[Hand hygiene: first measure to control nosocomial infection]. / Hygiène des mains: Première mesure pour la maîtrise des infections nosocomiales.

Hand hygiene prevents cross infection in hospi tals, however adherence to guidelines is commonly poor. The hand-hygiene promotion programme started on May 2004 at the University Hospital of Liège after a baseline survey of compliance. We attempted to promote hand hygiene and most par ticularly alcohol-based hand disinfection. We measured MRSA transmission rates and consumption of alcohol-based handrub solution and soap in parallel. During the campaign, consump tion of alcohol-based handrub solution and soap increased by 56% and 24% respectively and MRSA transmission rates decreased from 11,04 to 7,07 cases per 1000 admissions.

[The Hemovigilance Commission of the University Hospital Center]. / La commission d'hémovigilance du CHU.

As suggested by the National Blood Council, a Hemovigilance Committee was set up in the University Hospital of Liège in 1995. A multidisciplinary discussion takes place on any action aiming at the improvement of transfusion safety, and the follow-up of its implementation. The first issue to be discussed was the set up of a detailed documentation of all blood transfusions. The data are now recorded on a single document allowing proper identification of people and products involved, and of the eventual incidents. This document has lead to a better transfusion safety and to an improved administrative management of blood transfusion. The Commission has been coordinating two multi-centric studies analyzing the consumption of fresh blood products and the incidence of transfusion reactions. Among blood-saving policies, autologous transfusion and volume reduction of samples drawn for laboratory purposes have been discussed. Other measures were taken to improve the labeling of samples for cross-mach and to actively follow-up transfusion reactions. By its actions and advises, the Commission aims to direct strategies towards a safe and rational use of blood products.

Treatment of superficial bladder tumors: achievements and needs. The EORTC Genitourinary Group.

OBJECTIVE: The therapeutic objectives in the initial treatment of superficial tumors are to remove completely the tumor, to assess the need for further therapy and to plan the follow-up. METHODS/RESULTS: The EORTC Genitourinary Group assessed the percentage of patients with recurrence at 3 months (3RR) after complete resection of all visible lesions taking into account the institution, the number of tumors at presentation and the year of treatment. The 3RR was considered for 18 institutions. For single tumors, the 3RR varied from 0 to 36% and for multiple tumors from 7 to 75%. The 3RR by number of tumors was 8.7% for single tumors, 21% for 2-5 tumors and 32.2% for >5 tumors. The 3RR by year of entry for single tumors ranged from 21.0 to 43.8% during 1975-1978, from 6.3 to 12.7% during 1984-1986 and from 3 to 5.3% during 1987-1989. For multiple tumors it ranged from 50.0 to 61.5% during 1975-1978, from 20.2 to 27.3% during 1979-1983 and from 14.4 to 24.6% during 1984- 1986. The use of more refined instruments probably led to the decreasing percentage of the 3RR in more recent years, the large variation between institutions remains unexplained. The bladder's unique location renders its mucosa accessible to instillation of chemotherapeutic and immunotherapeutic agents. Cytostatics can be instilled into the bladder hours after surgery without severe complications. A single early instillation within 6 h after transurethral resection (TUR) in patients with a solitary bladder tumor category T(a)/T(1)G(1) to G(3) could reduce the recurrence rate per year by nearly 50%. The superiority of any of the commonly used intravesical drugs has never been demonstrated; the time to initiate therapy is important for treatment outcome. Optimal results can be achieved by initiating treatment early (within 24 h after TUR) and for a duration of 6 months, and maintenance (>6 months) for patients with a delayed first instillation (>7 days after TUR). Bacillus Calmette-Guérin (BCG) immunotherapy has been confirmed to be highly effective in the reduction of tumor recurrence, the treatment of residual papillary transitional cell carcinoma and the treatment of carcinoma in situ (CIS). The response rate in the treatment of the papillary disease averages 55%, and for CIS 73%. In the prevention of tumor recurrence the relative benefit of BCG is 45%. A direct prospective randomized comparison of BCG with intravesical chemotherapy has found it to be significantly superior to thiotepa, to doxorubicin and to mitomycin C when only patients with intermediate and high risk for recurrence were treated. In studies including patients with low recurrence risk, no advantage for BCG was found. Clinical trials showed no superiority of BCG immunotherapy to chemotherapy in preventing progression to > or =T(2). CONCLUSIONS: Investigation of the concept of chemoimmunotherapy up to now lacked evidence of advantages for this approach. Preventive regulatory measures directed to decrease tobacco smoking and some occupational exposures to aromatic amines may contribute to the reduction of bladder cancer. Bladder cancer is a multistep process making this tumor a candidate for chemoprevention. To date, retinoids are the best-studied chemopreventive agents achieving mixed clinical results in superficial bladder tumors. The potent apoptosis-inducing retinoid fenretinide is currently in the phase III trials. The follow-up of patients with all types of superficial tumors must be lifelong; unfortunately cystoscopy cannot be replaced yet by the control of any markers present or not in the urine. There is hope this may change in the near future.

