Delayed sudden hearing recovery after treatment of a large vertebral artery aneurysm causing hearing loss and imbalance: a case report

Purpose: Cerebral aneurysms that compress cranial nerve VIII can cause hearing loss and imbalance. Hearing function that does not recover after aneurysm occlusion can signal neurological damage with the potential for permanent deafness.Case Description: A 72-year-old woman presented with gradually worsening left-sided hearing loss and imbalance over a period of 10 years. She was found to have a lesion of the cerebellopontine angle, which proved to be a large fusiform vertebral artery aneurysm with mass effect on cranial nerve VIII. The patient underwent surgical clip occlusion of the vertebral artery distal to the posterior inferior cerebellar artery and proximal to the aneurysm, which no longer filled on catheter angiography. Postoperatively, the patient experienced delayed complete loss of ipsilateral hearing on the third post-operative day. Otherwise, she made a good recovery with improvement in her balance issues. At that time, we suspected that delayed occlusion of a perforating vessel had probably caused irreversible hearing loss. Ten months later, the patient awoke with significant subjective recovery of her hearing. Audiometry confirmed substantial improvement in her hearing likely due to the aneurysm shrinking away from and decompressing the cranial nerve.Conclusion: This case highlights the continued usefulness of vascular occlusion in the management of selected cases of intracranial aneurysms and also that neurological function may recover suddenly, even in very delayed fashion, following treatment.

Patient blood management: A solution for South Africa

For more than 70 years the default therapy for anaemia and blood loss was mostly transfusion. Accumulating evidence demonstrates a significant dose-dependent relationship between transfusion and adverse outcomes. This and other transfusion-related challenges led the way to a new paradigm. Patient blood management (PBM) is the application of evidence-based practices to optimise patient outcomes by managing and preserving the patient's own blood. 'Real-world' studies have shown that PBM improves patient outcomes and saves money. The prevalence of anaemia in adult South Africans is 31% in females and 17% in males. Improving the management of anaemia will firstly improve public health, secondly relieve the pressure on the blood supply, and thirdly improve the productivity of the nation's workforce. While high-income countries are increasingly implementing PBM, many middle- and low-income countries are still trying to upscale their transfusion services. The implementation of PBM will improve South Africa's health status while saving costs.

Preoperative smoking cessation: a questionnaire study

BACKGROUND

Preoperative smoking cessation has been shown to improve postoperative outcomes.

METHODS

A total of 120 anonymous questionnaires were distributed to non-vascular surgeons practising in four centres in the UK asking about their smoking cessation advice practices, and whether they appreciated both the benefits of preoperative smoking cessation, and the efficacy of smoking cessation interventions.

RESULTS

Eighty-three questionnaires were returned (response rate 69%). Twenty-three gastrointestinal surgeons, 11 orthopaedic surgeons, 9 breast surgeons, 12 plastic surgeons, 13 neurosurgeons and 15 urologists took part in this study. Eighty-eight per cent of respondents had not referred any elective patients to smoking cessation services in the previous month. Most non-vascular surgeons underestimated both the benefits of preoperative smoking cessation on outcome, and the efficacy of smoking cessation interventions.

CONCLUSIONS

This survey demonstrates that non-vascular surgeons underestimate the fact that preoperative smoking cessation can improve postoperative outcome, and that smoking cessation interventions are successful in helping patients to quit smoking. They largely do not refer patients to smoking cessation services. In order for patients to benefit postoperatively from this intervention it would be necessary to educate surgeons about the scale of the benefit, and the efficacy of smoking cessation interventions or to set up systematic frameworks to offer smoking cessation advice to preoperative patients who smoke.

Retraining: Can do, will do? A practical guide to process and pitfalls

This article reports the lessons learnt from a period of retraining and from discussion with others who have been involved in a similar process. The conclusions are that retraining should only be undertaken once there is full agreement between all parties involved that it is necessary and feasible. There must also be agreement in advance of the criteria which will constitute successful retraining, and the actions which will be taken to ensure the rapid return of the retrainee to the type of practice which is being offered and has been accepted. The process of retraining requires especially close supervision and is very stressful for the retrainee. It is likely that this should only be undertaken in units specially staffed and funded to accommodate this type of work.

