Embolisation of recently ruptured intracranial aneurysms.

Patients with subarachnoid haemorrhage due to the rupture of aneurysms unsuitable for craniotomy and clipping have been treated by coil embolisation within three weeks. Sixty nine of 75 consecutive patients were successfully treated. Procedure related complications occurred in 10 patients, resulting in permanent neurological deficits in three and one death (4.8%). The Glasgow outcome scores at six weeks were 53 grade 1, seven grade 2, four grade 3, and five grade 5. These results are comparable with surgical series despite a high proportion of aneurysms in the posterior cerebral circulation.     

Are positive axillary nodes in breast cancer markers for incurable disease?

OBJECTIVE: This study was designed to determine if resection of positive regional nodes in patients with breast cancer provided a group of cured patients. SUMMARY BACKGROUND DATA: Previous studies of long-term follow-up of patients with breast cancer have demonstrated that 30% of patients with positive nodes may be alive at 10 or 20 years. Randomized, prospective studies have not shown a difference in survival between modified radical and total mastectomy. METHODS: The authors analyzed the statistical basis of randomized, prospective studies of breast cancer. Patients from University and Kings County Hospital with breast cancer were observed (n = 1024) and the 10-year survival curves were analyzed. Data from the Surveillance, Epidemiology, and End Results (SEER) program were evaluated to determine the prognosis of patients with positive-node breast cancer who survived 10 and 15 years. RESULTS: The authors found that no current randomized study of primary treatment of breast cancer has the power to determine the advantage of one treatment over another if the primary cancer is treated. Additionally, evaluation of the patients in this study demonstrated that those with regional disease usually had a recurrence by 7 years; however, at 10 years, 30% are still alive and have the same prognosis as patients with negative-node breast cancer. CONCLUSIONS: Regional breast cancer is a curable disease in some resected patients.     

Pleuroperitoneal shunt for recurrent malignant pleural effusions.

The therapeutic options available for the management of malignant pleural effusions associated with a restricting malignant cortex remain unsatisfactory. The efficacy of pleuroperitoneal shunts was evaluated in 16 patients with recurrent malignant effusions. There were no operative deaths; one patient died on the third postoperative day as a result of lymphangitis carcinomatosa. The median hospital stay was five (range 3-21) days. Palliation was obtained in all but one of the other 15 patients. There was no appreciable reaccumulation of pleural fluid as judged by radiography. Two patients developed occlusion of the shunt. In one case this was due to blood clots in the pleural catheter and necessitated insertion of a new shunt. The other shunt was removed because of obstructing infected fibrin debris, and a rib resection was performed. There were eight deaths related to the underlying malignancy after a mean interval of 7.3 (range 1.5-23) months. The other six patients are still alive, with a mean survival of 11.0 (range 5-20) months, and have achieved good symptomatic relief. The insertion of a pleuroperitoneal shunt can offer effective palliation for patients with recurrent malignant pleural effusions.     

Effect of nicotine, silver acetate, and ordinary chewing gum in combination with group counselling on smoking cessation.

Four hundred and ninety six smokers participated in a randomised comparison of the effect of silver acetate, nicotine, and ordinary chewing gum on smoking cessation. All were motivated to stop smoking abruptly and all had smoked at least 10 cigarettes a day for at least five years. Side effects and taste acceptability were related to outcome after six months. The participants attended nine meetings over a year, at which lectures, support, and advice about stopping smoking were given. Tobacco abstinence was confirmed by measurement of carbon monoxide in expired air. The chewing gums were used for 12 weeks. After 12 weeks there was a trend towards more abstainers in the nicotine group (59%) than in the silver acetate (50%) and ordinary (45%) chewing gum groups that was not quite significant (p = 0.07). At 26 and 52 weeks the number of cigarette abstainers was similar in the three treatment groups. Subjects in the nicotine chewing gum group had a longer mean time before relapse than those in the silver acetate and ordinary chewing gum groups. Mean success rates for all subjects combined at 12, 26, and 52 weeks were 52.8%, 39.7%, and 23.3%. The side effects of nicotine and silver acetate chewing gum were generally mild and transient, and unimportant except for mouth irritation from silver acetate, which had a negative effect on outcome, and the low taste acceptability of nicotine, which had a strong negative influence on the success rate. The results suggest a short term effect on nicotine chewing gum on smoking cessation, but the abstinence rates after one year were generally disappointing.     

