What matters for people with brain cancer? Selecting clinical quality indicators for an Australian Brain Cancer Registry

BACKGROUND

The goal of a clinical quality registry is to deliver immediate gains in survival and quality of life by delivering timely feedback to practitioners, thereby ensuring every patient receives the best existing treatment. We are developing an Australian Brain Cancer Registry (ABCR) to identify, describe, and measure the impact of the variation and gaps in brain cancer care from the time of diagnosis to the end of life.

METHODS

To determine a set of clinical quality indicators (CQIs) for the ABCR, a database and internet search were used to identify relevant guidelines, which were then assessed for quality using the AGREE II Global Rating Scale. Potential indicators were extracted from 21 clinical guidelines, ranked using a modified Delphi process completed in 2 rounds by a panel of experts and other stakeholders, and refined by a multidisciplinary Working Group.

RESULTS

Nineteen key quality reporting domains were chosen, specified by 57 CQIs detailing the specific inclusion and outcome characteristics to be reported.

CONCLUSION

The selected CQIs will form the basis for the ABCR, provide a framework for achievable data collection, and specify best practices for patients and health care providers, with a view to improving care for brain cancer patients. To our knowledge, the systematic and comprehensive approach we have taken is a world first in selecting the reporting specifications for a brain cancer clinical registry.

Studienwahlmotive von Bewerberinnen und Bewerbern auf ein Lehramtsstudium und auf andere Studiengänge

Zusammenfassung. Studienwahlmotive von Lehramtsstudentinnen und -studenten sind in den vergangenen Jahren vermehrt in den Fokus von Forschungsvorhaben gerückt und erweisen sich als wichtiger Prädiktor für Studienerfolg und den Aufbau professioneller Kompetenzen. Dabei zeigt sich insbesondere das Erwartungs-Wert-Modell der Motivation als geeignete theoretische Grundlage zur Klassifikation und Operationalisierung verschiedener Studienwahlmotive. Zudem tragen die Betrachtung von Motivprofilen und Vergleiche verschiedener Lehramtsstudiengänge sowie verschiedener Länder zum besseren Verständnis von Studienwahlentscheidungen bei. Studiengangübergreifende Vergleiche, die über Lehramtsstudiengänge hinausgehen und Studienwahlmotive mittels reliabler Fragebogenskalen erfassen, sind jedoch kaum zu finden. Für den vorliegenden Beitrag wurde deshalb durch Adaption bestehender Instrumente ein Fragebogen zur studiengangübergreifenden Erhebung von Studienwahlmotiven entwickelt und von 690 Bewerberinnen und Bewerbern auf insgesamt 13 verschiedene Studiengänge bearbeitet. Es zeigt sich, dass sich die sechs Studienwahlmotive fachliche Fähigkeitsüberzeugung, fachliches Interesse, berufliches Interesse, gesellschaftlicher Wert des Studiums, persönliche Nützlichkeit und geringe Schwierigkeit des Studiums auch studiengangübergreifend reliabel (Cronbachs α > .69) erfassen lassen und dass sich Bewerberinnen und Bewerber auf verschiedene Studiengänge signifikant in diesen Studienwahlmotiven unterscheiden ( p ≤ 0.003). Insbesondere zeigt sich, dass das Studienwahlmotiv Fachinteresse bei Bewerberinnen und Bewerbern auf ein Lehramtsstudium niedriger als in anderen Studienganggruppen ausfällt (Cohens d = –0.45), und dass alle anderen erhobenen Studienwahlmotive bei Bewerberinnen und Bewerbern auf ein Lehramtsstudium am höchsten ausgeprägt sind – mit großen Effekten bei beruflichem Interesse ( d = 1.39) und der persönlichen Nützlichkeit ( d = 1.07) sowie mittleren Effekten in der fachlichen Fähigkeitsüberzeugung ( d = 0.56) und dem gesellschaftlichen Wert des Studiums ( d = 0.47). Eine personenzentrierte Betrachtung von Studienwahlmotiven über Motivprofile verdeutlicht darüber hinaus, dass für die Entscheidung für ein Lehramtsstudium vor allem das Zusammenspiel verschiedener (nicht nur inhaltlich fachlich begründeter) Studienwahlmotive relevant ist, wohingegen in einigen nicht lehramtsspezifischen Studiengängen insbesondere fachliche Interessen überwiegen. Die Ergebnisse werden mit Blick auf bisherige Forschungsergebnisse und ihre mögliche Relevanz für die praktische Ausgestaltung von universitären Lehrveranstaltungen diskutiert.

Eignung und Zulassung von Bewerber_innen auf ein Hochschulstudium

Zusammenfassung. Mit dem Urteil des Bundesverfassungsgerichts vom Dezember 2017 ist es Hochschulen in Deutschland zukünftig untersagt, Bewerber_innen auf einen Studienplatz allein unter Rückgriff auf die Note der Hochschulzugangsberechtigung auszuwählen. Hochschulen stehen daher vor der Herausforderung, Auswahlverfahren zu entwickeln, die die Eignung der Bewerber_innen feststellen und hierauf aufbauend die „besten Bewerber_innen“ für einen Studiengang zulassen. Im Beitrag werden theoretische Fundierung und empirische Befunde eines Auswahlverfahrens für Bewerber_innen auf ein Lehramtsstudium vorgestellt. Das Verfahren erhebt neben kognitiven Fähigkeiten auch Vorwissen, außerschulisches Engagement, Interesse, Motivation und pädagogische Vorerfahrungen von Studieninteressierten. Die auf diese Weise im Auswahlverfahren erhobene Studieneignung korreliert positiv mit der späteren Studienleistung der Bewerber_innen.

