Infradiaphragmatic versus supradiaphragmatic Hodgkin lymphoma: a retrospective review of 1,114 patients.

Infradiaphragmatic Hodgkin lymphoma (IDH) accounts for 4-13% of cases of stage I-II Hodgkin lymphoma (HD). It has been associated with distinct pre-treatment characteristics and outcomes when compared with supradiaphragmatic HD (SDH). The comparison of IDH vs SDH can only be made in early and intermediate stages (I-II), such a comparison is not possible for advanced stages (III-IV). This study retrospectively compared two groups of 1013 patients with stage I-II SDH and 101 patients with IDH (10%). These two sub-groups of patients were treated in 1988-1993 in 2 prospective randomized clinical trials in Germany for early and intermediate stages of Hodgkin lymphoma. IDH-patients were older (median 39 vs 31 years; p < 0.001), predominantly male (73% vs 52%; p < 0.001) and more often had involvement of 3 lymph node areas (LNA) (80% vs 55%; p < 0.001). Histology in IDH was more likely to be mixed cellularity (46.5% vs 23.6%, p < 0.001) or lymphocyte predominant (20 vs 10%, p = 0.003) and less likely nodular sclerosis (25% vs 63%, p < 0.001). In early-stage unfavorable disease, IDH was associated with a higher treatment failure rate (unadjusted hazard ratio 2, 95% CI, 1.3-3.4; p = 0.003). After controlling for age, sex, stage, histology, B-symptoms and involvement of 3 LNA, the adjusted hazard ratio was 1.25 (95% CI, 0.65-2.4; p = 0.51) so that IDH was no longer associated with a statistically significant treatment failure rate. Poorer outcomes with IDH as compared to SDH are attributable to its association with known adverse prognostic risk factors, but IDH, in itself, is not an independent adverse prognostic factor for treatment failure or survival.

Computer-aided navigation in neurosurgery.

The article comprises three main parts: a historical review on navigation, the mathematical basics for calculation and the clinical applications of navigation devices. Main historical steps are described from the first idea till the realisation of the frame-based and frameless navigation devices including robots. In particular the idea of robots can be traced back to the Iliad of Homer, the first testimony of European literature over 2500 years ago. In the second part the mathematical calculation of the mapping between the navigation and the image space is demonstrated, including different registration modalities and error estimations. The error of the navigation has to be divided into the technical error of the device calculating its own position in space, the registration error due to inaccuracies in the calculation of the transformation matrix between the navigation and the image space, and the application error caused additionally by anatomical shift of the brain structures during operation. In the third part the main clinical fields of application in modern neurosurgery are demonstrated, such as localisation of small intracranial lesions, skull-base surgery, intracerebral biopsies, intracranial endoscopy, functional neurosurgery and spinal navigation. At the end of the article some possible objections to navigation-aided surgery are discussed.

Frameless neuronavigation applied to endoscopic neurosurgery.

OBJECTIVE: We retrospectively analyzed the indications, surgical techniques, and applicability of frameless neuronavigation to endoscopic procedures in a heterogeneous group of 15 patients. MATERIAL AND METHODS: In 8 patients indications for surgery were cystic lesions, in 3 patients intraventricular tumors, and in 4 patients occlusive hydrocephalus. The mean age was 39 years (range 9-76 years). The follow-up period ranged from 5-24 months (mean 10 months). Frameless neuronavigation was accomplished with the "operating arm system" in 10 cases and with the "optical tracking system" in 5 cases (RADIONICS, Burlington, USA). RESULTS: In all 15 cases, neuronavigation sufficiently provided anatomical orientation, preoperative planning, and intraoperative realization of the approach. The calculated mean calibration error was 2.1 mm. There have been no permanent morbidities and no mortalities related to the use of endoscopes and neuronavigation. CONCLUSION: In endoscopic neurosurgery, frameless neuronavigation is a useful tool in planning and realizing the approach and improving intraoperative orientation in selected cases. Indications are small or hidden lesions, impaired visual conditions, abnormal anatomy, and narrow ventricles. Endoscopic procedures include fenestration and resection of intraventricular or intraparenchymal cysts, biopsy of intraventricular tumors, and third ventriculostomy in selected cases.

Basic principles and clinical applications of neuronavigation and intraoperative computed tomography.

