Corticosteroids in the management of bowel obstruction on a gynecological oncology unit

The development of gastrointestinal obstruction commonly occurs as a complication of advanced gynecological cancer. While surgery remains the mainstay of treatment for these patients, it is not always feasible, and when it is performed, it does not always resolve the obstruction. In this prospective study of patients presenting to a gynecologic oncology unit, 13 patients were administered 8 mg of dexamethasone subcutaneously or intravenously for a minimum of 3 days to manage the symptoms of bowel obstruction. Nine patients (69%) had a response to this therapy with decreased pain, nausea, and vomiting and improved oral intake. This response was maintained for a median of 31 days, with 7 of the 9 patients maintaining this symptomatic response until death. Mean survival of those responding was 39 days, including a subgroup of patients with extremely limited prognosis who, at their request, were discharged from the hospital in order to die at home. This subgroup had a mean survival of 20 days. The mean survival for nonresponders was 54 days. In patients for whom surgery is not contemplated, corticosteroids may provide a palliative treatment for bowel obstruction secondary to malignancy, provided there are no contraindications.

Increased survival after serious injury in patients admitted directly to critical care areas from the accident and emergency department

OBJECTIVES

We hypothesised that, in the subgroup of seriously injured patients who receive early critical care in the operating theatre or intensive care unit, there would be a greater actual survival rate than that statistically predicted using trauma scoring techniques.

METHODS

1031 seriously injured patients on a national trauma database were analysed. The numbers of survivors in 3 initial destination groups [intensive care unit (ICU), theatre and ward] were compared with the average number of survivors statistically predicted for similar groups of patients using the TRISS methodology. W statistics were then used to test for statistical significance.

RESULTS

77/122 patients admitted to an ICU survived (predicted number 66, W stat 8.8 [2.6-15.0]). 129/178 patients transferred to theatre survived (predicted number 113, W stat 8.8 [4.2-13.5]). 296/348 patients admitted to a ward survived (predicted number 292, W stat 1.3 [-1.9-4.4]).

CONCLUSIONS

The number of patients who survive after severe injury is significantly greater than the number predicted to survive by current trauma scoring methods if the patient is sent directly to theatre or are admitted directly to the ICU. Survival is as predicted if the patient is sent initially to a ward.

Initial assessment and outcome of head injured patients transferred to a regional neurosurgical service: what do we miss?

OBJECTIVE

To assess the level of missed extracranial injuries in patients transferred to a regional neurosurgical service for ongoing head injury management.

METHODS

A three year prospective study conducted under the auspices of the Scottish Trauma Audit Group. All patients were followed during their hospital stay by independent audit staff, their injuries being recorded and scored using established criteria.

RESULTS

115 head trauma patients were transferred during the study period. 15 patients died (13% mortality). Eight of a total of 87 separate, scorable extracranial injuries were missed (error rate 9%), none of which was serious. There were no missed injuries in patients who died. 77% of patients were managed by an accident and emergency doctor of at least registrar grade.

CONCLUSIONS

In contrast to other published series, this study has shown a low rate of missed extracranial injuries in a group of patients whose initial assessment is notoriously difficult. Early involvement by an experienced accident and emergency doctor may play an important part in the overall management of such patients.

A prospective study of rock climbing injuries

OBJECTIVES

To study the rate, causes, and nature of rock climbing injuries presenting to an accident and emergency (A&E) department.

METHODS

Patients presenting with rock climbing injuries to an urban A&E department were studied prospectively for one year.

RESULTS

19 rock climbers presented during the year, at a rate of one per 2774 A&E attendances. Fourteen climbers were injured on outdoor cliffs and five on the local indoor climbing wall, where the safety mats were noted to be in poor condition. Eighteen climbers had been injured during falls, 17 hitting the ground. Twelve of these climbers sustained fractures, four of which were missed on initial attendance. The remaining climber sustained the characteristic A2 pulley finger injury, which was treated conservatively with a good result.

CONCLUSIONS

The risks of rock climbing in Britain would be reduced if lead climbers arranged protection at earlier stages of climbs. Sports centres with climbing walls should regularly inspect and repair their safety equipment. It is important for staff in A&E departments to appreciate the large forces involved in any climbing fall, in order that significant injuries are not missed. Those treating injured climbers should also be aware of the specific injuries to which elite climbers are predisposed.