Comparative analysis of biofilm models to determine the efficacy of antimicrobials

Biofilms are one of the greatest challenges in today's treatment of chronic wounds. While antimicrobials kill platonic bacteria within seconds, they are rarely able to harm biofilms. In order to identify effective substances for antibacterial therapy, cost-efficient, standardized and reproducible models that aim to mimic the clinical situation are required. In this study, two 3D biofilm models based on human plasma with immune cells (lhBIOM) or based on sheep blood (sbBIOM) containing S. aureus or P. aeruginosa, are compared with the human biofilm model hpBIOM regarding their microscopic structure (scanning electron microscopy; SEM) and their bacterial resistance to octenidine hydrochloride (OCT) and a sodium hypochlorite (NaOCl) wound-irrigation solution. The three analyzed biofilm models show little to no reaction to treatment with the hypochlorous solution while planktonic S. aureus and P. aeruginosa cells are reduced within minutes. After 48 h, octenidine hydrochloride manages to erode the biofilm matrix and significantly reduce the bacterial load. The determined effects are qualitatively reflected by SEM. Our results show that both ethically acceptable human and sheep blood based biofilm models can be used as a standard for in vitro testing of new antimicrobial substances. Due to their composition, both fulfill the criteria of a reality-reflecting model and therefore should be used in the approval for new antimicrobial agents.

Verhaltensbezogenes Engagement im Unterricht

Zusammenfassung. Die vorliegende schülerzentrierte Videostudie untersucht die Generalisierbarkeit und Zuverlässigkeit von Videobeobachtungen des verhaltensbezogenen engagements von Schülerinnen und Schülern unter Berücksichtigung der aktiven Arbeitsphasen (Partner-, Gruppenarbeit, Ergebnissicherung im Plenum) einer dritten Grundschulklasse ( N = 20 Schülerinnen und Schüler). Anhand eines adaptierten Münchner Aufmerksamkeitsinventars ( Helmke & Renkl, 1992 ) wurden alle Lernenden in ihrem individuellen, verhaltensbezogenen engagement in Ein-Sekunden-Intervallen über den Verlauf des Unterrichts von vier unabhängigen Kodiererinnen während der aktiven Arbeitsphasen beurteilt. Videostudien werden in der pädagogisch-psychologischen Unterrichtsforschung häufig zur Beschreibung und Analyse unterrichtlicher Prozesse durchgeführt, obwohl sie als sehr ressourcenintensiv und aufwändig gelten. Daher wird in dieser Studie ebenso untersucht, bis zu welcher Anzahl an Sekunden das verhaltensbezogene engagement der Schülerinnen und Schüler noch reliabel beobachtet werden kann, um eine effiziente und ökonomische Designplanung zu ermöglichen. Die Ergebnisse der G-Studie zeigen erwartungskonform, dass der Großteil der erklärbaren Varianz über alle Arbeitsphasen hinweg auf die individuellen Lernenden (18.85%) zurückzuführen ist. Der Zeitpunkt in Sekunden (2.67%) erklärt hingegen nur einen marginalen Varianzanteil. Es bleibt ein großer Anteil unerklärter Residualvarianz (78.48%). Der Zuverlässigkeitskoeffizient liegt mit Φ = .99 in einem sehr guten Bereich. Die Entscheidungsstudie (D-Study) ergibt, dass selbst bei 30 beobachteten Sekunden ein zuverlässiges Ergebnis erzielt werden kann (Φ = .87). Die Ergebnisse weisen darauf hin, dass schülerzentrierte Videoanalysen sich besonders zur Erfassung des verhaltensbezogenen engagements aller Schülerinnen und Schüler eignen, da über den gesamten Unterrichtsverlauf Informationen über alle Lernenden vorliegen. Ebenso tragen die Ergebnisse zu einer ökonomischen Designplanung von schülerzentrierten Videostudien zum verhaltensbezogenen engagement bei.

Heparin resistance in COVID-19 patients in the intensive care unit

Patients with COVID-19 have a coagulopathy and high thrombotic risk. In a cohort of 69 intensive care unit (ICU) patients we investigated for evidence of heparin resistance in those that have received therapeutic anticoagulation. 15 of the patients have received therapeutic anticoagulation with either unfractionated heparin (UFH) or low molecular weight heparin (LMWH), of which full information was available on 14 patients. Heparin resistance to UFH was documented in 8/10 (80%) patients and sub-optimal peak anti-Xa following therapeutic LMWH in 5/5 (100%) patients where this was measured (some patients received both anticoagulants sequentially). Spiking plasma from 12 COVID-19 ICU patient samples demonstrated decreased in-vitro recovery of anti-Xa compared to normal pooled plasma. In conclusion, we have found evidence of heparin resistance in critically unwell COVID-19 patients. Further studies investigating this are required to determine the optimal thromboprophylaxis in COVID-19 and management of thrombotic episodes.

