The International Network of Obstetric Survey Systems study of uterine rupture: a descriptive multi-country population-based study.

OBJECTIVE: International comparison of complete uterine rupture. DESIGN: Descriptive multi-country population-based study. SETTING: International. POPULATION: International Network of Obstetric Survey Systems (INOSS). METHODS: We merged individual data, collected prospectively in nine population-based studies, of women with complete uterine rupture, defined as complete disruption of the uterine muscle and the uterine serosa, regardless of symptoms and rupture of fetal membranes. MAIN OUTCOME MEASURES: Prevalence of complete uterine rupture, regional variation and correlation with rates of caesarean section (CS) and trial of labour after CS (TOLAC). Severe maternal and perinatal morbidity and mortality. RESULTS: We identified 864 complete uterine ruptures in 2 625 017 deliveries. Overall prevalence was 3.3 (95% CI 3.1-3.5) per 10 000 deliveries, 22 (95% CI 21-24) in women with and 0.6 (95% CI 0.5-0.7) in women without previous CS. Prevalence in women with previous CS was negatively correlated with previous CS rate (ρ = -0.917) and positively correlated with TOLAC rate of the background population (ρ = 0.600). Uterine rupture resulted in peripartum hysterectomy in 87 of 864 women (10%, 95% CI 8-12%) and in a perinatal death in 116 of 874 infants (13.3%, 95% CI 11.2-15.7) whose mother had uterine rupture. Overall rate of neonatal asphyxia was 28% in neonates who survived. CONCLUSIONS: Higher prevalence of complete uterine ruptures per TOLAC was observed in countries with low previous CS and high TOLAC rates. Rates of hysterectomy and perinatal death are about 10% following complete uterine rupture, but in women undergoing TOLAC the rates are extremely low (only 2.2 and 3.2 per 10 000 TOLACs, respectively.) TWEETABLE ABSTRACT: Prevalence of complete uterine rupture is higher in countries with low previous CS and high TOLAC rates.

Reduction in advanced breast cancer after introduction of a mammography screening program in Tyrol/Austria.

BACKGROUND: We analysed all female breast cancer (BC) cases in Tyrol/Austria regarding the shift in cancer characteristics, especially the shift in advanced BC, for the group exposed to screening as compared to the group unexposed to screening. METHODS: The analysis was based on all BC cases diagnosed in women aged 40-69 years, resident in Tyrol, and diagnosed between 2009 and 2013. The data were linked to the Tyrolean mammography screening programme database to classify BC cases as "exposed to screening" or "unexposed to screening". Age-adjusted relative risks (RR) were estimated by relating the exposed to the unexposed group. RESULTS: In a total of about 145,000 women aged 40-69 years living in Tyrol during the study period, 1475 invasive BC cases were registered. We estimated an age-adjusted relative risk (RR) for tumour size ≥ 21 mm of 0.72 (95% confidence interval (CI) 0.60 to 0.86), for metastatic BC of 0.27 (95% CI 0.17 to 0.46) and for advanced BC of 0.83 (95% CI 0.71 to 0.96), each comparing those exposed to those unexposed to screening, respectively. CONCLUSION: In our population-based registry analysis we observed that participation in the mammography screening programme in Tyrol is associated with a 28% decrease in risk for BC cases with tumour size ≥ 21 mm and a 17% decrease in risk for advanced BC. We therefore expect the Tyrolean mammography programme to show a reduction in BC mortality.

Decrease in mortality of adult epilepsy patients since 1980: lessons learned from a hospital-based cohort.

BACKGROUND AND PURPOSE: Data on mortality in patients with epilepsy have been available since the 1800s. They consistently show a 2-3-fold increase compared to the general population. Despite major advances in diagnostic tools and treatment options, there is no evidence for a decrease in premature deaths. The temporal trend of mortality in a hospital-based epilepsy cohort over three decades was assessed. METHODS: A hospital-based incidence cohort was recruited from a specialized epilepsy outpatient clinic at Innsbruck Medical University between 1980 and 2007, divided by decade into three cohorts and followed for 5 years after initial epilepsy diagnosis. Deaths and their primary causes were determined using probabilistic record linkage with the Austrian death registry. Age-, sex- and period-adjusted standardized mortality rates (SMRs) were computed in relation to the general population of the same area and grouped according to time of diagnosis. RESULTS: In all, 122 deaths in 4549.9 person-years (1954.5 women, 2595.2 men) were identified. The overall SMR was 2.2 [95% confidence interval (CI) 1.8-2.6] and decreased from 3.0 (95% CI 2.1-4.3) in 1980-1989, to 2.7 (95% CI 2.0-3.5) in 1990-1999 and to 1.4 (95% CI 1.0-2.0) in 2000-2007. CONCLUSIONS: This study indicates a decrease in mortality in newly diagnosed epilepsy patients over the last three decades. This may be due to advances in diagnosis and treatment over the past three decades, including early identification of drug resistance, introduction of new anti-epileptic drugs and establishment of a comprehensive epilepsy surgery programme in this region.

