The treatment of malignant cerebral tumours

Malignant cerebral tumours are uncommon. While a large proportion are resistant to conventional therapies there are a significant number of curable malignant brain tumours that require recognition and appropriate therapy.     

Extracorporeal membrane oxygenation in the management of respiratory failure in the newborn

The history of ECMO and the development of its present-day use is discussed. The results of the National ECMO Registry and the first 100 patients at Children's Hospital National Medical Center are presented. Future developments and directions of ECMO are presented.     

Fixed drug eruption following metronidazole therapy and the use of topical provocation testing in diagnosis

Fixed drug eruption is characterized by recurrent well-defined lesions appearing in the same location each time the drug responsible is taken. A number of agents have been implicated. Metronidazole, a nitroimidazole agent widely used for its antibacterial and antiprotozoal activity, has been reported only rarely as the causative agent. We describe a patient with FDE due to metronidazole in whom we were able to induce the clinical and histological features of FDE by topical provocation testing. In agreement with the published literature we commend the use of topical provocation testing as a possible first-line investigation in the diagnosis of FDE. This may avoid the need for subsequent oral provocation testing and therefore the prevention of possible adverse sequelae.     

Reversible findings of restricted diffusion in 5‐flourouracil neurotoxicity

A 35‐year‐old woman presented with neurotoxicity correlated to an i.v. regimen of 5‐fluorouracil as episodes of acute confusional state and abnormalities of symmetrically restricted diffusion in the periventricular white matter and corpus callosum. On discontinuing the medication, the areas of severely restricted diffusion had entirely resolved, with minimal residual T2 signal abnormality. In this case, immediate discontinuation of the chemotherapeutic agent apparently reversed the patient's symptoms and findings on MRI. The scant information available in the published literature regarding this phenomenon is reviewed with regard to 5‐fluorouracil.     

A child with neurofibromatosis-1 and a lumbar epidural arteriovenous malformation

A 10-year-old child with neurofibromatosis-1 was evaluated for progressive lumbar scoliosis, back pain, and foot numbness. Magnetic resonance imaging showed several lumbar intraspinal and extraspinal masses consistent with neurofibromas. The mass at L3-L5 compressed the thecal sac and was thought to be the source of the symptoms. On operative exploration, a lumbar epidural arteriovenous malformation was found, which was removed in its entirety. The child's back pain and foot numbness resolved. Epidural arteriovenous malformations in patients with neurofibromatosis-1 are rare and have been reported only in the cervical spine. Our finding of a lumbar epidural arteriovenous malformation in a child with neurofibromatosis-1 demonstrates that vascular anomalies can be present throughout the spine of patients with neurofibromatosis-1 and should be considered in the differential diagnosis of any neurofibromatosis-1-related epidural mass.     

Hospital readmissions in people with chronic spinal cord injury

STUDY DESIGN: Longitudinal observational. OBJECTIVES: To examine frequency and duration of hospital readmissions in a population based sample of people with chronic spinal cord injury (SCI) and to look at medical reasons necessitating readmissions and factors influencing them. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK and Regional Spinal Injuries Centre, District General Hospital, Southport, UK. METHODS: One-hundred-and-ninety-eight SCI patients, all injured more than 20 years ago, were interviewed on three occasions and their medical records reviewed for the period 1990 - 1996. RESULTS: Between 1990 and 1996, 127 patients (64% of the sample) required hospital treatment for late medical complications, with 481 readmissions between them and the mean length of stay of 12.03 days per readmission. Only 58% of all readmissions were into specialised spinal injuries centres. Averaged over the entire sample, the readmission rate was 0.4 readmissions per person at risk per year, and the occupancy rate was 4.9 bed-days per person at risk per year. The most frequent reason for readmissions were urinary tract complications (40.5% of all readmissions) and the highest bed occupancy was for skin problems (32.2% of all bed-days). When compared with the non-hospitalised group (36% of the sample), the readmitted patients had longer duration of paralysis and lower disability and handicap scores as measured by Functional Independence Measure (FIM) and Craig Handicap Assessment & Reporting Technique (CHART). The subgroups did not differ significantly by neurological grouping or age. CONCLUSIONS: Urinary and skin complications are the two main reasons for hospital readmissions in people with chronic SCI. Risk of readmissions increases with time since injury and with disability and handicap severity. Hospital bed requirements for people with chronic SCI are greater than the amount of clinical provision currently available in specialised spinal centres. In order to meet the needs of the growing SCI population, more specialised spinal injuries care beds will be needed. Spinal Cord (2000) 38, 371 - 377.     

Chemoprevention of spontaneous tumorigenesis in nullizygous p53- deficient mice by dehydroepiandrosterone and its analog 16alpha-fluoro- 5-androsten-17-one

Transgenic mice with both alleles of the p53 tumor suppressor gene product 'knocked out' by gene targeting are susceptible to early development of tumors, chiefly lymphomas and sarcomas. Compared with the control group, administration of dehydroepiandrosterone (DHEA) at 0.3% of the diet to male p53-deficient mice extended their lifespan by delaying death due to neoplasms (from 105 to 166 days on study, P = 0.002), primarily by suppressing lymphoblastic lymphoma (from 45 to 6% of neoplastic deaths, P = 0.010). Treatment with a synthetic DHEA analog, 16alpha-fluoro-5-androsten-17-one (compound 8354), at 0.15% of the diet also increased lifespan, to 140 days for mice that developed tumors (P = 0.037). The effects of these steroids on lifespan and tumor development did not appear to be strongly related to inhibition of food consumption and weight gain, in that a group pair-fed with control diet to the reduced food consumption of the DHEA-treated group developed and died of the same types of neoplasms at the same rate as the controls fed ad libitum. The chemopreventive effect of these steroids has been proposed to be due to suppression of DNA synthesis by inhibition of glucose 6-phosphate dehydrogenase, the rate-limiting enzyme of the pentose phosphate pathway. Although DHEA and its analog are strong non- competitive inhibitors of this enzyme in vitro, treatment with DHEA did not deplete cellular nucleotide pools in the liver, as would have been predicted. The chemopreventive effect of DHEA in this model may be due to steroid-induced thymic atrophy and suppression of T cell lymphoma, permitting these mice to survive long enough to develop tumors with longer latency.      

Manometrically guided colon insufflation during double-contrast barium enemas

The double-contrast enema's potential for high accuracy depends in part on consistently good inflation of the colon. However, optimal inflation is often not obtained because of deflation during filming, underinflation because of fear of perforating the colon, or patient discomfort. To help meet the dual requirements of ensuring consistently good bowel inflation while avoiding over-inflation, we have designed a modified insufflator which incorporates a manometer and allows accurate readings of intraluminal large-bowel pressures during or following insufflation. In more than 3000 examinations using this method we have experienced no complications.