Efficacy of antiseptics in a novel 3-dimensional human plasma biofilm model (hpBIOM)

The increasing incidence of non-healing wounds constitutes a pivotal socio-economic burden. 60-80% of chronic wounds are colonized by pathogenic microorganisms within a protective extracellular polymeric substance, bearing a great challenge in wound management. Human plasma was used to prepare the biofilm model (hpBIOM), adding pathogens to the plasma and forming Coagula-like discs with integrated pathogens were produced. The antiseptics Octenisept and Lavasorb were tested regarding their antibacterial properties on clinically relevant biofilm-growing bacteria (MRSA, P. aeruginosa) in the hpBIOM. Biofilm-typical glycocalyx-formation was confirmed using immunohistochemical staining. Treatment of a 12 h-maturated biofilm with Octenisept resulted in complete eradication of P. aeruginosa and MRSA after 48 h. Lavasorb proved less effective than Octenisept in this setting. In more mature biofilms (24 h), both antiseptics showed a delayed, partially decreased efficacy. Summarized, the hpBIOM provides essential factors for a translational research approach to be used for detailed human biofilm analyses and evaluation of antimicrobial/-biofilm properties of established and novel therapeutic strategies and products. Octenisept and Lavasorb showed an attenuated efficacy in the hpBIOM compared to planktonic conditions and previously published biofilm-studies, prompting the question for the necessity of introducing new international standards and pre-admission requirements on a translational base.

Impact of probiotics on pathogen survival in an innovative human plasma biofilm model (hpBIOM)

BACKGROUND

Despite of medical advances, the number of patients suffering on non-healing chronic wounds is still increasing. This fact is attended by physical and emotional distress and an economic load. The majority of chronic wounds are infected of harmful microbials in a protecting extracellular matrix. These biofilms inhibit wound healing. Biofilm-growing bacteria developed unique survival properties, which still challenge the appropriate wound therapy. The present in-vitro biofilm models are not suitable for translational research. By means of a novel in-vivo like human plasma biofilm model (hpBIOM), this study systematically analysed the influence of 3 probiotics on the survival of five clinically relevant pathogenic microorganisms.

METHODS

Human plasma was used to produce the innovate biofilm. Pathogenic microorganisms were administered to the plasma. By stimulating the production of a fibrin scaffold, stable coagula-like discs with integrated pathogens were produced. The five clinically relevant pathogens P. aeruginosa, S. aureus, S. epidermidis, E. faecium and C. albicans were challenged to the probiotics L. plantarum, B. lactis and S. cerevisiae. The probiotics were administered on top of the biofilm and the survival was quantified after 4 h and 24 h of incubation. For statistics, two-way ANOVA with post-hoc Tukey's HSD test was applied. P-value > 0.05 was considered to be significant.

RESULTS

SEM micrographs depicted the pathogens on the surface of the fibrin scaffold, arranged in close proximity and produced the glycocalyx. The application of probiotics induced different growth-reducing capacities towards the pathogens. B. lactis and S. cerevisiae showed slight bacteria-reducing properties. The survival of C. albicans was not affected at all. The most antimicrobial activity was detected after the treatment with L. plantarum.

CONCLUSIONS

This study successfully reproduced a novel human biofilm model, which provides a human wound milieu and individual immune competence. The success of bacteriotherapy is dependent on the strain combination, the number of probiotics and the activity of the immune cells. The eradicating effect of L. plantarum on P. aeruginosa should be emphasized.

Side effects of frequently used oral antidiabetics on wound healing in vitro

Lifestyle diseases such as diabetes and arteriosclerosis are rising in the increasingly aging society, and the number of patients with daily intake of glucose-lowering medication has also increased. Interestingly, knowledge about oral antidiabetics with regard to wound healing is scarce. Therefore, the aim of this study was to identify possible (side) effects of the most frequently prescribed oral antidiabetics on skin cells and wound healing. Four oral antidiabetics of different substance classes (i.e., metformin, glibenclamide, sitagliptin, repaglinide) were investigated with regard to the promotion of cell metabolism and migration of human skin fibroblasts and keratinocytes by XTT and scratch assays. In addition, histological and immunohistochemical analyses were performed in a 3D wound model to address the impact of the antidiabetics on regeneration processes, such as cell migration, fibroblast activity, epidermal thickness, and cell apoptosis. In comparison to systemic application, metformin displayed the most adverse effects in vitro in nearly all analyses, interestingly at serum equivalent concentrations. In contrast, sitagliptin and glibenclamide had a slight but insignificant effect on fibroblasts compared with keratinocytes. Repaglinide tended to have a negative influence on keratinocyte metabolism. Interestingly, antidiabetics generally induced a significantly enhanced rate of apoptosis in fibroblasts, with the exception of repaglinide.Antidiabetics influenced key players in wound healing, namely, keratinocytes and fibroblasts. Particularly, metformin impaired human skin cells. These findings should be kept in mind in further studies because of their putative relevance in patients suffering from chronic wounds that do not respond to various wound therapies.

