Non-Risk-Adapted Surveillance in Clinical Stage I Nonseminomatous Germ Cell Tumors: The Princess Margaret Hospital's Experience.

BACKGROUND: Since 1981 Princess Margaret Hospital has used initial active surveillance (AS) with delayed treatment at relapse as the preferred management for all patients with clinical stage I nonseminomatous germ cell tumors (NSGCT). OBJECTIVE: Our aim was to report our overall AS experience and compare outcomes over different periods using this non-risk-adapted approach. DESIGN, SETTING, AND PARTICIPANTS: Three hundred and seventy-one patients with stage I NSGCT were managed by AS from 1981 to 2005. For analysis by time period, patients were divided into two cohorts by diagnosis date: initial cohort, 1981-1992 (n=157), and recent cohort, 1993-2005 (n=214). INTERVENTION: Patients were followed at regular intervals, and treatment was only given for relapse. MEASUREMENTS: Recurrence rates, time to relapse, risk factors for recurrence, disease-specific survival, and overall survival were determined. RESULTS AND LIMITATIONS: With a median follow-up of 6.3 yr, 104 patients (28%) relapsed: 53 of 157 (33.8%) in the initial group and 51 of 214 (23.8%) in the recent group. Median time to relapse was 7 mo. Lymphovascular invasion (p<0.0001) and pure embryonal carcinoma (p=0.02) were independent predictors of recurrence; 125 patients (33.7%) were designated as high risk based on the presence of one or both factors. In the initial cohort, 66 of 157 patients (42.0%) were high risk and 36 of 66 patients (54.5%) relapsed versus 17 of 91 low-risk patients (18.7%) (p<0.0001). In the recent cohort, 59 of 214 patients (27.6%) were high risk and 29 of 59 had a recurrence (49.2%) versus 22 of 155 low-risk patients (14.2%) (p<0.0001). Three patients (0.8%) died from testis cancer. The estimated 5-yr disease-specific survival was 99.3% in the initial group and 98.9% in the recent one. CONCLUSIONS: Non-risk-adapted surveillance is an effective, simple strategy for the management of all stage I NSGCT.

Advantages of using TEM when analysing asbestos in ambient air

Asbestos is an industrial term to describe some fibrous silicate minerals, which belong to the amphiboles or serpentines group. Six minerals are defined as asbestos including: chrysotile (white asbestos), amosite (grunerite, brown asbestos), crocidolite (riebeckite, blue asbestos), anthophyllite, tremolite and actonolite, but only in their fibrous form. In 1973, the IARC (International Agency for Research on Cancer) classified the asbestos minerals as carcinogenic substances (IARC,1973). The Swiss threshold limit (VME) is 0.01 fibre/ml (SUVA, 2007). Asbestos in Switzerland has been prohibited since 1990, but this doesn't mean we are over asbestos. Up to 20'000 tonnes/year of asbestos was imported between the end of WWII and 1990. Today, all this asbestos is still present in buildings renovated or built during that period of time. During restorations, asbestos fibres can be emitted into the air. The quantification of the emission has to be evaluated accurately. To define the exact risk on workers or on the population is quite hard, as many factors must be considered. The methods to detect asbestos in the air or in materials are still being discussed today. Even though the EPA 600 method (EPA, 1993) has proved itself for the analysis of bulk materials, the method for air analysis is more problematic. In Switzerland, the recommended method is VDI 3492 using a scanning electron microscopy (SEM), but we have encountered many identifications problems with this method. For instance, overloaded filters or long-term exposed filters cannot be analysed. This is why the Institute for Work and Health (IST) has adapted the ISO10312 method: ambient air - determination of asbestos fibres - direct-transfer transmission electron microscopy (TEM) method (ISO, 1995). Quality controls have already be done at a French institute (INRS), which validate our practical experiences. The direct-transfer from MEC's filters on TEM's supports (grids) is a delicate part of the preparation for analysis and requires a lot of trials in the laboratory. IST managed to do proper grid preparations after about two years of development. In addition to the preparation of samples, the micro-analysis (EDX), the micro-diffraction and the morphologic analysis (figure 1.a-c) are also to be mastered. Theses are the three elements, which prove the different features of asbestos identification. The SEM isn't able to associate those three analyses. The TEM is also able to make the difference between artificial and natural fibres that have very similar chemical compositions as well as differentiate types of asbestos. Finally the experiments concluded by IST show that TEM is the best method to quantify and identify asbestos in the air.

Age and adverse drug reactions from psychopharmacological treatment: Data from the AMSP drug surveillance programme in Switzerland.

