Evaluation of the effects of maternal anxiety on the duration of vaginal labour delivery.

OBJECTIVE: In the present study, the authors aim to investigate the effect of anxiety during late pregnancy periods and during labour on the duration of delivery in patients giving birth vaginally. MATERIALS AND METHODS: In the study we included 50 nulliparous and 35 multiparous patients who were at or above the 28th gestational age and followed-up and admitted for birth at the present hospital. During the admission at the outpatient clinic at third trimester and at the beginning of labour, anxiety levels of patients were detected by performing the Spielberger State-Trait Anxiety Inventory. The duration of the labour stages of pregnant women were recorded and these durations and maternal state-trait anxiety levels were compared. RESULTS: The trait anxiety of patients both during the third trimester and labour was similar, while during labour state anxiety was seen to be increased. Statistically, the levels of the trait anxiety of multiparous patients were significantly higher. There was a statistically significant correlation between state anxiety for both periods in nulliparous patients and latent and active phases, the first and the second stages, and total duration of the labour. In addition, there was a significant relationship between trait anxiety levels for both period and total duration of the labour. For multiparous patients, only positive significant correlation was detected with the level of state anxiety during labour. CONCLUSION: It has been seen that the anxiety occurring at the last trimester of pregnancy and labour, and especially acute state anxiety have negative effects on the duration of the phases of labour. It has been considered that the physical care provided for patients at the last trimester and during labour and also evaluation in terms of anxiety and provision of emotional support may cause positive outcomes for the duration of labour.

Evaluation of the importance of the serum levels of CA-125, CA15-3, CA-19-9, carcinoembryonic antigen and alpha fetoprotein for distinguishing benign and malignant adnexal masses and contribution of different test combinations to diagnostic accuracy.

PURPOSE: The aim of this study was to investigate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPPV) of the serum levels of CA-125, CA15-3, CA19-9, carcinoembryonic antigen (CEA), and alpha-fetoprotein (AFP) in the differentiation of benign and malignant ovarian tumors histopathologically diagnosed in patients and to determine the effects of the different test combinations on diagnostic accuracy. MATERIAL AND METHODS: One-hundred sixty-eight patients that had their preoperative CA-125, CA15-3, CA19-9, CEA, AFP levels assessed and that were subsequently surgically treated for adnexal masses, were included in the study. For each tumor markers in these patients with histopathologically-confirmed diagnosis, the sensitivity, specificity, PPV and NPV, and diagnostic accuracy, and odds ratio were calculated. RESULTS: The sensitivity, specificity, PPV, NPV of CA125 with cut-off 35 U/ml, were found to be 78.9%, 86.9%, 63.8%, and 93.3%, respectively. The diagnostic odds ratio of CA-125 with cut-off of 35 U/ml, was found to be 25. With cut-off65 U/ml, the sensitivity, specificity, PPV, NPV values were 65.7%, 95.3%, 80.6%, and 90.5%, respectively. The sensitivity, specificity, PPV, and NPV of CEA were 16%, 93%, 37%, and 83%, respectively. For AFP, the sensitivity, specificity, PPV and NPV were to be 2.6%, 98%, 33.3%, and 77.5%, respectively. For CA 15-3, the sensitivity, specificity, PPV and NPV were found to be 26.3% 96.1%, 66.6%, and 81.6%, respectively. Likelihood ratio tests: positive (LR+) = 6.83 and negative (LR-) = 0.76, with an odds ratio: 8.9. The risk of malignancy for adnexal masses with higher CA15-3 increased by approximately nine times. For CA19-9, the sensitivity, specificity, PPV and NPV value were found to be 18.4%, 93%, 43.7%, and 79.6%, respectively. CA19-9 was not statistically significant in the differentiation of benign and malignant of adnexal masses. Even the combinations of CA125 + CEA + CA19-9 and CA125 + CEA + CA19-9 +AFP and CA125 + CA15-3 made a small contribution (one, two, and four cases, respectively), but was not statistically significant. CONCLUSION: The levels of CA-125 and CA15-3 were found to be significant in order to distinguish benign and malign; CA 19-9, CEA, and AFP were not found to be significant. The different test combinations did not have contribution for diagnostic accuracy.

Attitudes towards mode of delivery and cesarean on demand in Turkey.

OBJECTIVE: To assess the attitudes of healthcare providers and the public in Turkey towards mode of delivery and cesarean delivery on demand. METHODS: A written questionnaire was given to female healthcare providers and women from the general public, and their answers were analyzed. RESULTS: A total of 329 female healthcare providers and 347 women from the public group completed the survey. In response, 48.1% of healthcare providers and 69.6% of the public group chose vaginal delivery as the preferred mode of delivery (P<0.001). Some 45.3% of healthcare providers and 20.6% of the public group had undergone a cesarean delivery without any medical indications (P<0.001). In addition, 37.8% of healthcare providers and 36.2% of the public group believed that women should have the right to a cesarean delivery on demand. CONCLUSIONS: In the two groups studied the preference for cesarean delivery is higher in Turkish healthcare providers than in the public population. In both groups the attitude towards cesarean delivery on demand is high.