Paclitaxel (Taxol) as salvage therapy for relapsed ovarian cancer

Thirty-two patients with epithelial ovarian cancer received paclitaxel 175 mg/m2, by 3-hour infusion, in this prospective phase 2 study. All patients had relapsed or progressed after initial cisplatin/cyclophosphamide therapy. Thirteen patients received paclitaxel as second line therapy, 14 as third line therapy and 5 as fourth line therapy. One patient was excluded from efficacy analysis, due to a severe anaphylactic reaction to the first cycle of paclitaxel therapy. Of the 31 evaluable patients, complete remission was observed in 3 patients (9.7%) and partial remission in 11 patients (35.5%), with a total response rate of 45.2%. The median survival from diagnosis for the 31 evaluable patients was 32.5 months and the median survival following therapy with paclitaxel was 12.2 months (range 4-27 months). The 3 patients who achieved a complete response remain alive, at greater than 20 months, since commencing paclitaxel. Twelve patients (38.7%) who achieved a partial response, or had stable disease, had a median survival, after paclitaxel treatment, of greater than 18 months. This study confirms the activity of paclitaxel in relapsed ovarian cancer and demonstrates a prolonged survival benefit in greater than one third of this group of patients.

Cytology in the follow-up of cervical cancer

OBJECTIVE

To determine the value of cytology in the follow-up of cervical cancer.

STUDY DESIGN

The study group consisted of 230 patients with invasive cervical carcinoma who were followed for one to seven years. Forty-four patients developed recurrences or metastases. During this period, cytologic investigations involved 795 exfoliative smears from the cervix or vaginal vault, 10 fine needle aspirates and 5 fluids.

RESULTS

Thirty-three patients had positive or inconclusive cervical or vault smears that were histologically proven to be recurrences, and the other 11 patients had clinically obvious recurrences that were not smeared. Cytology first alerted the clinicians to recurrence in eight patients. Of 25 cervical or vault smears reported as malignant, 24 (96%) were histologically confirmed, and 1 showed radiation change on biopsy. In all 22 cases of smears reported as inconclusive, a biopsy followed, and in 9 (41%) of these, recurrence was demonstrated histologically. Inability to distinguish radiation change from recurrent malignancy was the chief cause of inconclusive smears. Five fluids and seven fine needle aspirates were diagnosed as malignant, saving patients an invasive diagnostic procedure.

CONCLUSION

Cytology is a useful, cost-effective, noninvasive and accurate investigation in the follow-up of cervical cancer.

Acute psychiatric problems in an A&E Department

A study of patients with psychiatric problems attending the Accident & Emergency Department at the Western Infirmary, Glasgow was performed over a four month period. Those requiring admission to other specialties for treatment were excluded (e.g. overdoses). Forty-seven patients presented during the study period and all were self-referred. Seventy-seven per cent had a past history of psychiatric illness. Sixty-six per cent of cases presented with self harm. Eighty-one per cent of cases presented after normal working hours. Alcohol intoxication was a contributing factor in only one quarter of patients presenting. Of all cases seen, 62% were referred to a duty psychiatrist. In this group 38% were admitted and 45% were discharged with psychiatric follow-up, three absconded and two were referred back to their general practitioners. Results indicated that the majority of patients referred to the psychiatric services from Accident & Emergency needed some form of psychiatric input. In the self harm group results showed a correlation between known risk factors for suicide and a need for admission or follow up. Due to local psychiatric referral policies, patients were referred to four different psychiatric hospitals in the area. After initial assessment by the duty psychiatrist, 52% of these patients were subsequently discharged with or without psychiatric follow up. Availability of an on site psychiatrist would alleviate many of the present delays in obtaining definitive management.

Grapelike leiomyoma of the uterus

A 24-year-old nulliparous woman underwent laparotomy for a large pelvic mass. Grapelike tumor extending from the uterus into the broad ligaments and peritoneal cavity was found. A diagnosis of sarcoma appeared likely, but radical surgery was avoided when frozen sections indicated a histologically benign smooth muscle tumor.

Extrauterine malignant mixed müllerian tumor of primary peritoneal origin

The case of an extrauterine heterologous malignant mixed müllerian tumor (MMMT) of primary peritoneal origin occurring in a 63 yr old woman is presented. The tumor was a 19 cm, soft, friable mass arising from the serosa of the sigmoid colon and spreading to adjacent pelvic peritoneum. The uterus, tubes and ovaries were uninvolved. It was composed of sarcomatous areas showing cartilaginous and rhabdomyoblastic differentiation and sharply demarcated carcinomatous areas showing endometrioid and serous differentiation. This is the thirteenth reported case of an extragenital MMMT. It demonstrates the pluripotentiality of female pelvic peritoneum to differentiate into tumors resembling those of the genital tract.