Prostate cancer: to screen or not to screen?

Screening of prostate cancer in asymptomatic men over 50 years is subject to discussion. A review of the medical and economical arguments in favor and against screening is given. It is concluded that widespread screening should not be undertaken but that correct information of the population is necessary with an adapted response to individual demands.

A combined analysis of European Organization for Research and Treatment of Cancer, and Medical Research Council randomized clinical trials for the prophylactic treatment of stage TaT1 bladder cancer. European Organization for Research and Treatment of Cancer Genitourinary Tract Cancer Cooperative Group and the Medical Research Council Working Party on Superficial Bladder Cancer.

PURPOSE: The use of prophylactic agents after primary resection can decrease the incidence of tumor recurrence in patients with stage TaT1 bladder cancer. However, the long-term impact on progression to muscle invasive disease as well as on duration of survival is unknown. A combined analysis of individual patient data from previously performed European Organization for Research and Treatment of Cancer (EORTC) and Medical Research Council (MRC) randomized clinical trials was done in an attempt to answer these crucial questions. We compared immediate versus no adjuvant prophylactic treatment after transurethral resection with respect to disease-free interval, time to progression to muscle invasive disease, time to appearance of distant metastases, duration of survival and progression-free survival. MATERIALS AND METHODS: All EORTC and MRC prophylactic, randomized phase III trials with primary or recurrent, stage TaT1 transitional cell bladder cancer that compared transurethral resection alone or with adjuvant prophylactic treatment were included in the study. Four EORTC and 2 MRC trials using intravesical chemotherapy or oral agents and including a total of 2,535 patients were studied. RESULTS: A statistically significant effect of adjuvant treatment over no adjuvant treatment was found in terms of the duration of the disease-free interval (p < 0.01). No clear advantage of adjuvant treatment was shown with respect to progression to invasive disease, time to appearance of distant metastases or duration of survival and progression-free survival. Median survival followup was 7.8 years. CONCLUSIONS: Despite prologation of the disease-free-interval adjuvant treatment has no apparent long-term impact on the evolution of stage TaTi bladder cancer.

Factors affecting recurrence and progression in superficial bladder tumours.

Prognostic factors in superficial bladder tumours are highly correlated with each other. In this study, their relative importance is examined and grouping of patients in three different prognostic groups suggested. 576 patients (from EORTC protocols 30790 and 30782) were analysed. They have been followed from 3 months to 8.6 years with a median of 4 years. 76 patients developed an invasive tumour (> or = T2); the shortest time to invasion was 12 weeks, the longest was 6.6 years. Time from invasion to death ranged from 3 weeks to 4.4 years with a median of 2 years. Prognostic factors contributing to recurrence, invasion and survival were investigated: age, sex, size of largest tumour, number of tumours, T-category, G-grade, time from diagnosis (years), prior recurrence rate/year, site of involvement. The relative importance of these factors was measured by performing a multivariate analysis based on Cox's proportional hazards regression model. Based on the most important prognostic factors and their association with invasion and death, an index was computed reflecting the risk of both invasion and death due to malignant disease, respectively. The index was used to assign patients to one of three prognostic groups. Three main factors determined patient's prognosis: tumour size, G-grade and prior recurrence rate/year. The model coefficients for invasion were 0.51 (recurrence rate < 1/year, 1-3/year, > 3/year), 84 (grade 1, 2, 3), 0.48 (size < 1.5, 1.5-3, > 3 cm) and for death due to malignant disease 0.89 (recurrence rate), 0.73 (grade) and 0.44 (size), respectively. Risk groups are suggested based on the index. Additional treatment in patients with superficial transitional cell carcinoma of the bladder may be decided depending on the risk group to which the patient belongs.

Intravesical adjuvant chemotherapy for superficial transitional cell bladder carcinoma: results of 2 European Organization for Research and Treatment of Cancer randomized trials with mitomycin C and doxorubicin comparing early versus delayed instillations and short-term versus long-term treatment. European Organization for Research and Treatment of Cancer Genitourinary Group.

The European Organization for Research and Treatment of Cancer genitourinary group has completed 2 parallel prospective randomized studies, one with 30 mg. mitomycin C and the other with 50 mg. doxorubicin as adjuvant intravesical treatment after transurethral resection of superficial transitional cell bladder carcinoma. These studies were designed to compare early (the day of resection) versus delayed (between 7 and 15 days after resection) instillations and short-term (6 months) versus long-term (12 months) treatment. The results indicate that in regard to recurrence rate patients having a delayed and short-term treatment do worse than those having early instillations (for 6 or 12 months) or those having prolonged treatment (either immediate or delayed). With an average followup of 4 years survival, progression beyond T1 disease, development of distant metastases and appearance of a second primary were not influenced by the therapeutic regimen. A multivariate analysis of prognostic factors is presented, which indicates that after adjustment for these factors, patients in the delay, no maintenance arm have a significantly higher recurrence rate than the other patients.

