The diagnosis of blocked cerebrospinal fluid shunts: a prospective study of referral to a paediatric neurosurgical unit

A prospective study was undertaken of all children referred to the Hospital for Sick Children with a provisional diagnosis of shunt blockage over a 5-month period. Fifty-two admissions were recorded, relating to 45 children, 5 of whom had multiple admissions. Only 19 of the 52 admissions led to a final diagnosis of shunt malfunction. No source of referral, whether by the child's general practitioner or from another hospital, was found to be more accurate than direct referral by the parents to the neurosurgical ward. Headache, vomiting and irritability were not significant indicators as to whether the child's shunt was actually blocked, and nor was the duration of the symptoms. Drowsiness was a significant, but not definite, indicator of shunt blockage, while pyrexia made it more likely that the patient had an alternative diagnosis. In 35 of the admissions a computed tomographic scan was performed: a normal scan, unchanged from previous scans, did not reliably exclude the diagnosis of shunt blockage. Percutaneous manometry via the reservoir of the shunt system was performed during 26 admissions: this investigation produced no false positives nor false negatives, but was equivocal in 5 cases, all of which were found at surgery to have a definite shunt blockage. The accuracy of the diagnosis of shunt blockage made prior to referral to a neurosurgical unit is discussed, together with the implications for resource use.     

Percentile regression analysis of correlated antibody responses

Antibody responses following vaccination usually are analysed by comparing geometric mean concentrations across levels of relevant covariates and by comparing the proportions of vaccinees responding. In the regression setting, the analyses are done on log-transformed concentrations, estimating geometric mean responses conditional on a vector of covariates. More detailed analyses examining the relationship of covariates to different parts of the response distribution may be performed through the application of asymmetric least squares estimation of regression percentiles. We present a method for accounting for correlation in percentile regression analyses of longitudinal antibody response data. We illustrate the procedures with measles antibody response data from Haitian children who participated in a randomized trial of high titre vaccines. The strongest dose and strain effects were seen in the low end of the antibody concentration distributions.     

Risk of lung cancer among patients with head and neck cancer

A cohort of 5180 patients with head and neck cancer, who were part of the tumor registry of the Surveillance, Epidemiology, and End Results area of western Washington State, was followed up for as many as 15 years to determine the risk of lung cancer. A sample of 522 patients from this cohort was interviewed to determine smoking history. Lung cancer developed in 356 (6.9%) of the 5180 patients. The overall annual incidence of lung cancer remained relatively constant between approximately 1.0% and 2.0% during the 15 years of follow-up. Men had an increased risk of lung cancer compared with women (relative risk [RR] = 1.56; 95% confidence interval [CI] = 1.18 to 2.03). Compared with patients with oral cavity cancer (RR = 1.00), the relative risk of lung cancer developing by the site of the index tumor was 0.63 (95% CI = 0.40 to 0.98) for lip, 1.12 (95% CI = 0.81 to 1.56) for intrinsic larynx, 1.73 (95% CI = 1.21 to 2.47) for oropharynx, 1.84 (95% CI = 1.16 to 2.92) for hypopharynx, and 2.28 (95% CI = 1.60 to 3.24) for extrinsic larynx. Among the 522 patients who were interviewed, men smoked more than women ( p < 0.0001), and patients with laryngeal or pharyngeal cancer smoked more than patients with cancer of the lip or the oral cavity ( p < 0.05). Among patients with head and neck cancer, the risk of lung cancer is highest for men and for patients with cancer of the pharynx or extrinsic larynx. These findings may be explained by differences in smoking consumption. (Otolaryngol Head Neck Surg 1997;116:630-6.)     

Surgical Management of Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus

Background. The optimal management of patients with renal cell carcinoma with inferior vena cava tumor thrombus remains unresolved. Traditional approaches have included resection with or without the use of cardiopulmonary bypass. Chemotherapy has played a minor role except for biotherapeutic agents used for metastatic disease.

Methods. From January 1989 to January 1996, 37 patients with renal cell carcinoma and inferior vena cava tumor thrombus underwent surgical resection. The 27 men and 10 women had a median age of 57 years (range, 29 to 78 years). Thirty-six patients presented with symptoms; 21 had hematuria. Distant metastases were present in 12 patients. Tumor thrombi extended to the infrahepatic inferior vena cava (n = 16), the intrahepatic inferior vena cava (n = 16), the suprahepatic inferior vena cava (n = 3), and into the right atrium (n = 2). All tumors were resected by inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of the vena cavotomy. Cardiopulmonary bypass was necessary in only 2 patients with intraatrial thrombus.

Results. Complications occurred in 11 patients, and 1 patient died 2 days postoperatively of a myocardial infarction (mortality, 2.7%). Twenty patients are alive; overall 2- and 5-year survival rates were 61.7% and 33.6%, respectively. For patients without lymph node or distant metastases (stage IIIa), 2- and 5-year survival rates were 74% and 45%, respectively. The presence of distant metastatic disease (stage IV) at the time of operation did not have a significant adverse effect on survival, as reflected by 2- and 5-year survival rates of 62.5% and 31.3%, respectively. Lymph node metastases (stage IIIc) adversely affected survival as there were no long-term survivors.