Decerebrate posturing in alcoholic coma

Two cases of alcoholic coma are presented where extensor responses to noxious stimuli are demonstrated. Decerebrate posturing normally indicates severe structural or functional depression of midbrain function but can be caused by depressant drugs. Blood alcohol measurements are a vital test in the comatose patient as the clinical picture may be caused, or temporarily significantly worsened, by severe alcohol intoxication. The preservation of pupillary light reflexes in the presence of deep coma with decerebrate posturing should alert the clinician to a possible metabolic cause for the coma, including alcohol. Nevertheless, a diagnosis of alcoholic coma should not be made unless the blood alcohol concentration is grossly elevated and other causes of coma have been excluded by careful physical examination, blood glucose and electrolyte measurement, skull radiography and, in the absence of a rapid improvement, computerized tomography.

The treatment of gynaecological malignancy in a general public hospital

OBJECTIVE

To assess the adequacy of treatment of gynaecological cancer in a public hospital and to determine the influence of referral patterns on patient outcome.

DESIGN

A retrospective analysis of clinical histories.

SETTING

A tertiary-level general public hospital.

PATIENTS

89 patients admitted between 1 January 1979 and 31 December 1987 for primary treatment of a gynaecological malignancy.

MAIN OUTCOME MEASURES

The primary study parameter was patient survival. During data analysis, the study parameters were altered to include the adequacy of initial surgery and survival time in relation to the involvement of the Gynaecology Unit.

RESULTS

Initial presenting symptoms had a major influence on the referral patterns of patients with a gynaecological malignancy. All patients who presented with abnormal vaginal bleeding were managed by the Gynaecology Unit. Patients with ovarian cancer who presented with non-specific abdominal symptoms and ascites were often managed by other units. There was a statistically significant difference in the adequacy of initial surgery depending on whether the patient was managed by the Gynaecology or the Surgical Unit (P < 0.05). The median survival time of patients managed by the Gynaecology Unit was 20 months; this was considerably longer than the figure of 14 months for other units (P < 0.05).

CONCLUSIONS

Patients with ovarian cancer who are managed by a specialised gynaecology unit are more likely to have adequate initial surgery and a longer median survival time. Female patients presenting with non-specific abdominal symptoms, ascites and other signs of intra-abdominal malignancy should be reviewed by a gynaecology unit before initial surgery.

Maximum effort in the management of ovarian cancer, including pelvic and para-aortic lymphadenectomy

Patients treated for ovarian cancer at the Mercy Hospital for Women, Melbourne over a 5 1/2 year period were studied with an emphasis on the need for lymphadenectomy. There were 80 patients identified with ovarian cancer. Forty patients underwent pelvic and/or para-aortic lymphadenectomy and 25 (62.5%) were found to have lymph node metastases, in 7 of the 40 women the lymphadenectomy resulting in upstaging of the disease. FIGO has adopted a surgicopathological approach to the staging of ovarian cancer and this requires lymphadenectomy to be performed. The importance of accurate staging in clinically early ovarian cancer and maximum surgical effort in advanced disease is discussed with particular regard to the place of lymphadenectomy.

The diagnosis of pelvic fractures by 'springing'

Thirty-six patients were studied prospectively to assess the benefit of 'springing' the pelvis in traumatized patients, to confirm or refute a fracture of the pelvis. None of the patients was multiply injured and half of those with fractures were elderly, sustaining their injuries in simple falls. Springing the pelvis was a poor predictor of the presence or absence of a pelvic fracture, at best it yielded a specificity of 71% and sensitivity of 59%. Its routine use in clinical examination should be abandoned.

The haemodynamic effects of sublingual nitroglycerin spray in severe left ventricular failure

The use of sublingual nitroglycerin spray has been studied in twenty patients referred to our Intensive Care Unit for further treatment of severe left ventricular failure. Within five minutes of spray administration significant falls in pulmonary artery occlusion pressure, mean arterial pressure, heart rate, right atrial pressure and systemic vascular resistance occurred. Similarly significant increases in cardiac index, stroke volume index and left ventricular stroke work index were found. These results show a considerable improvement in the haemodynamic parameters of invasively monitored patients and we believe that its administration undoubtedly "buys time" for the critically ill patient. However, we would caution against its routine use at present in view of the potential problem of hypotension, until further information is available.

Pelvic radiation therapy for gynecologic malignancy in geriatric patients

Thirty-one patients, aged 75 years or older, who received pelvic radiation therapy as part of primary treatment for a gynecologic malignancy, were reviewed. Ten patients (32%) failed to complete their treatment and 4 patients (13%) died of treatment-related complications. The treatment-related complications were independent of increasing age, but did correlate closely with the patients' pretreatment ECOG performance status. Ten patients with performance levels of 2 or higher had a mortality rate of 30%, while 70% failed to complete treatment. Treatment fractions of greater than 220 cGy per day also resulted in unacceptably high complication rates. Alternative treatment formats should be considered in geriatric patients with poor initial performance levels.

