Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Using an Electronic Bulletin Board Platform in a Disaster Tabletop Exercise

Introduction

We evaluate the use of an electronic bulletin board system in a tabletop disaster exercise.

Methods

Two tabletop exercises were carried out during a 5 hour course for 26 members of the Singapore Disaster Site Management Command (DSMC). As the events happened, the participants were updated via the electronic bulletin board. Response to the events was through the bulletin board. A written survey was held upon completion.

Result

Most (96.2%) felt that the exercise had helped identify issues in current operating procedures. The electronic bulletin board was deemed easy to use and learn, and that it helped in their learning (61.5%, 88.5% and 73.1% respectively). Using the electronic platform was an effective (76.9%) and efficient way (65.4%) of conducting the exercises. 53.8% of participants prefer the use of the electronic bulletin board and 61.5% felt that it was more realistic using the electronic platform. However the electronic bulletin board did not improve the participant's understanding of the current operating procedures (43.2%) and their role in DSMC (50%).

Conclusion

The use of the electronic platform is easy and over half of the involved participants thought it is preferred over the traditional tabletop exercise.

Pain Management in the Emergency Department

Objectives

To determine the waiting time for administration of analgesia to patients presenting to the emergency department (ED) with traumatic pain, and to determine how the severity of pain affects the patient's perception of pain and the treatment they receive.

Methods

Consecutive patients aged 18–65 years presenting to the ED during the 2-week study period with complaint of pain secondary to trauma were prospectively recruited. The numeric rating scale (NRS) was used to indicate the level of pain experienced by the patients. They were interviewed using a structured questionnaire and a chart review was also done after the patients had completed their ED visit.

Results

The mean time to analgesia was 77.6 min (95% CI = 63.2–92.0 min). Patients requesting analgesia at triage had a median pain score of 7 (range 0–10) while those who declined had a median pain score of 5 (range 0–10) (p = 0.002, Mann-Whitney U-test). The severity of the injuries sustained did not affect the patient's perception of their pain nor their preference for early analgesia. Indian patients had a significantly higher median pain score (p = 0.048).

Conclusion

Time to delivery of analgesia fell short of our patients' expectations. Assessing pain using the NRS is useful and should be incorporated as the ‘fifth’ vital sign. Process-improvement, healthcare workers and patient education regarding pain management are needed. Patients with a pain score of 7 or more should be offered analgesia at triage. Those with a pain score of 6 or less should still be given analgesia at triage if they request it.

Study on the Discrepancies between the Admitting Diagnoses from the Emergency Department and the Discharge Diagnoses

Objective

To study the extent of diagnostic discrepancies at admission (diagnoses made by doctors in the Emergency Department) and discharge (final diagnoses at the ward) in our Emergency Department (ED) where the doctors have direct admitting rights; and how such discrepant diagnoses affected inter-departmental transfer of patients after their admission.

Method

A non-concurrent cohort study was performed on admissions through our ED between 24th to 30th April 1997. The admitting and discharge diagnoses and units were recorded. The reasons for the unmatched diagnoses and inter-departmental transfers were studied. The significance of transfers amongst patients who had matched and unmatched diagnoses was compared using the Chi-test at 95% confidence interval.

Results

Three hundred and sixty-one admissions were recorded during the study period. There were 314 (86.7%) and 47 (13.3%) admissions with matched and unmatched diagnoses respectively. Nine of the 47 admissions with unmatched diagnoses and 16 of the 314 admissions with matched diagnoses were transferred (p=0.001).

Conclusion

The ED doctors achieved a high level of diagnostic accuracy. The most common reason for unmatched diagnosis was because of the difficulty of diagnosing the patient's complex medical problem in the short contact time in the ED. The level of accuracy should increase with the advent of more diagnostic modalities and increased contact time with the patients in the ED.

A cocoon immunisation strategy against pertussis for infants: does it make sense for Ontario?

