Delays in treatment in the cancer services: impact on cancer stage and survival

This study describes waiting times for cancer treatment in Ireland, tests for differences between health board areas and investigates if delay affected cancer stage or prognosis. We measured the times between referral, outpatient attendance and treatment for all patients diagnosed with five common cancers in Ireland in 1999. There was a four-fold spread of waiting time between the 25th and 75th centile. The time from referral to treatment was shortest for breast cancer (median 4 weeks), twice this for colorectal cancer, lung cancer and lymphoma, and 15 weeks for prostate cancer. Delays varied significantly, but not consistently, between health boards. Patients with longer waiting times generally had less advanced disease and better survival, suggesting that typical delays are not of clinical significance, but that patients with advanced disease are probably being "fast-tracked" by GPs and hospitals.     

Posterior reversible encephalopathy syndrome (PRES) associated with liquorice consumption

Importance

Posterior reversible encephalopathy syndrome (PRES) is a medical emergency but prompt recognition, early institution of supportive care and identifying and removing potential triggers are associated with a good clinical outcome. We report an unusual case of PRES associated with liquorice consumption.

Observations

A 56-year-old lady presented with thunderclap headache, visual disturbance and a generalised tonic–clonic seizure. Blood pressure on admission was markedly elevated but improved within 24 h. Cranial CT and lumbar puncture were normal (no xanthochromia). She had hypokalaemia. Cranial MRI revealed abnormalities in the occipital lobes consistent with PRES. There was no evidence of restricted diffusion or vasoconstriction. Follow-up MRI 3 weeks later demonstrated complete resolution. On direct questioning she revealed in recent months she had habitually eaten liquorice sweets each day; they were “on special offer” in her local shop.

Conclusion and relevance

Liquorice contains a biologically active compound glycyrrhizic acid which inhibits 11β hydroxysteroid dehydrogenase. Excessive liquorice consumption can cause mineralocorticoid excess and has been recently reported to cause PRES. We propose that in the absence of other triggers, frequent liquorice consumption precipitated the development of PRES in our patient and should be considered as a possible cause of this condition.

     

Fever in returned travellers: a prospective review of hospital admissions for a 2(1/2) year period.

AIM: To identify causes of fever, treatable diseases, and the most helpful investigations in febrile children, who had travelled to the tropics or subtropics in the preceding year. METHODS: Prospective observational study of all admissions to children's wards in a district general hospital in Birmingham between January 1997 and July 1999. Children with fever >37.5 degrees C and a history of travel to the tropics or subtropics in the preceding 12 months were included. Data were available on 153/162 children; median age was 5 years (range 0.1-15). A total of 133 (85%) children had visited South Asia; only 18/135 had received malarial prophylaxis. Median time to presentation after travel was four weeks. Children were investigated with full blood count, blood film, and stool culture. Other investigations were performed at the discretion of the admitting paediatrician. RESULTS: Diarrhoeal illness (n = 41) and malaria (n = 22) were the most common diagnoses. A treatable cause for the febrile illness was identified in 70 (46%) children. One or more investigations were positive in 60% of children. Stool culture (17% positive) and blood film (14% positive) were the most helpful investigations. Platelet counts greater than 190 x 10(9)/l had a negative predictive value of 97% for malaria in this population. CONCLUSIONS: Children who present with fever and have travelled to the tropics or subtropics in the preceding year, often have a treatable infection. They should have a full blood count, blood film for malarial parasites, stool culture, blood culture, and chest x ray.     

Mosaic trisomy of a small r(1) with an abnormal phenotype

Cytogenetic studies of a mildly dysmorphic 10-year-old male with mild developmental delay and learning difficulties revealed mosaicism for a supernumerary ring chromosome in approximately half of the cells. The karyotype of this patient was established as 47,XY,+r[15]/46,XY[15].ish r(1)(D1Z7+,wcp1-). Although the presence of euchromatic material was shown by C banding, the lack of hybridization with the whole chromosome paint 1 (wcp1) probe suggests that few unique sequences are contained in the ring and that these sequences likely explain the child's dysmorphic features and developmental delay. A review of the literature, including the present case, suggests that the significance of euchromatin in supernumerary r(1) as determined by both C banding and fluorescence in situ hybridization (FISH) with chromosome 1 painting probes can be used as a prognostic indicator for potential severity of the clinical phenotype.     

