Bridging that gap: a qualitative study of perceptions of equality, diversity and inclusivity in colorectal surgery in the UK and Ireland

BACKGROUND

There is a growing recognition on the importance of equality, diversity and inclusion (EDI) within surgery and the need to diversify the surgical community and its various organisations, in a bidto reflect the diverse populations they serve. To create, sustain and encourage a diverse surgical workforce requires an in-depth understanding of the current makeup of key surgical institutions, relevant issues pertaining to EDI and appropriate solutions and strategies to ensure tangible change.

OBJECTIVES

Following on from the recent Kennedy Review into Diversity and Inclusion commissioned by the Royal College of Surgeons of England, the aim of this qualitative study was to understand the EDI issues which affected the membership of the Association of Coloproctology of Great Britain and Ireland, while seeking appropriate solutions to address them.

DESIGN

Dedicated, online and qualitative focus groups.

PARTICIPANTS

Colorectal surgeons, trainees and nurse specialists were recruited using a volunteer sampling strategy.

METHODS

A series of online, dedicated, qualitative focus groups across the 20 chapter regions were held. Each focus group was run informed by a structured topic guide. All participants who were given the opportunity to remain anonymous were offered a debriefing at the end. This study has been reported in keeping with the Standards for Reporting Qualitative Research.

RESULTS

Between April and May 2021, a total number of 20 focus groups were conducted, with a total of 260 participants across 19 chapter regions. Seven themes and one standalone code pertaining to EDI were identified: support, unconscious behaviours, psychological consequences, bystander behaviour, preconceptions, inclusivity and meritocracy and the one standalone code was institutional accountability. Five themes were identified pertaining to potential strategies and solutions: education, affirmative action, transparency, professional support and mentorship.

CONCLUSION

The evidence presented here is of a range of EDI issues which affect the working lives of those within colorectal surgery in the UK and Ireland, and of potential strategies and solutions which can help build a more inclusive, equitable and diverse colorectal community.

Medication dose reductions after pallidal versus subthalamic stimulation in patients with Parkinson's disease

OBJECTIVE

To compare the medication dose reduction between deep brain stimulation (DBS) of the globus pallidus interna (GPi) vs subthalamic nucleus (STN) in matched patients with Parkinson's disease (PD).

MATERIALS AND METHODS

Records of 12 patients with PD who underwent GPi-DBS at our institution from 2002 to 2008 were matched by pre-operative PD medication doses and pre-operative motor Unified Parkinson's Disease Rating Scale (UPDRS) scores to 12 cases of STN-DBS. PD medication doses were converted to levodopa equivalent doses (LEDs).

RESULTS

GPi and STN groups had similar mean pre-operative LEDs and motor UPDRS scores. At 6 months post-DBS, there was no significant difference in percent reduction in LEDs between the GPi (47.95%) and STN (37.47%) groups (P = 0.52). The mean post-operative 'medication off/stimulation on' motor UPDRS scores did not differ significantly between GPi (15.33) and STN (16.25) groups (P = 0.74). The mean percent reduction in motor UPDRS scores was also similar between GPi (58.44%) and STN (58.98%) patients (P = 0.94).

CONCLUSIONS

We conclude that in disease-matched patients with PD undergoing DBS, both GPi and STN may result in similar reduction in PD medication doses.

The impact of alcohol hand sanitizer use on infection rates in an extended care facility

BACKGROUND

Nosocomial infections are a major problem in health care facilities, resulting in extended durations of care and substantial morbidity. Since alcohol gel hand sanitizers combine high immediate antimicrobial efficacy with ease of use, this study was carried out to determine the effect of the use of alcohol gel hand sanitizer by caregivers on infection types and rates in an extended care facility.

METHOD

Infection rate and type data were collected in a 275-bed extended care facility for 34 months (July 1997 to May 2000), during which an alcohol gel hand sanitizer was used by the caregivers in 2 units of the facility.

RESULTS

The primary infection types found were urinary tract with Foley catheter, respiratory tract, and wound infections. Comparison of the infection types and rates for the units where hand sanitizer was used with those for the control units where the hand sanitizer was not used showed a 30.4% decrease in infection rates for the 34-month period in the units where hand sanitizer was used.

