A Safe Home? A Qualitative Study into the Experiences of Adolescents Growing Up in the Dutch Area Impacted by Earthquakes Induced by Gas Extraction.

For decades, the Netherlands has experienced minor earthquakes due to gas extraction. This study aims to obtain insight into the experiences of adolescents and the impact of these earthquakes on their well-being and living environment. Focus groups were held with 24 adolescents, and interviews were held with 3 adolescents (N = 27; M = 15 years). Through qualitative analysis, we identified six themes. The adolescents shared experiences of anxiety related to the earthquakes and their consequences and considered these to be a normal part of their life. Anxiety and feelings of endangerment not only related to their own experiences but were also connected to the impact of earthquakes on their social environment, such as the restoration of buildings. Several sources of support (e.g., talking, social cohesion) were mentioned to deal with the negative consequences of the earthquakes. A lack of trust in the government was an additional main theme, with adolescents mentioning several needs, potentially relevant to policymakers in the Netherlands. Growing up in the gas extraction area of Groningen had many consequences on the adolescents in the study, who felt inhibited from expressing feelings of anxiety and fear. To support their needs, interventions at the individual, family, educational, societal, and policy levels are recommended.

Social competence in newly diagnosed pediatric brain tumor patients.

Brain tumors (BTs) are a common pediatric malignancy. Improved treatment has resulted in higher survival rates. There is, however, increasing concern about adverse effects of the disease and its treatment, including effects on social competence (i.e. effective social functioning in everyday life). The aim of this study is to examine multiple levels of social competence (i.e. social skills and social adjustment) in newly diagnosed pediatric BT patients. Thirty newly diagnosed BT patients aged 5-12 years were assessed shortly after diagnosis with a neuropsychological test battery focusing on social competence, including tests for IQ, social skills (i.e. social-affective and executive functioning) and social adjustment (rated by parents and teachers). Their performance was compared to 95 healthy controls who completed the same assessment. Patients and healthy controls were largely comparable with regard to demographic and environmental factors and did not differ on measures of IQ, social skills and social adjustment. Furthermore, age was found to have a positive significant effect on social skills independent of group. Shortly after diagnosis, pediatric BT patients did not perform different from healthy controls on IQ and measures of social skills and social adjustment. This is an encouraging finding. However, because of potentially neurotoxic adjuvant therapy and the ongoing development of social skills, longitudinal follow-up studies are needed to investigate long-term outcome regarding social competence in BT survivors.

Cancer patients use hospital-based care until death: a further analysis of the Dutch Bone Metastasis Study.

PURPOSE: To describe health care utilization (HCU) at the end of life in cancer patients. These data are relevant to plan palliative care services, and to develop training programs for involved health care professionals. METHODS: The Dutch Bone Metastasis Study (DBMS) was a nationwide study proving equal effectiveness of single fraction palliative radiotherapy compared with multiple fractions for painful bone metastases in 1157 patients. The 860 (74%) patients who died during follow-up were included in the current analysis. The main outcome was the frequency of hospital-based (outpatient contact or admission) and/or general practitioner (GP) contact during the last 12 weeks of life. Changes in HCU towards death were related to data on quality of life and pain intensity using a multilevel regression model. RESULTS: Hospital-based HCU was reported in 1801 (63%) returned questionnaires, whereas GP contact was stated in 1246 (43%). In 573 (20%) questionnaires, both types of HCU were reported. In multilevel regression analyses, the frequency of outpatient contacts remained constant during the weeks towards death, whereas the frequency of GP contacts increased. Lower valuation of quality of life was related to both GP- and hospital-based HCU. CONCLUSIONS: There was a high consumption of hospital-based HCU in the last 12 weeks of life of cancer patients with bone metastases. Hospital-based HCU did not decrease during the weeks towards death, despite an increase in GP contacts. Future planning of palliative care and training programs should encompass close collaboration between medical specialists and GPs to optimize end-of-life care.

A prospective randomized multicenter clinical trial of the Provox2 and Groningen Ultra Low Resistance voice prostheses in the rehabilitation of post-laryngectomy patients: a lifetime and preference study.