Dental surgery attendance amongst patients with moderately advanced dementia attending a day unit: a survey of carers' views

OBJECTIVE

To ascertain the views of carers of patients with dementia, on the patient's dental health needs.

DESIGN

Prospective survey using semi-structured interview.

SETTING

Dementia day care unit for patients living in their own homes.

SUBJECTS AND METHOD

Twenty-eight carers of dementia sufferers were interviewed between March and September 2000, as part of regular clinical reviews of patient's needs. Carers' views on the dental care needs of patients were ascertained. Cognitive and behavioural assessments of patients were also made using the Clifton Assessment Procedure for the Elderly (CAPE).

MAIN OUTCOME MEASURE

Dental unmet need ie the carer deciding that the patient needed a dental examination, but anticipating that this would be problematic, the carer would not take them.

RESULTS

Twenty one per cent met criteria for dental unmet need.

CONCLUSIONS

Carers of people with dementia may be reluctant to take those they care for to the dentist. We need to explore ways to ensure appropriate dental surgery attendance.

The Medical Education Commission report on trends in graduate medical education 2001

The state of Louisiana Medical Education Commission offers the second publication in the Journal of Louisiana State Medical Society on Graduate Medical Education (GME) in Louisiana. The four previous annual reports of the Commission have provided data to focus on trends in size, status, proportions, and issues on GME. The Commission was established by Act 3 of the 1997 Louisiana Legislature. This summary report for 2001 provides the detailed and updated data on all GME residents and fellows in Louisiana for the last academic year. The presentation of data and trends poses three questions for analysis. First, what are the trends in Graduate Medical Education in Louisiana for total residents and fellows? Second, how do these trends relate to the size, status, and proportions of Graduate Medical Education in Louisiana and as compared to the United States? Third, where do these trends lead to the future in predictions and recommendations for Graduate Medical Education in Louisiana? The 4-year trend in the total number of Graduate Medical Education filled positions has been relatively consistent, with some recent increases in primary care residency positions, especially in Family Medicine and Medicine/Pediatrics. These increases will plateau as current trends on new program formation stabilize, requiring emphasis on recruitment and factors promoting recruitment for GME in the state of Louisiana. The state of Louisiana has participated proportionately relative to population in the growth of medical education in the last century and compares favorably with other states and the nation. Louisiana has exceeded national averages in the increases in primary care programs and residents and in the retention of trainees in practice sites in the state.

The Medical Education Commission report at the turn of then new millennium 2000

The State of Louisiana Medical Education Commission was formed by Act 3 of the 1997 Louisiana Legislature. The members are appointed by the Louisiana State University Health Sciences Center, Tulane University Medical Center, and Alton Ochsner Medical Foundation and report to and advise the Department of Health and Hospitals (DHH). This summation from the Medical Education Committee is designed to answer three questions. First, how does the State of Louisiana compare nationally in the renewal of physician supply and capability? Second, what are the current status and trends of graduate medical education in Louisiana? Third, what recommendations are proposed to continue and improve the important relationship between the State public hospitals and educational programs? The State of Louisiana has participated proportionately relative to population in the growth and progress of medical education in this last century and compares favorably with other states and the nation. Louisiana exceeds national averages in the increase of primary care residency programs and positions and in the retention of trainees in practice sites in the State. The three-year trends in total number of graduate medical education filled positions has been consistent with only 0.4% change, with primary care showing an overall increase of 9%, reflecting increases in Family Medicine (56%) and Medicine/Pediatrics (41%).

Psychological distress among younger siblings of patients with homozygous sickle cell disease in the Jamaican cohort study

The presence of a chronically ill family member may adversely affect the psychological health of siblings. This study used the General Health Questionnaire and the Modified Social Adjustment Scale to assess psychological distress in 20 younger siblings (4 AA, 16 AS genotypes), aged 16-19 years, of patients with homozygous sickle cell (SS) disease. The results were compared with those previously obtained in the 20 older siblings with SS disease and in 89 controls with a normal haemoglobin (AA) genotype. High levels of psychological distress occurred among all three groups. Greater psychological distress and poorer social adjustment occurred among siblings compared to AA controls but these differences disappeared after adjusting for the reduced age of siblings. The two measures were similar in SS patients and AA controls. The level of psychological distress among siblings of SS patients did not differ from that in SS patients or AA controls.