CONCLUSION

This study indicates that use of an alcohol gel hand sanitizer can decrease infection rates and provide an additional tool for an effective infection control program.

Test-retest reproducibility of the exercise treadmill examination in lumbar spinal stenosis

OBJECTIVE

To provide further validation of the treadmill test by assessing its "test-retest" reproducibility.

PATIENTS AND METHODS

In this prospective study, 28 patients with severe lumbar spinal stenosis underwent exercise treadmill testing, first at a walking speed of 1.2 mph and then at the patient's preferred walking speed. All patients had a second treadmill examination or "retest." No treatment intervention was performed between the initial test and the retest. Time to first symptoms (TFS) and total ambulation time (TAT) were measured. Differences between the baseline examination and the retest examination were assessed by using the concordance correlation coefficient (CCC) as well as graphically.

RESULTS

There was good reproducibility between baseline test and retest results for all 4 end points: 1.2 mph, TFS (CCC = 0.90); 1.2 mph, TAT (CCC = 0.89); preferred walking speed, TFS (CCC = 0.98); and preferred walking speed, TAT (CCC = 0.96). The median difference between trials was not significantly different from zero for any of the 4 outcomes.

CONCLUSIONS

Exercise treadmill testing has good test-retest reproducibility. There was no learning phenomenon associated with the test procedure. The study further validates the clinical utility of exercise treadmill testing in patients with lumbar spinal stenosis and neurogenic claudication.

Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience

OBJECT

The authors report a retrospective analysis of 194 patients surgically treated at their institutions for symptomatic lumbar synovial cysts from January 1974 to January 1996.

METHODS

Patient characteristics including age, sex, symptoms, signs, and preoperative neuroimaging studies were reviewed. Surgical procedures, complications, results, and pathological findings were correlated with preoperative assessment. One hundred ninety-four patients were surgically treated for symptomatic lumbar synovial cysts. Eighty percent were diagnosed and treated between 1987 and 1996. There were 100 men and 94 women with an average age of 66 years (range 28-94 years). The most common symptoms were painful radiculopathy (85%) and neurogenic single or multiroot claudication (44%). However, sensory loss (43%) and motor weakness (27%) were also presenting symptoms. Eleven percent of patients had undergone previous lumbar surgery prior to being referred to the Mayo Clinic. Preoperative neurological examination demonstrated motor weakness (40%), sensory loss (45%), reflex changes (57%), and variants of cauda equina syndrome (13%). In 19% of patients, normal neurological status was demonstrated. There was equal left/right-sided laterality, and eight patients presented with bilateral synovial cysts. The most commonly affected level was L4-5 (64%). All patients underwent laminectomy and resection of the cyst. Concomitant fusion was performed in 18 patients in whom clinical evidence of instability had been observed. However, subsequent fusion was required in only four patients who developed symptomatic spondylolisthesis. Surgery-related complications included cerebrospinal fluid leak (three patients), discitis (one patient), epidural hematoma (one patient), seroma (one patient), and deep vein thrombosis (one patient). One patient died 3 days after surgery of cardiac dysrhythmia. Follow-up data obtained for at least 6 months postoperatively were available in 147 patients. Of these, 134 (91%) reported good relief of their pain and 82% experienced improvement in their motor deficits.

CONCLUSIONS

Lumbar synovial cysts are a more common cause of lumbar radicular pain than previously thought. Surgical removal of the cyst is a safe and effective treatment for symptomatic relief in patients with lumbar synovial cysts. A concomitant fusion procedure may be performed in select cases. In this study, only a few patients developed symptomatic spinal instability requiring a second operation.

The results of radiotherapy for ependymomas: the Mayo Clinic experience

PURPOSE

This analysis was performed to examine the outcome of patients with histologically confirmed ependymomas of the brain or spinal cord who received postoperative radiotherapy.

METHODS AND MATERIALS

Eighty patients with histologically confirmed ependymomas were evaluated retrospectively. All were treated with various combinations of surgery, radiotherapy (RT), and chemotherapy. Follow-up ranged from 5 to 30 years (median 10.4 years).