To prospectively study patients' preference for and the lifetime of the Groningen Ultra Low Resistance (GULR) and Provox2 tracheo-esophageal shunt prosthesis (TESP, plural TESPs) in post-laryngectomy patients. Eighty post-laryngectomy patients were included in 4 oncological centers in the Netherlands. We used a repeated measures design study with 4 randomized groups in a partial cross-over design using 3 consecutive TESPs (3 intervals) in different orders. (Group 1: GULR-GULR-GULR; Group 2: GULR-GULR-Provox2; Group 3: Provox2-Provox2-GULR; and Group 4: Provox2- Provox2-Provox2). Replacement dates and reasons for replacement were monitored with questionnaires as were patients' preferences for GULR or Provox2. A great variability of lifetime within and between groups was seen. Mean lifetimes found (all groups and intervals added) were 106.2 and 102.7 days, and median lifetimes were 76 and 65 days for GULR and Provox2, respectively. Lifetime showed no significant differences between groups, intervals, and TESP types. Many patients dropped out due to reasons having to do with GULR-characteristics (n=21). The main dropout reason was "high phonating resistance (HPR)" (57.1%). Only 10 patients preferred GULR. A significantly larger number of patients (n=39, 79.6%) preferred Provox2 either by choice or by dropping out due to GULR-characteristics (P<0.001). The main replacement reasons were "leakage though TESP" (GULR 59.1%, Provox2 52.1%) and HPR (GULR 15.9%, Provox2 12.7%). No significant differences in lifetime between GULR and Provox2 were found. The patients' preference for Provox2 was significant (P<0.001). Patients' preference was a more important outcome measurement in TESP effectiveness than device lifetime.

Worldwide, multicenter study of peristomal geometry and morphology in laryngectomees and its clinical effects.

BACKGROUND: The purpose of this study was to improve attachment of automatic tracheostoma valves, the knowledge on tracheostoma geometry, and its clinical influences preferred. This article investigates whether the number of removed trachea rings, incision of the sternocleidomastoid muscles, neck dissection, reconstruction, time after operation, and age have any effect on the (peri)stomal geometry of the patient. METHODS: (Peri)stomas of 191 patients from 10 institutes worldwide were photographed, measured, and compared. RESULTS: Paired comparisons between the number of trachea rings removed showed significant differences in horizontal and vertical trachea-opening diameters, but failed to demonstrate an effect in the depth of the stoma. T tests did not demonstrate significant differences in peristomal geometry between the sternocleidomastoid-cleaved and non-cleaved group. CONCLUSION: The number of removed tracheal rings during laryngectomy does not seem to influence stoma depth. However, this study does not demonstrate that cleaving the sternocleidomastoid muscle (SCM) at the time of a laryngectomy will result in a geometrically flatter stoma.

Cancer-related fatigue and rehabilitation: a randomized controlled multicenter trial comparing physical training combined with cognitive-behavioral therapy with physical training only and with no intervention.

BACKGROUND: Research suggests that cancer rehabilitation reduces fatigue in survivors of cancer. To date, it is unclear what type of rehabilitation is most beneficial. OBJECTIVE: This randomized controlled trial compared the effect on cancer-related fatigue of physical training combined with cognitive behavioral therapy with physical training alone and with no intervention. DESIGN: In this multicenter randomized controlled trial, 147 survivors of cancer were randomly assigned to a group that received physical training combined with cognitive-behavioral therapy (PT+CBT group, n=76) or to a group that received physical training alone (PT group, n=71). In addition, a nonintervention control group (WLC group) consisting of 62 survivors of cancer who were on the waiting lists of rehabilitation centers elsewhere was included. SETTING: The study was conducted at 4 rehabilitation centers in the Netherlands. PATIENTS: All patients were survivors of cancer. INTERVENTION: Physical training consisting of 2 hours of individual training and group sports took place twice weekly, and cognitive-behavioral therapy took place once weekly for 2 hours. MEASUREMENTS: Fatigue was assessed with the Multidimensional Fatigue Inventory before and immediately after intervention (12 weeks after enrollment). The WLC group completed questionnaires at the same time points. RESULTS: Baseline fatigue did not differ significantly among the 3 groups. Over time, levels of fatigue significantly decreased in all domains in all groups, except in mental fatigue in the WLC group. Analyses of variance of postintervention fatigue showed statistically significant group effects on general fatigue, on physical and mental fatigue, and on reduced activation but not on reduced motivation. Compared with the WLC group, the PT group reported significantly greater decline in 4 domains of fatigue, whereas the PT+CBT group reported significantly greater decline in physical fatigue only. No significant differences in decline in fatigue were found between the PT+CBT and PT groups. CONCLUSIONS: Physical training combined with cognitive-behavioral therapy and physical training alone had significant and beneficial effects on fatigue compared with no intervention. Physical training was equally effective as or more effective than physical training combined with cognitive-behavioral therapy in reducing cancer-related fatigue, suggesting that cognitive-behavioral therapy did not have additional beneficial effects beyond the benefits of physical training.