Analysis of pulmonary embolus size at the time of recurrence compared with presentation: a single-centre retrospective study

Essentials Size of pulmonary embolus (PE) at the time of recurrence compared with first event is unstudied. In a retrospective cohort of patients we compared PE size at recurrence versus the initial PE. Rates of massive PE at recurrence were low whether the first PE was massive or unmassive. Studies to determine PE size and severity at recurrence when anticoagulation is stopped are needed.

SUMMARY

Background The size of recurrent pulmonary embolus (PE) in relation to a prior event could be a factor in deciding whether to continue anticoagulation. There are no published data on this subject to help with counselling patients. Objectives To determine whether size of a first PE predicts the size at recurrence. Patients and methods This was a retrospective cohort study of consecutive patients with recurrent PE over 25 months at a single tertiary center. In confirmed cases the sizes of first and recurrent PEs were grouped into radiologically non-massive PE (RNMPE) or radiologically massive PE (RMPE) if there was bilateral main pulmonary artery thrombus, saddle PE or right ventricular strain on the computerized tomography pulmonary angiogram. Results Sixty-three patients were included in the study (37 exclusions). Thirty-seven patients were men and 26 women, with a median age of 72 years; 33.3% of PEs were unprovoked. Patients whose first PE was an RNMPE (46/63 or 73% of patients) had a 15.2% (95% confidence interval [CI], 7.6-28.2%) chance of RMPE at recurrence and a 32.6% (95% CI 20.9-47.0%) chance of having a larger PE at recurrence, whereas those who presented first with an RMPE (17/63 or 27% or patients) had a 17.6% (95% CI, 6.2-41.0%) chance of RMPE at recurrence (odds ratio, 1.19; CI, 0.27-5.27). Conclusions Risk of a massive PE at recurrence is low (and similar) irrespective of the size of the first PE in this single study. Further studies are warranted as this could help in decisions on long-term anticoagulation.

International consensus statement on the peri-operative management of anaemia and iron deficiency

Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.

Combined external pressure and Cu-substitution studies on BaFe₂As₂ single crystals

We report a combined study of external pressure and Cu-substitution on BaFe2As2 single crystals grown by the in-flux technique. At ambient pressure, the Cu-substitution is known to suppress the spin density wave (SDW) phase in pure BaFe2As2(T(SDW) ≈ 140 K) and to induce a superconducting (SC) dome with a maximum transition temperature T(c)(max) ≃ 4.2 K. This T(c)(max) is much lower than the T(c) ∼ 15-28 K achieved in the case of Ru, Ni and Co substitutions. Such a lower T(c) is attributed to a Cu(2+) magnetic pair-breaking effect. The latter is strongly suppressed by applied pressure, as shown herein, Tc can be significantly enhanced by applying high pressures. In this work, we investigated the pressure effects on Cu(2+) magnetic pair-breaking in the BaFe(2-x)Cu(x)As2 series. Around the optimal concentration (x(opd) = 0.11), all samples showed a substantial increase of T(c) as a function of pressure. Yet for those samples with a slightly higher doping level (over-doped regime), T(c) presented a dome-like shape with maximum T(c) ≃ 8 K. Remarkably interesting, the under-doped samples, e.g. x = 0.02 display a maximum pressure induced T(c) ≃ 30 K which is comparable to the maximum T(c)'s found for the pure compound under external pressures. Furthermore, the magnetoresistance effect as a function of pressure in the normal state of the x = 0.02 sample also presented an evolution consistent with the screening of the Cu(2+) local moments. These findings demonstrate that the Cu(2+) magnetic pair-breaking effect is completely suppressed by applying pressure in the low concentration regime of Cu(2+) substituted BaFe2As2.

Wirkung von Lehrerfortbildungen auf Expertise von Lehrkräften zu formativem Assessment im kompetenzorientierten Mathematikunterricht

Die Expertise von Lehrkräften wird im Kontext einer Auseinandersetzung mit Bedingungsfaktoren des Lehrens und Lernens als ein entscheidendes Moment erfolgreicher Lehr-Lern-Prozesse angesehen. Insbesondere Fachwissen, fachdidaktisches Wissen sowie allgemein-pädagogisches Wissen werden dabei als zentrale Facetten von Lehrerexpertise verstanden. Weitestgehend unklar ist jedoch, wie sich Expertise von Lehrkräften (weiter)entwickelt bzw. inwieweit diese im Kontext von Lehrerfortbildungen gezielt aufgebaut werden kann. Im Rahmen des Forschungsprojekts Co2CA sind Lehrerfortbildungen zu ausgewählten pädagogischen und didaktischen Themenschwerpunkten wissenschaftlich begleitet und mittels fortbildungssensitiver Expertisetests evaluiert worden. Innerhalb zweier nach Interesse gebildeter Untersuchungsbedingungen haben 30 Lehrkräfte an Fortbildungen zu formativem Assessment im kompetenzorientierten Mathematikunterricht (Untersuchungsbedingung A), 37 Lehrkräfte an Fortbildungen zu allgemein-didaktischen Fragen eines kompetenzorientierten Mathematikunterrichts (Untersuchungsbedingung B) teilgenommen. Quantitative Auswertungen des Expertisetests belegen die Wirksamkeit der Fortbildungen: Unter Kontrolle allgemein-fachdidaktischer Expertise verfügen Lehrkräfte aus Untersuchungsbedingung A am Ende der Fortbildungen über ein signifikant höheres Wissen zu formativem Assessment im kompetenzorientierten Mathematikunterricht als Lehrkräfte aus Untersuchungsbedingung B.

