Elderly depressed patients: What are their views on treatment options?

The aim of this study was to explore attitudes of elderly patients with depression receiving secondary psychiatric care towards different types of treatment for depression. One hundred patients, recruited from a large teaching hospital in Birmingham, were subjected to structured interviews at which their attitudes towards the effectiveness, likelihood of causing side-effects and acceptability of anti-depressant medication, ECT and psychotherapy were measured on a five-point Likert scale. Psychotherapy was considered both effective and acceptable by our patients although it is not widely available across the UK. Anti-depressants were also considered to be effective and acceptable although likely to cause side-effects. However, our patients did not think highly of ECT, either in its effectiveness or acceptability.     

Hormone therapy for radiorecurrent prostate cancer

Background

The management of patients who relapse after radical radiotherapy is a challenging problem for the multidisciplinary team. This group of men may have been considered ineligible or chosen not to be treated with an initial surgical approach as a result of high-risk features or significant comorbid conditions. It is important not to miss the opportunity for definitive local salvage therapies at this stage, and eligible patients should undergo careful restaging to determine their suitability for these approaches. For those men not suitable for local treatment, androgen deprivation therapy (ADT) remains an option.

Methods

Literature review of the evidence relating to the management of hormone therapy for radiorecurrent prostate cancer.

Results

Results from retrospective studies have shown that not all men with biochemical relapse will experience distant metastasis or a reduction in survival due to prostate cancer progression. Therefore, the timing of ADT commencement remains controversial. However, it would seem appropriate to offer immediate therapy to men with advanced disease or unfavourable prostate-specific antigen (PSA) kinetics at relapse. Patients with more favourable risk factors and PSA kinetics may be considered for watchful waiting and deferred ADT to avoid or delay the associated toxicities. Patients with non-metastatic disease can be given the option of castration-based therapy or an antiandrogen such as bicalutamide which may have potential advantages in maintenance of sexual function, physical capacity and bone mineral density but at the expense of an increase in gynaecomastia and mastalgia. Recent data suggest the burden of toxicity from ADT may be reduced by the use of intermittent hormone therapy without compromising survival in this group of patients with radiorecurrence.

Conclusions

Hormone therapy remains an option for men with radiorecurrent prostate cancer.     

Complications,outcomes, and need for fusion after minimally invasive posterior cervical foraminotomy and microdiscectomy

Background context

Posterior cervical foraminotomy (PCF) with or without microdiscectomy (posterior cervical discectomy [PCD]) is a frequently used surgical technique for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. Currently, these procedures are being performed with increasing frequency using advanced minimally invasive techniques. Although the safety and efficacy of minimally invasive PCF/PCD (MI-PCF/PCD) have been established, reports on long-term outcome and need for secondary surgical intervention at the index or adjacent level are lacking.

Purpose

To determine the rates of complications, long-term outcomes, and need for secondary surgical intervention at the index or adjacent level after MI-PCF and microdiscectomy.

Study design

Retrospective analysis of a prospective cohort.

Patient sample

Seventy patients treated with MI-PCF and/or MI-PCD for cervical radiculopathy.

Outcome measures

Visual Analog Scale for neck/arm (VAS_N/A) pain and Neck Disability Index (NDI).

Methods

Ninety-seven patients underwent MI-PCF with or without MI-PCD between 2002 and 2011. Adequate prospective follow-up was available for 70 patients (95 cervical levels). The primary outcome assessed was need for secondary surgical intervention at the index or adjacent level. The secondary outcomes assessed included complications and improvements in NDI and VAS_N/A scores. All complications were reviewed. Mixed-model analyses of variance with random subject effects and autoregressive first-order correlation structures were used to test for differences among NDI, VAS_A, and VAS_N measurements made over time while accounting for the correlation among repeated observations within a patient. All statistical hypothesis tests were conducted at the 5% level of significance.

Results

Patients were followed for a mean of 32.1 months. Of 70 patients operated, there were 3 (4.3%) complications (1 cerebrospinal fluid leak, 1 postoperative wound hematoma, and 1 radiculitis), none of which required a secondary operative intervention. Five patients required an anterior cervical discectomy and fusion (eight total levels fused) on average 44.4 months after the index surgery. Of those, five (5.3%) were at the index level and three (2.1%) were at adjacent levels. Neck Disability Index scores improved significantly (p<.0001) immediately postoperatively and continued to decrease gradually with time. Visual Analog Scale for neck/arm scores improved significantly (p<.0001) from baseline immediately postoperatively but tended to plateau with time.

Conclusions

Minimally invasive PCF with or without MI-PCD is an excellent alternative for cervical radiculopathy secondary to foraminal stenosis or a laterally located herniated disc. There is a low rate (1.1% per index level per year) of future index site fusion and a very low rate (0.9% per adjacent level per year) of adjacent-level disease requiring surgery.     