Pertussis deaths occur primarily among infants who have not been fully immunised. In Ontario, Canada, an adult booster dose was recently added to the publicly funded immunisation programme. We applied number-needed-to-treat analyses to estimate the number of adults that would need to be vaccinated (NNV) to prevent pertussis disease, hospitalisation and death among infants if a cocoon strategy were implemented. NNV=1/(P(M) X R) + 1/(P(F) X R), where P(M),P(F) (proportion of infants infected by mothers, fathers) were sourced from several studies. Rates of disease, hospitalisation or death (R) were derived from Ontario's reportable disease data and Discharge Abstract Database. After adjusting for under-reporting, the NNV to prevent one case, hospitalisation or death from pertussis was between 500-6,400, 12,000-63,000 and 1.1-12.8 million, respectively. Without adjustment, NNV increased to 5,000-60,000, 55,000-297,000 and 2.5-30.2 million, respectively. Rarer outcomes were associated with higher NNV. These analyses demonstrate the relative inefficiency of a cocoon strategy in Ontario, which has a well-established universal immunisation programme with relatively high coverage and low disease incidence. Other jurisdictions considering a cocoon programme should consider their local epidemiology.

Abstract W P35: Assessment of Collaterals on Day-2 CT Angiography Can Predict Functional Outcome in Thrombolyzed Anterior Circulation Acute Ischemic Stroke

Background: Several methods exist that assess the intracranial collaterals on CT-angiography (CTA) of the brain. We compared existing methods for quantification of collaterals on day-2 CTA in thrombolyzed AIS patients to assess their predictive value for functional outcome.

Methods: Consecutive AIS patients treated with intravenous tissue plasminogen activator (IV-tPA) during 2007-2012 were included. Data were collected for demographics, vascular risk factors, NIHSS scores and stroke subtypes. Intracranial collaterals were evaluated by 2 independent neuroradiologists using 4 existing methods- Miteff’s system (grades middle cerebral artery (MCA) collateral branches with respect to sylvian fissure); Maas system (compares collaterals in affected hemisphere against the contralateral side); Modified Tan’s scale (collaterals in 50% or more of MCA territory classified as good); and 20-point collateral grading scale by Alberta Stroke Program Early CT score (ASPECTS) methodology. Good functional outcome at 3-months was determined by modified Rankin scale (mRS) scores of 0-1.

Results: Day-2 CTA was performed in 150 patients with anterior circulation AIS treated with IV-tPA. Median age 66yrs (range 33-92), 47% males, median NIHSS 19 points (range 4-34) and median onset-to-treatment time 165 minutes (range 74-274). Overall, 67 (44.6%) patients achieved good functional outcome at 3-months. On univariable analysis- younger age, lower pre-tPA NIHSS scores, atrial fibrillation, good collaterals according to ASPECTS scoring and good collaterals by Maas methodology were significantly associated with good functional outcome. On multivariable analysis, lower NIHSS (OR 1.155 per NIHSS point; 95% CI 1.066-1.251, p=0.001), younger age (OR 1.052 per year; 95% CI 1.012-1.094, p=0.010), good collaterals by Maas methodology (OR 2.805 95% CI 1.122 -7.011, p =0.002) and good collaterals (score of 9 or more) by ASPECTS methodology (OR 3.769 ; 95%CI: 1.327- 10.708, p= 0.013 ) were found as independent predictors of good outcome.

Conclusion: Of the existing intracranial collaterals scoring systems, only the ASPECTS and Maas methods are reliable predictor of favourable outcome in thrombolyzed anterior circulation AIS patients.

Abstract 2: Extensive Collateral Recruitment after Intravenous Thrombolysis in Acute Ischemic Stroke is Associated with Symptomatic Intracranial Haemorrhage

Background: Various collateral channels are recruited to provide alternative pathways in acute ischemic stroke (AIS), however the relationship with patient outcomes remain unclear. We compared various existing methods of scoring collaterals on the pre-treatment and day-2 computed tomographic angiogram (CTA) of the brain in thrombolyzed AIS patients.