Postoperative fibrinogen level is associated with postoperative bleeding following cardiothoracic surgery and the effect of fibrinogen replacement therapy remains uncertain

BACKGROUND

Traditionally, a fibrinogen level > 1 g L(-1) has been viewed as the critical plasma concentration required for hemostasis. No definitive trial has investigated the plasma fibrinogen hemostatic threshold and fibrinogen replacement in complex surgical patients with acquired bleeding.

OBJECTIVES

To explore the plasma fibrinogen level required for hemostasis in cardiothoracic surgery patients and assess the association of fibrinogen replacement therapy (using cryoprecipitate or fibrinogen concentrate) with reducing postoperative bleeding rate.

PATIENTS/METHODS

Data from a prospectively collated database were used to examine the relationship between postoperative plasma fibrinogen level and the postoperative rate of bleeding within the hour of plasma fibrinogen measurement (n = 430) and to explore the effect of cryoprecipitate infusion (n = 76) or fibrinogen concentrate administration (n = 8) on postoperative bleeding rate.

RESULTS

A low plasma fibrinogen level was significantly associated with bleeding, with an odds ratio of 3.06 for every 1 g L(-1) decrease in fibrinogen (95% confidence interval 1.05-8.90) with adjustment for confounders. A fibrinogen threshold associated with excess bleeding was not identified, but this relationship was a continuum. There was no reduction in bleeding following administration of cryoprecipitate or fibrinogen concentrate to raise the post-infusion fibrinogen level to a median of 2.00 and 1.70 g L(-1) , respectively.

CONCLUSIONS

There is a continuum of bleeding severity with reducing fibrinogen concentration. Fibrinogen concentrate or cryoprecipitate infusion did not significantly reduce bleeding rate; however, confirmation by a randomized controlled trial is required. It remains uncertain whether low postoperative fibrinogen levels are causally associated with postoperative bleeding.

Management of giant intracranial aneurysms of the posterior circulation

Between 1980 and 1995, 14 patients underwent treatment at Royal Prince Alfred Hospital for giant posterior circulation aneurysms. Two (14%) patients presented with subarachnoid haemorrhage (SAH). Eight (57%) of the 14 giant aneurysms were located at the basilar caput. A total of 7 (50%) contained significant intraluminal thrombus. Surgery was undertaken in 10 (72%) patients and endovascular embolization in the remaining 4 (28%). Of the patients treated surgically, 3 underwent clipping and a further 4 underwent Hunterian ligation. Of the 4 patients in whom embolization was carried out, 2 were coil treated and 2 balloon treated. Six (60%) patients undergoing surgery experienced significant complications, but in only 4 (40%) surgically treated patients was the complication directly attributable to the surgical procedure. All 4 (100%) patients treated interventionally suffered major complications, and in 3 (75%) of these the complication was directly attributable to the endovascular procedure. The clinical outcome at a median of 12 months follow-up was favourable in 8 (62%) of the 13 patients for whom follow-up information was available. We conclude that radiological techniques are not satisfactory for direct treatment of giant posterior circulation aneurysms and surgical exploration is advisable. In addition, timely referral to, and well planned management at, an experienced centre will undoubtedly contribute significantly towards securing a more favourable overall outcome.

Diagnosis and localisation of insulinoma: the value of modern magnetic resonance imaging in conjunction with calcium stimulation catheterisation

CONTEXT

Preoperative localisation of insulinoma improves cure rate and reduces complications, but may be challenging.

OBJECTIVE

To review diagnostic features and localisation accuracy for insulinomas.

DESIGN

Cross-sectional, retrospective analysis.

SETTING

A single tertiary referral centre.

PATIENTS

Patients with insulinoma in the years 1990-2009, including sporadic tumours and those in patients with multiple endocrine neoplasia syndromes.

INTERVENTIONS

Patients were identified from a database, and case notes and investigation results were reviewed. Tumour localisation by computed tomography (CT), magnetic resonance imaging (MRI), octreotide scanning, endoscopic ultrasound (EUS) and calcium stimulation was evaluated.

MAIN OUTCOME MEASURE(S)

Insulinoma localisation was compared to histologically confirmed location following surgical excision.

RESULTS

Thirty-seven instances of biochemically and/or histologically proven insulinoma were identified in 36 patients, of which seven were managed medically. Of the 30 treated surgically, 25 had CT (83.3%) and 28 had MRI (90.3%), with successful localisation in 16 (64%) by CT and 21 (75%) by MRI respectively. Considered together, such imaging correctly localised 80% of lesions. Radiolabelled octreotide scanning was positive in 10 out of 20 cases (50%); EUS correctly identified 17 lesions in 26 patients (65.4%). Twenty-seven patients had calcium stimulation testing, of which 6 (22%) did not localise, 17 (63%) were correctly localised, and 4 (15%) gave discordant or confusing results.