RESULTS

The 5- and 10-year survival rates for the entire study group were 79% and 73%, respectively. Patients with low-grade (1 and 2 of 4) tumors had a 5-year survival rate of 87% as compared to 27% for those with high-grade (3 and 4 of 4) tumors (p < 0.0001). Patients with tumors of the spine had a 5-year survival rate of 97% as compared to 68% for those with infratentorial tumors, and 62% for those with supratentorial tumors (p = 0.03). Patients with myxopapillary ependymomas of the spine had a 5-year survival rate of 100% as compared with 76% for patients with other histological subtypes of ependymoma (p = 0.02). Multivariate analysis revealed that the survival rate was independently associated with tumor grade (p = 0.0007) and histological subtype (p = 0.02). Twenty-eight patients (35%) experienced local failure and 10 patients (13%) developed leptomeningeal seeding. The 5-year leptomeningeal failure rate was 10% in patients with low-grade tumors as compared to 41% for patients with high grade tumors (p = 0.01).

CONCLUSION

Patients with low-grade tumors, especially those with myxopapillary subtypes, have high 5-year survival rates when treated with post-operative radiotherapy. High grade ependymomas are associated with a much poorer outcome. New forms of therapy are required to improve the outcome of patients with high-grade ependymomas.

The results of radiotherapy for brainstem tumors

OBJECTIVE

This analysis was performed to examine the outcome of adult and pediatric patients with brainstem tumors.

METHODS AND MATERIALS

Forty patients with brainstem glioma were evaluated retrospectively. Included were 24 females and 16 males ranging in age from 3 to 81 years (median, 29.5 years). These patients were treated with various combinations of surgery, chemotherapy, and radiotherapy (RT). The length of follow-up in survivors ranged from 0.6 to 20 years (median: 3.2 years, mean: 6 years). Survival rates were calculated with the Kaplan Meier method and differences between survival curves were calculated using the log-rank test.

RESULTS

The overall 2 and 5-year survival rates were 44% and 34%, respectively. The median survival time was 19 months. The 5-year survival rate was 54% for patients with tumors outside the pons compared to 21% for those with tumors involving the pons (p = 0.04). The 5-year survival rate was 59% for patients with exophytic tumors as compared to 23% for those with intrinsic tumors (p = 0.05). Patients undergoing subtotal resection had a 5-year survival rate of 53% compared to 28% for those having only a biopsy or no surgical intervention (p = 0.04). None of the other potential prognostic or treatment related factors evaluated [patient age, tumor grade, tumor histology, radiotherapy parameters (including BID fractionation, 3-D treatment planning, or the use of doses > 55 Gy), or the administration of adjuvant chemotherapy] evaluated were associated with patient survival.

CONCLUSIONS

Brainstem gliomas generally occur in younger individuals. The survival rates were better for patients with exophytic tumors, those involving sites other than the pons, and tumors amenable to subtotal resection. Improvements in the outcome of patients with brainstem gliomas will require new therapeutic approaches.

Use of the exercise treadmill to measure baseline functional status and surgical outcome in patients with severe lumbar spinal stenosis

STUDY DESIGN

A prospective study of exercise tolerance on the treadmill before and after decompressive laminectomy in patients with severe lumbar spinal stenosis.

OBJECTIVES

To determine whether treadmill testing provides useful information about baseline functional status and surgical outcome.

SUMMARY OF BACKGROUND DATA

Historically, criteria for selecting patients for surgery and assessing postoperative outcome have been variable. Functional testing has not been used in a systematic fashion.

METHODS

Fifty patients with severe lumbar spinal stenosis underwent decompressive laminectomy. Preoperatively and 3 months postoperatively, functional capacity was assessed on an exercise treadmill. Time to first symptoms and total ambulation time were recorded. The examination was stopped at the onset of severe symptoms or after 15 minutes.

RESULTS

In the preoperative trial, mean time to first symptoms (+/- standard deviation) was 1.82 minutes (median, 0.58), and mean total ambulation time was 6.91 minutes (median, 5.22). In the postoperative trial, mean time to first symptoms increased to 11.93 minutes (median, 15) and mean total ambulation time increased to 13.26 minutes (median, 15). There was significant improvement after surgery in both time to first symptoms (P < 0.001) and total ambulation time (P < 0.001).

