Impact of cyclophosphamide and etoposide on outcome of clear cell sarcoma of the kidney treated on the National Wilms Tumor Study-5 (NWTS-5).

PURPOSE: To improve the event-free survival (EFS) and overall survival (OS) for patients with clear cell sarcoma of the kidney (CCSK) by incorporating cyclophosphamide and etoposide into treatment on National Wilms Tumor Study (NWTS)-5. PATIENTS AND METHODS: Patients less than 16 years of age with a centrally confirmed pathological diagnosis of CCSK were eligible for treatment on this prospective single-arm study conducted between August 1995 and June 2002. Staging consisted of CT scans of chest, abdomen, pelvis, bone scan, skeletal survey, and CT or MRI of the head. Treatment consisted of vincristine/doxorubicin/cyclophosphamide alternating with cyclophosphamide/etoposide for 24 weeks and radiation to sites of disease. RESULTS: One hundred eight eligible patients were enrolled on study (69% males, 63% Caucasian), with a median age of 22 months. Stage distribution was as follows: stage I, 12; II, 44; III, 45; IV, 7. Median follow-up was 9.7 years. Five-year EFS and OS were 79% (95% CI: 71%-88%) and 90% (95% CI: 84%-96%). Five-year EFS for stage I-IV was 100%, 88%, 73%, and 29%, respectively. Twenty of the 23 disease-related events occurred within three years of initial treatment. The most common site of recurrence was brain (12/23). CONCLUSION: The outcome for patients with CCSK treated on NWTS-5 was similar to NWTS-4 and accomplished over a shorter treatment duration. Stage was highly predictive of outcome. Brain metastases occurred more frequently than on NWTS-4. Regimen I showed more benefit for patients with stage I and II disease as compared with higher stages of disease where new therapies are needed.

Applying the Theory of Planned Behavior to Physical Activity: The Moderating Role of Mental Toughness.

This study explored whether mental toughness, the capacity to maintain performance under pressure, moderated the relation between physical activity intentions and subsequent behavior. Participants (N = 117) completed the Mental Toughness Index and a theory of planned behavior questionnaire. Seven days later, physical activity was assessed using the International Physical Activity Questionnaire. Attitudes, subjective norms, and perceived behavioral control explained substantial variance (63.1%) in physical activity intentions. Intentions also significantly predicted physical activity behavior. The simple slopes analyses for the moderation effect revealed a nonsignificant intention-behavior relation at low levels of mental toughness. However, intentions were significantly and positively related to physical activity when mental toughness was moderate or high, suggesting that the development of a mentally tough mindset may reduce the gap between behavior and physical activity intention. Future research is needed to confirm these findings and apply them in the design of mental toughness interventions to facilitate physical activity engagement.

Outcome of patients with Stage II/favorable histology Wilms tumor with and without local tumor spill: a report from the National Wilms Tumor Study Group.

BACKGROUND: Intra-operative tumor spill increases the risk of local recurrence of Wilms tumor, and adversely impacts relapse-free (RFS) and overall survival (OS) rates. METHODS: Surgical checklists, operative notes, institutional pathology reports, central pathology review and flow sheets of 602 patients registered between August 1986 and September 1994 on National Wilms Tumor Study-4 as randomized, followed or switched and coded as Final Stage II, favorable histology (FH) were reviewed. RFS and OS were estimated using the Kaplan-Meier method. Hazard ratios (HRs) were estimated using the Cox model and tested for statistical significance by the log-rank test. RESULTS: Four hundred ninety-nine patients were found after review to have Stage II, FH Wilms tumor. The 8-year RFS percentages were 85.0% (95% confidence interval (CI): 81.1%, 88.1%) for those with no spill compared to 75.7% (65.8%, 83.2%) for those with spill. The 8-year OS percentages were 95.6% (93.1%, 97.3%) for those with no spill compared to 90.3% (82.2%, 94.9%) for those with spill. The HR for relapse among those with spill was 1.55 ((95%CI: 0.97,2.51), P = 0.067) and the HR for death was 1.94 ((0.92,4.09), P = 0.077). CONCLUSIONS: RFS and OS were lower for patients who had intra-operative tumor spill. The majority of NWTS Stage II, FH patients with intra-operative tumor spill have an overall excellent outcome when treated with two drug chemotherapy (vincristine and actinomycin D) and no abdominal irradiation.

