High-risk behaviours for the fœtus in pregnant women: The medicolegal and judicial aspects.

Pregnancy is a period of psychological change which may lead to difficulties of adaptation and psychological suffering and give rise to high-risk behaviours for the fœtus in pregnant women. These risk behaviours, which are defined by certain authors as a form of "maltreatment" of the fœtus, usually spring from the psychological distress of the pregnant woman but are not recognised as a specific medical disorder. We illustrate the difficulties encountered in the identification of, and the specific intervention in, these situations through the clinical case of a pregnant drugs-dependent patient subjected to several stress factors who, in addition to consuming substances, developed high-risk behaviours for herself and her pregnancy: self-endangerment under the influence of substances, falls or refusals of treatment. In our first part, we discuss the medicolegal possibilities afforded by French law to protect the fœtus in the event of the future mother's high-risk behaviours. In our second part, we discuss the successive evolutions of the legal status of the fœtus and pregnancy, and their consequences for medical practice and the clinical situations concerned. The lack of an answer concerning the designation of these behaviours, as either medical, legal or social acts, will prompt perinatal practitioners to a certain medicolegal prudence.

Central nervous system involvement following diagnosis of non-Hodgkin's lymphoma: a risk model.

BACKGROUND: To determine the incidence and risk factors for central nervous system (CNS) relapse in patients with non-Hodgkin's lymphoma (NHL). PATIENTS AND METHODS: Patient records were registered prospectively in successive patients with NHL admitted to the Norwegian Radium Hospital from 1980 to 1996. A total of 2514 patients had no CNS involvement at diagnosis and were treated according to standard protocols. The incidence and risk factors for CNS progression or relapse were examined retrospectively. RESULTS: In low-grade (L)-NHL, the risk of CNS involvement was low (2.8%). In high-grade (H)-NHL, lymphoblastic and Burkitt's NHL patients had a high risk of CNS recurrence (24.4%) at 5 years, and prophylaxis seemed to reduce this risk. For the other patients with H-NHL, the proportion with CNS involvement at 5 years was 5.2%. Multivariate analysis identified five independent risk factors, each present in >5% of patients: elevated serum lactate dehydrogenase, serum albumin <35 g/l, <60 years of age, retroperitoneal lymph node involvement and involvement of more than one extranodal site. If four or five of these risk factors were present, the risk of CNS recurrence was in excess of 25% at 5 years. CONCLUSIONS: The risk of CNS involvement in this study is comparable with the results from other large series. CNS prophylaxis is not recommended in any subgroup of L-NHL. The risk of CNS involvement among patients with either Burkitt's or lymphoblastic lymphomas is considerable and these patients should therefore receive intensive chemotherapy including systemic and intrathecal methotrexate. Patients with other types of H-NHL should receive adequate CNS prophylaxis if at least four of the five risk factors identified are present.

Prognostic factors in 140 adult patients with non-Hodgkin's lymphoma with systemic central nervous system (CNS) involvement. A single centre analysis.

We examined retrospectively the outcome of patients with non-Hodgkin's lymphoma (NHL) with systemic involvement of the central nervous system (CNS) registered at The Norwegian Radium Hospital (NRH) from 1980 to 1996, in order to evaluate our treatment strategy for these patients. 170 of 2561 patients (6.6%) had CNS involvement, 140 (5.5%) systemic CNS lymphoma (SCNSL) and 30 (1.2%) primary CNS lymphoma (PCNSL). Description of the patients, time of SCNSL diagnosis, symptoms at CNS diagnosis, treatment and survival were registered. The overall median survival for the 140 patients with SCNSL was 2.6 months (95% confidence interval (CI) 2.1-3.2), only 12 patients are alive in complete remission (CR). Patients with CNS involvement at diagnosis, relapse or progression during treatment for NHL had a median survival of 5.4 months (95% CI: 0.3-10.6), 3.8 months (95% CI: 0.0-9.1), and 1.8 months (95% CI: 1.0-2. 7), respectively (P=0.001). 5 of the 8 patients consolidated with high-dose therapy (HDT) are in CR. Paresis was the only symptom that predicted survival for SCNSL. Patients above 60 years of age with CNS involvement at progression or relapse and those with paresis at the time of CNS diagnosis have a dismal prognosis. For these patients supportive therapy only should be considered. For patients under 60 years of age with chemosensitive disease, the trend was toward better prospects, and they should be offered intensive chemo-radiotherapy including HDT with autologous stem cell support.

