Patterns and correlates of attempted suicide by heroin users over a 3-year period: findings from the Australian treatment outcome study

In order to determine patterns and correlates of attempted suicide amongst heroin users across 3 years, a cohort of 387 heroin users (134 entering maintenance treatment, 134 entering detoxification, 81 entering residential rehabilitation and 38 not entering treatment) were interviewed about suicide attempts at baseline, 12, 24 and 36 months. Across the follow-up period, 11.6% attempted suicide. There were declines in the proportion who attempted suicide each year amongst both males and females and significant declines in Major Depression, suicidal ideation and current suicide plans. Despite this, levels of attempted suicide, suicidal ideation and Major Depression in the cohort remained higher than in the general population. Those who had made a previous suicide attempt were five times more likely to make an attempt across follow-up and there was a strong association between an attempt in any 1 year and increased probability of an attempt in the subsequent year. A quarter of those who reported suicidal ideation at baseline made an attempt across follow-up. At each interview point, current suicidal ideation was strongly associated with increased risk of a suicide attempt in the following year. Independent predictors of a suicide attempt across follow-up were a lifetime suicide history, baseline suicidal ideation, social isolation and the extent of baseline polydrug use. Given the strong predictive value of suicidal ideation and previous attempts, regular brief screening would appear warranted to identify those at greatest risk.     

The role of staging investigations for oesophago-gastric carcinoma.

AIMS: To study the frequency with which unresectable disease was identified on pre-operative staging investigations in patients with oesophago-gastric carcinoma, and to audit whether a staging protocol had reduced the rate of exploratory surgery. METHODS: Ninety-eight patients with oesophageal carcinoma, 89 patients with adenocarcinoma of the gastro-oesophageal junction (GOJ) and 68 patients with gastric carcinoma were staged according to a protocol of computerised tomography, laparoscopy and endoscopic ultrasound. RESULTS: The frequency with which each investigation identified unresectable disease was as follows: (a) computerised tomography-oesophagus 12/67, GOJ 13/58, stomach 10/60; (b) laparoscopy-oesophagus 3/22, GOJ 5/45, stomach 8/23; and (c) endoscopic ultrasound-oesophagus 15/55, GOJ 3/30. By tumour location, rates of exploratory surgery were 1/18 for the oesophagus, 12/35 for the GOJ and 4/42 for the stomach. All of the staging failures in patients with GOJ carcinomas related to posterior tumour extension into the lesser sac. CONCLUSIONS: Staging investigations precluded resection in one-third of patients, the greatest yield being for laparoscopy in gastric carcinoma. In spite of this, 18% of patients undergoing surgical intervention underwent exploratory surgery alone, notably patients with GOJ carcinoma.     

Does age play a role in mylohyoideus muscle function?

Because swallowing disorders are frequent in the elderly, we assessed the relationship between age and mylohyoideus muscle contraction, which is an important component of the initial step in swallowing. In a prospective study, 120 subjects without any personal history of diseases associated with swallowing disorders underwent electromyographic recording (EMG) of mylohyoideus muscle activity. Four groups of equal size (n = 30) were defined according to age (< or = 50, 51-70, 71-85, >85 years). The frequency and duration of mylohyoideus muscle asynchronisms were compared among the four groups. The comparison of mylohyoideus muscle EMG among groups did not show a significant difference in the mean number of asynchronisms, in duration per subject or in the frequency of long-lasting asynchronisms. Asynchronisms were a very frequent event, observed in 98% of subjects, and were mostly short, lasting less than 0.1 s in 90% of subjects. In healthy elderly patients, there was no linear relationship between the mean duration of asynchronisms and ageing. The occurrence of one or more long-lasting asynchronisms or of at least six asynchronisms during a sequence of 10 successive swallows should be considered to be abnormal.     

The assessment of prognosis of surgically resected oesophageal cancer is dependent on the number of lymph nodes examined pathologically

Aims:  The prognosis in surgically resected oesophageal carcinoma (OC) is dependent on the number of regional lymph nodes (LN) involved, but no guidance exists on how many LNs should be examined histopathologically to give a reliable pN status. The aim of this study was to determine whether the number of LNs examined after OC resection has a significant effect on the assessment of prognosis.
Methods and results:  Routinely generated pathology reports from 237 consecutive patients undergoing oesophagectomy for OC were examined and analysed in relation to survival. The main outcome measure was survival from date of diagnosis. Lymph node count (LNC) correlated strongly with survival; a plateau was reached after a count of 10. Median and 2-year survival was 30 months and 42%, respectively, if <10 nodes were examined ( n  = 88), compared with 51 months and 61% if >10 nodes were examined ( P  = 0.005). This effect was greatest in pN0 cases. The prognostic value of the absolute number of LN metastases (<4) and LN ratio (<0.4) was strongly dependent on a LNC of >10.
Conclusions:  These results demonstrate the importance of careful pathological examination and lymph node retrieval after OC resection. At least 10 nodes should be examined to designate an OC as pN0.     

Electrolyte disturbances and cardiac failure with hypomagnesaemia in anorexia nervosa

A 32 year old woman with anorexia nervosa was admitted to hospital with severe hypocalcaemia and hypokalaemia that was refractory to replacement treatment but that responded immediately to an infusion of magnesium. She also had congestive cardiac failure that responded to magnesium replacement. The mild hypomagnesaemia found in this patient was responsible for the refractory hypocalcaemia. Minor deficiencies of magnesium may cause severe hypocalcaemia and hypokalaemia that are refractory to replacement treatment. Prompt replacement of magnesium may prevent prolonged tetany, cardiac arrhythmias, and heart failure.