CONCLUSION

Exercise stress testing on a treadmill is a safe, easily administered, and quantifiable means of assessing baseline functional status and surgical outcome in patients with neurogenic claudication due to lumbar spinal stenosis. Treadmill testing provides objective evidence that surgery is beneficial in most cases and is helpful in guiding subsequent management of patients with residual symptoms.

Central neurocytomas

BACKGROUND

This analysis was performed to examine the outcome of patients with histologically confirmed central neurocytomas.

METHODS

Thirty-two patients with histologically confirmed central neurocytomas were evaluated retrospectively. Patients were treated with various combinations of surgery, chemotherapy, and radiotherapy (RT). Follow-up ranged from 2.3 to 15.3 years (median, 4.7 years).

RESULTS

The overall 5-year survival and local control rates were 81% and 79%, respectively. No patient developed metastases. The 5-year local control rate was 70% for patients undergoing subtotal resection (STR) and 100% for those undergoing gross total resection (GTR) (P = 0.08). The 5-year survival rate was 77% for patients undergoing STR and 90% for those undergoing GTR (P = 0.44). The effect of RT was evaluated for patients undergoing STR. The 5-year local control rate was 100% for patients who received RT after STR compared with 50% for those who did not (P = 0.02). The 5-year survival rate was 88% for patients who received RT after STR compared with 71% for those who did not (P = 0.3). Three patients received salvage RT for local progression after resection. All were alive and free of disease 1 to 6 years after RT.

CONCLUSIONS

GTR results in a very high likelihood of local control and survival. Postoperative RT appears to improve local control rates significantly for patients who have undergone STR. The overall prognosis of patients with central neurocytomas is quite favorable, with an actuarial 5-year survival rate of 81%.

Histologically confirmed pineal tumors and other germ cell tumors of the brain

BACKGROUND

This study examined the outcome of patients with histologically confirmed pineal region tumors.

METHODS

One hundred thirty-five patients with histologically confirmed pineal tumors and other germ cell tumors of the brain were evaluated retrospectively. The pineal parenchymal tumors (PPTs) included 15 pineoblastomas (PB), 2 mixed PPTs, 4 PPTs with intermediate differentiation, and 9 pineocytomas. The germ cell tumors included 48 germinomas, 26 mixed germ cell tumors, 11 mature teratomas, 9 immature teratomas, 6 malignant teratomas, 2 yolk sac tumors, and 3 choriocarcinomas. Patients were treated with various combinations of chemotherapy, radiotherapy, and surgery. The duration of follow-up ranged from 0.25 to 37.3 years, with a median follow-up of 5.3 years.

RESULTS

The 5-year patient survival rate was 86% for those with mature teratomas; 86% with pineocytomas; 80% with germinomas; 67% with immature teratomas; 49% with PPTs, excluding pineocytomas; 38% with mixed germ cell tumors; and 17% with other germ cell histologies (P = 0.0001). The delivery of > 44 Gray (Gy) to germinomas and > 50 Gy to PPTs and nongerminomatous germ cell tumors (NGGCTs) other than mature and immature teratomas was associated with improved survival. A greater extent of resection was associated with a higher rate of survival in all patients with NGGCTs. The administration of chemotherapy was associated with improved survival in those patients with NGGCTs other than mature and immature teratomas.

CONCLUSIONS

Prognosis was dependent on tumor type. Obtaining a tissue diagnosis made it possible to tailor therapy according to tumor type and potentially improve the survival of patients. Survival was dependent on the dose of radiation administered to patients with PPTs, germinomas, and NGGCTs other than mature and immature teratomas. More extensive resection and the use of chemotherapy were also associated with improved survival in subgroups of patients with NGGCTs. Treatment recommendations are described in detail in the article.

Nongerminomatous germ cell tumors of the brain

PURPOSE

This analysis was performed to determine the clinical outcome of patients with primary nongerminomatous germ cell tumors of the brain. The efficacy of various treatment options was evaluated.

METHODS AND MATERIALS

A total of 57 patients with primary nongerminomatous germ cell tumors of the brain were identified. Patient-related data were collected and analyzed retrospectively. Follow-up in surviving patients ranged from 3 to 243 months (median follow-up 36). Survival and failure rates were determined using the Kaplan-Meier method, and differences between the survival curves were evaluated using either the log rank test or the Wilcoxon test.

