A survey of neurological disability at a district general hospital.

Neurological disease accounts for 20% of all admissions to medical wards, but the number of inpatients with neurological disability is unknown. The notes of all adult inpatient in a district general hospital were reviewed to identify all those with a neurological disorder. Over 40% of inpatients on medical wards and 4% on surgical wards had a neurological disorder. Stroke was the most common neurological diagnosis, accounting for 36% of neurological disorders and 22% of all patients on medical wards. Other neurological diagnoses included dementias 10%, degenerative disorders 10%, epilepsy 7%, demyelination 4%, and head injuries 3%. Neurological patients have long inpatient stays (mean 80 days), and often remain in hospital awaiting changes in accommodation. Seven patients under 65 years stayed more than 6 months awaiting long-term care. Neurological disorders contribute significantly to the inpatient workload. Identifying those requiring rehabilitation and concentrating them on one ward could improve the quality and efficiency of their care.

The management of histologically unverified presumed cerebral gliomas with radiotherapy.

PURPOSE: To define the natural history, and prognostic factors of patients with histologically unverified presumed gliomas diagnosed on CT or MR imaging, and treated with external beam radiotherapy. METHODS AND MATERIALS: Retrospective review of 111 adults with histologically unverified presumed cerebral glioma treated with radiotherapy between 1974 and 1990. Using CT or MRI criteria alone 41 were presumed low grade, 63 high grade gliomas and 7 were unclassified. Survival results were compared to a cohort of 82 adults with histologically verified low grade gliomas treated over the same period with surgery and radiotherapy. RESULTS: The 5 year survival probability of the whole cohort was 31%. Age, performance status, and the degree of contrast enhancement were independent prognostic factors for survival. Patients with presumed low grade glioma had a 5 year survival of 41% compared to 52% for patients with verified low grade glioma. After correction for prognostic factors no significant difference was found in the survival between patients with verified and unverified low grade tumors. One of 15 cases with subsequent histology, obtained at autopsy or salvage surgery, had nonglial pathology. CONCLUSION: Patients diagnosed on the basis of clinical features and imaging as having presumed glioma have similar natural history and clinical behavior after treatment with radiotherapy to those with histologically confirmed gliomas. However, the results should not be taken as justification for avoiding biopsy. A proportion of patients may have nonglial pathology and new more effective treatment strategies for patients with glial tumors can only evolve on the basis of full diagnostic information including pathology.

Osmotic production of sterile oral rehydration solutions--an economic, low-technology method.

A sterile oral rehydration solution can be produced by immersing in water a semi-permeable cellulose tube containing glucose and salts. Osmotically-driven ultrafiltration excludes all microbes and particulate matter even when the immersion water contains 45 x 10(6) cfu/ml of Pseudomonas aeruginosa, 25 x 10(7) cfu/ml of Staphylococcus aureus or 20 x 10(7) cfu/ml of Escherichia coli. Solutions of consistent composition can be obtained by having a standard amount of glucose-electrolytes in a cellulose tube of appropriate dimensions and immersing this in a fixed volume of water for a minimum period of time. The method is simple, inexpensive, low-technology and requires no external source of power. It has potential for producing sterile solutions for injections and intravenous use in situations with very limited and simple resources, in emergencies and during natural disasters. Further studies are now needed to determine whether the method can be adapted to provide the large quantities of oral rehydration fluid needed in field conditions.

Epilepsy as the presenting feature of neuroacanthocytosis in siblings.

A brother and sister developed epilepsy at the age of 28 and 30 years respectively, and were subsequently found to have neuroacanthocytosis. The brother developed tics, and a tendency to self-mutilate a year later, but his sister had not developed any movement disorder in the 5 years since the onset of epilepsy. In families with epilepsy, the diagnosis of neuroacanthocytosis should be considered, particularly when one family member has tics or other involuntary movements.

Bone weakness after the removal of plates and screws. Cortical atrophy or screw holes?

Bone weakness leading to refracture is a recognised complication of the removal of rigid fixation plates. We have used partially demineralised rabbit tibiae to simulate atrophic changes and to determine whether weakness is due to atrophy or to residual screw holes. Partial demineralisation and a screw hole each reduced maximum bending moment. However, energy absorbing capacity was little affected by demineralisation, but was reduced to 50% by a single drill hole. Residual screw holes are a considerably more important cause of bone weakness after plate removal than is cortical atrophy.

Neoplastic meningitis in malignant melanoma: diagnosis with monoclonal antibodies.

Six patients with neoplastic melanomatous meningitis were studied. The diagnosis of this complication of malignant disease rests on the demonstration of malignant cells within the CSF. The addition of monoclonal antibody immunocytology to conventional techniques significantly improved the diagnostic sensitivity of CSF cytology, allowing for earlier and therefore more effective palliative treatment.

Neurosurgery for cervical spondylosis.

The pathogenesis of radiculopathy and myelopathy secondary to cervical spondylosis is described, together with the clinical features of these conditions and the factors that influence their natural history. After discussing the differential diagnosis the medical management and the indications for surgery are considered. Details of the operative approaches are presented in association with the results of treatment.

Radiographic appearance of frontal osteomyelitis in two patients with extradural abscess.

Extradural abscess can be a complication of frontal sinusitis. The chronicity of this condition can give rise to extreme frontal hyperostosis which can be an important radiological sign in a condition which may be clinically obscure.

Use of histological samples for assessing skeletal calcium.