Hepatic insulin clearance increases after weight loss in obese children and adolescents

BACKGROUND

Obesity is a rapidly increasing health problem among US youth. Hyperinsulinemia is associated with obesity and has been found to be a contributory factor for the development of cardiovascular disease in the obese. It has been suggested that hyperinsulinemia of obesity is a result of increased insulin secretion caused by insulin resistance. However, it has been shown in adults that decreased hepatic insulin clearance (HIC) is the primary cause of hyperinsulinemia in this population.

METHODS

We studied 15 obese children and adolescents (11 F, 4 M; 8.6 to 18.1 years) before and 10 weeks after their enrollment in a multidisciplinary weight reduction program, which included a protein-sparing modified fast, a moderate intensity progressive exercise program, and a behavior-modification intervention.

RESULTS

All patients lost weight (P < 0.05). Measurements of immunoreactive insulin (IRI) and C-peptide reactivity (CPR) were performed before the program and at 10 weeks. IRI levels dropped significantly, whereas CPR levels did not change. CPR/IRI molar ratios, considered an indirect estimation of HIC, rose significantly after weight loss.

CONCLUSIONS

Our data suggest that hyperinsulinemia seen in obese children and adolescents is caused by decreased HIC. The cause for this decrease remains unknown, but it is reversible upon weight loss.

General paralysis of the insane and AIDS in old age psychiatry: epidemiology, clinical diagnosis, serology and ethics--the way forward

While the incidence of general paralysis of the insane (GPI) has declined, AIDS (acquired immune deficiency syndrome) has emerged as a new illness. Today, in England and Wales, as many elderly people die from AIDS as from neurosyphilis, although both diagnoses are rare in this age group. Both are serious medical conditions with psychiatric manifestations. For both, serological tests may identify the disease, and treatment may be of benefit, but there is considerable social stigma attached to the diagnoses. Ethical guidelines for serological testing for HIV (human immunodeficiency virus) have been available for over a decade. In view of the similarities between the diseases, it may be unethical to test patients for syphilis routinely. Epidemiology, risk factors, neurological and neuropsychiatric features and ethics must be considered before testing for both syphilis and HIV.

Role of orthotopic heart transplantation in the management of patients with recurrent ventricular tachyarrhythmias following myocardial infarction

OBJECTIVE

To report the outcome of an intention to treat by heart transplantation strategy in two groups of patients after infarction, one with both left ventricular failure (LVF) and ventricular tachyarrhythmias (VTA) (group A) and the other with progressive LVF following antiarrhythmic surgery for VTA (group B).

PATIENTS AND METHODS

Group A comprised 17 consecutive patients for whom transplantation was considered the best primary non-pharmacological treatment; group B comprised five consecutive patients assessed and planned for transplantation after antiarrhythmic surgery.

RESULTS

In group A, eight patients underwent transplantation and all survived the first 30 day period. At median follow up of 55 months (range 11 to 109) seven of this subgroup were still alive. Five patients died of recurrent VTA before transplantation, despite circulatory support. In the face of uncontrollable VTA, four of these underwent "high risk" antiarrhythmic surgery while awaiting transplantation: three died of LVF within 30 days and one was saved by heart transplantation two days after arrhythmia surgery. Mortality for the transplantation strategy in group A patients was 47% by intention to treat analysis. Quality of life in the eight actually transplanted, however, was good and only one died during median follow up of 56 months. The five patients in group B were accepted for transplantation for progressive LVF at a median of 21 months (range 12 to 28) after antiarrhythmic surgery. One died of LVF before transplantation, 22 months after initial surgery; another died of high output LVF three days after transplantation. Thus mortality of the intended strategy was 40%. The three transplanted patients are alive and well at 8-86 months.

CONCLUSIONS

Although the short and medium term outcome in category A or B patients who undergo transplantation is good, the overall success of the transplantation strategy in category A patients is limited by lack of donors in the short time frame in which they are required.

