[Barbarism: education without history of medicine]. / Barbarij: opleiding zonder medische geschiedenis.

Rudolf Virchow regarded medical education that did not include the history of medicine as barbarism. Despite this view, current education on medical history in medical faculties in the Netherlands is minimal in terms of the number of teaching staff and the hours spent on the subject. Important arguments for teaching medical history to medical students are academic development, a better understanding of the historic fundamentals of research, clinical practice and the medical profession and, more recently, a better understanding of the historical and social context of medicine. Modern education on the history of medicine provides a perfect opportunity for critical reflection on the complexity of modern-day medicine. On the basis of these arguments, history of medicine belongs within the framework for Undergraduate Medical Education as an independent domain with appropriate assessment.

[The court physician, the clergyman, a learned society and smallpox]. / De hofarts, de dominee, een geleerd genootschap en de pokken.

Variolation was introduced in England in the first half of the 18th century. The positive effects of this new method for preventing smallpox were already known in the Netherlands around 1720, one of whom was the Dutch physician Boerhaave. In spite of this, it took another 30 years before variolation was used in the Netherlands. Despite receiving positive advice and information from his learned English friends Sloane and Sherard, Boerhaave did not apply nor advise the use of variolation. There were various arguments for this restrained approach. In 1754 Thomas Schwencke found that conditions were favourable for the introduction of variolation in The Hague. There was support from the House of Orange-Nassau (the current royal family in the Netherlands) and from a learned society; a highly motivated clergyman acted as ambassador for the new technique and the court physician Schwencke was willing to take the lead. A similar combination had previously been effective in England, though the ambassador there was not a clergyman but an influential noble lady.

Effects of medroxyprogesterone acetate on appetite, weight, and quality of life in advanced-stage non-hormone-sensitive cancer: a placebo-controlled multicenter study.

PURPOSE: To investigate the effects of medroxyprogesterone acetate (MPA) on appetite, weight, and quality of life (QL) in patients with advanced-stage, incurable, non-hormone-sensitive cancer. PATIENTS AND METHODS: Two hundred six eligible patients were randomized between double-blind MPA 500 mg twice daily or placebo. Appetite (0 to 10 numerical rating scale), weight, and QL (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC-QLQ-C30]) were assessed before the start of treatment (t = 0), and 6 weeks (t = 6) and 12 weeks (t = 12) thereafter. RESULTS: One hundred thirty-four patients (68 MPA and 66 placebo) were assessable at t = 6 and 99 patients (53 MPA and 46 placebo) at t = 12. A beneficial effect of MPA on appetite was observed after both 6 weeks (P = .008) and 12 weeks (P = .01) of treatment. After 12 weeks, a mean weight gain of 0.6 +/- 4.4 kg was seen in the MPA, versus an ongoing mean weight loss of 1.4 +/- 4.6 kg in the placebo group. This difference of 2.0 kg was statistically significant (P = .04). During the study, several areas of QL deteriorated in the total group of patients. With the exception of an improvement in appetite and possible also a reduction in nausea and vomiting, no measurable beneficial effects of MPA on QL could be demonstrated. The side effects profile of MPA was favorable: only a trend toward an increase in (usually mild) peripheral edema was observed. CONCLUSION: In weight-losing, advanced-stage non-hormone-sensitive cancer patients, MPA exhibits a mild side effects profile, has a beneficial effect on appetite, and may prevent further weight loss. However, general QL in the present study was not measurably influenced by MPA treatment.

The prognostic value of the soluble urokinase-type plasminogen activator receptor (s-uPAR) in plasma of breast cancer patients with and without metastatic disease.

Elevated levels of soluble uPAR (s-uPAR) and other fibrinolytic parameters functionally related to the urokinase-type plasminogen activator system might indicate the presence of cancer cells. In 25 breast cancer patients with metastases s-uPAR was significantly increased compared with 25 patients without metastases and with 25 healthy controls: 420 pg mL-1 vs. 145 pg mL-1 (P = 0.005) and 190 pg mL-1 (P = 0.003). Plasmin-alpha2-antiplasmin (PAP) complexes and d-dimers were significantly increased in breast cancer patients with metastases compared with patients without metastases and with healthy controls. The levels of plasminogen activator inhibitor (PAI)-1 activity, uPA antigen and factor (F)XIIa did not significantly differ between the patient groups and healthy controls. PAP complexes (529 microg L-1 vs. 420 microg L-1; P = 0.03), d-dimers (278.5 ng mL-1 vs. 79.0 ng mL-1; P = 0.005) and FXIIa (1.64 ng mL-1 vs. 1.19 ng mL-1; P = 0.01) were significantly higher in patients with metastases not surviving compared with patients with metastases surviving the 3-year follow-up period. Plasma s-uPAR levels in the patients with metastases did not discriminate between patients surviving and patients not surviving after 3-year follow-up. No significant differences in s-uPAR or any of the other parameters were found in the five patients developing metastases during follow-up. A single value of s-uPAR is of limited value in the follow-up of breast cancer patients with and without metastatic disease and does not predict survival or future metastases.