Quality of life with functional pharyngeal preservation in advanced carcinomas of the base tongue complex using an integrated trimodality approach.

Standard management of advanced carcinoma arising from the base of the tongue or infiltrating that region from contiguous areas (henceforth referred to as base of tongue complex [BTC] tumors) with radical surgery and postoperative radiation therapy results in extensive loss of function affecting deglutition, speech, and physical appearance. From January 1995, 16 patients with advanced stage BTC tumors were entered in this phase II study. Eleven patients (74%) had N2-3 neck disease. To optimize neck control, those with clinical N+ nodes at presentation had neck dissection. This was followed by hyperfractionated radiotherapy at 120 cGy twice daily to a median dose of 7,320 cGy to the primary and 6,240 cGy to areas with pathologically positive nodes. Concomitant chemotherapy was administered during weeks 1 and 4 of the radiation therapy using bolus cisplatin 75 to 100 mg/m2 on day 1 and continuous infusional 5-fluorouracil 750 to 1,000 mg/m2/d from days 1 to 4 of each chemotherapy cycle. Survival curves were plotted for various events, using actuarial life table methods. A functional assessment was made at least 1 year after completion of treatment using a previously validated Head/Neck Performance Status Scale. The median follow-up period was 23 months. There was a 100% complete response to the treatment at the primary site. The actuarial 4-year local (primary site) control was 100%, locoregional control (including nodes) was 69%, and disease-specific survival was 70% at 4 years. The predominant acute toxicity (63% incidence) was reversible grade III mucositis resulting in a median of 9 days' interruption in treatment. All of the patients were able to complete the prescribed treatment course, and there were no treatment-related deaths. Quality of Life assessment after treatment examined all facets of oropharyngeal function. Of note, none of the patients required long-term tube feedings. For the nine patients who responded to the functional assessment questionnaire, the results were excellent (score >75). The mean score for ability to eat in public was 75, mean of 76 for normalcy of diet, and 91 for understandability of speech. Concomitant hyperfractionated chemoradiation therapy produced excellent functional preservation with good long-term control in this patient group with historically poor prognosis. A 4-year actuarial local control rate of 69% was obtained, which is comparable to results of radical surgery and adjuvant radiation therapy. Further studies with modifications of fractionation and use of newer chemotherapy agents/radioprotectors will improve on these gains while reducing toxicity.

The role of infusional chemotherapy and radiation in organ preservation.

Chemotherapeutic agents, used alone or in combination, have had a largely palliative effect in the treatment of solid tumors. The curative ability of these agents has been limited to about 15% of cases, in large measure due to chemotherapy's failure to accomplish locoregional control, leaving surgery or irradiation for local control of primary disease as modes of treatment. In many cases, however, surgery is not a feasible alternative, and radiation therapy may fail because of radioresistance. Whether this is caused by anoxia or by the innate radioresistance of the tumor cell, radiation oncologists have tried a number of methods to overcome the resulting insensitivity. Experience with the continuous concomitant infusion of various cytotoxic agents and radiation therapy in the treatment of advanced malignancies has been encouraging. The resultant radiosensitization has let to an increased rate of locoregional clearance of advanced carcinomas with a worthwhile increase in survival rates. The use of infusion chemo- and radiation therapy also has allowed the use of an organ-sparing program in all but the most advanced stages. There are already encouraging reports on successful organ-sparing treatment programs for carcinoma of the anus, esophagus and bladder. (ABSTRACT TRUNCATED)

Eagle's syndrome masquerading as pain of dental origin. Case report.

Eagle's syndrome, also known as elongated styloid process, is a condition that may be the source of craniofacial and cervical pain. It is infrequently reported but is probably more common than generally considered. The symptoms related to Eagle's syndrome can be confused with those attributed to a wide variety of facial neuralgias and/or oral, dental and TMJ diseases. In this paper, a case of Eagle's syndrome masquerading as pain of dental origin is presented and the literature is reviewed.

Age and race as prognostic factors in endometrial carcinoma.