Small steps of improvement in small-cell lung cancer (SCLC) within two decades: a comprehensive analysis of 484 patients.

BACKGROUND: It is not clear whether or not the fate of patients suffering from small-cell lung cancer (SCLC) has improved. To better understand the course of disease, we aimed at documenting disease features at initial diagnosis, sequences of therapy modalities and outcome in consecutive patients over two decades. We postulated that SCLC patients might have benefitted from refined diagnosis and treatment options during the last decade. METHODS: All SCLC cases diagnosed at the Innsbruck University Hospital and associated institutions between 1991 and 2011 have been documented in detail in accordance with a prespecified protocol. RESULTS: A total of 484 patients diagnosed with SCLC were followed. The most important symptoms at initial diagnosis were cough, dyspnea and tumor pain in 55%, 51% and 44%, respectively. Patients who were operated during early stage of disease (n = 26) had a favorable 5-year, relapse-free survival (74%). A total of 112 patients with locally advanced disease were treated by radiochemotherapy in curative intent (RCT), and achievement of CR offered a chance of long term overall survival (OS), reaching 44% after 10-years. In the palliative setting (median OS in 304 evaluable patients, 9.7 months), a therapeutic progress in the more recent decade could not be observed. Parameters independently associated with favorable OS were: response to therapy and prophylactic brain irradiation in patients with RCT; and response, age < 70 years and absence of LDH elevation in the palliative setting. CONCLUSIONS: In this comprehensive view on SCLC, the findings on symptomatology, comorbidity, and spectrum of treatments may help to better understand individual courses of the disease. Overall, modern medicine failed to translate into substantial benefit of SCLC patients, except in patients in locally advanced disease receiving multimodal therapy.

[Perinatal mortality by mother's country of origin in Tyrol 2000-2008]. / Perinatale Mortalität nach Herkunftsland der Mutter in Tirol 2000-2008.

INTRODUCTION: This study analyses for the first time the Tyrolean perinatal mortality stratified by the country of origin of the mother. Data of the Tyrolean birth registry were evaluated from 2000-2008. The aim of our study was to analyse differences in perinatal mortality according to the country of origin of the mother. METHODS: 58 787 single births were assessed between the years 2000-2008. Mothers with similar experiences of how to access the health-care system were aggregated into 5 groups: (1) "Tyrol/Austria", (2) "western Europe/West", (3) "former Yugoslavia/eastern Europe", (4) "Turkey" and (5) "other countries". The odds ratio for perinatal mortality according to the country of origin of the mother was calculated in a multivariate model. The following independent variables were included: age of mother at birth, parity, housewife during pregnancy, week of gestation at the first check-up visit, smoking, preterm delivery and weight of the newborn. RESULTS: The number of mothers of Tyrolean/Austrian origin decreased over the years by 2% whereas the number of mothers from Western Europe/West increased by 3%. The other migration groups remained constant or were slightly decreased. In the multivariate model; the perinatal mortality [odds ratio (CI)] was for the subgroups "Turkey" 1.06 (0.61-1.83) and for "western Europe/West" 1.09 (0.64-1.86), and therefore almost identical with the reference subgroup "Tyrol/Austria" (OR=1); the perinatal mortality was significantly increased with 2.14 (1.37-3.34) for the subgroup "former Yugoslavia/eastern Europe and for the subgroup "other countries" 2.54 (1.21-5.36). The variables "age under 18 years" OR 1.99 (0.80-4.93) and "mulitpara" OR 1.30 (0.96-1.74) were not significantly increased. Significantly increased was "preterm delivery" OR 4.53 (2.80-7.33) and "low birthweight" (<1 500 g) OR 53.60 (32.02-89.73) and 1 500 to 2 499 g OR 4.85 (2.96-7.96). There are considerable differences comparing the odds ratios between the 5 subgroups for perinatal mortality. The subgroups "Turkey" and "western Europe/West" have a similar odds ratio compared to the reference group "Tyrol/Austria". The subgroups "former Yugoslavia" and "other countries" have a significantly increased perinatal mortality (OR 2-2.5). CONCLUSION: The good outcome of the mothers from "Turkey" can be seen as similar to the "Latina paradoxon", which means a better outcome of pregnancy and birth of mothers from "Turkey", even though they are more comparable with other migrant groups in some risk factors, such as a lower socioeconomic standard, late check-ups, language difficulties and cultural factors. A single case analysis would be necessary to examine the exact causes.