Computed tomography (CT) images in combination with a navigation device enable three-dimensional (3-D) localization of intracranial lesions. Furthermore, CT scanning can be adapted for intraoperative application to actualize the image data and to check the anatomical situation during the operation. Frameless navigation was used in 100 patients. The procedure was performed in 46 cases with an optical navigation system, in 38 cases with a sensory arm, and in 16 cases with a navigated microscope. Six skin markers were used for registration. Mean fiducial registration error was 2.18 mm with a standard deviation of 1.03 mm. The indication for navigation was tumor localization and planning of the craniotomy in 81 cases, stereotactic biopsy in eight cases, and endoscopic procedures in 11 cases. Technical problems with the navigation system were observed in nine cases. In two additional cases the tumor was not found by navigation. All eight biopsy cases were successful, and histologically relevant specimens were obtained without complications. Navigation was helpful in 11 endoscopic cases for choosing an optimal trajectory through the foramen of Monro or for connecting multiple intraventricular cysts. For intraoperative CT imaging, the mobile Philips Tomoscan M was adapted to the needs of the operating environment. The mobile CT was used in 78 cases in the operating room: 16 patients who underwent a stereotactic procedure had only preoperative CT scans, 36 patients had an intraoperative CT during tumor surgery, and 26 patients during the test period of the device had only a postoperative CT investigation. In 10 cases (28%) of the intraoperative group the remaining tumor tissue could be demonstrated on the CT scans. The tumor remnants that were not visible in the microscopical surgical field were subsequently removed. According to our results, intraoperative navigation seems superior for the localization of intracranial lesions and intraoperative CT is more useful when considering the radicality of tumor removal.

Childbearing among young Latino women in the United States.

We analyzed 1979 and 1982 data from the Youth Cohort of the National Longitudinal Surveys (NLS) of Labor Market Experience to compare rates of early childbearing among White, Black, Mexican-origin and Puerto Rican women up to age 21. Latino young women fall in between the extremely low rate of the Whites and the extremely high rate of the Blacks. Mexican and Puerto Rican young women have similar proportions of premarital first births, but the marital first birth rate for young Mexicans is twice that of the Puerto Ricans. The bulk of Mexican first births, like births to Whites, occur within marriage, while Puerto Rican first births are similar to those of Blacks, the majority being out-of-wedlock. These racial/ethnic differences in premarital first birth rates do not change greatly when socioeconomic status, and birthplace of respondents and respondents' parents are controlled.

Hispanic adolescent fertility.

Knowledge regarding the fertility of Hispanic adolescents in the US is quite limited. This paper discusses the fertility of these adolescents and summarizes what is known about sexuality, contraception, pregnancy, and childbearing among male and female Hispanics of various countries of origin. As a group, Hispanic adolescents have birth rates that fall between those of non-Hispanic whites and blacks, but there is considerable within-group variation in Hispanic fertility. More research is needed concerning the correlates of these rates with factors such as age, marital status, socioeconomic level, or generational status in the US.

Motivations for adolescents' first visit to a family planning clinic.

Although family planning clinics routinely gather data on referral sources and primary reasons for visits, little is known about the "precipitating events" which motivate young women to make an appointment or show up at a clinic on a given day. In this study, 150 new patients at a large urban clinic were interviewed to determine what events or advice specifically led to their decision to approach a family planning clinic for the first time. The roles of pregnancy scares, advice from significant others, and situational factors in motivating service use are presented along with a discussion of the program implications of these findings.

PIP: This paper presents findings from a descriptive study concerning the motivating factors and events which led Hispanic and black teenagers to attend the Young Adult Clinic (YAC) at the Presbyterian Hospital in New York. Between November 1983 and April 1984, 150 young women who were making their 1st visit to the YAC were interviewed to determine what motivating factors or events influenced their decisions to seek fertility-related services on a given day. These interviews represent the 3rd stage of a 3-part study aimed at identifying barriers to the use of family planning services among Hispanic adolescents and how some young people overcome them. The interviews also assessed whether parents, friends, or boyfriends knew or encouraged the visit. In addition, the questionnaire gathered background information, pregnancy histories, prior contraceptive use, and whether the teenager ever thought that she had been pregnant or ever had a late period. The majority of the teenagers were between 16 and 19 years old at the time of the interview. Nearly 1/2 were Hispanic and slightly fewer were black. Very few of the young women were married, and only 1 out of 10 lived away from parents or other relatives. 85% of the teenagers had initiated sexual activity before their 1st visit to the YAC. The average age of 1st intercourse was about 16 years, although black adolscents tended to be slightly younger than Hispanics. The average Hispanic adolescent was almost 19 and the average black was almost 18 at their 1st visit to the YAC. For teenagers who had never used birth control, and for those who had never attended a clinic, the average length of time between 1st intercourse and 1st visit to the YAC was longer for Hispanics than for blacks. Hispanic contraceptive-seekers were much more likely to have experienced a prior pregnancy than were their black counterparts. Clinic-related reasons e.g. convenience of hours for the clinic visit, predominated in both groups.