Epidemiology of unknown primary tumours; incidence and population-based survival of 1285 patients in Southeast Netherlands, 1984-1992.

Patients with an unknown primary tumour (UPT) represent 5-10% of all new cancer patients. Data on survival and prognostic factors of UPTs are based on selected patient series from specialised institutions. Population-based data on incidence, histology and determinants of survival for patients with UPT are not available. All patients diagnosed with UPT between 1984 and 1992 and entered in the population-based Eindhoven Cancer Registry for Southeast Netherlands were included. Follow-up of vital status is complete up to 1999. 1285 patients were registered. In 1024 patients, the diagnosis was confirmed histopathologically: 479 (47%) had adenocarcinoma, 453 (44%) poorly differentiated carcinoma (PDC) or adenocarcinoma (PDA), 76 (7%) squamous cell carcinoma and 16 patients (2%) had an undifferentiated malignant neoplasm. In 26% of these patients with UPT, the tumour was already widely disseminated at presentation. The majority of patients (67%) received only supportive treatment. The median survival was 11 weeks and only 15% were still alive 1 year after diagnosis. Favourable subgroups comprised young patients and patients with metastases localised in lymph nodes. In 261 cases, the diagnosis was made clinically. These patients were evaluated separately. They were older than the biopsy-confirmed patients, received less cancer therapy and their prognosis was even worse (median survival of 7 weeks). In a comparison with data from a tertiary referral centre in the United States of America (USA), our patients were older, received less therapy and had a poorer prognosis. Demographics of our favourable subgroup resembled the patients from the American study. The differences were most likely caused by the differences in the patient populations. In conclusion, we have demonstrated in a population-based study that the prognosis for patients with UPT is more unfavourable than suggested in most clinical studies.

Phase II trial of 5-fluorouracil, adriamycin and cisplatin (FAP) in advanced gastric cancer.

Twenty patients (15 male, 5 female) with nonresectable gastric adenocarcinoma were treated with FAP (5-fluorouracil 300 mg/m2 IV on days 1-5, adriamycin 50 mg/m2 IV on day 1, cisplatin 20 mg/m2 IV on days 1-5). Each course was repeated every 21 days. Eighteen patients were evaluable for response. The median age was 51 years, the range extending from 34 to 68. None had undergone chemotherapy. The median Karnofsky performance score was 80%. Nine (50%) partial responses (PR) and eight (44%) cases of stable disease (SD) were observed. One patient showed progression of the disease and died after 6 months. The median duration of response was 6+ months for PR and 6 months for SD. The median survival was 12 months. FAP toxicity was moderate, with the median WBC nadir 3.2 X 10(9)/l (range 0.7-4.2). One patient in PR died of septicemia. Nausea and vomiting were not dose-limiting. Neuropathy was mild in four and moderate in two patients. This FAP combination appears to be as effective with respect to response rate and duration as reported for 5-fluorouracil, adriamycin and mitomycin C (FAM).

Relevance of the expression of bcl-2 in combination with p53 as a prognostic factor in breast cancer.

BACKGROUND: Both the proto-oncogene bcl-2 and the tumour suppressor gene p53 are involved in the regulation of apoptosis. PATIENTS AND METHODS: We have investigated the prognostic value of the immunohistochemical expression of p53 and bcl-2 separately and in combination in a group of 345 breast cancer patients from one hospital with a long median follow-up of more than 10 years. RESULTS: Bcl-2 expression was not a prognostic factor. p53 was an independent prognostic factor for overall survival (p = 0.005) and for post-relapse survival (p = 0.006). Looking at bcl-2/p53 subgroups in the bcl-2 positive subgroup there was a large difference in both disease-free and overall survival between p53 negative and p53 positive patients. In the bcl-2 negative subgroup the p53 status was not a prognostic factor at all. CONCLUSIONS: p53 is an independent prognostic factor for overall survival and post-relapse survival. However, p53 status is only important in the bcl-2 positive subgroup.

pS2 is an independent prognostic factor for post-relapse survival in primary breast cancer.