RESULTS

The 3-year survival rate was 86% for patients with mature teratomas, 67% for patients with immature teratomas, 44% for patients with mixed germ cell tumors, and 13% for patients with the other histologic types (p = 0.02). The 3-year survival rate was 0% for patients having biopsies alone, 32% for patients having subtotal resections, and 73% for patients having gross total resections (p = 0.0001). Patients with tumors other than mature or immature teratomas were evaluated for possible relationships between the administration of chemotherapy or radiotherapy and survival. Patients who received chemotherapy had a 3-year survival rate of 56% compared to 8% for those patients who did not receive chemotherapy (p = 0.0001) Patients who received radiotherapy had a 3-year survival rate of 46% compared to 11% for those patients who did not receive radiotherapy (p = 0.0015).

CONCLUSION

The survival of patients with primary nongerminomatous germ cell tumors of the brain is dependent on tumor histology and the extent of surgical resection. Patients with tumors other than mature or immature teratomas appear to benefit from the administration of chemotherapy and radiotherapy.

Radiation-induced meningioma following radiation therapy for pituitary adenoma

The authors report the long-term result of treatment of a presumed pituitary adenoma with external-beam radiation therapy, which appears to be the development of a radiation-induced meningioma. Of the post radiation neoplasms that have been reported, meningiomas constitute a large proportion of these lesions.

Diagnosis and management of primary spinal epidural non-Hodgkin's lymphoma

OBJECTIVE

To describe the diagnosis, management, and outcome in 10 patients with histologically confirmed primary spinal epidural non-Hodgkin's lymphoma.

MATERIAL AND METHODS

We review the findings in a cohort of seven men and three women in whom this tumor was diagnosed between January 1979 and January 1993 and discuss the prognostic differences between primary and secondary spinal lymphomas.

RESULTS

All patients (median age at diagnosis, 70 years) underwent a decompressive laminectomy, subtotal tumor resection, and spinal irradiation (median dose, 3,800 cGy). Nine of 10 tumors were of B-cell origin. Six patients are alive and well. In four patients, recurrent disease developed from 15 to 62 months after the original diagnosis; of these, one has died. The median duration of survival of all patients was 42 months; of those living more than 24 months after diagnosis, the median duration of survival was 80 months.

CONCLUSION

A rapidly progressive spinal cord or cauda equina syndrome with neuroimaging findings consistent with an extradural compressive lesion should alert caregivers to the possibility of spinal epidural lymphoma. Although the prognosis for patients with secondary spinal epidural non-Hodgkin's lymphoma is often poor, primary spinal epidural non-Hodgkin's lymphoma can be associated with a favorable outcome if diagnosed and treated early.

Health risk appraisal and serum cholesterol nutrition education: an outcome study

Records of 59 U.S. Army service members identified as at-risk for coronary heart disease were reviewed. Soldiers were divided into groups that completed and did not complete cholesterol nutrition education classes. Differences in the means of repeated cholesterol measures were compared within each group. Results showed statistically significant declines in total cholesterol, with t(35) = 2.94, p < 0.01 for the class completion group and t(22) = 2.18, p < 0.05 for the dropout group. Similar results were noted for low-density lipoprotein measures. However, cholesterol differences in the means between the two groups were not statistically significant. Results indicate that decreases in serum cholesterol may occur due to at-risk reactive behavior, but that full compliance with the current nutrition education program does not appear to further reduce cholesterol levels to any appreciable degree.

Perioperative use of botulinum toxin for movement disorder-induced cervical spine disease

Patients with cervical dystonia or tics of the nuchal muscles can develop serious cervical spine disease. We report a series of four patients who received botulinum toxin injections to control their movement disorders prior to their required surgery. One patient with cervical tic-induced radiculomyelopathy required botulinum toxin injection postoperatively to facilitate stabilization of the cervical fusion. Two patients with torticollis-induced cervical radiculomyelopathy, and one patient with dystonia-induced C5 fracture, had botulinum toxin injected preoperatively to facilitate postoperative recovery. Botulinum toxin appears to be a useful adjunct in the treatment of cervical movement disorders prior to or following surgery for associated cervical spine disease.