Conclusions. Resection of an intracaval tumor thrombus arising from renal cell carcinoma can be performed safely and can result in prolonged survival even in the presence of metastatic disease. In our experience, extracorporeal circulatory support was required only when the tumor thrombus extended into the heart.     

The effect of acidic fibroblast growth factor and live yeast cell derivative on tympanic membrane regeneration in a rat model

The current treatment of choice for chronic tympanic membrane perforations is surgery. Recent studies using various polypeptide growth factors to accelerate closure of tympanic membrane perforations in model systems have produced mixed results. This study evaluates the effect of acidic fibroblast growth factor (AFGF) and live yeast cell derivative (LYCD) on the rate of healing of acute tympanic membrane perforations in a rat model. Thirty-seven rats had both ears separately randomized in a blinded fashion to receive AFGF in one of three concentrations, LYCD, or a control solution. The rats initially underwent subtotal removal of the tympanic membranes bilaterally. Solutions were applied to the randomized ears daily for 3 days, starting at the time of the surgical perforation. The ears were photographed every 3 to 8 days for 35 days. The photographs were digitally scanned and a computer analysis was used to calculate the percentage of residual perforation. No significant difference in the rate of healing was observed for ears treated with AFGF or LYCD versus the controls. Given the potential advantages of medical treatment of tympanic membrane perforations and the established efficacy of growth factors in other model systems, however, further research is warranted. (Otolaryngol Head Neck Surg 1997;117:616-21.)     

Breast Conservation Therapy in Patients with Early-Stage Breast Cancer Who Have Undergone a Second Re-Excision of the Primary Tumor Bed: A Report of Four Cases

Abstract: For the women with early-stage breast cancer who are candidates for breast conservation therapy, re-excision of the primary tumor bed has commonly been used in patients for several indications. These indications include positive margin or uncertain margin status of the primary excision or residual microcalcifications on postbiopsy mammogram. If the pathology from the re-excision does not confirm negative margin status, mastectomy is generally recommended. This article examines patients who have undergone a second re-excision (i.e., a lumpectomy followed by two re-excisions) who have been treated with breast conservation therapy rather than a mastectomy.
From September 1977 to November 1995, 1,562 patients underwent breast conserving therapy at this institution. Seven hundred forty of these patients underwent a re-excisional biopsy because of positive or uncertain margin status or residual microcalcifications after the first excision. Four patients (0.5%) underwent a second re-excision because of positive or uncertain margin status or residual microcalcifications on mammogram after the first re-excision. The final margin status after the second re-excision of all four patients was negative. The radiation dose was 4,600–5,000 cGy to the whole breast followed by a conedown to bring the total dose to 6,400–6,800 cGy to the primary tumor bed.
Follow-up in the four patients was 13 years, 4 years, 14 months, and 8 months respectively. All four patients are clinically without disease and have not had a locoregional recurrence. Cosmesis was excellent in all four patients. One patient had an adriamycin-induced recall reaction causing a cellulitis, which resolved with antibiotics. There were no other complications.
Highly selected patients may undergo breast-conserving therapy after a second re-excision. Good outcome and cosmesis can be achieved for this small subset of patients with avoidance of a mastectomy.     

Dynamic contrast-enhanced MR imaging assessment of vascularized free fibular grafts

Magnetic resonance (MR) imaging may be a noninvasive method for assessing perfusion of vascularized bone grafts placed for treatment of avascular necrosis. One proximal femur of seven beagles was devascularized, with insertion of a vascularized fibular graft. MR imaging at 1 week (seven dogs) and 6 weeks (five dogs) after surgery included pre- and postcontrast spin-echo sequences, unenhanced twodimensional time-of-flight (TOF) vascular imaging, and dynamic gradient-echo imaging during infusion of gadolinium. Relative signal intensity values of selected regions obtained from the dynamic gradientecho images were plotted as percent enhancement versus time. In the operated hip, MR imaging did not show enhancement in six of seven femoral heads and greater trochanters at 1 week after surgery, with similar results after 6 weeks. MR imaging of fibular grafts 6 weeks after surgery showed an initial rapid increase in enhancement and a subsequent slower increase in five of five dogs, although no enhancement was seen in six of seven dogs at 1 week. These findings contrasted with a rapid initial increase in enhancement followed by slow decline in non-operated hips. Two-dimensional TOP imaging did not show the vascular pedicle of the graft in any dog. Findings of radionuclide bone scanning performed 1 week after surgery were consistent with devascularization of the operated femur and fibular graft. However, tetracycline distribution and histologic findings confirmed the viability of five of five grafts within the devascularized femurs 6 weeks after surgery. Thus, dynamic contrast-enhanced MR imaging at 6 weeks after surgery is valuable for assessing vascular bone graft perfusion, while similar imaging at 1 week may suggest otherwise.