Methods: We included 115 consecutive patients in whom CTA was performed both pre-tPA and on day-2. Intracranial collaterals were evaluated by 2 independent neuroradiologists using 4 existing and one modified method- Miteff’s system (grades middle cerebral artery (MCA) collateral branches with respect to sylvian fissure); Maas system (compares collaterals in affected hemisphere against the contralatral side); Modified Tan’s scale (collaterals in 50% or more of MCA territory classified as good); and 20-point collateral grading scale by Alberta Stroke Program Early CT score (ASPECTS) methodology. For the modified scoring system we adapted ASPECTS methodology into a 14 point score for cortical and internal cerebral veins (ICV) and removing basal ganglia area from scoring. Symptomatic intracranial hemorrhage (SICH) was defined by new bleeding on the CT scan and an increase in NIH stroke scale (NIHSS) by 4 points or more.

Results: On univariate analysis collateral recruitment via the Tan scoring system, ASPECTS method (improvement of ≥6 points), modified scoring system (improvement ≥7 points), hypertension and higher NIHSS score were associated with SICH. On multivariate analysis only collateral recruitment on the Tan scoring system (OR 3.286 95% CI 1.014-11.025, p =0.049), Collateral recruitment on ASPECTS ≥6 points (OR 2.839 95% CI 1.064- 7.576, p = 0.037) and collateral recruitment on the modified scoring system ≥ 7 (OR 4.174 95% CI 1.212-14.372, p = 0.023) were independent predictors of SICH. Interestingly, collateral failure on the day-2 CTA did not show any association with SICH.

Conclusion: Large recruitment of the collateral channels on the day-2 CTA is strongly associated with SICH after thrombolysis . Perhaps, an unregulated cerebral hyperperfusion contributed to SICH and close monitoring along with aggressive blood pressure control might prevent complications.

Singapore cancer trends in the last decade

In this review, we examine the trends in cancer incidence, mortality and survival in the last decade, using published data from the Singapore Cancer Registry in the period 1998 to 2009. While overall cancer incidences have remained stable, overall cancer mortality rates have declined for both genders. Thus, it is not surprising that there was an improvement in cancer survival. A steady decrease in lung cancer among males and females was observed, thereby leading to a drop in its cancer ranking. In the last five years, the most frequently occurring cancer was colorectal cancer among the male population and breast cancer among females. Survival for both cancers remained relatively optimistic. There is good reason to pay special attention to colorectal cancer due to its high frequency of occurrence among the Singapore population and because it is amenable to early detection via screening.

Mammographic density and its interaction with other breast cancer risk factors in an Asian population

BACKGROUND

Joint effects of mammographic density and other risk factors on breast cancer risk remain unclear.

METHODS

From The Singapore Breast Screening Project, we selected 491 cases and 982 controls. Mammographic density was measured quantitatively. Data analysis was by conditional logistic regression.

RESULTS

Density was a significant risk factor, adjusting for other factors. Density of 76-100% had an odds ratio of 5.54 (95% CI 2.38-12.90) compared with 0-10%. Density had significant interactions with body mass index and oral contraceptive use (P=0.02).

CONCLUSIONS

Percent density increases breast cancer risk in addition to effects of other risk factors, and modifies the effects of BMI and OCs.

Effect of childbirth after treatment on long-term survival from breast cancer

Background

This study quantified long-term absolute and relative mortality risks of survivors of breast cancer with subsequent childbirth.

Methods

The Singapore Birth Register (n = 319 437), Swedish Multi-Generation Register (n = 11 million) and population-based cancer registries were linked to identify 492 women with childbirth after breast cancer. For these women, cumulative mortality risks and standardized mortality ratios (SMRs) were calculated and compared with those of 8529 women aged less than 40 years with breast cancer without subsequent childbirth, and with those predicted by Adjuvant! Online.