Solitary sacral osteochondroma without neurological symptoms: a case report and review of the literature

Purpose

To report a case of solitary sacral osteochondroma without neurological symptoms and describe the en bloc excision of the tumour, as well as review the literature on osteochondroma involving the sacrum.

Methods

Summary of the background data: although osteochondromas are among the most common benign tumours of the bone, they uncommonly involve the spine. Its occurence in the sacrum is rare, accounting for only 0.5 % of the osteochondromas involving spine. All previous cases of sacral osteochondroma have reported neurological symptoms on presentation.

Case report

A 21-year-old male presented with a palpable, painless mass in the left side of the sacral region of 1 year duration, without neurological symptoms. Radiological studies showed a well-circumscribed lesion with bony osteoid within arising from the sacrum at S3–S4 level left to midline, with features suggestive of osteochondroma. The tumour was excised en bloc through posterior approach. A literature review of sacral osteochondroma was conducted using MEDLINE search of English Literature and bibliographies.

Results

Histopathological studies showed the lesion to consist mature bone trabeculae with active enchondral ossification with cap of normal hyaline cartilage. Literature review yielded only 8 cases of sacral osteochondroma reported earlier.

Conclusion

This is the 9th case of solitary osteochondroma of the sacrum to be reported, the first to be reported without any neurological symptoms, and third case reported for which en bloc excision was performed.

     

Mediastinal atypical carcinoid and neurofibromatosis type 1

We report a case of mediastinal atypical carcinoid in a 63-year-old woman with neurofibromatosis type 1 (NF-1), who presented with shortness of breath and a bulky mediastinal mass. Initial consideration was given to a neurogenic tumor. However, on thoracoscopic biopsy, the histologic appearance was consistent with an atypical carcinoid. Carcinoid tumors have been reported in association with NF-1 previously, but commonly in such unusual sites as the ampulla of Vater and duodenum and not in the thorax. The bulky, extensive, and highly vascular nature of the lesion precluded resection or debulking surgery. To our knowledge, there are no previous reports of atypical carcinoid of the lung or mediastinum in a patient with neurofibromatosis. This case report, therefore extends the spectrum of solid neoplasia in general and carcinoid tumors in specific, as they occur in association with NF-1.     

Campylobacter gastroenteritis in children in Riyadh, Saudi Arabia.

Campylobacter jejuni/coli (CJC) was isolated from the stools of 82 (1 per cent) of 7369 children with gastrointestinal symptoms during a 2-year period. Among 1130 control children, CJ was isolated from the stool of one (0.09 per cent). The peak incidence of CJC associated gastroenteritis was in the winter. Seventy-six per cent of the patients were 4 years of age and younger with the highest incidence (56 per cent) in children 2 years old and younger. The most common presenting symptoms and signs were diarrhoea (95 per cent), anorexia (71 per cent), abdominal pain (70 per cent), high fever (57 per cent), and frank blood in stools (48 per cent). In five (6 per cent) patients CJC isolates were resistant to erythromycin. In all patients CJC infection was self-limited and the majority of patients required only supportive therapy.     

Training traditional birth attendants in clean delivery does not prevent postpartum infection

OBJECTIVE: To compare the maternal outcome, in terms of postpartum infection, of deliveries conducted by trained traditional birth attendants (TBAs) with those conducted by untrained birth attendants. METHODS: The study took place in a rural area of Bangladesh where a local NGO (BRAC) had previously undertaken TBA training. Demographic surveillance in the study site allowed the systematic identification of pregnant women. Pregnant women were recruited continuously over a period of 18 months. Data on the delivery circumstances were collected shortly after delivery while data on postpartum morbidity were collected prospectively at 2 and 6 weeks. All women with complete records who had delivered at home with a non-formal birth attendant (800) were included in the analysis. The intervention investigated was TBA training in hygienic delivery comprising the 'three cleans' (hand-washing with soap, clean cord care, clean surface). The key outcome measure was maternal postpartum genital tract infection diagnosed by a symptom complex of any two out of three symptoms: foul discharge, fever, lower abdominal pain. RESULTS: Trained TBAs were significantly more likely to practice hygienic delivery than untrained TBAs (45.0 vs. 19.3%, p < 0.0001). However, no significant difference in levels of postpartum infection was found when deliveries by trained TBAs and untrained TBAs were compared. The practice of hygienic delivery itself also had no significant effect on postpartum infection. Logistic regression models confirmed that TBA training and hygienic delivery had no independent effect on postpartum outcome. Other factors, such as pre-existing infection, long labour and insertion of hands into the vagina were found to be highly significant. CONCLUSIONS: Trained TBAs are more likely to practice hygienic delivery than those that are untrained. However, hygienic delivery practices do not prevent postpartum infection in this community. Training TBAs to wash their hands is not an effective strategy to prevent maternal postpartum infection. More rigorous evaluation is needed, not only of TBA training programmes as a whole, but also of the effectiveness of the individual components of the training.