Time-dependent association of total serum cholesterol and cancer incidence in a cohort of 172,210 men and women: a prospective 19-year follow-up study.

BACKGROUND: The relationship between serum cholesterol and cancer incidence remains controversial. PATIENTS AND METHODS: We investigated the association of total serum cholesterol (TSC) with subsequent cancer incidence in a population-based cohort of 172 210 Austrian adults prospectively followed up for a median of 13.0 years. Cox regression, allowing for time-dependent effects, was used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (95% CIs) for the association of TSC with cancer. RESULTS: We observed pronounced short-term associations of TSC and overall cancer incidence in both men and women. For malignancies diagnosed shortly (<5 months) after baseline TSC measurement, the highest TSC tertile (>235.0 mg/dl in men and >229.0 in women) compared with the lowest tertile (<194.0 mg/dl in men and <190.0 in women) was associated with a significantly lower overall cancer risk [HR = 0.58 (95% CI 0.43-0.78, P(trend) = 0.0001) in men, HR = 0.69 (95% CI 0.49-0.99, P(trend) = 0.03) in women]. However, after roughly 5 months from baseline measurement, overall cancer risk was not significantly associated with TSC. The short-term inverse association of TSC with cancer was mainly driven by malignancies of the digestive organs and lymphoid and hematopoietic tissue. CONCLUSION: The short-term decrease of cancer risk seen for high levels of TSC may largely capture preclinical effects of cancer on TSC.

The advantage of women in cancer survival: an analysis of EUROCARE-4 data.

We analysed 1.6 million population-based EUROCARE-4 cancer cases (26 cancer sites, excluding sex-specific sites, and breast) from 23 countries to investigate the role of sex in cancer survival according to age at diagnosis, site, and European region. For 15 sites (salivary glands, head and neck, oesophagus, stomach, colon and rectum, pancreas, lung, pleura, bone, melanoma of skin, kidney, brain, thyroid, Hodgkin disease and non-Hodgkin's lymphoma) age- and region-adjusted relative survival was significantly higher in women than men. By multivariable analysis, women had significantly lower relative excess risk (RER) of death for the sites listed above plus multiple myeloma. Women significantly had higher RER of death for biliary tract, bladder and leukaemia. For all cancers combined women had a significant 5% lower RER of death. Age at diagnosis was the main determinant of the women's advantage, which, however, decreased with increasing age, becoming negligible in the elderly, suggesting that sex hormone patterns may have a role in women's superior ability to cope with cancer.

Weight change and cancer risk in a cohort of more than 65,000 adults in Austria.

BACKGROUND: To investigate relations between weight loss or weight gain and the incidence of cancer. PATIENTS AND METHODS: Weight change was assessed in a population-based cohort of >65 000 Austrian adults (28 711 men and 36 938 women) for a period of 7 years, after which participants were followed for incident cancers over 8 years on average. Incident cancers (other than nonmelanoma skin cancers) were ascertained by a population-based cancer registry (n = 3128). Cox proportional hazards models were used to estimate hazard rate ratios (HRs) stratified by age and adjusted for smoking, occupational group, blood glucose and body mass index at baseline. RESULTS: In both men and women, neither weight loss nor weight gain was clearly associated with the incidence of all cancers combined. Weight loss (>0.10 kg/m(2)/year) was inversely associated with colon cancer in men [HR 0.50; 95% confidence interval (CI) 0.29-0.87], while high weight gain (> or =0.50 kg/m(2)/year) was inversely associated with prostate cancer (HR 0.43; 95% CI 0.24-0.76). Among women, high weight gain was positively associated with ovarian cancer (HR 2.48; 95% CI 1.05-5.85). CONCLUSION: These findings indicate that recent weight change may influence the incidence of several types of cancer.