Results

Women with subsequent childbirth had a lower 15-year cumulative overall mortality rate than other women with breast cancer (16·8 (95 per cent confidence interval (c.i.) 13·3 to 20·9) versus 40·7 (39·5 to 41·9) per cent), but a higher relative mortality risk than the background population (SMR 13·6, 95 per cent c.i. 10·6 to 17·3). Mortality risks decreased significantly with increasing interval between diagnosis and subsequent childbirth. Mean 10-year cumulative mortality risks of women with subsequent childbirth were within the range of 10-year mortality predicted by Adjuvant! Online for women with T1 N0 tumours in otherwise perfect health.

Conclusion

This study reinforced the view that pregnancy after breast cancer is not detrimental to survival. However, women who gave birth after this diagnosis had substantially higher mortality risks than young women in the general population. This information may be a valuable addition to routine mortality estimates.

Evaluating the Role of a Triage Electrocardiogram Protocol at an Urban Emergency Department

Objective

Our emergency department (ED) performs triage ECG for a variety of complaints to identify patients in need of treatment escalation. The aim of this study was to evaluate the existing triage ECG protocol as a means of treatment decision making.

Methods

This prospective observational study was conducted in an urban ED over one week. We recruited all patients aged 18 years and above with an undiagnosed complaint requiring a triage ECG based on the existing departmental protocol. As part of the protocol, an experienced emergency doctor then reviewed the ECG to determine the need for treatment escalation. Explicit data collection was performed using our electronic database. The outcome measures were proportions of triage treatment escalations, reasons for escalation and disposition status. Analysis was by descriptive statistics.

Results

739 patients were recruited from a total attendance of 3228. The rate of triage ECG was 23%. There were 22 (3%) triage escalations. Usually each escalation resulted from a combination of reasons. These included important ECG changes (77%), abnormal vital signs (5%) and ongoing symptoms (95%).

Conclusions

The triage ECG protocol resulted in important escalations in a small proportion of presentations. Future research is needed to refine guidelines on the use of triage ECG for different ED complaints.

Clinical predictors of abnormal computed tomography findings in patients with altered mental status

INTRODUCTION

While non-contrast computed tomography (CT) of the brain can be used to rapidly identify patients with altered mental status (AMS) in the emergency department (ED), with an acute intracranial bleed or infarct, a wide variation in its use exists. The aim of this pilot study was to identify the clinical predictors of an abnormal CT result in ED patients with AMS.

METHODS

We conducted a retrospective study of patients aged 15 years and older presenting with undifferentiated AMS in a busy urban ED over one year. Data collected included demographical, clinical, laboratory and radiological features. The primary outcome of interest was the presence of an abnormal CT result defined as an acute infarct or intracranial bleed. Secondary outcomes were clinical predictors of an abnormal CT result. The data was analysed using descriptive statistics. Logistic regression was used to identify clinical predictors of an abnormal CT result. Odds ratios (ORs) were reported with 95 percent confidence intervals (CIs).

RESULTS

578 patients were recruited, of which 284 (49.1 percent) were males. 327 (56.6 percent) patients underwent CT of the brain. 128 scans (39.1 percent) were abnormal. Logistic regression revealed seven clinical features that were associated with an abnormal CT result. They were mean age greater than or equal to 73 years (OR 1.03; 95 percent CI 1.015-1.045), drowsiness or unresponsiveness (OR 1.73; 95 percent CI 0.17-17.72), previous cerebrovascular accident (OR 2.03; 95 percent CI 0.82-5.02), previous epilepsy (OR 1.63; 95 percent CI 0.63-4.19), tachycardia [greater than 120/min] (OR 1.16; 95 percent CI 0.38-3.54), bradycardia [less than 60/min] (OR 1.35; 95 percent CI 0.19-9.59) and exposure to drugs (OR 1.90; 95 percent CI 0.58-6.26).

CONCLUSION

We identified seven clinical predictors of an abnormal CT result in AMS patients. Future research in prospective studies is needed to validate these findings.