Upper-limb virtual rehabilitation for traumatic brain injury: a preliminary within-group evaluation of the elements system.

AIM: The aim of this study was to assess the efficacy of the Elements virtual reality (VR) system for rehabilitation of upper-limb function in patients with traumatic brain injury (TBI). METHODS: Using a within-group design, patients were tested three times, each 4 weeks apart: Pre-intervention 1 and 2 and Post-intervention. During intervention, participants received 12 1-hour training sessions over 4 weeks in addition to their usual care. Five males and four females aged 18-48 years with severe TBI were recruited. The Elements system consisted of a 100-cm tabletop LCD, camera tracking system, tangible user interfaces (i.e. graspable objects of basic shape) and software. The system provided two modes of interaction with augmented feedback: goal-directed and exploratory. Upper-limb performance was assessed using system-rated measures (movement speed, accuracy and efficiency) and standardized tests. RESULTS: Planned comparisons revealed little change in performance over the pre-test period apart from an increase in movement speed. There were significant training effects, with large effect sizes on all measures except the nuts-and-bolts task. CONCLUSIONS: These preliminary findings support the results of an early case study of the Elements system, further demonstrating that VR training is a viable adjunct to conventional physical therapy in facilitating motor learning in patients with TBI.

Stress Inoculation Training (SIT-NORCAL), Part 1: The Development and Preliminary Evaluation of a Psychological Performance Training Protocol.

BACKGROUND: Stress inoculation training (SIT) interventions have demonstrated promise within military contexts for human performance enhancement and psychological health applications. However, lack of manualized guidance on core content selection, delivery, and measurement processes has limited their use. PURPOSE: The purpose of this study was to develop and evaluate a comprehensive SIT intervention protocol to enhance the performance and health of military personnel engaged in special warfare and first-response activities. METHODS: Multidisciplinary teams of subject matter experts (n = 19) were consulted in protocol generation. The performance improvement/human performance technology (HPT) model was used in the selection, refinement, and measurement of core skills. The protocol was trialed and refined (44 cohorts, n = =300; 2013-2020) to generate the results. RESULTS: Four primary aims were achieved: (1) The generation of a flexible, evidence-based/evidence-driven psychological performance and health sustainment hybrid, SIT-NORCAL. (2) Manualized content and process guidance. (3) The creation of multimedia materials using evidence-based methodologies. (4) The design of initial measurement systems. Preliminary quality improvement analysis demonstrated positive results using standard-of-care and performance enhancement assessments. CONCLUSION: Hybridized human performance and psychological health sustainment protocols represent a paradigm shift in the delivery of psychological performance training with the potential to overcome barriers to success in traditional care. Further study is needed to determine the effectiveness and reach of SIT-NORCAL.

Stress Inoculation Training (SIT-NORCAL), Part 2: A Pilot Study Among Explosive Ordnance Disposal Special Warfare Enablers.

BACKGROUND: Despite being a well-supported strategy, Stress Inoculation Training (SIT) has not been fully incorporated in the advancement of human performance among most military personnel. The RAND Study recommendations for maximizing SIT's potential within high-risk/ high-intensity occupational groups were used in designing the Core Training protocol targeting psychological performance, SIT-NORCAL (Part 1). PURPOSE: The current project (Part 2) sought to further develop the protocol as a health and human performance hybrid through quality improvement analysis of the content, process, and measurement elements for use in the human performance context. METHODS: Evidence-based/evidence-driven methodologies were used in collaborative design tailored to the unique needs of special warfare enablers specializing in Explosive Ordnance Disposal (n = 17). The resultant three-phase training was conducted with a novice group (n = 10) using standardized measurements of collaboration, human performance, and adaptive capabilities on identified training targets. RESULTS: Process elements demonstrated high feasibility, resulting in high collaboration and trainee satisfaction. Significant improvements in psychological performance targets were observed pre- to post-training, and during an Adaptive Environmental Simulation designed by unit members. Two weeks post-training, unit members (n = 5) responded to an actual crash of an F-16 aircraft; measurements indicated maintenance of skill set from training to real-world events. CONCLUSION: Deployment of the elements in the SIT-NORCAL protocol demonstrated early feasibility and positive training impact on occupationally relevant skills that carried over into real-world events.