CONCLUSIONS

Preoperative localisation of insulinomas remains challenging. A pragmatic combination of CT and especially MRI predicts tumour localisation with high accuracy. Radionuclide imaging and EUS were less helpful but may be valuable in selected cases. Calcium stimulation currently remains useful in providing an additional functional perspective.

Preservation of basophils in dapsone-induced agranulocytosis suggests a possible pathogenetic role for leucocyte peroxidases

We describe a hitherto unreported laboratory observation, namely the selective preservation of basophils, in a case of severe dapsone-induced agranulocytosis. Dapsone is known to be metabolised by peroxidases to nitroso derivatives in non-hemopoietic cells where these can in turn act as haptens. Our observation that basophils are selectively spared in this syndrome supports the hypothesis that leucocyte peroxidases function in a similar way to facilitate the pathogenesis of this form of agranulocytosis in susceptible individuals.

High rate of unprovoked recurrent venous thrombosis is associated with high thrombin-generating potential in a prospective cohort study

OBJECTIVE

To determine the predictive value of measurement of parameters of thrombin generation for unprovoked recurrent venous thrombosis.

METHODS

Measurements were made of thrombin generation in a prospective cohort study of 188 patients with a first episode of venous thrombosis that was unprovoked, or provoked by a non-surgical trigger.

RESULTS

The endogenous thrombin potential (ETP) was the only parameter associated with unprovoked recurrent thrombosis in a multivariate model [hazard ratio (HR) 1.3 per 100 nmol L min(-1) increase, 95% confidence interval (CI) 1.0-1.6]. Patients with a high ETP had a significantly higher rate of unprovoked recurrence than those with a low ETP (HR 2.9, 95% CI 1.3-6.6, cumulative recurrence at 4 years 27% vs. 11%). Patients with an unprovoked first event had a significantly higher rate of unprovoked recurrence than those with a provoking factor (HR 2.7, 95% CI 1.2-6.1), and in these patients there was a significantly higher rate of unprovoked recurrence in association with a high ETP (HR 4.0, 95% CI 1.3-11.8). After adjustment for D-dimer, thrombophilia, sex, and whether or not the first event was unprovoked, a high ETP remained a significant predictor of recurrence (HR 2.6, 95% CI 1.2-6.0).

CONCLUSIONS

This study demonstrates a high rate of unprovoked recurrent venous thrombosis in patients presenting with a first episode of venous thrombosis and a high ETP.

Durally-based occipital cavernous haemangioma indistinguishable from meningioma

A rare case of a durally-based cavernous haemangioma over the occipital convexity is presented. The lesion had been preoperatively diagnosed as a meningioma. The clinical, radiological and pathological features of the case are described, along with a review of the relevant literature.

Repair under cardiopulmonary bypass of giant internal carotid aneurysm following GDC embolization

Endovascular embolization techniques have increased the complexity of aneurysm surgery in those lesions that have been incompletely obliterated. We report a case of giant cerebral aneurysm initially treated with Guglielmi detachable coils which required cardiopulmonary bypass for successful endoaneurysmorrhaphy.

Failed stereotactic radiosurgery for acoustic neuroma

A case of recurrent acoustic neuroma in a 58-year-old man is presented. The tumour was initially subtotally removed and then was irradiated using stereotactic radiosurgery. He represented with ataxia and new onset headache four years later and underwent further surgery for recurrence of his acoustic neuroma. The literature is reviewed and the authors' view point on the different modalities of treatment is discussed.

Anterior clinoid mucocele causing acute monocular blindness

We report a patient who presented with acute painful monocular visual loss reminiscent of idiopathic optic neuritis. After treatment with corticosteroids was commenced, an anterior clinoid mucocele causing compressive optic neuropathy was demonstrated on imaging studies. The diagnosis was proven histopathologically following excision of the lesion via craniotomy. Although very rare as a cause of optic neuropathy, anterior clinoid mucocele should be excluded by adequately imaging the optic canal, as visual prognosis is poor if surgical decompression is not performed in a timely fashion.

Desmoplastic infantile ganglioglioma/astrocytoma with cerebrospinal metastasis

Desmoplastic infantile ganglioglioma and astrocytoma (DIG/DIA) are rare intracranial tumours of early childhood that involve superficial cerebral cortex and leptomeninges. Despite the large size of the tumour and the presence of poorly differentiated cells, it is believed that the prognosis of DIG/DIA is excellent. We report two patients with DIG/DIA who developed multiple cerebrospinal metastases. To our knowledge only two similar cases have been reported in the literature. It appears that not all tumours with histological features of DIG/DIA behave in a benign way. It is possible that what is called DIG/DIA may be a heterogenous group of tumours with variable biological behaviour.