Penile strangulation: report of two unusual cases

We report two cases of penile strangulation that presented to our emergency department. In the first case, a 60-year-old man, the object of strangulation was a metallic ring that was extricated using an orthopaedic cutter in the operating theatre. The patient recovered uneventfully. In the second case, a 77-year-old man, the object of strangulation was a plastic bottle, which was extricated using surgical instruments in the emergency department, but the patient subsequently developed postobstructive diuresis. The first case illustrates the difficulty that may be encountered in this delicate yet urgent situation, while the second case reports a rare complication.

Herd management factors that affect duration and variation of adherence of an external teat sealant

During 1998 and 1999, a purposive sample of Ontario dairy herds was enrolled in a study to examine management factors associated with adherence of an external teat sealant. A total of 74 herds were recruited that had previously complied with a provincial Sentinel Herd mastitis study. All herds were sent a management survey and a commercially available external teat sealant product. The sealant was applied to all cows in first lactation or greater that were scheduled to go dry. Adherence of the teat sealant was scored on a scale of 1 to 5 (1 = sealant completely removed) for the first 12 d following dry off. Complete data were analyzed from 806 cows in 48 herds (mean of 17 cows/herd). Mean duration of adherence of the teat sealant was 4 d (range 1 to 7 d). Of the management factors recorded, only changing the feed to reduce milk production prior to drying off was significantly associated with 0.78-d prolonged adherence. No factors related to dry cow housing, bedding material, or floor surface were associated with the duration of adherence. The variance around the duration of adherence was examined. The median variance of adherence was 3.0 d(2), which was equivalent to a standard deviation of 2.6 d. Herds in which dry cows were housed in tie-stall barns, and the herds that used a penicillin and novobiocin combination dry cow antibiotic had the greatest variation. We concluded that modifying the ration to reduce milk production enhanced adherence of an external teat sealant. Teat-end preparation prior to application of the teat sealant is an important factor to consider when choosing to adopt this dry period mastitis prevention strategy. This study demonstrates that beyond cow- and quarter-level factors, herd management factors can influence the duration and variation of sealant adherence experienced among different herds.

Diagnostic laparoscopy in the evaluation of right lower abdominal pain: a one-year audit

INTRODUCTION

Acute appendicitis is the commonest cause for right lower abdominal pain. Clinical features, laboratory and imaging investigations are either not very sensitive or specific, and neither is therapeutic. We aimed to define the role of diagnostic laparoscopy in patients with right lower abdominal pain.

METHODS

Data was collected retrospectively from January 1, 2005 to December 31, 2005. Patients admitted to the Emergency Department and subsequently transferred to the Department of Surgery, National University Hospital, Singapore, with right lower abdominal pain and who eventually underwent diagnostic laparoscopy were evaluated.

RESULTS

691 patients with right lower abdominal pain were admitted with suspected diagnosis of appendicitis. Diagnostic laparoscopy was undertaken in 103 patients aged 17-71 years old. Of the 83 females, 78 (94 percent) were premenopausal . Histology-proven acute appendicitis was diagnosed in 78 (75.7 percent) patients. Interestingly, within this group, 25.6 percent had other concomitant pathologies found on laparoscopy. 25 patients had a normal appendix; gynaecological causes accounted for pain in 15 of these 25 (60 percent) cases. In four (3.9 percent) patients, no pathology was found. Complication rate was 1.9 percent, which included ileus in two patients. In 32 (31.1 percent) patients, diagnostic laparoscopy altered the management plan, requiring either intervention or care by a subspecialty.

CONCLUSION

Diagnostic laparoscopy is useful in evaluating patients with right lower abdominal pain, especially in those with equivocal signs of acute appendicitis. It also has the additional benefit of being therapeutic. Premenopausal women benefit the most from this procedure.