Safety of laparoscopy versus laparotomy in early-stage endometrial cancer: a randomised trial.

BACKGROUND: The standard surgery for early-stage endometrial cancer is total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy, which is associated with substantial morbidity. Total laparoscopic hysterectomy (TLH) and bilateral salpingo-oophorectomy is less invasive and is assumed to be associated with lower morbidity, particularly in obese women. This study investigated the complication rate of TLH versus TAH in women with early-stage endometrial cancer. METHODS: This randomised trial was done in 21 hospitals in The Netherlands, and 26 gynaecologists with proven sufficient skills in TLH participated. 283 patients with stage I endometrioid adenocarcinoma or complex atypical hyperplasia were randomly allocated (2:1) to the intervention group (TLH, n=187) or control group (TAH, n=96). Randomisation by sequential number generation was done centrally in alternate blocks of six and three participants, with stratification by trial centre. After assignment, the study coordinators, patients, gynaecologists, and members of the panel were not masked to intervention. The primary outcome was major complication rate, assessed by an independent panel. Data were analysed by a modified intention-to-treat analysis, since two patients in both groups were excluded from the main analysis. This trial is registered with the Dutch trial registry, number NTR821. FINDINGS: The proportion of major complications was 14.6% (27 of 185) in the TLH group versus 14.9% (14 of 94) in the TAH group, with a difference of -0.3% (95% CI -9.1 to 8.5; p=0.95). The proportion of patients with an intraoperative major complication (nine of 279 [3.2%]) was lower than the proportion with a postoperative major complication (32 of 279 [11.5%]) and did not differ between TLH (five of 185 [2.7%]) and TAH (four of 94 [4.3%]; p=0.49). The proportion of patients with a minor complication was 13.0% (24 of 185) in the TLH group and 11.7% (11 of 94) in the TAH group (p=0.76). Conversion to laparotomy occurred in 10.8% (20 of 185) of the laparoscopic procedures. TLH was associated with significantly less blood loss (p<0.0001), less use of pain medication (p<0.0001), a shorter hospital stay (p<0.0001), and a faster recovery (p=0.002), but the procedure took longer than TAH (p<0.0001). INTERPRETATION: Our results showed no evidence of a benefit for TLH over TAH in terms of major complications, but TLH (done by skilled surgeons) was beneficial in terms of a shorter hospital stay, less pain, and quicker resumption of daily activities. FUNDING: The Dutch Organization for Health Research and Development (ZonMw), programme efficacy.

An assessment of clinical interchangeability of TEG and RoTEM thromboelastographic variables in cardiac surgical patients.

BACKGROUND: Bedside thromboelastography is increasingly used, but an assessment of the clinical interchangeability of the 2 major systems, TEG (Hemoscope) and RoTEM (Pentapharm), has not been performed. METHODS: We measured blood samples from 46 cardiac surgical patients after induction of anesthesia with kaolin TEG(R) (kaoTEG), native TEG(R) (natTEG), intrinsic RoTEM (inTEM), and extrinsic RoTEM (exTEM). Each measurement consisted of reaction time (R), coagulation time (K), maximum amplitude (MA), and angle (alpha). Bland-Altman plots and mixed-model analysis were used. To assess repeatability, we made 7 replicated measurements in rapid succession in 2 volunteers. RESULTS: One hundred sixty-six measurements were available for analysis. The R time of the kaoTEG (345 + or - 102 seconds, mean + or - sd) was longer than that of the inTEM (179 + or - 74 seconds, P < 0.001) and the exTEM (55 + or - 28 seconds, P < 0.001). The K time of the kaoTEG (78 + or - 18s) was not different from that of the inTEM (75 + or - 52 seconds, P = 0.60) but was longer than the K time of the exTEM (61 + or - 24 seconds, P < 0.003). The MA of the kaoTEG (71 + or - 6.5 mm) was larger than the MA of the inTEM (67 + or - 5.2 mm, P < 0.02) and almost similar to that of the exTEM (69 + or - 6.3 mm). The alpha of the kaoTEG (72 degrees + or - 4.1 degrees ) was not significantly different from that of both the inTEM (76 degrees + or - 7 degrees ) and the exTEM (79 degrees + or - 4.5 degrees ). The variability for MA and alpha was <10%. The repeatability of the R and K times was poor in both devices, whereas the repeatability of the MA and alpha was sufficient for clinical purposes. CONCLUSIONS: The TEG and RoTEM measurements demonstrated a close correlation for the MA, but the alpha did not for the R and K variables. The kaoTEG had the best agreement with the exTEM measurement. Therefore TEG and RoTEM measurements are not completely interchangeable, and the clinical interpretation of thromboelastograhic data should be used with caution.