"Preplacement" of the back of the halo vest in patients undergoing cervical traction for cervical spine injuries: a technical note

BACKGROUND

In patients with unstable cervical spine injuries initially managed with in-line traction, there is some risk of loss of cervical alignment and of new neurologic deficit when the halo vest is applied. This report outlines a simple technique which facilitates halo application in these patients.

METHODS

The back of the halo vest is "prepositioned" before traction is instituted. Once alignment is optimized, halo vest application is easily completed without lifting the patient or discontinuing cervical traction.

RESULTS

The authors have used this technique in four patients without complication.

CONCLUSIONS

In patients with unstable cervical spine injuries who require an initial period of in-line traction, halo vest application is made easier and safer by "prepositioning" the back of the vest.

Measurement of exercise tolerance on the treadmill in patients with symptomatic lumbar spinal stenosis: a useful indicator of functional status and surgical outcome

A prospective study of patients with neurogenic claudication and lumbar spinal stenosis was undertaken to determine whether measurement of exercise tolerance on the treadmill would be useful in defining baseline functional status and response to surgical treatment. Twenty patients with an average age of 73 years, all of whom had intractable neurogenic claudication and radiographically confirmed severe lumbar spinal stenosis, were studied. Lumbar decompressive laminectomy was performed in all patients. Preoperatively and 2 months postoperatively, quantitative assessment of ambulation was conducted on a treadmill at 0 degree ramp incline at two different speeds: 1.2 mph and the patient's preferred walking speed. The following information was recorded: time to first symptoms, time to severe symptoms, and nature of symptoms (leg pain, back pain, or generalized fatigue). The examination was stopped after 15 minutes or at the onset of severe symptoms. In the preoperative 1.2-mph trial, the mean time to first symptoms was 2.68 minutes (median 1.31) and the mean time to severe symptoms was 5.47 minutes (median 3.42). In the postoperative trial at the same speed, 13 patients (65%) were able to walk symptom free for 15 minutes. The mean time to first symptoms was 11.12 minutes (median 15) and the mean time to severe symptoms was 11.81 minutes (median 15). Similar findings were recorded in the preferred walking-speed trials. There were no complications from the treadmill testing procedure. These findings indicate that exercise stress testing on a treadmill is a safe, easily administered, and quantifiable means of assessing baseline functional status and outcome following laminectomy in patients with symptomatic lumbar spinal stenosis.

Video-assisted thoracoscopic resection of intercostal neurofibroma

BACKGROUND Video-assisted thoracoscopy (VAT) is being increasingly utilized by thoracic surgeons as an alternative to thoracotomy for several thoracic disorders. Neuroendoscopy is an exciting addition to the neurosurgical armamentarium. These procedures are attractive alternatives in the era of minimally invasive surgery and cost containment, while providing the highest quality medical care to patients. METHODS We report the application of this technology in a patient presenting with intractable thoracic radicular pain secondary to an intercostal neurofibroma. Complete excision of the intercostal neurofibroma was performed utilizing VAT. RESULTS The patient reported good relief of her preoperative thoracic radicular pain. She was ready for discharge from the hospital within 72 hours of surgery. CONCLUSIONS With the advent of improved instrumentation, video-assisted thoracoscopy offers a safe alternative to thoracotomy and the potential benefits of less postoperative discomfort and shorter hospital stays. The potential neurosurgical applications of VAT should not be overlooked.

Analysis of early failures after lumbar decompressive laminectomy for spinal stenosis

OBJECTIVE

To determine why some patients have no improvement after surgical treatment of lumbar spinal stenosis.

DESIGN

We conducted a retrospective study of patients who were referred to our institution between 1990 and 1993 because their symptoms were unchanged or worsened after lumbar decompressive laminectomy.

MATERIAL AND METHODS

For the 45 study patients (25 women and 20 men; mean age, 70.8 years), preoperative and postoperative clinical status, preoperative and postoperative imaging studies, and operative reports were analyzed.

RESULTS

Preoperatively, only 23 patients (51%) had the clinical syndrome of neurogenic claudication, and 15 (33%) had midline low-back pain without a radicular component. Three other patients had peripheral neuropathy, and three had atypical leg pain. Only 10 patients had radiographic evidence of severe lumbar canal stenosis; the others had moderate, mild, or no stenosis. In 10 patients, surgical decompression was inadequate. Only three patients had the triad of neurogenic claudication, radiographically confirmed severe lumbar stenosis, and adequate decompression of the lumbar canal and lateral recesses.