Long-term outcomes for infants with very low risk Wilms tumor treated with surgery alone in National Wilms Tumor Study-5.

OBJECTIVE: To determine the event-free survival (EFS) and overall survival (OS) of children with very low risk Wilms tumor (VLRWT) treated with surgery only. BACKGROUND: Previous studies suggested that postoperative chemotherapy had not improved the prognosis of children with VLRWT. A total of 77 children <24 months of age with small (<550 g) Stage I favorable histology Wilms tumors were treated with surgery only. This study was closed based on stopping rules to ensure that the 2-year EFS was > or =90%. METHODS: A total of 77 children were assessed for EFS and OS. Of these patients, 21 enrolled at the time of closure were recalled, treated with dactinomycin and vincristine (regimen EE4A), and censored for analysis thereafter. About 111 children subsequently treated with EE4A were available for comparison. RESULTS: Median follow-up of surviving patients was 8.2 years for surgery only (range, 1.9-11.8 years) and 5.2 years for the EE4A group (range, 1.6-8.9 years). The estimated 5-year EFS for surgery only was 84% (95% confidence interval [CI]: 73%, 91%); for the EE4A patients it was 97% (95% CI: 92%, 99%, P = 0.002). One death was observed in each treatment group. The estimated 5-year OS was 98% (95% CI: 87%, 99%) for surgery only and 99% (95% CI: 94%, 99%) for EE4A (P = 0.70). CONCLUSION: The surgery-only EFS was lower than anticipated but, coupled with a much higher than anticipated salvage rate of the chemotherapy naive patients whose disease recurred, led to an observed long-term OS equivalent to that seen with 2-drug chemotherapy. This approach to the treatment of patients with VLRWT eliminates the toxic side-effects of chemotherapy for a large majority of patients. A follow-up study is underway to confirm these findings.

Upper limb virtual rehabilitation for traumatic brain injury: initial evaluation of the elements system.

PRIMARY OBJECTIVE: To evaluate the effectiveness of a tabletop virtual-reality (VR) based upper-limb rehabilitation system (called Elements) for promoting movement skill in patients with TBI. RESEARCH DESIGN: An ABA case study design with multiple baselines was employed. Baseline performance in this design is contrasted against the results during the treatment phase. RESEARCH METHODS: Three patients with TBI participated in 12 1-hour sessions of VR-based training. The VR system consisted of a 42-inch tabletop LCD, camera tracking system and tangible user interface. The system requires participants to move an object to cued locations while receiving augmented movement feedback to reinforce speed, trajectory and placement. Upper limb performance was assessed using these three system-measured variables and standardized tests. Trends in the time-sequence plots for each patient were assessed by sight inspection of smoothed data and then by statistical analyses. RESULTS: Participants demonstrated improvements on movement accuracy, efficiency and bimanual dexterity and mixed improvement on speed and other measures of movement skill. CONCLUSION: Taken together, the findings demonstrate that the Elements system shows promise in facilitating motor learning in these TBI patients. Larger scale trials are now deemed a viable step in further validating the system.

Treatment of Wilms tumor relapsing after initial treatment with vincristine, actinomycin D, and doxorubicin. A report from the National Wilms Tumor Study Group.