Elevated urinary free and deconjugated catecholamines after consumption of a catecholamine-rich diet.

CONTEXT: The biochemical diagnosis of pheochromocytoma depends on the demonstration of elevated levels of catecholamines (i.e. epinephrine, norepinephrine, and dopamine) and their metabolites. OBJECTIVE: The aim of the study was to determine the preanalytical influence of a catecholamine-rich diet on urinary free and deconjugated catecholamines in healthy volunteers with a highly specific and sensitive analytical technique. DESIGN, SETTING, AND PARTICIPANTS: We conducted a crossover study involving 27 healthy adults in a specialist medical center. INTERVENTIONS: Subjects consumed catecholamine-rich nuts and fruits at fixed times on one day (about 35 micromol dopamine and 1 micromol norepinephrine) and catecholamine-poor products on another day. Urine samples were collected at timed intervals before, during, and after experimental and control interventions. MAIN OUTCOME MEASURES: We performed automated online sample preparation coupled to isotope-dilution mass spectrometry measurements of urinary concentrations of free and deconjugated catecholamines. RESULTS: The catecholamine-rich diet had substantial effects on urinary excretions of deconjugated dopamine (up to 20-fold increases) and norepinephrine (up to 10-fold). Dietary catecholamines had less but significant effects on urinary excretion of free dopamine and norepinephrine (up to 1.5-fold increases). Outputs of urinary free and deconjugated epinephrine remained unaffected. CONCLUSIONS: Urinary excretion of deconjugated norepinephrine and dopamine is strongly affected by consumption of catecholamine-rich food products, thereby increasing the likelihood of a false-positive test result during hormonal evaluation for pheochromocytoma. Measurement of deconjugated catecholamines should therefore preferably be avoided, in favor of measurement of urinary free catecholamines. In case of demonstrating increased urinary excretion of deconjugated norepinephrine and dopamine, repeated measurements are warranted with dietary restrictions prior to sample collection.

Volumetric measurement of pulmonary nodules at low-dose chest CT: effect of reconstruction setting on measurement variability.

OBJECTIVE: To assess volumetric measurement variability in pulmonary nodules detected at low-dose chest CT with three reconstruction settings. METHODS: The volume of 200 solid pulmonary nodules was measured three times using commercially available semi-automated software of low-dose chest CT data-sets reconstructed with 1 mm section thickness and a soft kernel (A), 2 mm and a soft kernel (B), and 2 mm and a sharp kernel (C), respectively. Repeatability coefficients of the three measurements within each setting were calculated by the Bland and Altman method. A three-level model was applied to test the impact of reconstruction setting on the measured volume. RESULTS: The repeatability coefficients were 8.9, 22.5 and 37.5% for settings A, B and C. Three-level analysis showed that settings A and C yielded a 1.29 times higher estimate of nodule volume compared with setting B (P = 0.03). The significant interaction among setting, nodule location and morphology demonstrated that the effect of the reconstruction setting was different for different types of nodules. Low-dose CT reconstructed with 1 mm section thickness and a soft kernel provided the most repeatable volume measurement. CONCLUSION: A wide, nodule-type-dependent range of agreement between volume measurements with different reconstruction settings suggests strict consistency is required for serial CT studies.

The analysis of longitudinal quality of life measures with informative drop-out: a pattern mixture approach.