Adherence and Efficacy of an External Teat Sealant to Prevent New Intramammary Infections in the Dry Period

The efficacy and adherence of an external teat sealant applied at drying off was evaluated in 2 studies between 1997 and 1999. At drying off, 2 quarters were randomized to receive intramammary dry-cow antibiotic therapy, and the remaining 2 quarters were treated with either a single or double application of external teat sealant. Approximately 3 d before calving, all teats that had been dipped at drying off were redipped in a single coating of teat sealant. Adherence of the teat sealant was scored for the first 2 wk after drying off, and physical traits of the teat skin and teat ends were recorded. Quarter milk samples were collected 1 wk before drying off, at drying off, 0 to 7 d, and 14 to 21 d postcalving. Somatic cell counts were determined from quarter samples taken at d 7 and 14 to 21 d after calving. Data were analyzed from 172 dry periods of 162 cows. The mean time of sealant adherence following drying off application was 3 +/- 0.13 d. Double sealant application significantly increased the duration of adherence by 0.67 d. Teats that had teat sealant applied twice at drying off and that had up to 3 d of adherence had the lowest linear score (LS) at 14 to 21 d (1.89 +/- 0.31) of all quarters. The LS of quarters that received antibiotic therapy only was 2.27 +/- 0.19. The majority of intramammary infections identified at drying off were caused by the minor pathogens, coagulase-negative staphylococci and Corynebacterium bovis (51 and 23%, respectively). The results from this study indicate that duration of sealant adherence to the teat-end should be considered when evaluating the impact of teat sealant treatment at drying off on the level of infection after calving. Double sealant application, cooler seasons, and longer teat lengths were associated with a significant increase in the duration of sealant adherence to the teat-end.

Sensitivity and specificity of somatic cell count and California Mastitis Test for identifying intramammary infection in early lactation

Associations between values for the somatic cell count (SCC) or the California Mastitis Test (CMT) and intramammary infection (IMI) were studied in 131 dairy cows from three herds during the first 10 d post-calving. Intramammary infection was defined as the presence of one or two bacterial species in one or both quarter milk samples taken within 12 h of calving and at d 3 postcalving. Quarter milk samples identified IMI in 36% of glands. Values for SCC declined at a significantly faster rate over the first 10 d postcalving in non-infected quarters than in infected quarters. The usefulness of quarter milk SCC and CMT for screening was evaluated by calculating the sensitivity and specificity for various threshold values and days postcalving. A SCC threshold of 100,000 cells/ml for quarter samples evaluated on d 5 postcalving had the maximal sensitivity and specificity for detecting IMI. Evaluation of the CMT samples taken on d 3 postcalving using a threshold reaction of greater than zero had the highest sensitivity and specificity for detecting IMI. With this CMT sampling scheme, the sensitivities for detecting IMI with any pathogen, IMI with a major pathogen, and IMI with a minor pathogen were 56.7, 66.7, and 49.5, respectively. The CMT could have a useful role in dairy herd monitoring programs as a screening test to detect fresh cows with IMI caused by major pathogens.

Comparison of intrathecal and epidural diamorphine for elective caesarean section using a combined spinal-epidural technique

To assess calculated equivalent doses of intrathecal and epidural opioids for elective Caesarean section in terms of quality and duration of analgesia, and incidence of side effects, we have compared 50 patients, allocated randomly to one of two groups to receive either diamorphine 0.25 mg intrathecally (group 1) or 5 mg epidurally (group 2), in addition to intrathecal bupivacaine 10 mg, using a combined spinal-epidural technique. There was no significant difference in duration of analgesia between groups (group 1 mean 14.6 (SD 5.9) h, group 2 14.2 (6.5) h; mean difference 0.8 h; 95% Cl -2.8-4.5; P = 0.65) or quality of analgesia (VAPS and VRS scores). The degree of pruritus was similar in both groups (80-88%) but the incidence of postoperative nausea and vomiting was significantly higher in the epidural group (24% vs 4%; P < 0.05). Intrathecal diamorphine 0.25 mg produced the same duration and quality of postoperative analgesia as epidural diamorphine 5 mg for elective Caesarean section but with significantly less nausea and vomiting.

