperal pyrexia, although these differences between the groups were not statistically significant.

Maternal post-delivery weight in the assessment of obesity.

Maternal weight recorded on the day after delivery correlated significantly with maternal skinfold thickness measured at multiple sites. Skinfold thickness probably reflects total body fat stores. It is suggested that the relationship between maternal weight and fetal birth weight may be mediated by the amount of maternal fat available to meet the energy requirements of the growing fetus.

Risk of pre-term delivery in patients with previous pre-term delivery and/or abortion.

Patients with a history of two or more pregnancies which ended spontaneously before 37 weeks gestation had an increased risk of spontaneous pre-term labour and delivery in future pregnancies. This increased risk related mainly to previous second trimester abortions and not to previous first trimester abortions. Patients with one previous spontaneous pre-term labour and delivery had a 37 per cent risk, and those with two or more pre-term deliveries a 70 per cent risk of again delivering pre-term. There appeared to be no beneficial effect of cervical suture on the incidence of pre-term delivery in these patients.

The gastric aspirate foam test in the prediction of hyaline membrane disease.

The gastric aspirate foam test was performed on 99 infants of low birth weight. In 59 of 61 infants with no respiratory distress, the test was positive. All infants who developed hyaline membrane disease (HMD) had negative or intermediate foam test results. There was no consistent relationship between the foam test result and the development of wet lung syndrome. Infants who were small for gestational age had a significantly lower incidence of HMD, as did infants with amniotic fluid infection syndrome. These data indicate that the gastric aspirate foam test is a reliable index of neonatal lung maturity.

Contribution of preterm delivery to perinatal mortality.

A detailed retrospective analysis was made of the records of 486 preterm infants, who accounted for 5-1% of all births during 1973 and 1974. Whereas preterm delivery did not contribute to perinatal mortality in terms of stillbirth, it outweighed all other causes in terms of early neonatal deaths. Preterm birth was responsible for 85% of the early neonatal deaths not due to lethal congenital deformities. Early neonatal mortality rates were closely linked both to gestational age and birth weight and to the reason for preterm birth. Early neonatal mortality was high (97 per 1000) when preterm labour was spontaneous, whether or not associated with material or fetal disease or with multiple pregnancy, but low (27 per 1000) when preterm delivery was elective. Preventing spontaneous preterm labour would considerably reduce neonatal mortality in our community.