A relative-value-based system for calculating faculty productivity in teaching, research, administration, and patient care

PURPOSE

To design and test a simple, easily modifiable system for calculating faculty productivity in teaching, research, administration, and patient care in which all areas of endeavor would be recognized and high productivity in one area would produce results similar to high productivity in another at the Louisiana State University School of Medicine in New Orleans.

METHOD

A relative-value and time-based system was designed in 1996 so that similar efforts in the four areas would produce similar scores, and a profile reflecting the authors' estimates of high productivity ("super faculty") was developed for each area. The activity profiles of 17 faculty members were used to test the system.

RESULTS

"Super-faculty" scores in all areas were similar. The faculty members' mean scores were higher for teaching and research than for administration and patient care, and all four mean scores were substantially lower than the respective totals for the "super faculty". In each category the scores of those faculty members who scored above the mean in that category were used to calculate new mean scores. The mean scores for these faculty members were similar to those for the "super faculty" in teaching and research but were substantially lower for administration and patient care. When the mean total score of the eight faculty members predicted to have total scores below the group mean was compared with the mean total score of the nine faculty members predicted to have total scores above the group mean, the difference was significant (p < .0001). For the former, every score in each category was below the mean, with the exception of one faculty member's score in one category. Of the latter, eight had higher scores in teaching and four had higher scores in teaching and research combined.

CONCLUSION

This system provides a quantitative method for the equal recognition of faculty productivity in a number of areas, and it may be useful as a starting point for other academic units exploring similar issues.

Media triggers of post-traumatic stress disorder 50 years after the Second World War

Post-traumatic stress disorder (PTSD) may present many years after the original trauma. Case studies of two elderly patients are described. Both had experienced life-threatening combat situations and witnessed intense suffering during the Second World War. Marked distress was triggered by the media commemorating the fiftieth anniversary of the end of the war. PTSD patients often avoid talking of their traumatic experiences because of associated distress. Without taking a military and trauma history from elderly patients the diagnosis is likely to be missed.

Psychiatric complications of homozygous sickle cell disease among young adults in the Jamaican Cohort Study

BACKGROUND

This study aimed to determine the prevalence of psychiatric disorder in young adults with homzygous sickle cell (SS) disease and in controls with normal haemoglobin, and to examine factors associated with psychiatric disorder.

METHOD

The study design was cross-sectional. Subjects were aged 18-20 years: 63 with SS disease and 89 controls. The Psychiatric Assessment Schedule was used to determine psychiatric disorder at index of Definition level 5.

RESULTS

Psychiatric disorder was identified in 18 (29%) SS disease patients and in 22 (25%) controls. In SS patients, psychiatric disorder was not related to illness severity but was associated with leaving school early, difficulties in social adjustment, impaired cognitive function and having previous psychiatric difficulties. Male SS patients with psychiatric disorder all had low body mass index (BMI < 17.60). In controls, psychiatric disorder was associated with female gender, unemployment and difficulties in social adjustment.

CONCLUSIONS

The prevalence of psychiatric disorder was similar in patients and controls, although associated factors tended to be different. The association with low BMI in SS men merits further study.

Cyclo(His-Pro) augments the insulin response to oral glucose in rats

Cyclo(His-Pro) (CHP) is a gut-brain peptide found in rat and man. Since plasma levels of CHP are altered by oral glucose ingestion, we wondered whether exogenous CHP might alter the insulin response to oral glucose ingestion. To this end, rats were given 3g/kg oral glucose load with either saline or increasing doses of CHP and plasma levels of insulin, C-peptide and glucose were measured. We found mean insulin but not C-peptide excursions and area under the insulin but not C-peptide response curves (AUC) were significantly higher in the CHP groups than controls despite similar glucose responses. In summary, these data show that in rats receiving oral glucose, CHP causes higher insulin excursions without any change in C-peptide suggesting that CHP may decrease hepatic insulin clearance.