The role of serum uric acid as an antioxidant protecting against cancer: prospective study in more than 28 000 older Austrian women.

BACKGROUND: It has been hypothesized that serum uric acid (SUA), via its antioxidant properties may protect against carcinogenesis. However, few epidemiological investigations have addressed this association and previous findings are inconsistent. PATIENTS AND METHODS: We prospectively investigated the relation of SUA levels to subsequent cancer mortality in a large cohort of 28613 elderly Austrian women with a median follow-up of 15.2 years. Adjusted Cox proportional hazards models were calculated to evaluate SUA as an independently related factor to fatal cancer events. RESULTS: High SUA (>5.41 mg/dL) was independently associated with increased risk of total cancer mortality (p<0.0001); the adjusted hazard ratio for the highest versus lowest quartile of SUA was 1.27 (1.08-1.48). SUA levels were further positively related to deaths from malignant neoplasms of breast and female genital organs (P = 0.02) and nervous system and unspecified sites (P = 0.02). We found no evidence for an inverse relationship between SUA levels and risk of total or site-specific cancer mortality. CONCLUSION: Our results are contrary to the proposed antioxidant and protective effect of SUA against cancer and rather suggest high SUA concentrations to be associated with outcome possibly reflecting more serious prognostic indication.

Errors in survival rates caused by routinely used deterministic record linkage methods.

OBJECTIVE: It was the objective of this study to assess the impact of applying various record linkage methods to one of the most important outcome measures in oncological epidemiology, namely survival rates. METHODS: To assess the life status of patients, incidence data published by the Cancer Registry of Tyrol were analyzed with three routinely used methods of record linkage for incidence and mortality data. Of these methods, two were deterministic and the third a probabilistic method developed by the Cancer Registry of Tyrol. We studied the impact of record linkage methods on a simple measure (mortality rate) and a more complex measure (relative survival rate). The analysis was based on the published incidence data for Tyrol for the years 1992 to 1996. Results of deterministic record linkage methods were simulated. RESULTS: The error rates for simple mortality rate and relative survival rate are considerable. For the first deterministic record linkage method, relative differences in mortality rate range from 11.9% to 14.8% (men) and 24.5% to 28.2% (women) and relative differences in relative five-year survival from 11.4% to 16.3% (men) and from 19.3% to 26.4% (women). For the second deterministic record linkage method, relative differences in mortality rate range from 4.8% to 5.9% (men) and from 4.9% to 7.4% (women), while relative differences in relative five-year survival range from 5.1% to 7.0% (men) and from 4.4% to 6.1% (women). CONCLUSIONS: Our study shows that in order to calculate valid mortality and survival rates a probabilistic method of record linkage must be applied.

Fasting blood glucose and cancer risk in a cohort of more than 140,000 adults in Austria.

AIMS/HYPOTHESIS: We investigated relations between fasting blood glucose and the incidence of cancer. METHODS: A population-based cohort of more than 140,000 Austrian adults (63,585 men, 77,228 women) was followed over an average of 8.4 years. Incident cancer (other than non-melanoma skin cancers) was ascertained by a population-based cancer registry (n=5,212). Cox proportional-hazards models were used to estimate hazard rate ratios (HR) stratified for age and adjusted for smoking, occupational group and body mass index. RESULTS: The highest fasting blood glucose category (> or =7.0 mmol/l) was weakly associated with all cancers combined (HR 1.20; 95% CI, 1.03-1.39 in men and 1.28; 95% CI, 1.08-1.53 in women) relative to the reference level (4.2-5.2 mmol/l). The strongest association was found for liver cancer in men (HR 4.58; 95% CI, 1.81-11.62). Positive associations between fasting hyperglycaemia (6.1-6.9 or > or =7.0 mmol/l) and cancer incidence were also observed for non-Hodgkin's lymphoma in men, and for colorectal and bladder cancer in women. Breast cancer in women diagnosed at or after age 65 was also associated with fasting blood glucose > or =7.0 mmol/l. Positive associations with glucose values >5.3 mmol/l were noted for thyroid cancer, gallbladder/bile duct cancer and multiple myeloma in men and women combined. CONCLUSIONS/INTERPRETATION: These findings provide further evidence that elevated blood glucose is associated with the incidence of several types of cancer in men and women.