QUESTION UNDER STUDY: The frequency of severe adverse drug reactions (ADRs) from psychotropic drugs was investigated in hospitalised psychiatric patients in relation to their age. Specifically, the incidence of ADRs in patients up to 60 years was compared to that of patients older than 60 years. METHODS: Prescription rates of psychotropic drugs and reports of severe ADRs were collected in psychiatric hospitals in Switzerland between 2001 and 2010. The data stem from the drug surveillance programme AMSP. RESULTS: A total of 699 patients exhibited severe ADRs: 517 out of 28,282 patients up to 60 years (1.8%); 182 out of 11,446 elderly patients (1.6%, ns). Logistic regression analyses showed a significantly negative relationship between the incidence of ADRs and patients' age in general and in particular for weight gain, extrapyramidal motor system (EPMS) symptoms, increased liver enzymes and galactorrhoea. A significantly negative relationship was observed for age and the dosages of olanzapine, quetiapine, risperidone, valproic acid and lamotrigine. When comparing age groups, frequency of ADRs was lower in general for antipsychotic drugs and anticonvulsants, in particular for valproic acid in the elderly. Weight gain was found to be lower in the elderly for antipsychotic drugs, in particular for olanzapine. For the group of mood-stabilising anticonvulsants (carbamazepine, lamotrigine and valproic acid) the elderly exhibited a lower incidence of reported allergic skin reactions. CONCLUSION: The results suggest that for psychiatric inpatients the incidence of common severe ADRs (e.g., weight gain or EPMS symptoms) arising from psychotropic medication decreases with the age of patients.

Surveillance post-professionnelle : enjeux, modalités et obstacles

La mise en place d'un suivi post-professionnel, par le médecin traitant, des travailleurs exposés à certaines substances toxiques à effets différés (agents cancérogènes et agents pneumoconiogènes) est indispensable. Toutefois, c'est encore un dispositif complexe actuellement sous-utilisé par les ex-salariés qui pourraient ou devraient en bénéficier.

Thirteen years of surgical site infection surveillance in Swiss hospitals

Contexte : Les infections du site opératoire (Surgical Site Infections - SSI) sont des complications fréquentes des procédures chirurgicales et un problème majeur de la santé publique. La surveillance constitue un élément essentiel de la prévention des SSI. Les résultats publiés récemment par certains pays européens suggèrent un impact positif qu'un réseau de surveillance active peut avoir sur le taux de SSI dans les hôpitaux participants. Objectif : La présente étude évalue les effets de la surveillance sur l'incidence des SSI en analysant les résultats du programme suisse multicentrique de surveillance des SSI. Méthodes : L'étude porte sur les 13 premières années du programme, regroupant au total 23 hôpitaux périphériques, cantonaux et universitaires de la Suisse occidentale et du sud. Ce programme, qui a intégré le consortium national Swissnoso en 2011, a été organisé conformément aux principes du système américain de National Nosocomial Infections Surveillance (NNIS). La surveillance incluait les procédures de la chirurgie viscérale (appendicectomie, cholécystectomie, chirurgie du colon et herniaire) et de l'orthopédie (arthroplastie de la hanche et du genou). Les données démographiques et cliniques étaient recueillies de manière standardisée par les infirmières cliniciennes en infectiologie pendant et après l'hospitalisation. Les rapports annuels, résumant les taux des SSI pour chaque type de procédure ainsi que la comparaison inter-hospitalière des risques relatifs ajustés à l'index NNIS, ont été discutés au sein de chaque établissement entre le comité des chirurgiens et le responsable local du programme. Analyses statistiques : Les taux cumulatifs des SSI ont été calculés pour chaque procédure chirurgicale. Une stratification selon le type de SSI (superficielle, profonde, organe/espace) et selon l'index NNIS a été respectée. Les facteurs de risque des SSI ont été identifiés pour chaque procédure par les analyses univariées des caractéristiques du patient (âge, sexe, score ASA, temps avant l'opération) et celles de l'opération (classe de contamination, durée de la chirurgie, urgence, antibioprophylaxie, laparoscopie, procédures multiples, ré¬intervention). Afin d'évaluer l'effet de la durée de la surveillance sur le taux des SSI, le temps de participation au programme a été calculé et stratifié par périodes d'un an par hôpital et par procédure. La corrélation entre la durée de la surveillance et les SSI a été estimée en utilisant les modèles de régression logistique pour chaque procédure avec l'ajustement pour les variables avec p ^ 0.2. Dans toutes les analyses, la valeur p < 0.05 était considéré significative. Résultats : Les taux globaux des SSI étaient : 18.2% pour les colectomies, 6.4% pour les appendicectomies, 2.3% pour les cholécystectomies, 1.7% pour les cures des hernies et 1.6% et 1.3% pour les arthroplasties de la hanche et du genou, respectivement. L'incidence des SSI post-hospitalières allait du 21% pour les colectomies au 94% pour les arthroplasties du genou. Concernant les facteurs prédictifs des SSI, l'index NNIS était valable seulement pour la chirurgie gastro-intestinale, la laparoscopie étant globalement protectrice mais associée à un taux d'infections profondes plus élevé après l'appendicectomie. La durée de la participation au programme de surveillance n'apportait pas de diminution des taux des SSI dans aucune procédure incluse dans l'étude. Conclusions : L'étude confirme l'impact de la surveillance post-hospitalière sur le taux des SSI, l'effet protectrice de la laparoscopie ainsi que l'absence de la valeur prédictive de l'index NNIS en orthopédie. Contrairement aux autres programmes européens nous n'avons pas détecté d'effet positif de la durée de la surveillance sur le taux des SSI. Les résultats obtenus ouvrent la discussion sur l'utilisation plus effective des données de surveillance des SSI.