OBJECTIVE: We evaluated the use of alternating cycles of cyclophosphamide/etoposide and carboplatin/etoposide in children entered on National Wilms Tumor Study (NWTS)-5 who were diagnosed between August 1, 1995 and May 31, 2002 and who relapsed after chemotherapy with vincristine, actinomycin D, and doxorubicin (VAD) and radiation therapy (DD-4A). PATIENTS AND METHODS: One hundred three patients who relapsed or had progressive disease after initial VAD chemotherapy and radiation therapy were registered on stratum C of the NWTS-5 Relapse protocol. Twelve patients were not evaluable: five due to insufficient data, six due to major protocol violations, and one for refusal of therapy. Among the 91 remaining patients, 14 with stage V Wilms tumor (WT), 1 with contralateral relapse, and 16 who did not achieve a complete response (CR) to the initial three-drug chemotherapy were not included in this analysis. Relapse treatment included alternating courses of the drug pairs cyclophosphamide/etoposide and carboplatin/etoposide, surgery, and radiation therapy. RESULTS: The outcomes of 60 patients were analyzed. The lung was the only site of relapse for 33 patients; other sites of relapse included the operative bed, the abdomen, and liver. Four-year event-free survival (EFS) and overall survival (OS) were 42.3 and 48.0% respectively for all patients and were 48.9 and 52.8% for those who relapsed in the lungs only. Thrombocytopenia was the most frequent toxicity. CONCLUSION: These results demonstrate that approximately one-half of children with unilateral WT who relapse after initial treatment with VAD and radiation therapy can be successfully retreated.

The link between motor impairment level and motor imagery ability in children with developmental coordination disorder.

The present study examined motor imagery ability in children with developmental coordination disorder (DCD). Specifically, it explored whether children with varying degrees of motor impairment differed in their ability to perform motor imagery tasks. Fourty-two children scoring below the 15th percentile on the Movement ABC were split into two groups--DCD severe (DCD-S), scoring on or below the 5th percentile, and DCD mild (DCD-M), scoring from the 6th to 15th percentiles--and compared to 21 age matched controls. Participants performed two motor imagery tasks--hand (performed without and with specific imagery instructions) and whole-body rotation. The results demonstrated that children in the DCD-S group had a generalized motor imagery deficit in that they were less accurate across tasks than controls (and the DCD-M group on the hand task) and showed little benefit when given specific imagery instructions. The DCD-M group appeared capable of performing simpler motor imagery transformations, but were less successful as task complexity increased. Unlike the DCD-S group, the DCD-M group did show some benefit from specific imagery instructions with increases in accuracy on the hand task. These results suggest that a motor imagery deficit does exist in many children with DCD but that its presentation can vary--factors such as the individual child's level of motor impairment and task complexity appear to be linked to the profile of deficits observed, which could explain the inconsistent findings of previous studies. Although this study lends support to the theory that a deficit in internal modeling is an underlying problem for children with DCD, still more research is required to develop the theory further.

Rhabdoid tumor of the kidney in the National Wilms' Tumor Study: age at diagnosis as a prognostic factor.

PURPOSE: The objective of this study is to determine prognostic factors in rhabdoid tumor of the kidney (RTK), including both demographic and treatment variables. PATIENTS AND METHODS: A total of 142 patients studied on National Wilms' Tumor Studies 1, 2, 3, 4, and 5 were analyzed. Patients were enrolled between the years 1969 and 2002. Variables examined included sex, age of diagnosis, tumor stage, presence of CNS lesions, as well as treatment variables, including the use of doxorubicin and/or radiotherapy (RT). RESULTS: No survival differences were observed between males and females, between those treated with or without doxorubicin, or with or without RT. Patients with tumors of lower stage had an overall survival rate of 41.8%, whereas, tumors of higher stage were associated with a 15.9% survival (P < .001). A highly significant difference in survival was noted when patients were stratified according to age of diagnosis. Survival at 4 years in infants under 6 months of age at diagnosis was 8.8%, whereas, survival in patients 2 years of age or older was 41.1% (P < .0001). Stratification into intermediate age brackets demonstrated a strong correlation of increasing survival with increasing age at diagnosis. All patients with a CNS lesion, except one, died. CONCLUSION: Age at diagnosis is a highly significant prognostic factor for survival of children with RTK. Infants have a dismal prognosis, whereas, older children have a more favorable outcome. Higher tumor stage and presence of a CNS lesion were both factors predictive of a poor survival rate.

