Management of breast cancer in the elderly

This paper examines data which has been published on breast cancer in the elderly and concludes that, wherever possible, combined modality treatment should be offered to elderly breast cancer patients. It appears from an examination of the literature that single modality treatment in the form of hormone treatment often results in very high rates of loco-regional recurrence.     

Leukoencephalopathy with Anterior Temporal Cysts Due to Congenital CMV Infection Diagnosed Retrospectively

Leukoencephalopathy with subcortical cysts has been described in a variety of conditions. However, few reports have highlighted congenital CMV as a cause of this imaging finding. We report a 1‐year‐old girl with developmental delay and sensorineural hearing loss whose MRI brain showed abnormal white matter and temporal cysts. Congenital CMV infection was diagnosed retrospectively by examination of dried blood spot from the newborn screening card.     

Guanidinoacetate methyltransferase (GAMT) deficiency: late onset of movement disorder and preserved expressive language

Guanidinoacetate methyltransferase (GAMT) deficiency is a disorder of creatine biosynthesis, characterized by early-onset learning disability and epilepsy in most affected children. Severe expressive language delay is a constant feature even in the mildest clinical phenotypes. We report the clinical, biochemical, imaging, and treatment data of two female siblings (18y and 13y) with an unusual phenotype of GAMT deficiency. The oldest sibling had subacute onset of a movement disorder at age 17 years, later than has been previously reported. The younger sibling had better language skills than previously described in this disorder. After treatment with creatine, arginine restriction and ornithine-supplemented diet, seizure severity and movement disorder were reduced but cognition did not improve. This report confirms that GAMT deficiency, a heterogeneous, potentially treatable disorder, detected by increased levels of guanidinoacetate in body fluids (e.g. plasma or urine) or by an abnormal creatine peak on magnetic resonance spectroscopy, should be considered in patients of any age with unexplained, apparently static learning disability and epilepsy.     

Rectal controlled-release morphine: plasma levels of morphine and its metabolites following the rectal administration of MST Continus 100 mg

Eight patients undergoing major maxillary surgery were given sustained-release morphine (100 mg MST Continus) rectally, immediately after induction of general anaesthesia. Blood samples for assay were taken just prior to morphine administration, together with a further 11 samples over the following 24 h. Assay of the plasma for morphine, morphine-3-glucuronide and morphine-6-glucuronide was carried out using a validated high-performance liquid chromatography technique. Morphine T _max ranged from 3 h to 12 h (median 6 h), C _max 8·0–40·0 ng/ml and AUC _0–24 90·1–429·7 ng/h/ml in subjects offering blood samples over the 24-h period. Likewise, morphine-3-glucuronide T _max ranged from 3 h to 24 h (median 9 h), C _max 153–370 ng/ml and AUC _0–24 2776–4390 ng/h/ml. Morphine-6-glucuronide T _max ranged from 8 h to 12 h (median 10 h), C _max 24–59 ng/ml and AUC _0–24 137–803 ng/h/ml.
Morphine and morphine metabolite AUC _0–24 ratios were calculated, but they did not correlate with analgesic needs. The AUC _0–24 ratios were similar to those following oral and rectal dosing in other studies involving cancer patients.
The wide variation of individual morphine and metabolite plasma levels, and their AUC ratios indicates considerable interpatient variability in the absorption and metabolism of rectal sustained-release morphine. This large interpatient variation may indicate that it is not suitable for acute pain, because analgesic requirements change much more rapidly than in the chronic pain situation where individual patient titration can take place.     

Desflurane in paediatric anaesthesia

Summary
Despite the low blood-gas coefficient of desflurane, inhalational induction is delayed by airway complications in paediatric practice. A slow induction technique reduces airway complications in adults. The aim of this study was to examine the use of desflurane for paediatric anaesthesia and to reduce airway complications with a slow induction technique. Sixty children (age range, 1 month to 12 years) were anaesthetized with 3% desflurane, increased by 1% every minute until anaesthesia was adequate for tracheal intubation. Anaesthesia was maintained with oxygen, nitrous oxide, and desflurane delivered by mechanical ventilation. During induction of anaesthesia, the incidence of moderate to severe coughing was 20%, breath-holding 14%, and laryngospasm 31%. Blood pressure fell significantly ( P < 0.05) from baseline after induction of anaesthesia and remained at this level during anaesthesia. Heart rate was stable in children less than six years, but increased significantly in older children. There were no significant airway problems during recovery from anaesthesia. Recovery time was rapid: the time to awakening was 10.2 min and to discharge from the recovery room, 29.2 min. Although desflurane is not an ideal anaesthetic agent for inhalational induction in children, it maintains stable anaesthesia and provides rapid smooth recovery.     

Paediatric post orchidopexy analgesia—effect of diclofenac combined with ilioinguinal/iliohypogastric nerve block

Summary
When ilioinguinal/iliohypogastric nerve blockade is used to provide postoperative analgesia after paediatric orchidopexy, supplemental analgesia may be required postoperatively. Diclofenac is a nonsteroidal analgesic which produces effective analgesia after tonsillectomy. We examined the effect of combining diclofenac with inguinal field block for post orchidopexy analgesia. Following induction of anaesthesia, group 1 ( n = 25) received ilioinguinal block and rectal diclofenac (2 mg·kg⁻¹) and group 2 ( n = 25) received ilioinguinal block alone. Objective pain scores were assessed for the first three h postoperatively and the incidence of postoperative rescue analgesia, noted. Pain scores were significantly less in group 1 at 45, 60, 90 and 120 min postop ( P < 0.05). The postoperative analgesic requirement was significantly lower in the diclofenac group compared to control ( P < 0.05). A single administration of rectal diclofenac is a simple and effective method of significantly improving analgesia associated with inguinal field block, after paediatric orchidopexy.