Arthroscopic treatment of osteochondral lesion of the talus

A retrospective study of the arthroscopic treatment of osteochondral lesions of the talus in 25 patients was conducted. The follow-up period ranged from 1 to 4 years with an average of 2 years. Of the 25 patients, 20 could recall a history of injury. The diagnosis could be made by standard anteroposterior and lateral X-rays in 22 out of 25 patients. The standard anteromedial and anterolateral portals were usually sufficient. Patients with stage I and II lesions did well uniformly. In the 16 patients with stage III and IV lesions, good results were obtained in 12 and fair in 4. Morbidity was minimal.

Accidental intrathecal insertion of an extradural catheter during combined spinal-extradural anaesthesia for caesarean section

The combined spinal-extradural technique is used to provide analgesia and anaesthesia in obstetric anaesthetic practice. The accidental insertion of an extradural catheter into the dural opening made previously by the spinal needle is thought to be a theoretical risk. We report a case during combined spinal-extradural anaesthesia for Caesarean section in which this complication occurred.

Spinal epidural leiomyoma occurring in an HIV-infected man. Case report

A case of spinal epidural leiomyoma is reported in a 52-year-old man infected with the human immunodeficiency virus (HIV). The tumor arose in the epidural region at the T-3 vertebral level, and the patient presented with radicular pain in the right T-3 dermatome. While soft-tissue tumors such as Kaposi's sarcoma and lymphomas have been well documented in association with HIV infection, this is the first reported case of primary spinal leiomyoma. Isolated cases of leiomyomas and leiomyosarcomas in unusual locations have been reported, notably in pediatric HIV-positive patients, perhaps indicating a causal relationship. This case may represent further evidence of such an association.

A micromethod for measuring swine fever antibody by neutralisation and immunofluorescence

A micromethod employing the neutralisation and direct immunofluorescence technique for the detection of antibodies against swine fever in pig serum samples is described. The micromethod is simple and reproducible when compared with the macromethod. A total of 80 blood samples were randomly collected for comparison. The results are promising and reveal a 100 per cent correlation with the macrotechnique.

Multiple progressive intracranial arterial occlusions ('moyamoya' disease)

Four adult female patients with moyamoya vessels are described. Hypertension and hyperlipidaemia were discovered in three patients. Vessels similar to moyamoya vessels were seen in the orbital and cortical collateral vessels as well as in the basal ganglia region. Attention should now be paid to the aetiological rather than the descriptive aspects of the disorder. An empirical trial of corticosteroids is worth while. Risk factors such as hypertension, hyperlipidaemia, and smoking should be eliminated.

Postadrenalectomy pituitary adenoma (Nelson's syndrome) in childhood: clinical and roentgenologic detection

Following total adrenalectomy in Cushing's syndrome associated with adrenal hyperplasia, but not with adrenal adenoma or malignancy, elements of the pituitary may be stimulated to grow rapidly and even aggressively. There is strong evidence to support the idea that there is a pre-existing tumor in many, if not all, of these cases. In some, the tumor may be too small to deform the sella turcica. After adrenalectomy, these patients should be observed carefully and frequently for hyperpigmentation, visual field defects, and sella turcica enlargement.

Bronchial brush biopsy and primary lung carcinoma

Bronchial brush biopsy was performed on 100 patients with pulmonary lesions suspected of being malignant. Of 61 cases of proved carcinoma of the lung, in 44 or 72-1% brush biopsy yielded positive results. The technique used is described and an analysis of the results is presented.

Comparison of bronchial brushing and percutaneous needle aspiration biopsy in the diagnosis of malignant lung lesions

The results of 100 bronchial brushings and 80 percutaneous needle aspiration biopsies of the lung performed in the same department were analyzed for their accuracy in the diagnosis of pulmonary neoplasms. While both procedures have a high degree of reliability, the aspiration needle biopsy appears to be the procedure of choice in smaller, more peripheral lesions, in Pancoast tumors, and whenever a metastatic neoplasm is suspected.