Loss of heterozygosity for chromosomes 1p and 16q is an adverse prognostic factor in favorable-histology Wilms tumor: a report from the National Wilms Tumor Study Group.

PURPOSE: To determine if tumor-specific loss of heterozygosity (LOH) for chromosomes 1p or 16q is associated with a poorer prognosis for children with favorable-histology (FH) Wilms tumor entered on the fifth National Wilms Tumor Study (NWTS-5). PATIENTS AND METHODS: Between August 1995 and June 2002, 2,021 previously untreated children with FH or anaplastic Wilms tumor, clear-cell sarcoma of the kidney (CCSK) or malignant rhabdoid tumor of the kidney (RTK), were treated with stage- and histology-specific therapy. Their tumors were assayed for LOH for polymorphic DNA markers on chromosomes 1p and 16q. ResultsLOH for 1p or 16q was rarely observed in CCSK (n = 90) or RTK (n = 22). The relative risk (RR) of relapse for patients with FH stage I to IV tumors with LOH, stratified by stage, was 1.56 for LOH 1p (P = .01) and 1.49 for LOH 16q (P = .01), whereas the RR of death was 1.84 (P = .03) and 1.44 (P = .15), respectively. When the effects of LOH for both regions were considered jointly among patients with stage I to II FH disease, the risks of relapse and death were increased for LOH 1p only (RR = 2.2, P = .02 for relapse; RR = 4.0, P = .02 for death), for LOH 16q only (RR = 1.9, P = .01 and RR = 1.4, P = .60) and for LOH for both regions (RR = 2.9, P = .001 and RR = 4.3, P = .01) in comparison with patients with LOH at neither locus. The risks of relapse and death for patients with stage III to IV FH tumors were increased only with LOH for both regions (RR = 2.4, P = .01 and RR = 2.7, P = .04). CONCLUSION: Tumor-specific LOH for both chromosomes 1p and 16q identifies a subset of FH Wilms tumor patients who have a significantly increased risk of relapse and death. LOH for these chromosomal regions can now be used as an independent prognostic factor together with disease stage to target intensity of treatment to risk of treatment failure.

Radiation therapy for favorable histology Wilms tumor: prevention of flank recurrence did not improve survival on National Wilms Tumor Studies 3 and 4.

PURPOSE: To determine whether radiation therapy (RT) of patients with Wilms tumor of favorable histology prevented flank recurrence and thereby improved the survival outcomes. METHODS AND MATERIALS: Recurrence and mortality risks were compared among groups of patients with Stage I-IV/favorable histology Wilms tumor enrolled in the third (n = 1,640) and fourth (n = 2,066) National Wilms Tumor Study Group studies. RESULTS: Proportions of patients with flank recurrence were 0 of 513 = 0.0% for 20 Gy, 12 of 805 = 1.5% for 10 Gy, and 44 of 2,388 = 1.8% for no flank RT (p trend = 0.001 adjusted for stage and doxorubicin); for intra-abdominal (including flank) recurrence they were 5 of 513 = 1.0%, 30 of 805 = 3.7%, and 58 of 2,388 = 2.4%, respectively (p trend = 0.02 adjusted). Survival percentages at 8 years after intra-abdominal recurrence were 0 of 5 = 0% for 20 Gy, 10 of 30 = 33% for 10 Gy, and 34 of 58 = 56% for no RT (p trend = 0.0001). NWTS-4 discontinued use of 20 Gy RT, and the 8-year flank recurrence risk increased to 2.1% from 1.0% on NWTS-3 (p = 0.013). However, event-free survival was unaltered (88% vs. 86%, p = 0.39), and overall survival was better (93.8% vs. 90.8%, p = 0.036) on NWTS-4. CONCLUSIONS: Partly because of lower postrecurrence mortality among nonirradiated patients, prevention of flank recurrence by RT did not improve survival. It is important to evaluate entire treatment policies with regard to long-term outcomes.