The long-term follow-up of women with gestational diabetes

Four hundred and forty-seven women who had gestational diabetes have been retested at intervals from 1 to 12 years following diagnosis; 49 (11%) were found to be diabetic and 35 (7.8%) had impaired glucose tolerance using the WHO criteria. An abnormal glucose tolerance test in the puerperium and obesity at the time of retesting had significant associations with abnormal glucose tolerance at follow-up. However, the best predictive factor of the likelihood of the development of significant hyperglycaemia was the recurrence of gestational diabetes in a subsequent pregnancy, since 28% of these women were diabetic and a further 4% had impaired glucose tolerance at the time of follow-up. These findings indicate that the criteria used for the diagnosis of gestational diabetes at the Mercy Maternity Hospital, Melbourne (1-hour greater than or equal to 9 mmol/l together with a 2-hour greater than or equal to 7 mmol/l) are appropriate for an Australian population.

Gadusol, an enolic derivative of cyclohexane-1,3-dione present in the roes of cod and other marine fish. Isolation, properties and occurrence compared with ascorbic acid

Gadusol, C8H12O6, has been isolated from roes of the cod (Gadus morhua L.), i.e., ovaries that contain ripe eggs just before spawning. The concentration is about 4 g/kg dry wt. It has been identified as 1,4,5-trihydroxy-5-hydroxymethyl-2-methoxycyclo-hex-1-en-3-one and this structure was confirmed by synthesis of the anhydro tetra-acetate derivative from methyl 3,5-diacetoxy-4-methoxybenzoate. Concentrations of gadusol in the roes of other marine teleost fish examined are of the same order as in cod roes. Gadusol has some properties similar to ascorbic acid and both compounds, after oxidation, react with 2,4-dinitrophenylhydrazine in the commonly-used assay procedure for ascorbic acid. Specific assays showed that the concentrations of gadusol in the roes of marine fish are severalfold greater than those of ascorbic acid. Gadusol is structurally related to the mycosporines previously reported from a number of different organisms.

Drugs from the sea--fact or fantasy?

Drugs from the sea are as much a potential marine resource as cultivated fish, and mineral deposits. The study of the chemical structure and properties of unusual metabolic products of marine life is a subject where marine ecology and the experimental sciences of chemistry, biochemistry, pharmacology and medicine share a common and complementary interest. The development of ad hoc collaboration between specialists has advanced basic knowledge and resulted in a significant feedback to marine biology and ecology as well as in the development of some useful drugs.

A haemagglutinin in the tissue fluid of the Pacific oyster, Crassostrea gigas, with specificity for sialic acid residues in glycoproteins

An agglutinin for human red cells has a specificity for sialic acid and a high affinity for bovine salivary glycoprotein. Digestion of the glycoprotein with Pronase or neuraminidas indicated that binding of sialic acid to receptors in the agglutinin is the first step in the mechanism of formation of a stable complex between ligand and receptor.

Differences in the nature of the interaction of insulin and proinsulin with zinc

1. The reversible interaction of zinc with pig insulin and proinsulin has been studied at pH7 by equilibrium dialysis (ultrafiltration) and by sedimentation equilibrium and velocity measurements in the ultracentrifuge. Binding values calculated from equilibria, where the ratio of free to bound zinc was varied in the range 0.01:1-10:1, indicated that proinsulin and insulin each contained two main orders of zinc binding with very different affinities for the metal. 2. In equilibria containing low concentrations of free zinc (free: bound ratios of 0.01-0.1:1) both insulin and proinsulin aggregated to form soluble hexamers containing firmly bound zinc (up to 0.284g-atom/monomer) with an apparent intrinsic association constant of 1.9x10(6)m(-1). 3. Higher concentrations of zinc (free: bound ratios of 0.1-10.0:1) resulted in a progressive difference in the zinc binding, aggregation and solubility properties of the metal complexes of insulin and proinsulin. At the highest concentration of free zinc, proinsulin bound a total of more than 5.0g-atom/monomer and aggregated to form a mixture of soluble polymers (mainly 5.1S). In contrast, insulin bound a total of only 1.0g-atom/monomer and was almost completely precipitated from solution. 4. These results would indicate that the presence of the peptide segment connecting the insulin moiety in proinsulin does not prevent the firm binding of zinc to the insulin moiety and the formation of hexamers of zinc-proinsulin. At the same time although the connecting peptide contains additional sites of lower affinity for zinc, which should facilitate inter- and intra-molecular cross-linking, the general conformation of the zinc-proinsulin hexamer must preclude the formation of very large and close-packed aggregates that are insoluble in solutions at equilibrium.