BACKGROUND: The pS2 protein is involved in the maintenance of the integrity of the gastrointestinal tract. In breast cancer pS2 can be demonstrated in at least half of the tumors and probably reflects the functional status of ER. Several features make it likely that pS2 is involved in growth regulation. PATIENTS AND METHODS: We have investigated the value of immunohistochemical pS2 determination as a prognostic factor in 339 breast cancer patients with long follow-up from one hospital. RESULTS: A prognostic role for pS2 could not be demonstrated considering disease-free and overall survival, although in pS2-negative tumors a trend for less locoregional relapse was found. However, in multivariate analysis pS2 showed independent prognostic value for post-relapse survival. CONCLUSIONS: PS2 is an independent prognostic factor for post-relapse survival, most likely because it is a predictive factor for response to systemic therapy.

The prognostic significance of steroid receptor activity in tumor tissues of patients with primary breast cancer.

The prognostic significance of steroid-receptor activity is still debatable. Discrepancies in results are probably attributable to few patients, heterogeneous patient populations, and short follow-up. We investigated the prognostic significance of estrogen- and progesterone-receptor (ER and PgR, respectively) activity as a continuous variable in a homogeneous patient population. The prognostic significance of steroid-receptor activity was examined in 329 node-negative and 320 node-positive unselected breast cancer patients. In node-negative patients, ER values of primary tumors between 100 and 400 fmol/mg protein appeared to be a significant predictor for low risk of recurrence, whereas high ER (> 400) revealed an unfavorable prognosis. The classic cutoff level of ER (< 10 fmol/mg proteins) had no prognostic significance, however. In patients receiving adjuvant chemotherapy--the node-positive breast cancer patients--the classic cutoff value of ER (10 fmol/mg protein) predicts significantly distant metastases-free survival and overall survival only in the first 4 years of follow-up after diagnosis. Progesterone receptor is a time-dependent prognosticator in node-negative breast cancer patients (cutoff point for PgR, 80 fmol/mg). In node-positive breast cancer patients treated with chemotherapy or a combination of chemo- and hormonal therapy, PgR values lower than 60 fmol/mg had a worse prognosis. The results show the poor performance of standard cutoff points for ER and PgR positivity in predicting prognosis. Better prognosis is related to higher receptor levels but this relation is predominantly time-dependent. Moreover, patients who have high ER levels have a prognosis that is worse when compared with intermediate ER levels. Standard cutoff points for steroid receptors should not be used to select patients for prognosis.

Controlled multicentre study of the influence of subcutaneous recombinant human erythropoietin on anaemia and transfusion dependency in patients with ovarian carcinoma treated with platinum-based chemotherapy.

This randomised controlled multicentre trial evaluated the effectiveness of recombinant human erythropoietin (rhEPO) in preventing anaemia and reducing the need for blood or erythrocyte transfusion in 122 ovarian cancer patients receiving platinum-based chemotherapy. The patients were randomly allocated to receive rhEPO 150 U/kg or 300 U/kg subcutaneously, three times a week, or open control. Patients also received up to 6 cycles of carboplatin or cisplatin, alone or in combination with other cytotoxic agents. Intention-to-treat analysis showed that 39.4% of patients in the control group received at least one blood transfusion, compared with 9.2% of patients treated with rhEPO. Patients treated with rhEPO experienced a significantly longer time to first erythrocyte transfusion than the control group and were less likely to experience nadir haemoglobin levels < 10 g/dl (P < 0.001 and < 0.05, respectively). A haemoglobin decrease < 1 g/dl during the first chemotherapy cycle, as well as a low baseline serum erythropoietin concentration, predicted a low transfusion need in rhEPO-treated patients but not in controls. During the study, 103 patients suffered at least one adverse event, but no serious, and only nine non-serious adverse events were considered possibly related to rhEPO therapy. These results indicate that treatment with rhEPO prevents anaemia, it reduces the need for blood or rhEPO erythrocyte transfusion in patients with ovarian cancer receiving platinum-based chemotherapy, and it is well tolerated. A starting dose of 150 U/kg of rhEPO, three times a week, may be recommended.

Pharmacological induction of foetal haemoglobin synthesis in sickle-cell disease.