Obstructive sleep apnoea due to a dermoid cyst of the floor of the mouth.

A case of obstructive sleep apnoea is reported that was caused by a dermoid cyst of the floor of the mouth and cured by surgery.     

McBurney's point--fact or fiction?

Anthropometric measurements were performed on 51 normal, supine, barium enema examinations to determine the position of the lower pole of the caecum and the base of the appendix relative to palpable bony landmarks (the anterior superior iliac spine and the symphysis pubis). Four quadrants were defined (iliac, umbilical, inguinal and pelvic) by the intersection of the right lateral line and the interspinous line (the line joining the left and right anterior superior iliac spines). The position of the lower pole of the caecum was iliac in 12%, inguinal in 37%, and pelvic in 51%. The appendix or appendix stump was visualised on 53% of the barium examinations. The position of the appendix was iliac in 15%, umbilical in 15%, inguinal in 11%, and pelvic in 59%. The positions of the lower pole of the caecum and base of the appendix are lower and more medial than previously described. 70% of appendices were found to lie inferior to the interspinous line, contrary to established surgical teaching, which assumes McBurney's point to be the surface landmark for the appendix.     

Venous disease: investigation and treatment,fact or fiction?

This review looks at some clinical and experimental methods and treatments used in venous disease, and attempts to dispel some myths which have been associated with it. Over the last century numerous techniques have been introduced to aid the understanding of the physiology of normal legs and the pathophysiology of those with venous disease. Tourniquet testing along with clinical examination remains the only method of venous assessment in most hospitals. Venous ulceration in the past has been associated with deep vein incompetence, but the newer, non-invasive techniques of Doppler ultrasound and duplex examination are now identifying patients with leg ulceration who have superficial venous insufficiency and therefore a surgically correctable condition. Perforating veins and their possible role in the aetiology of venous ulceration along with invasive and non-invasive methods for their detection is reviewed. Some of the conservative compression treatments and dressings available for the treatment of venous ulceration are discussed. It is concluded that adherence to sound surgical principles remains the mainstay of the successful management of patients with venous disease.     

The efficiency of management of emergency surgery in a district general hospital--a prospective study.

In a 6-month prospective study of management of surgical emergencies in a district general hospital, we have tried firstly to determine the degree to which non-life-threatening emergencies could be managed within 'social hours' (0800-1800), and secondly to identify examples of and reasons for potentially hazardous delay in the performance of urgent procedures. Emergency referrals undergoing surgery were categorised into three groups: Group A--patients requiring surgery either immediately or at the earliest possible time (maximum 3 h after diagnosis). Group B--patients requiring urgent but not immediate surgery (within 6 h of diagnosis). Group C--patients whose operations could be delayed until social hours without detriment. The reason for delay--shortage of theatre nursing, anaesthetic or surgical staff--was recorded in each case. Of the 95 patients in Group C (elective management) 63 (65%) underwent surgery within social hours, 15 (16%) between 1800 and 2100 and 17 (18%) at night. Unacceptable delays occurred in 37 (14%) of the 260 cases and were most likely to affect patients in Group A who most needed urgent care. We conclude that our current staffing levels in theatre nursing should be increased to consistently provide two (rather than one) staffed theatres for emergencies, in addition to a theatre team dedicated exclusively to obstetrics. Anaesthetic manpower should be increased to provide four duty anaesthetists with no more than one at SHO level as obstetric and intensive care duties can be complex. General surgical staffing requires expansion in order that on-call staff have no fixed commitments during and in the session immediately after their duty periods.     

School-Based Cardiovascular Health Promotion: The Child and Adolescent Trial for Cardiovascular Health (CATCH)

The Child and Adolescent Trial for Cardiovascular Health (CATCH) is a multisite intervention research study that builds on significant progress made in school health education research in the 1980s. The study has three phases: Phase I deals with study design, intervention, and measurement development, Phase II involves the main trial in 96 schools in four states, and Phase III focuses on analysis. The intervention program targets third-fifth grade students and focuses on multiple cardiovascular health behaviors, including eating habits, physical activity, and cigarette smoking. Classroom curricula, school environmental change, and family involvement programs are developed for each grade level and behavioral focus. This paper describes Phase II of CATCH with a rationale for cardiovascular health promotion with youth. The process of change that appears to be necessary for school-based health promotion and that will be tested in CATCH are presented as a framework to guide these efforts.