The diagnosis and differential diagnosis of endogenous Cushing's syndrome

Cushing's syndrome (CS) is a physically and psychologically disabling disease associated with high morbidity resulting from inappropriate elevation of circulating free cortisol levels. The main features of CS are disturbance of the normal circadian rhythm of cortisol secretion, impairment of the normal feedback of the hypothalamo-pituitary-adrenal (HPA)-axis, and excessive integrated 24 hours cortisol secretion. All biochemical tests used for the diagnosis of CS rely upon the ascertainment of a disturbance of these features. However, the diagnosis of CS (endogenous hypercortisolism) still remains a challenge, although the evolution of several diagnostic tests has allowed diagnosis at an earlier stage. In the initial investigation of CS, tests of high sensitivity are required to identify patients at risk, which are followed by tests of high specificity to confirm the diagnosis and establish the precise aetiology. This review will discuss the various causes of endogenous CS and focus on established and evolving diagnostic procedures used for its diagnosis, as several studies with large number of patients have recently appeared in the literature validating current practice and proposing improved diagnostic algorithms.

Arthroscopic subacromial decompression performed under local anesthesia

Shoulder arthroscopy is usually performed under general anesthesia or interscalene block. General anesthesia may be contraindicated and interscalene block sometimes fails. We had 8 patients who were at high-risk and, therefore, shoulder arthroscopy and decompression were performed under local anesthesia in the beach-chair position. We used 50 mL of 1% lidocaine; 30 mL were infiltrated into the skin and underlying tissues and into the glenohumeral joint, and the rest was infiltrated into the subacromial joint. Before the infiltration, all patients were given 5 mg midazolam and 0.1 mg fentanyl intravenously. All 8 patients were satisfied with the analgesia provided by the anesthesia. We conclude that arthroscopy and subacromial decompression can be readily performed under local anesthesia in combination with efficient sedation.

Long term outcome in children with Moyamoya disease: experience with 16 patients

We present our experience with 16 children with Moyamoya disease/variant diagnosed at the Royal Alexandra Hospital for Children, Westmead, Sydney, Australia in the period between January 1982 and March 2004. Thirteen of these patients had one of the different revascularisation procedures. We reviewed the modes of presentation and the long-term outcome in these children. In our series the functional outcome was related to the functional status at presentation and was not related to the type of surgical procedure or age at presentation. We believe this is the largest reported series of Moyamoya disease/variant in Australia.

[The treatment of meniscal tear with bio-absorbable arrow--3 years follow-up]

BACKGROUND

The introduction of bio-absorbable materials has improved the ability to offer a simple fast and friendly solution to meniscal tears. The technique of meniscal suture with bio-absorbable arrows is associated with lower morbidity and complication rates.

AIM

The clinical evaluation of treatment of meniscal tear by suture with bio-absorbable arrows.

METHODS

During the period 1997-2004, 14 patients underwent arthroscopic all-inside meniscus repair. The "Biofix" bio-absorbable arrows fixation technique was used. Fourteen patients were followed--11 males and 3 females. Their mean age was 23 years (range 16-34 years). Follow-up period was an average of 34 months (range 6-72 months). Sport injuries were the main cause of meniscal tear (60%). Other causes included: work accidents (20%) and military accidents (20%). All the tears were located in an area suitable for suture in the "red-red" or "red-white" zone.

RESULTS

One patient had a tear of the lateral meniscus. Four patients had anterior cruciate ligament (ACL) tear. The mean length of the tear was 9.6 mm. Tears were fixed with 2.5 arrows in average. The clinical evaluation was by the Lysholm Score. Excellent results were reported in 10 patients, good in one patient, fair in 2 patients and poor in 1 patient. One patient suffered from a transient tender point on the medial joint line due to protruded arrow tip, one patient needed a menisectomy due to unresolved symptoms and one patient underwent ACL reconstruction.

CONCLUSION

Meniscal suture with bio-absorbable arrows is an easy and reliable suture technique compared to the classical methods and it seems to have a lower complication rate. Further studies are needed to establish the quality of the repair and the associated morbidity.

A rapid method for analyzing serum pro-insulin-like growth factor-II in patients with non-islet cell tumor hypoglycemia

CONTEXT

Non-islet cell tumor hypoglycemia (NICTH) results from the hypersecretion of pro-IGF-II by a large, usually mesenchymal tumor. Detection of pro-IGF-II in serum is a potential tumor marker in these patients.

OBJECTIVE

The aim of this study was to validate a rapid and reliable method for determining serum pro-IGF-II.

PATIENTS

Serum samples from 16 patients with NICTH were studied.

MAIN OUTCOME MEASURE

The main outcome measure was serum concentration of pro-IGF-II determined by immunoblot analysis of pro-IGF-II and mature IGF-II after 16.5% tricine-SDS-PAGE, which was compared with pro-IGF-II measured by standard RIA after size-exclusion acid chromatography.

RESULTS

The analyses of patients' sera by size-exclusion acid chromatography showed that 68 +/- 19% of IGF-II were present in the pro-IGF-II form, whereas only 18 +/- 4% corresponded to pro-IGF-II in controls. Scanning densitometry of immunoblots showed 67 +/- 16% in the bands corresponding to pro-IGF-II in patients' sera, compared with 27 +/- 9% in controls. The detection sensitivity of tricine-SDS-PAGE method was the same as for size-exclusion chromatography, but the tricine-SDS-PAGE method is quicker and requires smaller amounts of serum.