Epidemiology of non-Hodgkin lymphomas in Tyrol/Austria from 1991 to 2000.

AIMS: To analyse the entity specific incidence and disease specific survival (DSS) of non-Hodgkin lymphomas (NHLs) in Tyrol/Austria, 1991-2000. METHODS: Data from 1307 NHLs (excluding primary cutaneous lymphomas and monoclonal gammopathies of undetermined significance) were obtained. Current status was available for all patients. Except for 29 cases of small lymphocytic (CLL/SLL), lymphoblastic leukaemia (ALL), and myeloma (MM), which were diagnosed cytologically, diagnoses were reclassified on paraffin wax embedded archival material according to new World Health Organisation criteria. Sex specific age adjusted standardised incidence rates were computed using Segi's population weighting. Annual incidence changes were calculated by weighted least square regression analysis. Survival was estimated by the Kaplan-Meier method and compared by log rank test. RESULTS: NHL more frequently affected men (male/female ratio, 1.52). Mean age of occurrence was 61 and 66 years for men and women, respectively. The incidence rate of 14.3 remained constant. There was a significant increase in diffuse large B cell lymphoma (DLBCL) and decrease in CLL/SLL in men, and a decrease in MM in women. Overall DSS was 64% during the mean follow up (43 months). Age, T-NHL, lambda light chain restriction in MM, and male sex in CLL/SLL were associated with poor prognosis. In B-NHL, DSS decreased in the following order: hairy cell leukaemia, marginal zone lymphoma, follicular lymphoma, Burkitt lymphoma, ALL, DLBCL, CLL, MM, and mantle cell lymphoma. CONCLUSIONS: The incidence of NHL in Tyrol has changed in the past decade, with a significant increase in DLBCL, decrease in CLL/SLL in men, and decrease in MM in women.

Obesity and incidence of cancer: a large cohort study of over 145,000 adults in Austria.

We investigated the relation of overweight and obesity with cancer in a population-based cohort of more than 145 000 Austrian adults over an average of 9.9 years. Incident cancers (n=6241) were identified through the state cancer registry. Using Cox proportional-hazards models adjusted for smoking and occupation, increases in relative body weight in men were associated with colon cancer (hazard rate (HR) ratio 2.48; 95% confidence interval (CI): 1.15, 5.39 for body mass index (BMI) > or =35 kg m(-2)) and pancreatic cancer (HR 2.34, 95% CI: 1.17, 4.66 for BMI>30 kg m(-2)) compared to participants with normal weight (BMI 18.5-24.9 kg m(-2)). In women, there was a weak positive association between increasing BMI and all cancers combined, and strong associations with non-Hodgkin's lymphomas (HR 2.86, 95% CI: 1.49, 5.49 for BMI> or =30 kg m(-2)) and cancers of the uterine corpus (HR 3.93, 95% CI: 2.35, 6.56 for BMI> or =35 kg m(-2)). Incidence of breast cancer was positively associated with high BMI only after age 65 years. These findings provide further evidence that overweight is associated with the incidence of several types of cancer.

Record linkage in the Cancer Registry of Tyrol, Austria.

OBJECTIVE: Record linkage of patient data originating from various data sources and record linkage for checking uniqueness of patient registration are common tasks for every cancer registry. In Austria, there is no unique person identifier in use in the medical system. Hence, it was necessary and the goal of this work to develop an efficient means of record linkage for use in cancer registries in Austria. METHODS: We adapted the method of probabilistic record linkage to the situation of cancer registries in Austria. In addition to the customary components of this method, we also took into consideration typing errors commonly occurring in names and dates of birth. The method was implemented in a program written in DELPHI(TM) with interfaces optimised for cancer registries. RESULTS: Applying our record linkage method to 130,509 linkages results in 105,272 (80.7%) identical pairs. For these identical pairs, 88.9% of decisions were performed automatically and 11.1% semi-automatically. For results decided automatically, 6.9% did not have simultaneous identity of last name, first name and date of birth. For results decided semi-automatically, 48.4% did not have an identical last name, 25.6% did not have an identical date of birth and 83.1% did not have simultaneous identity of last name and date of birth and first name. CONCLUSIONS: The method implemented in our cancer registry solves all record linkage problems in Austria with sufficient precision.