This research was undertaken to evaluate the effects of age and race on prognosis of patients with endometrial carcinoma. A total of 279 patients with endometrial carcinoma treated at State University of New York-Health Science Center and Kings County Hospital Brooklyn, New York from 1975 to 1990 were retrospectively analyzed. Patients were arbitrarily divided into young and old groups (< or = 60 years or > 60 years old, respectively). The distribution of grade, clinical stage, and extent of myometrial invasion by age was determined for the entire group and for black and white patients, respectively. Young and old patients were stratified by clinical stage, grade, and extent of myometrial invasion. The corrected median survival of young and old patients by race was evaluated by Kaplan Meier's method of analysis. Older patients in general had higher clinical stage, higher grade, and greater depth of myometrial invasion than younger patients. Also, black patients had higher clinical stage, higher grade, and greater depth of myometrial invasion than white patients. Older black patients had the least favorable distribution of prognostic factors. Overall younger patients had a median survival of 200 months compared to 90 months for older patients (p = 0.0085). The overall corrected median survival for whites was 232 months compared to 108 months for blacks (p = 0.0001). The median survival of older black patients was worst at 40 months, compared to 155 months for older white patients (p = 0.0005). Age is a very important prognostic factor in endometrial carcinoma for both blacks and whites, and it appears to be more pronounced in older black patients.

Poor survival of black patients in carcinoma of the endometrium.

PURPOSE: To compare the prognostic factors and survivals of black and white patients with endometrial carcinoma. METHODS AND MATERIALS: A retrospective study was undertaken of a total of 290 patients with endometrial carcinoma who were treated similarly at the Health Science Center at Brooklyn and Kings County Hospital Center from 1975 and 1990. One hundred and thirty-six of 290 (47.2%) were black and 135/290 (46.9%) were white. Well-known prognostic factors affecting endometrial carcinoma were studied in black and white group of patients. Their overall survival and comparison of survival in each prognostic group were also estimated using multi-variate analysis. RESULTS: Fifty-four percent of white patients had Stage I disease, compared to 45.9% in black patients. In Stage II, 51.6% were white and 48.4% were black, and in Stage III, 88.89% were black and 11.1% were white patients (p = 0.034). Fifty six percent Grade 1 patients were white and 44% were black. In Grade 2, 53.3% were white and 46.7% were black and in Grade 3 disease, 70.5% were black and 29.5% were white (p = 0.008). Up to the inner third of myometrial invasion had occurred in 60.6% of white patients and 39.4% in black patients. The middle third of the myometrium was invaded in 60.7% of white patients, and 39.3% of black patients. Thirty-seven percent of outer third of myometrial invasion was found in white patients and 63% in black patients (p = 0.038). Seventy-two percent of positive lymph nodes were found in black patients and 28.0% in white patients (p = 0.01). Sixty-one percent of patients with positive peritoneal cytology were black as compared to 38.7% in white patients (p = 0.017). The overall ten-year corrected survival for white and black patients was 72% and 40%, respectively (p = 0.0003). Survivals comparisons, when stratified by race and each prognostic group, showed statistically significant overall survival differences in favor of white patients. CONCLUSION: Black patients with endometrial carcinoma have poor survival. Low socio-economic status (SES) would not explain these findings. More research is required to determine the cause of poor survival in black patients with endometrial carcinoma.

Elimination of vasopressin analgesia following lesions placed in the rat hypothalamic paraventricular nucleus.

Pain thresholds are increased following central administration of arginine vasopressin (AVP), an effect which appears not to be mediated through opioid analgesic processes. In addition to magnocellular projections to the posterior lobe of the pituitary gland and parvocellular projections to the zona externa of the median eminence, the paraventricular nucleus (PVN) of the hypothalamus contains VP parvocellular neurons which also project to extrahypothalamic structures involved in pain inhibition. The present study examined whether AVP analgesia as measured by the tail-flick test was altered in animals with lesions placed in the PVN at either 7 or 35 days after surgery. VP levels in the pons-medulla and the lumbo-sacral spinal cord were measured by radioimmunoassay, as well as VP-like immunoreactivity in the PVN and spinal cord with immunocytochemistry. Lesions placed in the PVN eliminated AVP analgesia on the tail-flick test at both 7 and 35 days after surgery, and decreased radioimmunoassayable VP by 59% in the lumbo-sacral spinal cord and 36% in the pons-medulla. The extent of the lesions ranged from complete destruction of the PVN to partial sparing of ventro-medial PVN cells with VP-like immunoreactivity. These data indicate that the PVN is a critical structure for the integrity of AVP analgesia.

Chemotherapy for head and neck cancer relapsing after radiotherapy.

Thirty-nine patients (28 men and 11 women, ages 43 to 83 years) with advanced head and neck epidermoid carcinoma (33 had relapsed from previous radiotherapy) were treated with a three-day bleomycin administration (30 by continuous intravenous infusion and nine by subcutaneous route) followed on the fifth day by intravenous administration of cyclophosphamide + methotrexate + 5-fluorouracil (Bleo-CMF). This drug schedule was based on the cell cycle synchrony principle. Twenty-one of 39 patients (54%) responded (seven complete, 14 partial remission) lasting from 4 to 20 months. The median duration of survival for complete remission, partial remission, and disease progression was 15, ten, and four months, respectively. The Bleo-CMF was well tolerated with minimal toxicity. The effectiveness of this regimen in previously irradiated patients compels us to pursue its application in a randomized study as an adjuvant for Stages III and IV head and neck cancer following maximum eradication of the local disease by surgery and/or radiotherapy.