CONCLUSION

The most common pattern in patients with early failure after lumbar laminectomy was the absence of actual neurogenic claudication coupled with the absence of severe stenosis on preoperative imaging studies. The most common technical error was inadequate neural decompression. These data suggest that the outcome may be improved by more careful selection of patients and by performance of an adequate surgical decompression.

Mast cell-rich convexity meningioma presenting as chronic subdural hematoma: case report and review of the literature

A 47-year-old woman with a convexity meningioma presenting as a chronic subdural hematoma is reported. This case is unique in that the symptoms were cyclical and stereotypic. The tumor contained an unusually high number of mast cells. A possible etiologic role of histamine-related vasodilation and tumoral hemorrhage is explored. The relationship between meningioma and subdural hematoma is discussed, and the literature is reviewed.

Primary spinal epidural non-Hodgkin's lymphoma: report of eight patients and review of the literature

Eight patients treated for histologically confirmed primary spinal epidural non-Hodgkin's lymphoma diagnosed between January 1979 and August 1989 (6.6% of all cases of intraspinal lymphoma) were studied. There were six men and two women. The median age was 70 years (range, 43-80 yr). Patients sought treatment for a prodrome of back pain (median duration, 3 mo) followed by an acute neurological deterioration (median duration, 6 d). The most common findings were a discrete sensory level in 5 patients, hyperreflexia in 5 patients, and paraparesis or paraplegia in 5 patients. Radiographically, there was an absence of bony destruction by these tumors. All patients underwent a decompressive laminectomy, subtotal tumor resection, and spinal irradiation (median dose, 3800 cGy). Two patients had low-grade lymphomas (one B cell and one T cell), and 6 patients had intermediate-grade lesions (six B cell). Two patients with B-cell lymphomas (one low-grade and one intermediate-grade) developed metastatic disease 15 and 17 months after the initial diagnosis; no evidence of lymphoma developed in the other 6 patients. The median survival was 22 months (range, 2-71 mo). Lymphoma was the cause of death in only 1 of the 4 patients who died, and the 4 younger patients are alive and well. Primary spinal epidural non-Hodgkin's lymphoma should be a diagnostic consideration in the older patient who seeks treatment for spinal cord compression manifested by a prodrome of back pain, followed by a rapid neurological deterioration, normal plain spine radiographs, and neuroimaging consistent with an extradural compressive lesion. Surgery for this diagnosis followed by spinal irradiation should result in significant neurological improvement.

Computer-assisted stereotactic biopsy and volumetric resection of thalamic pilocytic astrocytomas. Report of 23 cases

Twenty-three cases of pathologically verified thalamic pilocytic astrocytomas diagnosed at computer-assisted stereotactic biopsy and/or volumetric resection at the Mayo Clinic between January 1985 and October 1990 were reviewed. Computer-assisted stereotactic volumetric resection was performed in 19 patients. Postoperative imaging demonstrated no residual contrast-enhancing tumor in 14 patients and a small amount of contrast-enhancing tumor (less than 5% of the original tumor volume) in 5 patients. Biopsy only was performed in 4 patients: 2 with primarily cystic tumors successfully treated with stereotactic instillation of 32P, and 2 patients with stable (nonprogressive) deficits. There was 1 operative death; a patient with tumor extending into the midbrain became comatose and died 10 days after surgery. The remaining 22 patients are alive and well. Computer-assisted stereotactic volumetric resection of thalamic pilocytic astrocytomas can be performed with low morbidity and a favorable long-term prognosis.

Basic fibroblast growth factor promotes in vivo cerebral angiogenesis in chronic forebrain ischemia

This experiment was designed to determine if intraventricular administration of basic fibroblast growth factor (bFGF) could promote cerebral angiogenesis in a model of mild chronic forebrain ischemia. Wistar rats underwent bilateral carotid artery ligation. Animals received intraventricular injections of bFGF every 4 days for 28 days. Basic fibroblast growth factor caused a significant dose-dependent increase in capillary density compared to ischemic controls in all regions examined. These results support the hypothesis that chronic intraventricular administration of bFGF induces in vivo cerebral angiogenesis.