Radon in homes and risk of lung cancer: collaborative analysis of individual data from 13 European case-control studies.

OBJECTIVE: To determine the risk of lung cancer associated with exposure at home to the radioactive disintegration products of naturally occurring radon gas. DESIGN: Collaborative analysis of individual data from 13 case-control studies of residential radon and lung cancer. SETTING: Nine European countries. SUBJECTS: 7148 cases of lung cancer and 14,208 controls. MAIN OUTCOME MEASURES: Relative risks of lung cancer and radon gas concentrations in homes inhabited during the previous 5-34 years measured in becquerels (radon disintegrations per second) per cubic metre (Bq/m3) of household air. RESULTS: The mean measured radon concentration in homes of people in the control group was 97 Bq/m3, with 11% measuring > 200 and 4% measuring > 400 Bq/m3. For cases of lung cancer the mean concentration was 104 Bq/m3. The risk of lung cancer increased by 8.4% (95% confidence interval 3.0% to 15.8%) per 100 Bq/m3 increase in measured radon (P = 0.0007). This corresponds to an increase of 16% (5% to 31%) per 100 Bq/m3 increase in usual radon--that is, after correction for the dilution caused by random uncertainties in measuring radon concentrations. The dose-response relation seemed to be linear with no threshold and remained significant (P = 0.04) in analyses limited to individuals from homes with measured radon < 200 Bq/m3. The proportionate excess risk did not differ significantly with study, age, sex, or smoking. In the absence of other causes of death, the absolute risks of lung cancer by age 75 years at usual radon concentrations of 0, 100, and 400 Bq/m3 would be about 0.4%, 0.5%, and 0.7%, respectively, for lifelong non-smokers, and about 25 times greater (10%, 12%, and 16%) for cigarette smokers. CONCLUSIONS: Collectively, though not separately, these studies show appreciable hazards from residential radon, particularly for smokers and recent ex-smokers, and indicate that it is responsible for about 2% of all deaths from cancer in Europe.

Phase II study of single-agent pegylated liposomal doxorubicin HCl (PLD) in metastatic breast cancer after first-line treatment failure.

OBJECTIVES: Aim of this study was to evaluate the clinical benefit and the toxicity of pegylated liposomal doxorubicin. PATIENTS AND METHODS: Patients with metastatic breast cancer (n = 30) who failed a prior chemotherapy regimen for metastatic disease received 45 mg/m2 pegylated liposomal doxorubicin (PLD) every 4 weeks following prophylactic administration of metoclopramide (10 mg) and dexamethasone (8 mg). RESULTS: 29 of 30 patients were assessed for clinical benefit and time to progression. All patients were assessed for toxicity and analysis of overall survival. 9 patients (31%) had a partial response, and 16 patients (55%) responded with stable disease, resulting in a clinical benefit rate of 86% (n = 25). Median time to progression was 4 months (95% CI: 2.8-5.2), median duration of response was 7 months (95% CI: 4.7-8.2), and median survival was 12 months (95% CI: 6.7-17.2). Skin toxicity was the most common adverse event (30%, all < or = grade 2). Other toxicities were remarkably low in occurrence. CONCLUSION: PLD is a well-tolerated, second-line monotherapy with a high rate of clinical benefit.

European health systems and cancer care.