PURPOSE: The analysis of longitudinal health-related quality of life measures (HRQOL) can be seriously hampered due to informative drop-out. Random effects models assume Missing At Random and do not take into account informative drop-out. We therefore aim to correct the bias due to informative drop-out. METHODS: Analyses of data from a trial comparing standard-dose and high-dose chemotherapy for patients with breast cancer with respect to long-term impact on HRQOL will serve as illustration. The subscale Physical Function (PF) of the SF36 will be used. A pattern mixture approach is proposed to account for informative drop-out. Patterns are defined based on events related to HRQOL, such as death and relapse. The results of this pattern mixture approach are compared to the results of the commonly used random effects model. RESULTS: The findings of the pattern mixture approach are well interpretable, and different courses over time in different patterns are distinguished. In terms of estimated differences between standard dose and high dose, the results of both approaches are slightly different, but have no consequences for the clinical evaluation of both doses. CONCLUSION: Under the assumption that drop-out is at random within the patterns, the pattern mixture approach adjusts the estimates to a certain degree. This approach accounts in a relatively simple way for informative drop-out.

Analyzing longitudinal data with patients in different disease states during follow-up and death as final state.

This paper considers the analysis of longitudinal data complicated by the fact that during follow-up patients can be in different disease states, such as remission, relapse or death. If both the response of interest (for example, quality of life (QOL)) and the amount of missing data depend on this disease state, ignoring the disease state will yield biased means. Death as the final state is an additional complication because no measurements after death are taken and often the outcome of interest is undefined after death. We discuss a new approach to model these types of data. In our approach the probability to be in each of the different disease states over time is estimated using multi-state models. In each different disease state, the conditional mean given the disease state is modeled directly. Generalized estimation equations are used to estimate the parameters of the conditional means, with inverse probability weights to account for unobserved responses. This approach shows the effect of the disease state on the longitudinal response. Furthermore, it yields estimates of the overall mean response over time, either conditionally on being alive or after inputting predefined values for the response after death. Graphical methods to visualize the joint distribution of disease state and response are discussed. As an example, the analysis of a Dutch randomized clinical trial for breast cancer is considered. In this study, the long-term impact on the QOL for two different chemotherapy schedules was studied with three disease states: alive without relapse, alive after relapse and death.

Dietary influences on plasma and urinary metanephrines: implications for diagnosis of catecholamine-producing tumors.

CONTEXT: Measurements of the 3-O-methylated metabolites of catecholamines [metanephrines (MNs)] in plasma or urine are recommended for diagnosis of pheochromocytoma. It is unclear whether these tests are susceptible to dietary influences. OBJECTIVE: The aim of the study was to determine the short-term influence of a catecholamine-rich diet on plasma and urinary fractionated MNs. DESIGN, SETTING, AND PARTICIPANTS: We conducted a crossover study in a specialist medical center involving 26 healthy adults. INTERVENTIONS: Subjects consumed catecholamine-rich nuts and fruits at fixed times on one day (about 35 mumol dopamine and 1 mumol norepinephrine) and catecholamine-poor products on another day. Blood and urine samples were collected at timed intervals before, during, and after experimental and control interventions. MAIN OUTCOME MEASURES: Isotope-dilution mass spectrometry-based measurements of plasma and urinary concentrations of free and deconjugated 3-methoxytyramine (3-MT), normetanephrine (NMN), and MN were made. RESULTS: The catecholamine-rich diet had substantial effects (up to 3-fold increases) on plasma concentrations and urinary outputs of free and deconjugated 3-MT. Dietary catecholamines had negligible influences on free NMN in plasma and urine, but substantial effects (up to 2-fold increases) on deconjugated NMN in plasma and urine. Concentrations of free and deconjugated MN in plasma and urine remained unaffected. CONCLUSIONS: Dietary restrictions should be considered to minimize false-positive results for urinary and plasma deconjugated MNs during diagnosis of pheochromocytoma. Similar considerations appear warranted for plasma and urinary free 3-MT, but not for free NMN or MN, indicating advantages of measurements of the free compared to deconjugated metabolites.

C-reactive protein and angiographic characteristics of stable and unstable coronary artery disease: data from the prospective PREVEND cohort.