A randomized trial of preoperative radiotherapy in cancer of the oropharynx and hypopharynx.

One hundred patients with stage II and stage III cancer of the oropharynx and hypopharynx were treated under a protocol in which they were randomly selected for treatment by surgery alone or by combined preoperative radiotherapy and surgery. The schedule of preoperative radiation therapy chosen was 2,000 rads from a cobalt 60 machine delivered in five days. Eighty-six of the patients were evaluable at three years; there was no difference in the outcome of the treatment of the two groups. A similar study is urgently needed to determine the value of postoperative radiotherapy in the management of similar cancers.

Mediastinal irradiation for chronic lymphocytic leukemia.

Thirty-one patients with chronic lymphocytic leukemia were treated with mediastinal radiation. In none of the patients was complete remission achieved; either partial remission or clinical improvement was achieved in 52 per cent, but the duration of response was short. The response rate was 77 per cent for the patients receiving a total radiation dose greater than 3,000 rads and 45 per cent for those receiving less than 3,000 rads. Severe life-threatening toxicity was noted in 11 patients and seven of these patients died; two patients died with progressive disease. Severe toxicity was manifested by one or more of the following: bone marrow aplasia, pancytopenia, gram-negative sepsis, generalized herpes zoster and severe esophagitis. Neither the total dose of radiation nor the dose per week correlated withe the severity of reaction or death.

Staging laparotomy and splenectomy: treatment and complications of Hodgkin's disease in children.

Twenty-five cases of hodgkin's Disease (15 males and 10 females) aged 5 to 17 years were studied from April 1970 to July 1976 (75 month period). Histology revealed that 2 had lymphocytic predominance, 12 had nodular sclerosis, and 11 had mixed cellularity. Pathologic staging revealed that 3 were IA, 1 IB, 5 IIA, 4IIB, 6IIIA, and 6 IIIB. Laparotomy altered the staging in 12 patients (9 were staging up and 3 down). All but 2 patients received extended field radiation, and 5 had recurrence of disease and were treated with combination chemotherapy. Twenty-three are alive without evidence of disease (21-75 months), and the 2 deaths were not due to Hodgkin's Disease but to hemobilia (postliver biopsy) and penumococcal septicemia, purpura fulminans, and disseminated intravascular coagulation (14 months postsplenectomy). Other complications included 2 patients with intestinal obstruction, 1 with postoperative subphrenic abscess, and 1 with streptococcal septicemia and polyarthritis. Nineteen patients received continuous penicillin prophylaxis postoperatively and the 2 with serious infections were amongst the 6 who had not received penicillin or whose penicillin had been discontinued at the time of infection. It is concluded that laparotomy and splenectomy in children is essential for accurate staging but carries significant risk, and continuous penicillin prophylaxis is recommended.

Organ irradiation and combination chemotherapy in treatment of acute lymphocytic leukaemia in children.

Lanzkowsky, P., Shende, A., Aral, I., Saluja, G. (1975). Archives of Disease in Childhood, 50, 685. Organ irradiation and combination chemotherapy in treatment of acute lymphocytic leukaemia in children. A total of 30 consecutive children with acute lymphocytic leukaemia (ALL) were treated from June 1971 until December 1974. Remission was induced with the use of vincristine and prednisone. After induction of remission, cranial irradiation and intrathecal methotrexate were given. Then the liver, spleen, and kidney were irradiated and 6-mercaptopurine, cyclophosphamide, and methotrexate were administered during the maintenance phase. Pulsed doses of vincristine and prednisone were administered at 10- to 12-week intervals. The patients were subdivided into two groups based on their initial white blood cell (WBC) counts: a standard risk group with an initial WBC count of less than 25 000/mm3 (25 X 10(9)/1) and a high risk group with an initial WBC count greater than 25 000/mm3 (25 X 10(9)/1). Of the 30 children entered in this study one standard risk patient died in the induction phase before attaining remission. Analysis of the results is therefore based on the remaining 29 patients, 22 standard risk and 7 high risk patients, who attained complete remission. Survival rates in continuous remission were found to be 43% of the high risk group, 88% for the standard risk group, and 77% for the combined group. Analysis of the data indicates that this therapy is unsatisfactory in high risk ALL. The results to date of this therapy for standard risk are sufficiently encouraging to continue its use in this subgroup of patients.