Psychiatric disorder in young adults in Jamaica

INTRODUCTION

Much research into psychiatric disorder in Jamaica has investigated psychotic illness but studies of neurotic disorders are lacking. This study investigated psychiatric disorder in a group of mainly urban, lower social class, young adults who had been regular clinic attenders as a physically healthy control group in a cohort study of sickle cell disease.

METHOD

The study was cross-sectional in design. Subjects, 44 male and 45 female, were aged 18 to 20 years at the time of the study. The Psychiatric Assessment Schedule was used to determine psychiatric disorder at Index of Definition level 5.

RESULTS

All subjects approached participated. Rates of psychiatric disorder were 6 (14%) in the male group and 16 (36%) in the female group. There were no psychotic disorders. In the group as a whole, psychiatric disorder was associated with female gender, unemployment, difficulties with social adjustment and number of episodes of physical illness in the 6 months prior to interview. Variables associated with psychiatric distress amongst males included not having a steady relationship, unemployment, criminal activity and difficulties with social adjustment. Variables associated with psychiatric distress amongst females included lack of domestic amenities, not having a mother at home, lack of education, unemployment and social adjustment difficulties.

CONCLUSION

Rates of psychiatric disorder were higher than expected, especially for women. Larger studies are indicated to investigate the prevalence of neurotic disorders amongst young people in Jamaica, compared to similar groups in other countries.

Collecting ethnic group data for inpatients: is it useful?

Since April last year British hospitals have had to collect data on the ethnic group of every patient. Patients must categorise their own ethnic group using the categories of the 1991 census. Claire Hilton argues that such data collection is unhelpful and will not meet its stated aim of helping to provide equitable access to NHS services for all ethnic groups. Self categorisation is unreliable, and the number of ethnic groups available is inadequate, in particular for the white population. Additional data on the size of each ethnic group in the local population and on rates of illness in particular groups are necessary to assess whether services are being provided equitably. Moreover, ethnicity is a multidimensional concept, and information on patients' language and cultural and religious practices, as well as their place of origin, is necessary if services are to be culturally sensitive.

The Hodgkin family papers

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A paradoxical elevation of brain cyclo(His-Pro) levels in hyperphagic obese Zucker rats

Several studies suggest a role for endogenous cyclo(His-Pro) or CHP in appetite regulation. In the present study, we have examined the regional brain distribution of CHP in hyperphagic obese Zucker rats and their lean littermates. The data show a significant elevation in the levels of CHP in many brain regions, including hypothalamus of the obese rat. Within the hypothalamus, the lateral hypothalamic (LH) nucleus of obese rats had significantly higher levels of CHP when compared to that of the lean littermates. Administration of dehydroepiandrosterone, a steroid hormone known to decrease food intake and body weight gain, to obese rats led to decrease in the levels of CHP in the LH. These data further suggest a role for the endogenous CHP in attenuating food intake.

Elizabeth Gaskell and mesmerism: an unpublished letter

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The gut-brain peptide cyclo(His-Pro) is secreted in a pulsatile fashion in fasting humans

Histidyl-proline diketopiperazine (CHP) is a cyclic dipeptide that is found in many animal tissues, most notably brain and gut. It has been found to have a variety of biologic actions and has been postulated to play a role in appetitive behavior and energy metabolism. This study was conducted in order to characterize the secretory pattern of CHP during a 24 h fast. Four subjects (2 obese and 2 lean) were studied during the latter 24 h of a 36 h fast. Blood was sampled every 10-15 min and assayed for CHP concentration using a specific radioimmunoassay. Analysis revealed that circulating CHP oscillates in humans and that diurnal variation occurred but only in the obese subjects.

Does cyclo(His-Pro) act like amphetamine?

In many pharmacologic tests, cyclo(His-Pro) (CHP) appears to act like a dopaminergic agonist and augments the actions of amphetamine (AMP). Therefore, to determine whether CHP is an AMP-like peptide, a comparison between CHP and AMP was made using four separate tests known to be AMP-responsive. These include, food intake, locomotor activity, dopamine uptake and modulation of binding sites for amphetamine and mazindol. A decrease in food intake and increase in spontaneous locomotor activity and stereotypy was observed after peripheral administration of amphetamine but not CHP. Chronic CHP administration resulted into a decrease in striatal amphetamine - and increase in mazindol-binding sites; in contrast, chronic amphetamine decreased both amphetamine - and mazindol-binding sites. These results show a clear dissociation between CHP and AMP suggesting that CHP is not an amphetamine-like peptide.