Evaluation of sex education outreach.

PIP: Reports on a sex education program for adolescents designed to address the problem of ignorance of pregnancy risk, which may contribute to inconsistent contraceptive use among teenagers. The course was in 4 sessions: on frequency of sexual activity and the likelihood of pregnancy; on ovulation and menstruation; on advantages and disadvantages of various contraceptive methods; and on ways to deal with partner and parental resistance to contraceptive use. The sessions were held at 2 junior high schools and 10 community agencies in New York City. The majority of participants were hispanic females between 14 and 15 years old who had never had sexual intercourse and were not familiar with the adolescent contraceptive clinic associated with the education program. Pre- and posttests were used to assess increases in knowledge and changes in attitude. There was a statistically significant increase in knowledge of timing of pregnancy from pre- to posttest, regardless of age, sex, prior knowledge or use of the clinic, or sexual activity. While only 23% of sexually active teenagers had reported always using contraception before the course, 57% of all participants stated an intention of always using it on the posttest. Within 12 months of the course, 4% of the participants had been identified as new clinic referrals, probably an underestimation. The authors conclude that this study indicates a demonstrable effect on knowledge and attitude stemming from sex education focusing on timing of pregnancy risk, and at least a modest effect on behavior. The need for further research along this line is indicated.^ieng

A perspective on adolescent fertility in developing countries.

PIP: While the best data at present indicate that adolescent fertility is declining in the developing world, it is still very high relative to the developed world. Access by teenage women to family planning information does not seem to be restricted (except in the cases of abortion and sterilization), if only because much of adolescent fertility takes place in marriages or other sanctioned unions, nor is there much evidence that they are proportionally underrepresented as family planning acceptors. However, services are rarely designed to meet the special needs of young clients. The health and social consequences of adolescent childbearing are a major cause of concern. High maternal, neonatal, and infant mortality have been documented, and U.S. studies show that teenage mothers suffer education and income deficits. Future trends toward urbanization seem likely to exacerbate these problems, and the large number of people entering adolescence in the developing world could have a major demographic effect. In the U.S., recognition of the need for special services to teenagers only became a high priority when teenage fertility had reached 20% of total births. It appears that reassessment of the low priority now being given to adolescent fertility in the developing countries is in order.^ieng

Collaborative study on hysteroscopic sterilization procedures. Preliminary report.

Preliminary results of a retrospective study of 773 cases of hysteroscopic sterilization are presented. Of the 524 cases tested for tubal patency, 186 (35.5%) were considered failures either because of incomplete blockage of the tubes or pregnancy. Fifty-nine pregnancies (23.7%) were reported in the 249 cases which were not tested for tubal patency. In the total population 25 complications were designated as major, for a major complication rate of 3.2%. These included uterine perforation, bowel damage, peritonitis, ectopic preganncy, and 1 death from bowel perforation with peritonitis. The implications of these excessively high failure and complication rates are discussed, and plans are described for further analysis of the data.

Education and fertility in Iran.

PIP: Studies providing evidence concerning literacy's relationship to fertility in Iran are reviewed. Reliable demographic data are unavailable for Iran before the 1st census in 1956. The 1966 census revealed a reversal of the normally expected larger female population, with a sex ratio of 107 men for every 100 women. The female population in Iran is accorded low status; only 29.6% of the population over the age of 10 was literate according to the 1966 census. A negative relationship between literacy or levels of education and fertility seems to have become a basic tenet of demographic theory. The hypothesis that as a woman's education increases she has fewer children has been confirmed in numerous studies, and, in response to this information, the Iranian government has sponsored several projects which incorporate family planning education into literacy projects. In view of the associations noted in other studies of the relationship between education and fertility, it seems wise to examine the effects of education on fertility in Iran. None of the studies reviewed give conclusive evidence that literacy is unrelated to fertility in Iran. Several of the studies reveal built-in biases: the husbands in Siassi's study were all military personnel; Gulick interviewed women who were already attending family planning clinics; Edlefsen and Liberman made some highly abstract and speculative predictions, and Lieberman et al. were basically measuring incomes instead of education. All of the studies do, however, give some indication of an irregular effect of education on fertility in Iran and swggest the need for further study of this variable.^ieng