CONCLUSION

Tricine-SDS-PAGE followed by IGF-II immunoblot analysis provides a rapid, reproducible, and sensitive method for the separation of serum pro-IGF-II from mature IGF-II and is a useful laboratory evaluation of patients with a clinical diagnosis of NICTH.

Cerebellar liponeurocytoma

A case of cerebellar liponeurocytoma in a 34-year-old man is reported. There are only 19 other cases reporting this entity in the medical literature. The diagnostic, radiological and clinical features associated with this tumour are reviewed and discussed in relation to our case. The differences in behaviour and prognosis between medulloblastoma and cerebellar liponeurocytoma are presented with the corresponding implications for management.

Extradural hematoma causing venous sinus obstruction and pseudotumor cerebri syndrome

CASE REPORT

The case of a small right occipital extradural hematoma in a 10-year-old girl is presented. The patient had bifrontal occipital headache out of proportion to the size of the hematoma, as well as diplopia. MR venography revealed compression and occlusion of the dominant right transverse sinus resulting in a pseudotumor cerebri syndrome.

DISCUSSION

The relationship between venous sinus obstruction and the pseudotumor syndrome is discussed. Clinicians should be aware of the possible effects of an extra-axial collection on the cerebral venous sinuses.

Outcome scoring in neurosurgery: the cognitive outcome score, an alternative to the Glasgow outcome scale

The qualitative method, the Glasgow outcome scale, remains the convention for patient outcome assessment in the neurosurgical literature. This is despite the fact that sampling methods subject to bias confer low confidence in the conclusions. An alternative, quantitative method, the cognitive outcome score (COS), decreases bias, is cost effective and delivered in less than 10 min. Utilisation of the COS in statistical correlations against common clinical parameters is discussed in theory and practice.

Metabolites from cerebrospinal fluid in aneurysmal subarachnoid haemorrhage correlate with vasospasm and clinical outcome: a pattern-recognition 1H NMR study

Following subarachnoid haemorrhage the most significant complication is sustained cerebral vascular contraction (vasospasm), which may result in terminal brain damage from cerebral infarction. Despite this, the biochemical cause of vasospasm remains poorly understood. In this study, the global high-concentration metabolite composition of CSF has been correlated with patient outcome after subarachnoid haemorrhage using multivariate statistics and 1H NMR spectroscopy. In total, 16 patients with aneurysmal subarachnoid haemorrhage (aSAH) were compared with 16 control patients who required a procedure where CSF was obtained but did not have aSAH. Multivariate statistics readily distinguished the aSAH group from the heterogeneous control group, even when only those controls with blood contamination in the CSF were used. Using principal components analysis and orthogonal signal correction, vasospasm was correlated to the concentrations of lactate, glucose and glutamine. These pattern recognition models of the NMR data also predicted Glasgow Coma Score (54% within +/- 1 of the actual score on a scale of 1-15 for the whole patient group), Hunt and Hess SAH severity score (88% within +/- 1 of the actual score on a scale of 1-5 for the aSAH group) and cognitive outcome scores (78% within +/- 3 of the actual score on a 100% scale for the whole patient group). Thus, the approach allowed the prediction of outcome as well as confirming the presence of aSAH.

Cranial venous outflow obstruction and pseudotumor Cerebri syndrome

The pathophysiology of PTS including idiopathic intracranial hypertension or 'BIH', remains controversial. The older literature frequently referred to pathology in the cerebral venous drainage but more modern imaging techniques (CT and early MR) failed to reveal gross venous pathology. The role of impaired cranial venous outflow has recently been re-examined in the light of new methods of investigation (advanced MR venography and direct microcatheter venography with manometry) and of treatment (venous sinus stenting). Venous sinus obstruction in PTS is a more common factor in the pathogenesis of the condition than previously recognised. Venous obstruction may be primary, that is, it is the underlying aetiological factor in PTS. Venous sinus obstruction may also be secondary to raised CSF pressure which may exacerbate problems with intracranial compliance and raised CSF pressure. Early experience with venous stenting suggests that it may be a helpful treatment for patients with PTS but more experience and longer follow-up is required to define the subgroups of patients for whom it is most appropriate.

Syringomyelia with Chiari malformation; 3 unusual cases with implications for pathogenesis

Syringomyelia is an important cause of neurological deficit. Most cases of non-traumatic syringomyelia occur in association with a Chiari malformation. We present three unusual examples of syringomyelia with such an association. The first case is that of syringomyelia in a young woman with Marfan's syndrome, a spontaneous CSF leak and intractable intracranial hypotension. The second is a woman with long-standing lumbo-peritoneal shunt for pseudotumour cerebri who developed an acquired Chiari malformation. A young woman with a Dandy-Walker cyst that herniated into the upper cervical canal is the third case. These cases provide a basis for discussion of the pathogenesis and management of syringomyelia and the Chiari malformation in such cases.

Traumatic unilateral deep cerebral venous infarction

A case of unilateral deep cerebral venous infarction in a young man associated with mild head injury is presented. The diagnosis is made on the basis of the clinical, radiological, operative and histopathological findings. We propose that a thrombosis or obstruction of the anterior segment of the basal vein of Rosenthal (BVR) was the primary pathology. This is discussed in respect to current knowledge of deep cerebral venous anatomy and embryology.