Survival of patients with viable malignant non-seminomatous germ cell tumour persistent after cisplatin-based induction chemotherapy.

OBJECTIVES: Review of the outcome in patients with viable residual postchemotherapy malignant germ cell tumour treated at the Norwegian Radium Hospital from 1980 to 1993 and to establish prognostic factors. METHODS: During the years 1980-1993, about 270 patients with malignant non-seminomatous germ cell tumours underwent postchemotherapy surgery at the Norwegian Radium Hospital. In 27 of these patients, residual viable malignant germ cell tumour was found in the operation specimen. These patients were scheduled to receive 3 adjuvant cisplatin-based chemotherapy cycles after surgery, if possible, containing cytostatic agents not given during induction chemotherapy. All patients were followed up until death or January 1st, 1995 (median observation time in surviving patients: 51 months; range: 9-166 months). RESULTS: Sixteen patients developed a relapse after surgery after a median time of 4 weeks (range 1-19 weeks), 12 of them before any adjuvant chemotherapy could be started. Only 2 of these relapsing patients could be salvaged. At the last follow-up, 13 patients were alive, and a 43% 5-year survival was obtained. All deaths occurred within 3 years after surgery. The 9 patients with elevated alpha-fetoprotein and/or human chorionic gonadotropin before surgery have a particularly low survival rate (11%), as compared to the 18 patients with normal markers (62%). The most important prognostic parameter for the postoperative survival was, however, the initial tumour burden: the 14 patients with initially large or very large tumour volume (MRC criteria) had a 9% 5-year survival, whereas the percentage was 84% for the 13 patients with small volume disease. CONCLUSION: Prognosis is poor in patients in whom residual malignant germ cell tumour persists in spite of conventional cisplatin-based induction chemotherapy, especially in patients who initially present with large or very large volume disease and/or pre-operatively elevated tumour markers. More effective treatment modalities have to be developed for these patients. The role of high-dose chemotherapy with stem cell support should be investigated in future trials, especially in the subgroup of patients with poor prognosis.

Improved continuous-flow (SMAC) determination of serum albumin.

The albumin values determined by the bromcresol green methods do not compare well with values by more specific methods for albumin determination. The discrepancies have been related to, among other things, acute-phase reactants and are especially pronounced in the lower albumin range. These disadvantages are also inherent in a routine continuous-flow method for albumin (SMAC). The bromcresol green method has been improved considerably by shortening the reaction time before the absorbance is measured, as is described here. The modified method yields values that better agree with those by more specific methods and an influence of acute-phase reactants is no longer observed.

The use of a short-lived radionuclide in the investigation of acute bleeding in the upper gastrointestinal tract.

A method is described for the detection and monitoring of bleeding in the upper gastrointestinal tract. A short-lived radionuclide (113In-m) is used. Acute bleeding in the upper gastrointestinal tract in patients without signs of shock and preshock usually stopped within a short time after onset.

Blood glucose measurement with Dextrostix and new reflectance meter.

A new instrument, Eyetone, has been produced for use with a Dextrostix reagent strip for estimating blood sugar levels. It differs from the Dextrostix Reflectance Meter in having only one meter scale, a two-point calibration, and a range of measurement limited to 10-400 mg/100 ml. Results with the manufacturers' original calibration were unsatisfactory, but when recalibrated the performance of the instrument gave a regression equation line close to the ideal. The three Eyetone instruments tested were comparable in their accuracy and functional stability. Packed cell volumes in the blood samples in the range of 30-50% had a negligible effect on the results. The Dextrostix-Eyetone method represents a quick and reliable alternative to conventional laboratory methods for blood sugar estimation. It is especially useful for patients outside hospital.