Anthropogenic radionuclides in atmospheric air over Switzerland during the last few decades.

The atmospheric nuclear testing in the 1950s and early 1960s and the burn-up of the SNAP-9A satellite led to large injections of radionuclides into the stratosphere. It is generally accepted that current levels of plutonium and caesium radionuclides in the stratosphere are negligible. Here we show that those radionuclides are present in the stratosphere at higher levels than in the troposphere. The lower content in the troposphere reveals that dry and wet deposition efficiently removes radionuclides within a period of a few weeks to months. Since the stratosphere is thermally stratified and separated from the troposphere by the tropopause, radioactive aerosols remain longer. We estimate a mean residence time for plutonium and caesium radionuclides in the stratosphere of 2.5-5 years. Our results also reveal that strong volcanic eruptions like Eyjafjallajökull in 2010 have an important role in redistributing anthropogenic radionuclides from the stratosphere to the troposphere.

Antigen presentation in the lung: dendritic cells and macrophages.

Antigen presentation is a required prime event before T-cell activation can occur. Cells which constitutively express major histocompatibility antigen class I or II are responsible for presenting antigens. These are essentially alveolar macrophages (AM) residing mostly in the air spaces, and dendritic cells (DC), which create a tight surveillance network just below the epithelial cells of the airways and in the loose connective tissue around the vessels or in the pleura. AM are poor antigen presenting cells compared to DC. AM when encountering foreign particles or organisms may, however, influence the degree of activity or maturation of neighbouring DC, by releasing cytokines. Thus, we will describe how the innate immune processes may influence specific immunity and perhaps Th1 and Th2 differentiation. Following the description of the differences in phenotype and functions of AM and DC, we will provide data showing that in some pathological conditions, such as sarcoidosis, AM can acquire some specificities of DC.

Influence de la topographie et des accumulations d'air froid sur les températures moyennes mensuelles et annuelles en Suisse

Les températures moyennes mensuelles et annuelles mesurées à 177 endroits de la Suisse ont été ramenées à une même altitude à l'aide d'une formule empirique afin de détecter les influences de la topographie locale sur ce paramètre. Ces calculs ont montré que des accumulations d'air froid influencent fortement les températures moyennes en saison froide au fond de certaines vallées alpines larges et dépressions du Jura sur une épaisseur d'environ 100 mètres. Le déficit thermique dans ces vallées peut atteindre 2 à 3°C à l'échelle annuelle et 5 à 7°C en hiver comparativement aux versants et sommets environnants. Ces accumulations d'air froid n'influencent que peu les températures moyennes dans les vallées étroites et bien ventilées.

Quantitative antibiogram as a typing method for the prospective epidemiological surveillance and control of MRSA: comparison with molecular typing.

OBJECTIVE: Evaluation of the quantitative antibiogram as an epidemiological tool for the prospective typing of methicillin-resistant Staphylococcus aureus (MRSA), and comparison with ribotyping. METHODS: The method is based on the multivariate analysis of inhibition zone diameters of antibiotics in disk diffusion tests. Five antibiotics were used (erythromycin, clindamycin, cotrimoxazole, gentamicin, and ciprofloxacin). Ribotyping was performed using seven restriction enzymes (EcoRV, HindIII, KpnI, PstI, EcoRI, SfuI, and BamHI). SETTING: 1,000-bed tertiary university medical center. RESULTS: During a 1-year period, 31 patients were found to be infected or colonized with MRSA. Cluster analysis of antibiogram data showed nine distinct antibiotypes. Four antibiotypes were isolated from multiple patients (2, 4, 7, and 13, respectively). Five additional antibiotypes were isolated from the remaining five patients. When analyzed with respect to the epidemiological data, the method was found to be equivalent to ribotyping. Among 206 staff members who were screened, six were carriers of MRSA. Both typing methods identified concordant of MRSA types in staff members and in the patients under their care. CONCLUSIONS: The quantitative antibiogram was found to be equivalent to ribotyping as an epidemiological tool for typing of MRSA in our setting. Thus, this simple, rapid, and readily available method appears to be suitable for the prospective surveillance and control of MRSA for hospitals that do not have molecular typing facilities and in which MRSA isolates are not uniformly resistant or susceptible to the antibiotics tested.