In the present review the role and regulation of foetal haemoglobin (HbF) in sickle-cell disease as well as the clinical results of therapy aimed at augmenting HbF synthesis are briefly discussed. Enhanced levels of HbF have an inhibitory effect on sickling and ameliorate the clinical course of sickle-cell disease. This knowledge has incited a search for pharmacological agents capable of stimulating HbF production. Cytostatic drugs, in particular hydroxyurea, but also other agents such as erythropoietin, butyrate and its analogues have been shown to induce HbF production. The mechanisms of action and the clinical effects of these agents are summarized. Only hydroxyurea has shown significant clinical effects in terms of reduction of pain-crises, chest syndrome and transfusions in sickle-cell patients. However, not all patients experience clinical amelioration and it appears difficult to predict which patient will gain from hydroxyurea therapy. Further studies need to expand the clinical experience with hydroxyurea, other HbF-inducing agents and combinations of these drugs. Moreover, they will hopefully provide criteria to enable appropriate selection of those patients with sickle-cell anaemia who will benefit clinically from HbF stimulation, also taking into account the risks and costs of long-term pharmacological therapy.

Correction of neutropenia following treatment with granulocyte colony-stimulating factor results in a decreased frequency of infections in Shwachman's syndrome.

We report the clinical efficacy of granulocyte colony-stimulating factor (G-CSF) in a 17-year-old woman with Shwachman's syndrome who was repeatedly admitted with severe infections and neutropenia. Bone marrow culture showed no increase in granulocyte colony-forming units upon stimulation with granulocyte-macrophage colony-stimulating factor (GM-CSF). The patient was treated with G-CSF 300 micrograms 3 times a week subcutaneously. A complete and sustained response of the neutropenia was obtained without side-effects during 21 months of treatment. No infectious episodes were encountered after starting G-CSF. This observation demonstrates the beneficial effect of G-CSF in treating the severe neutropenia in patients with Shwachman's syndrome.

Effect of high-dose dexamethasone in prednisone-resistant autoimmune thrombocytopenic purpura (ITP).

This study investigated whether high-dose dexamethasone pulse therapy could bring about a remission in adult chronic idiopathic thrombocytopenic purpura (ITP) patients who had not achieved a remission on the usual prednisone therapy. Newly diagnosed patients with ITP received the usual prednisone therapy, 1 mg/kg/day, for 3 weeks, after which period the dosage was tapered off. If after 6 weeks of treatment the platelets were less than 50 x 10(9)/l the prednisone therapy was considered a failure and 200 mg dexamethasone i.v. was given on 3 consecutive days. Six of the twenty-five patients with newly diagnosed ITP treated according to this protocol achieved a sufficient response with prednisone therapy. Nineteen patients were resistant to or relapsed during prednisone therapy and were treated with high-dose dexamethasone. Four of these nineteen patients showed a sufficient response. Three are still in remission. As no serious adverse effects were observed, high-dose dexamethasone therapy can be considered before splenectomy in prednisone- resistant ITP patients.

Acute pernicious or fulminating beriberi heart disease. A report of 6 patients.

OBJECTIVE: To investigate the incidence and presentation of acute pernicious or fulminating beriberi in a general district hospital. METHODS: All patients with a diagnosis of acute pernicious or fulminating beriberi heart disease made between 1978 and 1994 were identified, and their medical records were retrospectively examined. RESULTS: Six cases of acute pernicious or fulminating beriberi heart disease were recognized. The disease was characterized by circulatory shock and peripheral cyanosis. All patients had severe lactic acidosis, in 5 of them without hypoxaemia. Four patients were alcoholics. The most important diagnostic criterion was the impressive improvement after thiamine administration. CONCLUSIONS: Acute pernicious or fulminating beriberi heart disease can be recognized occasionally. Thiamine should be administered as soon as possible in suspected cases.

Tumour angiogenesis: pathophysiology and clinical significance.

In the 1970s it was first proposed that tumours depended on the establishment of a microcirculation in order to grow beyond a few millimetres. Thereafter, the search to prove this hypothesis increased strongly and by the end of the 1980s, evidence was given that tumours were angiogenesis-dependent and metastatic cells were only shed after the tumour had established its microcirculation. The process of neovascularization is regulated by numerous growth factors, vascular endothelial cells, and matrix proteins released from host stromal cells such as macrophages and mast cells. The process of tumour growth and metastasis involves tumour cell-host cell and cell-matrix interactions and many of the underlying mechanisms of these interactions still remain to be elucidated. Although in a minority of cases treatment of solid tumours has been effectively improved, for the majority of cases more adequate treatment is still required to reduce the mortality rate. It has been proposed only recently that specific targeting of the angiogenic process might inhibit tumour growth and metastasis. This promising field of research is now exponentially growing. It is the purpose of this review to summarize current knowledge on the pathophysiology and clinical significance of tumour angiogenesis.