Effect of duration of treatment on treatment outcome for patients with clear-cell sarcoma of the kidney: a report from the National Wilms' Tumor Study Group.

PURPOSE: To evaluate the effect of conventional and standard (ST) versus pulse-intensive (PI) chemotherapy and short-duration versus long-duration chemotherapy on relapse-free survival (RFS) and overall survival rates of patients with clear-cell sarcoma of the kidney (CCSK) entered onto the National Wilms' Tumor Study (NWTS)-4. PATIENTS AND METHODS: The 5-year and 8-year RFS rates were determined for patients with CCSK treated on the NWTS-4. After August 6, 1986, 40 previously untreated children younger than 16 years with CCSK were randomly assigned, after the completion of 6 months of chemotherapy, to discontinue (short) or continue 9 additional months (long) of treatment with chemotherapy regimens that included vincristine and either divided-dose (ST) courses (5 days) or single-dose (PI) treatment with dactinomycin and divided-dose (ST) courses (3 days) or single-dose (PI) treatment with doxorubicin. RESULTS: For patients with CCSK, the 5- and 8-year RFS rates were 65.2% and 60.6%, respectively, for patients randomly assigned to the short chemotherapy and 87.8% (both 5- and 8-year RFS) for patients randomly assigned to the long chemotherapy (P =.08). The overall survival rates for patients at 5 and 8 years were 95.5% and 85.9%, respectively, for the short chemotherapy and 87.5% (both 5- and 8-year overall survival) for the long chemotherapy (P =.99). In NWTS-4, the overall survival rates for patients with CCSK improved from NWTS-3 (83% v 66.9% at 8 years, respectively; P <.01). CONCLUSION: CCSK patients exhibit an improved RFS from a longer course of therapy when using vincristine, doxorubicin, and dactinomycin, but their long-term survival is unchanged compared with patients receiving 6 months of therapy. The overall survival rates for patients with CCSK have improved from NWTS-3.

Pregnancy outcomes after abdominal irradiation that included or excluded the pelvis in childhood Wilms tumor survivors: a report from the National Wilms Tumor Study.

PURPOSE: This report describes the pregnancy outcomes among 7 survivors of childhood Wilms tumor, who were treated on one of the National Wilms Tumor Studies (NWTS) with radiation therapy (RT) portals that extended beyond the flank. METHODS AND MATERIALS: Pregnancy outcomes among female survivors of childhood Wilms tumor treated with abdominal irradiation in NWTS 1-4 were analyzed as part of the long-term follow-up study. Medical records and maternal questionnaires were used to gather information on pregnancy outcomes. RESULTS: A total of 130 patients received abdominal RT and survived to at least 15 years of age. Seven patients (5.4%) had at least 1 recorded pregnancy. The extent of RT fields was ascertained in 126 patients. For 4 patients, the extent of RT fields could not be determined. Twelve girls received RT using portals that included the upper abdomen but not the entire pelvis. Ten pregnancies were recorded in 5 of these patients; 9 resulted in live births, and 1 resulted in a miscarriage. One hundred fourteen girls received RT using portals that included the entire abdomen and pelvis. The abdominal RT dose distribution among these 114 patients was as follows: 9 received 0-10.49 Gy, 22 patients received 10.5-14.99 Gy, and 83 patients received 15+ Gy. Four pregnancies were recorded in 2 of these patients. After 21 Gy to the abdomen and pelvis in 1 patient, all 3 pregnancies resulted in miscarriages and fetal deaths. However, after 10.5 Gy, a normal live birth was reported in the other patient. Pregnancy-related complications were also more common if the RT portals included the pelvis. CONCLUSIONS: Fertility can be preserved in children with Wilms tumor after upper abdominal RT (10-20 Gy) that does not include the entire pelvis. In rare instances, fertility can be preserved after low-dose whole-abdominal RT (10.5 Gy). The indications and dosages for RT currently used have been greatly refined compared to NWTS-1 and NWTS-2. Childhood Wilms tumor survivors should be considered to be at a high risk for infertility and pregnancy-related complications during their reproductive years. Prompt obstetric evaluation is indicated for optimal prenatal, antenatal, and postnatal care.