AIMS: High sensitive-C-reactive protein (hs-CRP) is associated with coronary risk, which may be explained by an association with (unstable) coronary artery disease (CAD). Until now, histopathological and angiographic studies have failed to consistently demonstrate a strong relationship. However, most of these studies were limited by a cross-sectional design. Our aim was to prospectively evaluate the association between hs-CRP and plaque instability. Therefore, firstly, we investigated the relation between hs-CRP measured long before coronary angiography (CAG) and angiographic characteristics of stable and unstable CAD. In addition, we investigated the association with coronary events during follow up in the total PREVEND population. METHODS AND RESULTS: Of the population based Prevention of Renal and Vascular Endstage Disease (PREVEND) study, 8139 subjects without previous documented CAD were followed for the incidence of CAG and coronary events from 1997 to 2003. For the qualitative angiographic analysis, 216 CAGs were available. Mean time to CAG was 37+/-19 months. The 864 coronary vessels were graded as follows: 436 coronary vessels as normal, 175 as non-obstructive CAD, 179 as stable obstructive CAD and 74 as unstable obstructive CAD. Multilevel ordinal regression analysis was performed to study associations between baseline clinical variables and angiographic findings. Hs-CRP contributed significantly to the multivariate model after adjustment for age, gender, smoking, lipids and blood pressure. In 8139 subjects, 201 (2.5%) first coronary events occurred during follow up. Cox survival analysis showed age- and sex-adjusted hazard ratios for hs-CRP 1-3 and >3mg/L of, respectively, 1.26 (95% CI 0.67-2.40) and 3.16 (95% CI 1.26-3.16), relative to hs-CRP <1mg/L. CONCLUSION: In the prospective PREVEND study of subjects without previous documented CAD, hs-CRP levels at baseline were associated with angiographic characteristics and clinical consequences of plaque instability during follow up. This observation supports the concept that hs-CRP significantly contributes to coronary atherogenesis.

Prospective study of long-term impact of adjuvant high-dose and conventional-dose chemotherapy on health-related quality of life.

PURPOSE: To evaluate and compare health-related quality of life (HRQOL) after conventional- and high-dose adjuvant chemotherapy in patients with high-risk breast cancer. PATIENTS AND METHODS: Patients were randomly assigned to either a conventional or high-dose chemotherapy regimen; both regimens were followed by radiotherapy and tamoxifen. HRQOL was evaluated until disease progression using the Short Form-36 (SF-36), Visual Analog Scale, and Rotterdam Symptom Checklist and assessed every 6 months for 5 years after random assignment. For the SF-36, data from healthy Dutch women with the same age distribution served as reference values. RESULTS: Eight hundred four patients (conventional-dose chemotherapy, n = 405; high-dose chemotherapy, n = 399) were included. Median follow-up time was 57 months. Directly after high-dose chemotherapy, HRQOL decreased more compared with conventional chemotherapy for all SF-36 subscales. After 1 year, the reference value of healthy women was reached in both groups. Small differences were observed between the two groups in the role-physical and role-emotional subscales, but 1 year after treatment, these differences were minor and not clinically relevant. During follow-up, patients with a lower educational level and many complaints before chemotherapy experienced a worse HRQOL. CONCLUSION: Shortly after high-dose chemotherapy, HRQOL was more affected than after conventional-dose chemotherapy. One year after random assignment, differences were negligible. Identifying patients who have a higher chance of persistent impaired quality of life after treatment (which, in the present study, included patients with a lower educational level and many complaints before chemotherapy) is important and may open the way for better patient-tailored prevention strategies.

Persistent low urinary excretion of 5-HIAA is a marker for favourable survival during follow-up in patients with disseminated midgut carcinoid tumours.

Survival of patients with disseminated midgut carcinoid tumours varies. We investigated which factors predict survival at referral and during follow-up, with emphasis on urinary 5-hydroxyindolacetic acid (5-HIAA) levels. Between 1992 and 2003, 76 patients were studied; urine was prospectively collected over a 24 h period every 3 months in order to measure 5-HIAA levels. Uni- and multivariate analyses were performed. Median follow-up was 55 months with a median survival of 54 months. Prognostic factors for poor survival were high age, high gamma-glutamyltransferase levels and greatly increased 5-HIAA levels (>20 mmol/mol creatinine) The Hazard Ratio (HR) of a greatly increased 5-HIAA level was 3.33 (95% confidence interval (CI) 1.66-6.66, p=0.001). In a multivariate survival analysis with the 5-HIAA level as time dependent covariable, the HR for the 5-HIAA level was 1.007 (95% CI 1.004-1.010, p=0.000). In conclusion, patients with persistent moderately increased urinary 5-HIAA levels (< or =20 mmol/mol creatinine) have favourable outcome.

The ordering of milestones in language development for children from 1 to 6 years of age.