EORTC (30885) randomised phase III study with recombinant interferon alpha and recombinant interferon alpha and gamma in patients with advanced renal cell carcinoma. The EORTC Genitourinary Group.

In the treatment of renal cell carcinoma both complete (CRs) and partial remissions (PRs) have been obtained using recombinant (r) interferon alpha (IFN-alpha), with response rates ranging from 0 to 31% (mean 16%). rIFN-gamma is a potent immunostimulating agent, but the clinical experience of its use is limited and results are conflicting. In a phase II study with the combination of rIFN-alpha 2c (Boehringer Ingelheim) and rIFN-gamma (Genentech, supplied by Boehringer Ingelheim) in 31 eligible patients, a response rate of 25% was recorded. Based on this observation a randomised phase III study was initiated to investigate the possible advantage of the addition rIFN-gamma to rIFN-alpha 2c treatment. Treatment consisted of rIFN-alpha 2c 30 micrograms m-2 = 10 x 10(6) IU m-2 s.c. twice weekly in arm A and the same dose of rIFN-alpha combined with rIFN-gamma 100 micrograms m-2 = 2 x 10(6) IU m-2 in arm B. Eligibility criteria included documented progression of disease; patients with bone lesions only and overt central nervous system metastases were excluded. Between November 1988 and September 1990, 102 patients were entered into the study. An interim analysis showed a response in 7/53 (13%) patients (two CRs and five PRs) in the rIFN-alpha 2c monotherapy arm and in 2/45 (4%) (one CR and one PR) patients in the combination arm. This difference was not statistically significant (P = 0.17). The probability of missing an eventual 10% advantage for the combination is 0.001. The numbers are insufficient to rule out a negative effect of the addition of rIFN-gamma. The dose intensity of IFN-alpha 2c for the two treatment arms was the same. The addition of rIFN-gamma does not improve the response rate of rIFN-alpha 2c monotherapy. A possible detrimental effect cannot be excluded.

The experience of the CHU Liège with conservative surgery in the management of upper urinary tract tumors.

A review of 20 cases of conservative surgery for urothelial tumors of the upper tract is presented. The morbidity is limited; the recurrence rate is around 15% in the ipsilateral urinary tract with a mean follow up of 41 months. Conservative surgery does not seem to carry a higher fatal risk as compared to more radical surgery. It has indications in some cases which are defined.

The experience of radical prostatectomy for locally confined prostate cancer in Liège.

The authors report their experience of 148 radical prostatectomies performed for adeno-carcinoma. They expose the reasons which have led them to adopt this kind of treatment and the reasons explaining a nearly exponential increase of the frequency of the operation during the last 5 years. They underline the importance of lymphadenectomy and the safety of frozen sections of the nodes. The surgical technique is briefly commented and the (low) morbidity of the operation is reviewed. They compare the results of RPV to those of external radiotherapy, watchful attitude or immediate hormonal treatment and they conclude in insisting on the benefit of the surgical approach as far as indications (which are defined) are strictly followed.

Adjuvant chemotherapy of recurrent superficial transitional cell carcinoma: results of a European organization for research on treatment of cancer randomized trial comparing intravesical instillation of thiotepa, doxorubicin and cisplatin. The European Organization for Research on Treatment of Cancer Genitourinary Group.

A total of 356 patients with recurrent superficial transitional cell carcinoma of the bladder was entered in a randomized clinical trial to compare intravesical thiotepa, doxorubicin and cisplatin with respect to the recurrence rate and disease-free interval. After complete transurethral resection of all visible lesions, the drugs were administered weekly for 4 weeks and monthly for 11 months. The recurrence rates per year were 0.50 for thiotepa, 0.54 for doxorubicin and 0.58 for cisplatin. Of 266 patients (mean followup 41 months) 35 reported an increase in T category and 19 of them had distant metastases. No association between treatment and progression was noted. Thus, there is no difference among treatments with respect to efficacy. However, severe anaphylactic reactions were observed in the cisplatin arm and chemical cystitis was more frequently reported in patients who received doxorubicin.

Original lithotomy positioning for transperineal extracorporeal shockwave lithotripsy for distal ureteric calculi with Tripter X1.

Extracorporeal shockwave lithotripsy (ESWL) has been initially designed for stones located in the kidney and the upper ureter. Our lithotripter is no exception. Its components (the table and the orientation of the semi-ellipsoid reflector) are adapted for the treatment of kidney or lumbar ureter stones. However, the elements forming the unit of treatment (the table, the C-arm and the Tripter) can be modified in such a way that focalization of stones of the lower ureter becomes possible through a perineal exposure. The aim is to avoid the pelvic bone shield while a good focalization of the stone is realized. From June 1989 to March 1991, 35 patients were treated for distal ureteric stones by ESWL in this original positioning.