A randomized trial of laser vaporization in the management of cervical intraepithelial neoplasia associated with human papilloma virus infection

A randomized controlled trial was carried out at colposcopy clinics in the Birmingham and Midland Hospital for Women, to determine the efficacy of laser vaporization in the management of cervical Human Papilloma Virus (HPV) infection occurring alone or in association with cervical intraepithelial neoplasia (CIN), and to study the natural history of these lesions. The subjects were 365 women referred for investigation of cytological abnormality who were found to have histological evidence of HPV infection alone or in association with CIN1 or CIN2 and were considered suitable for local destructive treatment. The intervention consisted of immediate treatment using a carbon dioxide laser or no treatment. Women in both groups were followed by cytological and colposcopic examinations at intervals of four months. Twelve months after randomization, 25 per cent of women in the non-treatment group had progressed to a more severe degree of histological abnormality compared with 4 per cent in the treatment group (95 per cent confidence interval (CI) for difference in proportion 14-28 per cent). Spontaneous regression of cytological abnormality occurred in 26 per cent (95 per cent CI 19-33 per cent) of untreated women. It is concluded that the short-term efficacy of laser vaporization in the treatment of these lesions has been established. The substantial rate of spontaneous regression suggests, however, that intervention is frequently unnecessary.

Black-white contrasts in insulin levels during pubertal development. The Bogalusa Heart Study

Three hundred and seventy-seven children and adolescents aged 5-17 yr from the biracial (black-white) community of Bogalusa, Louisiana, were evaluated for Tanner stage of sexual development, plasma glucose, and insulin levels during an oral glucose tolerance test. Children of the two races were of similar age, weight, and height at each Tanner stage. Overall insulin response was compared by measuring the area under the insulin curve from the glucose tolerance test. Blacks, especially black females, had significantly higher insulin responses than their white counterparts. The insulin-glucose ratio at the initial t = 0 min baseline did not vary with race or sex throughout the Tanner stages. However, the 30 min postglucose data revealed clear differences between the races with blacks showing a higher insulin-glucose ratio. Ratios increased throughout puberty for both blacks and whites, boys and girls. The trends of racial contrasts seemed to be discernible even at the earliest stage of development. It is concluded that there is a clear difference between blacks and whites in insulin response to a glucose load early in childhood. These findings lead to the hypothesis that the greater prevalence of non-insulin-dependent diabetes mellitus seen in adult blacks, especially females, may be an expression of a difference in insulin secretion and related insulin resistance in early childhood.

Nonsteroidal antiinflammatory drugs for postthoracotomy pain. A prospective controlled trial after lateral thoracotomy

Diclofenac (Voltarol) as an adjunct to papaveretum for pain relief was examined by a prospective, randomized trial in 44 patients who had lateral thoracotomies. Patients given diclofenac, 75 mg intramuscularly twice daily, required less papaveretum in the first 3 days after operation (p less than 0.005) and had lower pain scores on a visual analog scale on all 5 postoperative days (p = 0.02 to less than 0.001); their respiratory vital capacity on the first postoperative day was also significantly higher (p less than 0.02). Diclofenac is a useful adjunct in the management of postthoracotomy pain.

Short-duration (three cycles) cisplatin combination chemotherapy with alkylating agent consolidation in advanced epithelial ovarian cancer

Forty-eight patients with advanced epithelial ovarian cancer were treated with a two-part cytotoxic regimen consisting of three cycles of cisplatin-based induction therapy followed by five cycles of escalating doses of cyclophosphamide, all given at 3-weekly intervals. The total cisplatin dose was 225 mg/m2. Seventeen patients with optimal primary surgery received chemotherapy only, while 17 of the 31 patients with suboptimal primary surgery underwent optimal interval cytoreductive surgery at the end of induction (cisplatin) therapy. Median survival for all patients was 15.4 months. Median survival was 15 months for patients with optimal primary surgery and 22 months for patients who had optimal secondary cytoreduction. Only 10 patients suffered WHO grade 3 or greater toxicity during therapy. This study suggests that the total dose of cisplatin can be reduced for patients with advanced ovarian carcinoma, resulting in reduced overall toxicity, without compromising response or response duration. A randomized trial to test this concept is now underway.

