Preoperative and follow-up bone scans in patients with primary carcinoma of the breast.

We have attempted to evaluate the role of preoperative and postoperative bone scans in patients with localized carcinoma of the breast. The yield of positive preoperative scans in patients with Stages I and II disease is low and confounded by a relatively high percentage of false-positive results. Conversely, 16 per cent of patients with Stage III disease had evidence of bony metastasis at the time of operation. Positive bone scans were found three times as frequently in patients with axillary node involvement than in those without. Thirty per cent of those observed for varying times up to 41 months had evidence of bony metastases. Again, there was a correlation with initial clinical staging with 3.6 to 8.0 times more conversions in patients with Stage II or III disease than in those with Stage I disease. It appears that the majority of metastases to the bone become apparent within the first years. This observation deserves further study to elaborate the natural history of metastatic carcinoma of the breast.     

Drug-induced cognition disorders in the elderly: incidence, prevention and management.

The aetiology of cognitive impairment is multifactorial; however, drugs are an important cause of delirium and dementia. Several factors may increase the risk of drug-induced cognition disorders in the elderly including imbalances in neurotransmitters (e.g. acetylcholine), age-related alterations in pharmacokinetics and pharmacodynamics, and high levels of medication use. Nearly any drug can cause cognitive impairment in susceptible individuals; however, certain classes are more commonly implicated. Benzodiazepines, opioids, anticholinergics, and tricyclic antidepressants are probably the worst offenders. Older antihypertensive agents (reserpine, clonidine) have negative effects on cognition; however, large clinical trials in the elderly indicate that commonly used agents [e.g. thiazide diuretics, calcium antagonists (amiodipine, diltiazem), ACE inhibitors (captopril, enalapril) and beta-blockers (atenolol)] have minimal effects on cognition. Newer antidepressants such as selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) and reversible inhibitors of monoamine oxidase A have not been shown to have negative effects on cognition. Although some drugs have shown low risk for causing cognition disorders in research studies, risk may be increased in frail older adults taking several medications and each case should be reviewed carefully. Identification of drug-induced cognitive impairment is crucial to early detection and resolution of symptoms. Preventive strategies directed at avoiding high risk medications when possible, appropriately adjusting doses based on age-related changes and close follow-up may prevent these conditions.     

Should anticoagulant therapy be stopped or reversed before venous intervention?

PURPOSE: To determine the safety of venous intervention and the incidence of complications in patients undergoing venous interventional radiological procedures while receiving anticoagulant therapy. METHOD: Data were collected prospectively for a 1-year period. One hundred patients receiving anticoagulant therapy underwent interventional radiological procedures requiring venous cannulation. Of these, 87 had documented prolonged bleeding times. There were 50 inferior vena cavograms obtained and filters placed (29 transfemoral, 21 transjugular), and 50 transfemoral pulmonary angiogram obtained, all in patients with thrombo-embolic disease who were receiving anticoagulant therapy. In most cases venous access was achieved with real-time sonographic guidance. RESULTS: Venous access was gained in all patients in all groups. There were 41/50 filter placements and 46/50 pulmonary angiograms performed in the patients with prolonged clotting times in or above the therapeutic range. There were no cases of arterial puncture and no cases of venous bleeding either during or after the procedures. No other complications were recorded. CONCLUSION: Venous intervention in patients receiving therapeutic anticoagulation is safe, with no complications reported in our series. There is no need to discontinue anticoagulant therapy in patients with life-threatening thrombo-embolic disease. Real-time sonographic guidance greatly facilitates venous cannulation and avoids inadvertent arterial puncture.     

Extradural haematoma in the Irish Republic: an analysis of 82 cases with emphasis on 'delay'

Eighty-two cases of extradural haematoma were analysed to elucidate the factors contributing to delay in treatment and poor outcome. The majority of cases occurred in the first three decades of life with falls being the commonest aetiological factor. Five distinct modes of presentation are described. Excessive delay occurred in recognizing the condition and in subsequent transfer of patients. This resulted in many patients being operated on while in coma. Associated intracranial and extracranial injury occurred in a significant number of cases. Recommendations for the management of these patients are outlined.