Treatment outcomes in adults with favorable histologic type Wilms tumor-an update from the National Wilms Tumor Study Group.

PURPOSE: To describe the clinical outcomes in adults with favorable histologic type (FH) Wilms tumor (WT) registered in the National Wilms Tumor Studies (NWTS) 4-5. We also describe the results of patients treated in the "modern era" (1979-2001) with surgical staging, central pathology review and stage-appropriate multimodality treatment. METHODS AND MATERIALS: Twenty-three adult patients (> or =16 years of age) with FHWT after central pathology review were registered on NWTS 4-5. The tumor stage distribution was Stage I in 5, Stage II in 8, Stage III in 6, and Stage IV in 4 patients. All patients underwent primary nephrectomy followed by multiagent chemotherapy and/or radiotherapy (RT). All patients underwent tumor stage-based chemotherapy that generally followed existing NWTS Group (NWTSG) protocols. To analyze the outcomes of adult patients treated in the "modern era," the data from this report were combined with the data from 22 patients with FHWT previously reported in 1990 by the NWTSG. RESULTS: The 5-year relapse-free survival, overall survival, and disease-specific survival (DSS) rate was 77.3%, 82.6%, and 95.7%, respectively, for patients registered in the NWTS 4-5 protocols. Three patients (13%) died of chemotherapy-induced hepatic venoocclusive disease. For a total of 45 adults with FHWTs treated in the "modern era," the overall survival rate was 82%. The survival rate for those with Stage I, II, III, and IV disease was 100%, 92%, 70%, and 73%, respectively. Of the 12 Stage I-II patients treated with two drugs and no RT, the survival rate was 100%. The survival rate for Stage III and IV patients treated with three drugs and RT was 63% and 70%, respectively. CONCLUSION: The results of this report demonstrate that adults with FHWT treated with a multimodality approach similar to NWTSG protocols have good survival. We recommend that all adult patients be treated with stage-appropriate combined modality therapy, and furthermore, be entered in current Children's Oncology Group WT protocols so that coherent data can be gathered for this relatively rare tumor. Finally, all patients should be monitored for signs and symptoms of hepatic venoocclusive disease.

Influence of radiation therapy delay on abdominal tumor recurrence in patients with favorable histology Wilms' tumor treated on NWTS-3 and NWTS-4: a report from the National Wilms' Tumor Study Group.

PURPOSE: This study was undertaken to determine whether radiation therapy (RT) delay of >or=10 days had an adverse impact on abdominal tumor recurrence among children with favorable histology (FH) Wilms' tumor enrolled in National Wilms' Tumor Study (NWTS) 3 and 4. METHODS AND MATERIALS: A total of 1226 patients with Stage II-IV FH tumors who received flank or abdominal RT in NWTS-3 and NWTS-4 were included in this analysis. Recurrent disease in the operative bed was classified as flank recurrence. Abdominal recurrence included all infradiaphragmatic tumor recurrences, including flank recurrences. This analysis included all flank/abdominal tumor recurrences, regardless of whether they might have been the initial or subsequent site of relapse. Based on the NWTS-1 results, RT delay was analyzed in two categories: 0-9 days and >or=10 days. RESULTS: The mean RT delay was 10.9 days; median delay was 9 days (range: 1-277 days). The RT delay was concentrated in a relatively narrow range of 8 to 12 days after nephrectomy in the majority of patients (59%). Univariate and multivariate analysis did not reveal RT delay of >or=10 days to significantly influence flank and abdominal tumor recurrence rates in NWTS-3 or NWTS-4. The 8-year flank tumor recurrence rates for 0-9 days and 10+ days RT delay were 1.9% and 1.2%, respectively (p value = 0.3). The 8-year abdominal tumor recurrence rates for 0-9 days and 10+ days RT delay were 4.8% and 5.3%, respectively (p value = 0.7). CONCLUSIONS: RT delay of >or=10 days did not significantly influence flank or abdominal tumor recurrence rates among children with FH tumors treated on NWTS-3 and NWTS-4. However, we were unable to test for a meaningful difference, because of the concentration of RT delay close to 10 days.