Proinflammatory and anti-inflammatory cytokines in meningococcal disease

Interleukin-10 (IL-10), an anti-inflammatory cytokine, was measured in 131 children with meningococcal disease. IL-10 concentrations were significantly higher in children who died and correlated positively with proinflammatory cytokines. Children who die from meningococcal disease have high IL-10 concentrations, which do not suppress proinflammatory cytokines.     

Liver iron concentrations in sudden infant death syndrome

To determine the biological significance of high concentrations of non-haem iron in the livers of infants dying from sudden infant death syndrome (SIDS), liver samples were obtained at necropsy from 66 infants who died from SIDS and 28 control infants who died before 2.5 years of age. All were full term deliveries. Liver iron concentrations decreased rapidly with age in the two groups. Liver iron concentrations in the SIDS infants and controls were compared for those infants who died between 1 month and 1 year of age. The median liver iron concentration in the SIDS infants was 296 micrograms/g wet weight; significantly higher than the median of 105 micrograms/g in controls. There was an inverse relation between iron concentration and age in the two groups, but an analysis of covariance confirmed the significantly lower values in controls. The frequency (22%) of HLA-A3 in SIDS infants was similar to that expected for the United Kingdom population (25%) and does not implicate the gene for haemochromatosis as a cause of high liver iron concentrations. These findings show that the peak incidence of SIDS occurs when mean concentrations of iron in liver tissue are higher than at any other time of life. Although a primary causal connection seems unlikely, high tissue iron concentrations may lower resistance to infection and enhance free radical formation, leading to tissue damage.     

Fluoride supplements and caries in a non-fluoridated child population

In Norway, there is no water fluoridation and little naturally occurring fluoride in drinking water. Fluoride toothpaste is used by 95% of the population and there is a long tradition of use of fluoride supplements. The purpose of this study was to analyse whether children who used fluoride toothpaste regularly and complied with the recommendations for use of fluoride supplements had less caries than other children at the age of 8 years. Most fluoride supplements sold in Norway are lozenge-type tablets, which allow for extended enamel exposure to fluoride. All children (n = 551) born in 1988 living in a suburban community in Norway were invited to participate. In those who participated (n = 470), caries was registered clinically and radiographically and parents provided data on use of supplements. Thirty-eight percent of the children had used fluoride supplements regularly during the period 0.5 to 4.0 years of age and 66% used supplements regularly at the age of 6 to 8 years. Multivariate analyses showed that the children complying with the recommendations for use of fluoride supplements during the period 0.5 to 4.0 years of age had lower caries experience (dmfs) and fewer decayed surfaces (ds) in primary teeth than other children. No significant associations were found between supplement use in childhood and caries prevalence (DMFS) or number of decayed surfaces (DS) in permanent teeth at the age of 8 years. Supplement use from 6 to 8 years of age was not associated with caries occurrence either in primary or in permanent teeth. Both mother's education and the quality of dental hygiene were inversely associated with caries occurrence.     

Intrapericardial haematoma: a rare cause of congestive cardiac failure after three years of coronary artery bypass grafting

We present a rare case of organised intrapericardial haematoma after three years of coronary artery bypass grafting. Delayed cardiac tamponade after open heart surgery usually occurs within first few weeks of surgery. Intrapericardial organised haematoma causing localised compression of cardiac chambers after three years of open heart surgery is very rare. Under cardiopulmonary bypass and cardioplegic cardiac arrest, we removed the haematoma. It is difficult to make a clinical diagnosis. However once diagnosis is made and haematoma removed, it gives good symptomatic relief to the patient.