Scalp cooling by cold air for the prevention of chemotherapy-induced alopecia.

A new system is described for cooling the scalp with cold air in order to prevent chemotherapy-induced alopecia. Compressed air was cooled by means of a vortex tube built into a hair-drier cap. This system reduced the blood flow in the scalp to 35%, the surface temperature to 14.2 degrees C and the intradermal temperature at hair follicle level to 29.2 degrees C. The low temperature could be kept constant for at least one hour of cooling. By means of comparison, with cryogel packs the lowest epidermal temperature attained was 17.9 degrees C; moreover, once this was reached after 10 min, it rapidly rose again to 20.6 degrees C after 40 min. Forty-eight patients receiving cytostatic treatment for breast cancer were subjected to scalp cooling with the cold air system, starting 15 min before chemotherapy and lasting for 90 min. With the system set at an air temperature of -12 degrees C, the treatment was well tolerated. Of the 13 patients treated with 40 mg/m2 doxorubicin in combination with other cytostatics, 6 had hair loss less than WHO grade 3, in contrast to 1 of 4 patients given cryogel packs. However, patients treated with epirubicin at 75 mg/m2 all showed grade 3 hair loss in spite of air cooling. In view of the possibility of achieving and maintaining low scalp temperatures, the cold air system is to be preferred to cryogel packs. Whether better clinical results may be obtained with cooling for longer periods and/or to lower temperatures remains to be determined.

[Breast cancer in patients, 70 years or older]. / Borstkanker bij patiënten van 70 jaar en ouder.

Over 30% of breast cancers are diagnosed after age 70. The incidence of breast cancer in the elderly has increased since 1960. Risk factors for breast cancer are a medical history without pregnancy, a first pregnancy after age 30 and the use of hormonal replacement therapy. The biology of breast cancer at advanced age indicates a relative slow, less aggressive and hormone dependent tumour growth. In spite of these favourable characteristics, the prognosis is not better than at middle age. Over 20% of older patients die from co-existing other diseases within 5 years after the diagnosis of breast cancer. This comorbidity, mostly cardiovascular or pulmonary, affects the possibilities and the outcome of treatment. Treatment of the primary tumour is performed according to the same guidelines as in younger patients. Indication exists for hormonal adjuvant treatment with tamoxifen in patients with oestrogen receptor positive tumours. Hormonal treatment is the treatment of choice in metastatic disease. Chemotherapy is given in patients with oestrogen receptor negative tumours and in patients with progressive hepatic or pulmonary metastases.

[Angiogenesis and the regulation of antitumor defense]. / Angiogenese en de regulatie van de afweer tegen tumoren.

Formation of new blood vessels is a prerequisite for outgrowth of solid tumours and metastasis. Leukaemia and lymphoma are also dependent on angiogenesis. Inhibition of angiogenesis is therefore a promising therapy for all cancer types. Angiogenic factors reduce the expression of tumour endothelial adhesion molecules for leukocytes, which enables tumours to escape the inflammation response. Antiangiogenic factors induce not only starvation of the tumour owing to deprivation of vasculature, but also re-expression of adhesion molecules, resulting in increased leukocyte infiltration. On the basis of de novo design of chemokines with antiangiogenic properties, novel inhibitors of angiogenesis are developed and selected for their ability to induce a tumour inflammatory reaction.

[Diagnosis and prognosis of polymyalgia rheumatica and giant cell arteritis]. / Diagnostiek en prognose van polymyalgia rheumatica en reuzencel-arteriitis.

Retrospectively the data were examined of 69 patients with polymyalgia rheumatica (PMR) and giant-cell arteritis (GCA), of whom 62 were treated with corticosteroids. The clinical and laboratory data, and the outcome of temporal artery biopsy were compared. In addition the relation between the course of the disease and survival was investigated. PMR and GCA are closely related syndromes with a multiform clinical presentation. There even is a group of patients with merely systemic symptoms, without specific signs of PMR or GCA. Concerning the course of the disease patients can be divided into groups with a shorter and longer period of disease activity; patients with a smooth stable remission and a chronic disease. The former group shows a significantly better five-year survival. At the time of diagnosis no reliable prediction of the course of the disease is possible.