INTRODUCTION: Data on the survival of all incident cases collected by population-based cancer registries make it possible to evaluate the overall performance of diagnostic and therapeutic actions on cancer in those populations. EUROCARE-3 is the third round of the EUROCARE project, the largest cancer registry population based collaborative study on survival in European cancer patients. The EUROCARE-3 study analysed the survival of cancer patients diagnosed from 1990 to 1994 and followed-up to 1999. Sixty-seven cancer registries of 22 European countries characterised by differing health systems participated in the study. This paper includes essays providing brief overviews of the state and evolution of the health systems of the considered countries and comments on the relation between cancer survival in Europe and some European macro-economic and health system indicators, in the 1990s. OVERVIEW OF THE EUROPEAN HEALTH SYSTEMS: The European health systems underwent a great deal of reorganisation in the last decade; a general tendency being to facilitate expanding involvement of the private sector in health care, a process which occurred mainly in the eastern countries (i.e. the Czech Republic, Estonia, Poland, Slovakia and Slovenia). In contrast, organisational changes in the northern European countries (i.e. Denmark, Iceland, Finland and Sweden) tended to confirm the established public sector systems. Other countries, including the UK and some southern European countries (i.e. England, Scotland, Wales, Malta and Italy) have reduced the public role while the systems remain basically public, at least at present. Our findings clearly suggest that cancer survival (all cancer combined) is related to macro-economic variables such as the gross domestic product (GDP), the total national (public and private) expenditure on health (TNEH) and the total public expenditure on health (TPEH). We found, however, that survival is related to wealth (GDP), but only up to a certain level, after which survival continues to be related to the level of health investment (both TNEH and TPEH). According to the Organisation for Economic Co-operation and Development (OECD), the TNEH increased during the 1990s in all EUROCARE-3 countries, while the ratio of TPEH to TNEH reduced in all countries except Portugal. CONCLUSIONS: Cancer survival depends on the widespread application of effective diagnosis and treatment modalities, but our enquiry suggests that the availability of these depends on macro-economic determinants, including health and public health investment. Analysis of the relationship between health system organisation and cancer outcome is complicated and requires more information than is at present available. To describe cancer and cancer management in Europe, the European Cancer Health Indicator Project (EUROCHIP) has proposed a list of indicators that have to be adopted to evaluate the effects on outcome of proposed health system modifications.

[Water Birth: experience at a university clinic and a district hospital in Austria]. / Gebären im Wasser. Erfahrungen einer Universitätsklinik und eines Bezirkskrankenhauses in Osterreich.

PURPOSE AND METHODS: In a retrospective case-control study, 265 water deliveries (with cephalic presentation) carried out at an Austrian university clinic and a district hospital were compared with a group of spontaneous births (without any surgical intervention) matched for age, gestational age and parity regarding the most important fetal and maternal obstetric parameters. RESULTS: 4.3% of all births at the university clinic and 13% of those at the district hospital took place in the water. Austrian women and women with a higher educational level were more numerous in this group. The duration of the different stages of birth was not essentially changed by the delivery in water. The cord blood pH of the water babies (median 7.29 and 7.35, respectively) was better than that of the control group (median 7.26), which may however be due to a positive selection of the women giving birth in the water. The number of episiotomies was markedly lower for water births (14 and 4%) than for land births (48%). In contrast, water births showed distinctly more first- and second-degree perineal tears (36 and 41%) and labial tears (23 and 21%) than the control group (perineal 23%; labial 7%). Women assigned to water birth needed fewer analgesics (8 and 9%) than the controls (64%). In puerperium, the haemoglobin values after water birth and after land birth did not differ. The infectious morbidity of the mother and child was not higher after water birth. CONCLUSIONS: Water birth is to be considered a safe method for a healthy mother and a healthy, full-term fetus with cephalic presentation (if the appropriate criteria are used at hospital wards with a specific infrastructure).

Survival after bone marrow transplantation from cytomegalovirus seropositive sibling donors.

HLA-A2-restricted T cells show peptide-specific activity against cytomegalovirus and leukaemia cells. We retrospectively analysed the influence of donor cytomegalovirus serostatus on the outcome of 103 consecutive patients who had leukaemia and who received bone-marrow transplants from HLA-identical sibling donors. We found that donor cytomegalovirus seropositivity significantly improved overall survival (p=0.02) as a result of lower relapse incidence (p=0.035) in HLA-A2-positive but not HLA-A2-negative recipients. In HLA-A2-positive recipients donor cytomegalovirus seropositivity was associated with chronic graft-versus-host disease (GVHD), but even in patients without chronic GVHD donor cytomegalovirus seropositivity significantly improved survival (p=0.0483). These preliminary data provide evidence that at least in HLA-A2-positive recipients, transplantation of bone marrow from cytomegalovirus positive, HLA-identical sibling donors seems to be associated with substantial graft-versus-leukaemia activity, and suggests a cross-reactivity of cytomegalovirus-specific donor-derived cytotoxic T cells with HLA-A2-restricted recipient minor histocompatibility antigens.