PURPOSE: To scale language milestones in a group of 527 children to provide an instrument for screening language development. Procedure The questionnaire regarding these milestones was completed by parental report. It was evaluated whether the scaled milestones satisfied the assumptions of the Mokken item response model. RESULTS: The scalability of the final scale of 14 milestones was strong (H = .95), its reliability was high (rho = .96), and it satisfied the assumptions of the Mokken model. CONCLUSIONS: A single, unidimensional scale of diverse milestones was developed. It taps lexical, syntactic, and phonological skills, as well as both receptive and expressive language skills, and is well suited for mapping progress in language ability.

Small size ductal carcinoma in situ of the breast: predictors of positive margins after local excision.

One of the most important predictors of local recurrence after local excision of ductal carcinoma in situ (DCIS) is margin status. The aim was to study the association between margin status and clinical, radiological, and pathological characteristics and to determine predictors of positive margins after local excision of small size (< or = 4 cm) DCIS. Data were tested for differences regarding margin status, and logistic regression was used to determine predictors of margin status. The population consisted of 105 cases. Overall, 51 cases (49%) had free margins and 54 cases (51%) had positive margins. Positive margins were more often associated with a mean mammographic tumor size of 2.1 cm (P = 0.044) and absence of fine granular calcifications (P = 0.004). Also, high-grade (P = 0.013) and a mean pathological size of 3.2 cm (P < 0.001) were associated with positive margins. The only independent predictor of margin status was pathological grade (P = 0.010).

Analysis of cytological specimens from mediastinal lesions obtained by endoscopic ultrasound-guided fine-needle aspiration.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) seems to be a powerful tool to obtain cytologic specimens from mediastinal and celiac lymph nodes, enlarged left adrenal glands, and intrapulmonary tumors with mediastinal extension. The diagnostic yield of EUS-FNA and the accuracy of cytologic specimens was evaluated. METHODS: Cytologic assessment of EUS-FNA specimens was performed and specimens were classified as positive, negative, suspicious for malignancy, or unsatisfactory for diagnosis. Cytology was compared with histologic and clinical (> or = 6 months) follow-up. RESULTS: Cytologic specimens were collected from 155 lymph nodes, 10 left adrenal glands, and 9 intrapulmonary tumor masses. For lymph nodes, the diagnostic yield was 0.65. After exclusion of unsatisfactory specimens, sensitivity, specificity, accuracy, and positive (PPV) and negative (NPV) predictive values of cytologic specimens were 0.92, 1.00, 0.93, 1.00, and 0.63, respectively. Subgroup analysis of lymph nodes with a dimension of > or = 10 mm showed similar results. With EUS imaging only, lymph node diameter and a round or irregular shape were significant predictors of malignancy at multiple logistic regression analysis, but their clinical usefulness is very limited (PPV = 0.78 and NPV = 0.45). For left adrenal gland specimens, sensitivity and specificity were 0.89 and 1.00, respectively. From intrapulmonary masses, 8 true-positive and 1 true-negative specimens were obtained. CONCLUSIONS: Cytologic specimens from mediastinal or celiac lymph nodes obtained with EUS-FNA were reliable and accurate. Specimens from left adrenal glands and intrapulmonary tumor masses showed promising results.

Does sentinel lymph node biopsy in cutaneous head and neck melanoma alter disease outcome?

BACKGROUND AND OBJECTIVES: In the head and neck region, value, reliability, and safety of sentinel lymph node biopsy (SLNB) have not yet been determined conclusively. The aim of study was to assess impact of SLNB on disease outcome in cutaneous head and neck melanoma. METHODS: Thirty-six patients with a clinically node-negative head and neck melanoma, > or =1.0 mm Breslow thickness, participated in a prospective study from 1995 to 2005. Sentinel lymph node (SLN) tumor-positive patients underwent completion lymphadenectomy. SLN tumor-negative patients underwent clinical monitoring. Median follow-up was 54 (range 10-114) months. Recurrence-free and overall survival curves were constructed by Kaplan-Meier. RESULTS: SLNs could be identified in 33 patients (92%). In 7 patients (21%) the SLN was tumor-positive. In 1 patient (13%) the SLNB was false-negative. In 17 patients (47%) SLNs could be identified in the parotid region (success rate parotid region 100%). This study showed no significant difference in recurrence-free and overall survival between patients with tumor-positive and tumor-negative SLN. CONCLUSIONS: The safety and accuracy of SLNB in the neck and parotid nodal basins were similar to those in non-head and neck sites. However, the technique is technically demanding in this region. In this small series SLNB did not alter disease outcome.