Motor imagery training ameliorates motor clumsiness in children.

Children with impaired motor coordination (or developmental coordination disorder) have difficulty representing internally the visuospatial coordinates of intended movements. We have proposed that this deficit reflects impairment in the generation of forward models of the efference copy of intended movements-the efference-copy-deficit hypothesis. In this study, we challenged this hypothesis by examining the efficacy of an imagery intervention designed specifically to train the forward modeling of purposive actions. A pre-post design was adopted. Fifty-four children referred with motor coordination problems were assigned randomly to one of three groups: imagery training, traditional perceptual-motor training, and wait-list control. The imagery protocol-delivered by an interactive CD-ROM-was shown to be equally effective to perceptual-motor training in facilitating the development of motor skill in the referred children. These results support the efference-copy-deficit hypothesis in explaining the cause of motor clumsiness in most children. Directions for future intervention studies and remediation in the field of developmental clumsiness are discussed.

Intraoperative spillage of favorable histology wilms tumor cells: influence of irradiation and chemotherapy regimens on abdominal recurrence. A report from the National Wilms Tumor Study Group.

PURPOSE: We undertook this study to determine (1) the frequency with which spilled tumor cells of favorable histology produced intra-abdominal disease in patients treated with differing chemotherapy regimens and abdominal radiation therapy (RT) and (2) the patterns of relapse and outcomes in such patients. METHODS AND MATERIALS: The influence of RT dose (0, 10, and 20 Gy), RT fields (flank, whole abdomen), and chemotherapy with dactinomycin and vincristine (2 drugs) vs. added doxorubicin (three drugs) on intra-abdominal tumor recurrence rates was analyzed by logistic regression in 450 patients. Each patient was considered at risk for two types of failure: flank and subdiaphragmatic beyond-flank recurrence, with the correlation between the two outcomes accounted for in the analyses. RESULTS: The crude odds ratio for the risk of recurrence relative to no RT was 0.35 (0.15-0.78) for 10Gy and 0.08 (0.01-0.58) for 20Gy. The odds ratio for the risk of recurrence for doxorubicin to two drugs after adjusting for RT was not significant. For Stage II patients (NWTS-4), the 8-year event rates with and without spillage, respectively, were 79% and 87% for relapse-free survival (p = 0.07) and 90% and 95% for overall survival (p = 0.04). CONCLUSIONS: Irradiation (10 Gy or 20 Gy) reduced abdominal tumor recurrence rates after tumor spillage. Tumor spillage in Stage II patients reduced relapse-free survival and overall survival, but only the latter was of statistical significance. These data provide a basis for assessing the risks vs. benefits when considering treatment for children with favorable histology Wilms tumor and surgical spillage.

The relationship between skill level and patterns in cardiac and respiratory activity during golf putting.

Individual differences in skill level during sport-related motor tasks, such as golf putting, can be related to not only performance, but also patterns in psychophysiological activity. The present study examined the similarities and differences in cardiac and respiratory activity among elite, experienced, and novice golfers. Participants attempted flat putts 2.4 m from the hole. Performance was better in elite and experienced golfers than in novice golfers. Compared to novice golfers, the experienced and elite golfers showed a pronounced phasic deceleration in heart rate immediately prior to the putt, greater heart rate variability in the very low frequency band, and a greater tendency to show a respiratory pattern of exhaling immediately prior to the putt. The psychophysiological patterns may be related to differences in attentional processes or task familiarity between the groups. The implications of the results for the assessment and training of athletes in precision sports are discussed.