Recapping the used needle

Using sharps containers for needle disposal to minimise the risk of accidental puncture with a needle after giving an injection is recommended. This permits immediate disposal of the needle. Various commercial and makeshift containers are available, examples of which are illustrated. We recommend to avoid recapping of needles, but should it be necessary the following tip by Dr Hilton is appropriate.

A randomized trial comparing whole abdominal radiotherapy with chemotherapy following cisplatinum cytoreduction in epithelial ovarian cancer. West Midlands Ovarian Cancer Group Trial II

The potential role of consolidation therapy has been tested in a randomized trial in ovarian cancer. Patients were randomized to receive either whole abdominal radiotherapy using the moving strip technique (n = 56) or one year of chlorambucil (n = 53) following primary surgery, five courses of cisplatinum 100 mg/m2, and second look laparotomy. Overall survival at two years was 35%. There was no significant difference in survival between the two groups, and in spite of the observation that approximately 50% of the patients were optimally debulked prior to consolidation, no subgroups in either arm could be identified who might benefit from consolidation therapy. Toxicity was considerable in both arms, and almost 50% of patients were unable to complete the planned treatment in both arms. These results suggest that after primary surgery and cisplatinum chemotherapy, there is no indication for consolidation therapy with either radiotherapy or alkylating agents.

Combination bleomycin, ifosfamide, and cisplatin chemotherapy in cervical cancer

We report a phase II study of bleomycin, ifosfamide, and cisplatin (BIP) in cervical cancer. Our aims were to assess response rate, toxicity, and survival in women treated with this combination. Among 49 patients, 34 objective responses (69%) were seen, with 10 complete responses (20%). Toxic effects were assessed in 186 treatment cycles. All patients had alopecia and nausea and vomiting. Other effects included myelosuppression, infection, reduction in renal function, and disturbance of consciousness. These data indicate that BIP is highly active against advanced and recurrent cervical cancer.

Failure of second-look laparotomy to influence survival in epithelial ovarian cancer

The survival benefit of second-look laparotomy after completion of primary chemotherapy in patients with epithelial ovarian cancer has been assessed in a prospective randomised trial of 166 patients. Patients were randomised into three groups. All were initially treated with cisplatin (100 mg/m2 x 5) after primary laparotomy. Group A (n = 53) was scheduled to have a second-look laparotomy, followed by cyclical oral chlorambucil. Group B (n = 56) was scheduled to have a second-look laparotomy, followed by total abdominal and pelvic irradiation, and group C (n = 57) received oral chlorambucil as for group A but had no second-look operation. With a median follow up of 46 months (range 21-64), no differences in survival were noted between the three groups. The median survival for group A was 21 months (95% CI 11-31 months), for group B 15 months (11-19), and for group C 17 months (8-26). Thus second-look laparotomy after completion of first-line single-agent cisplatin chemotherapy did not confer any survival benefit on patients with epithelial ovarian cancer.

Phase II studies of bleomycin, ifosfamide and cis-platinum in advanced and recurrent cervical carcinoma

We report the results of phase II studies using a combination of ifosfamide, cis-platinum and bleomycin (BIP) in advanced and recurrent cervical cancer. Fifty-one patients have been studied. In 37 patients with disease not amenable to radical local therapy 27 objective responses (73%) were seen with 7 complete responses. Eleven of 14 patients (79%) with primary inoperable disease had at least a 50% reduction in tumour bulk prior to radical local radiotherapy. All patients experienced alopecia, nausea and vomiting. Other toxicity included myelosuppression, infection, reduction in renal function and disturbance of consciousness. There was no evidence that primary chemotherapy enhanced the acute toxic effects of pelvic radiotherapy. These data indicate that BIP is highly active in cervical cancer and can be used for effective palliation and cytoreduction in more than 70% of patients.