Posterior fossa ependymomas: report of 30 cases and review of the literature

Thirty patients with histologically confirmed posterior fossa ependymomas operated on between January 1976 and December 1988 were reviewed. The median age was 44 years (range, 1-69 yr). There were 7 children (aged 5 yr or younger) and 23 adults (aged 16 yr or older). There were 18 female patients and 12 male patients. Headache, nausea and vomiting, and disequilibrium were the most frequent symptoms. The most common findings were ataxia and nystagmus. Gross total resection was performed in 8 patients (27%), subtotal resection in 21 patients (70%), and biopsy in only 1 patient (3%). Tumors were low grade in 73% and high grade in 27%. Twenty-seven patients underwent posterior fossa radiotherapy (median dose, 5400 cGy). Fourteen patients also underwent spinal irradiation (median dose, 3520 cGy). Age was the only significant prognostic factor identified (P less than 0.01). The 5-year survival rates were 76% for adults and 14% for children. All 14 patients who died had recurrent or residual tumor at the primary site. This review suggests that in patients with primary posterior fossa ependymomas the following is true: 1) the young patient (5 yr old or younger) has a poor prognosis; 2) there was a trend toward a better 5-year survival rate with a gross total resection; 3) if recurrence occurs, it will be at the primary intracranial site; and 4) symptomatic spinal seeding does not occur frequently.

Cerebral angiotropic large cell lymphoma (neoplastic angioendotheliosis): therapeutic considerations

Cerebral angiotropic large cell lymphoma (neoplastic angioendotheliosis) is a rare disease with a particular propensity to affect the central nervous system by vascular occlusion. Because the disease is rare and there are no specific diagnostic procedures apart from cerebral biopsy, it is difficult to diagnose in life. Accordingly, chemotherapy or radiotherapy has only rarely been attempted and their effectiveness is uncertain. We established the diagnosis in a 62-year-old patient by cerebral biopsy and observed remission following institution of combination chemotherapy. Unfortunately, neurologic deterioration recurred during maintenance chemotherapy. We identified 30 patients in the literature who initially presented with definite central nervous system manifestations and whose clinical conditions were described sufficiently enough for comparison with our case. Eleven patients had the diagnosis made in life, but only 5 received chemotherapy other than corticosteroid hormones. Our patient's survival for 16 months exceeded that in the majority of the 30 reported cases. Intense anti-lymphoma chemotherapy, and possibly radiotherapy, may be beneficial and should be studied in this otherwise rapidly fatal disease. It seems certain that early diagnosis is essential if therapeutic intervention is to be successful.

Corticotropin releasing factor antagonist reduces ischemic hippocampal neuronal injury

This experiment tested the hypothesis that corticotropin-releasing factor (CRF) contributes to hippocampal ischemic injury. The antagonist to CRF (alpha-CRF) was administered intraventricularly 15 min prior to 10 min of transient forebrain ischemia in the Wistar rat. alpha-CRF demonstrated a neuroprotective effect in a dose-dependent manner most notable in CA1. There was also an increase in postischemic EEG recovery. It is postulated that CRF contributes to hippocampal ischemic injury through increased neuronal activity.

Cerebrospinal fluid physiology and the management of increased intracranial pressure

Increased intracranial pressure can result in irreversible injury to the central nervous system. Among the many functions of the cerebrospinal fluid, it provides protection against acute changes in venous and arterial blood pressure or impact pressure. Nevertheless, trauma, tumors, infections, neurosurgical procedures, and other factors can cause increased intracranial pressure. Both surgical and nonsurgical therapeutic modalities can be used in the management of increased intracranial pressure attributable to traumatic and nontraumatic causes. In patients with cerebral injury and increased intracranial pressure, monitoring of the intracranial pressure can provide an objective measure of the response to therapy and the pressure dynamics. Intraventricular, intraparenchymal, subarachnoid, and epidural sites can be used for monitoring, and the advantages and disadvantages of the various devices available are discussed. With the proper understanding of the physiologic features of the cerebrospinal fluid, the physician can apply the management principles reviewed herein to minimize damage from intracranial hypertension.