Bone samples were decalcified using 5% formic acid. Their calcium content was then quantified by analysing the calcium extracted in the decalcification solution. This was correlated with matched samples digested in hydrochloric acid. No significant differences were found. This indicates that bone biopsy specimens taken for histological analysis can be used for the direct assessment of skeletal calcium. The method can therefore simplify investigations into metabolic bone diseases and provide a direct correlation between skeletal calcium and bone histology.

Mianserin in the prophylaxis of migraine: a double-blind study.

Evidence is reviewed indicating that instability in central nervous system handling of 5-hydroxytryptamine may be of primary importance in the pathogenesis of migraine, and that the observed diminution of platelet content and uptake of 5-hydroxytryptamine related to an attack may merely be a reflection of this. The rationale is discussed for selecting mianserin as a potentially effective migraine prophylactic based on: (i) its ability to restore to normal platelet 5-hydroxytryptamine uptake when this is decreased in depression; (ii) its effect on the central nervous system; and particularly (iii) its antiserotonergic activity. A double-blind control trial of mianserin versus placebo in the prophylaxis of migraine is described. There was a significant fall in both frequency and severity of migraine attacks when compared with baseline values in mianserin-treated patients but not in placebo-treated patients. There was no accompanying change on the Beck Depression Inventory. It is concluded that mianserin is an effective migraine prophylactic in some patients. There is no evidence indicating which pharmacological property of mianserin is responsible for this effect.

Is leucocyte ascorbic acid an unreliable estimate of vitamin C deficiency?

Leucocyte ascorbic acid levels failed to identify six of seven elderly patients shown to be deficient on an oral vitamin C saturation test. Compared to those with a normal saturation test, patients judged deficient had lower levels for triceps skinfold thickness, mean arm muscle circumference and Quetelet's index; there was a significant association with the habit of eating alone, and with a dietary intake of less than 30 mg of ascorbic acid daily (the recommended daily allowance in the U.K.). No significant difference was found in the values for haemoglobin, serum albumin or potassium concentrations between the two groups, and no association shown between a deficient saturation test and smoking, season, sublingual varicosities or an abnormal bleeding time.

Hair chromium concentrations in adult insulin-treated diabetics.

Hair chromium concentrations have been measured in age- and sex-matched groups of insulin-treated diabetics and normal controls. Average concentration (+/- S.E.M.) was reduced in female (2.9 +/- 0.5 compared with 5.1 +/- 0.7 nmol/g) but not in male diabetics.

The relation between plasma unconjugated oestriol and cystine aminopeptidase concentrations and uterine contractions.

The relation between maternal plasma unconjugated oestriol (E3) concentrations and uterine activity was investigated by very frequent, carefully timed determinations of E3 during synchronously recorded uterine contractions in six normal subjects. There was an initial rise (10 to 50 per cent above the mean) in E3 levels reaching a peak coincident with the contraction peak (range 20 seconds before to 15 seconds after) followed by a fall of similar magnitude below the mean reaching a nadir about 80 seconds (range 60 to 105 seconds) after the contraction peak. Although the pattern of E3 fluctuation was most marked in labour the overall degree of variation was no greater than at other times. Cystine aminopeptidase (CAP) concentrations in the same serum samples showed no significant correlation with uterine contractions. The reasons for, and practical applications of, the E3 results are discussed.

Plasma unconjugated oestriol and unconjugated oestradiol-17 beta in late pregnancy: individual fluctuation of concentrations from day to day and every 10 minutes.

Plasma unconjugated oestriol (E3) and unconjugated oestradiol-17 beta (E2) were determined by radioimmunoassay. In ten normal women in their last month of pregnancy the individual fluctuation of E3 concentrations (mean of the coefficients of variation, CV) from day to day (over 5 days) was 15.6% (range 6.4--26.2%). The individual fluctuation of E2 determined in eight of these women was 16.9 (10.4--25.5) %. In six of the same women who had blood samples collected every 10 min (for 3 h) the individual fluctuation of E3 concentrations was 13.8 (7.0--25.1) %, and of E2 was 16.1 (11.3--26.0) %. The degree of fluctuation of E3 in individuals was in proportion to the mean concentration, unlike E2, suggesting that in clinical practice individual changes in E3 values would be as easy to interpret at low levels as at high levels. The finding that concentrations of plasma unconjugated E3 fluctuate in individuals no more than for E2 or than reported for total E3, and less than reported for 24-h urinary oestrogens, lends practical support to the theoretical preference for the assay of plasma unconjugated E3 to assess fetoplacental function.

Plasma unconjugated oestriol in late pregnancy: circadian variation and the effect of meals and a glucose load.

Plasma unconjugated oestriol (E3) concentrations were determined by radioimmunoassay in 10 normal subjects in late pregnancy, throughout a normal day and night, and after a 50 g oral glucose load. There was a circadian pattern in E3 concentration characterized by an abrupt increase of 15 per cent at night. There was no significant rhythm during the day or night, taken separately. However there was a 10 to 11 per cent reduction in E3 concentrations soon after some meals and after a glucose load, possibly due to expansion of the plasma volume. Excluding the effect of meals, the fluctuation of E3 concentrations in individuals (median of the coefficients of variation) was 11.5 per cent in the day. Overall, it was 13.2 per cent in the day, 12.1 per cent at night and 15.9 per cent over the whole period studied. Since the variation in plasma unconjugated E3 concentrations through 24 hours was no greater than random fluctuations or day-to-day variation there is no need to restrict the time of blood sampling in clinical practice.