Unexpected difficult tracheal intubation secondary to subglottic stenosis leading to emergency front-of-neck airway.

A 26-year-old woman presenting for an elective day case procedure under general anaesthesia had undiagnosed subglottic stenosis leading to a life threatening airway emergency requiring emergency front-of-neck airway. We outline the case and discuss key anaesthetic considerations in subglottic stenosis, including concerning features of a medical/anaesthetic history and the potential for rapid deterioration of a stenotic airway following manipulation. We also consider the effect of anaesthesia on the calibre of subglottic stenosis and the effects of positive pressure ventilation. Subglottic stenosis is a rare condition with congenital, acquired and idiopathic origins; however, iatrogenic trauma is the most common cause. We are aware of a small number of published case reports of previously undiagnosed subglottic stenosis in adults discovered after induction of anaesthesia; situational deterioration to 'cannot intubate, cannot oxygenate' scenarios appear even rarer.

The emergence of magnetic ordering at complex oxide interfaces tuned by defects.

Complex oxides show extreme sensitivity to structural distortions and defects, and the intricate balance of competing interactions which emerge at atomically defined interfaces may give rise to unexpected physics. In the interfaces of non-magnetic complex oxides, one of the most intriguing properties is the emergence of magnetism which is sensitive to chemical defects. Particularly, it is unclear which defects are responsible for the emergent magnetic interfaces. Here, we show direct and clear experimental evidence, supported by theoretical explanation, that the B-site cation stoichiometry is crucial for the creation and control of magnetism at the interface between non-magnetic ABO3-perovskite oxides, LaAlO3 and SrTiO3. We find that consecutive defect formation, driven by atomic charge compensation, establishes the formation of robust perpendicular magnetic moments at the interface. Our observations propose a route to tune these emerging magnetoelectric structures, which are strongly coupled at the polar-nonpolar complex oxide interfaces.

Radioiodine ablation for differentiated thyroid cancer-none, one dose or two?

Patients with good prognosis differentiated thyroid cancer are at risk from over-treatment with radioiodine thyroid remnant ablation. Some with unfavourable localised disease might benefit from an elective second dose.

Gynaecology, forced sterilisation, and asylum in the USA.

PIP: On September 30, 1996, the US Congress enacted a law to grant asylum protection to victims of forced sterilization, forced abortion, and other forms of coerced population control and to opponents of these practices. Before this time, the US Board of Immigration Appeals judged forced sterilization insufficient grounds for political asylum unless it was performed for some discriminatory reason. The authors of this article have examined five women who claimed they were forcibly sterilized in China and were granted political asylum in the US as a result. The average age of these women was 32 years, while the average duration since forced sterilization was 8.6 years. Since asylum applications are not filed according to cause, there are no estimates of the number of women seeking asylum in the US as a result of forced sterilization. The Chinese government claims it does not authorize forced sterilization, but local officials acknowledge it sometimes occurs. In many cases, sterilization is not formally coerced but required as a condition of employment. Consistency between the woman's claim of forced sterilization and medical or psychological reports is essential to the success of asylum applications. US physicians should be prepared to play a documentary role in the evaluation of such requests.^ieng

Palliative radiotherapy for lung cancer: two versus five fractions.

The aim of this prospective randomized trial was to compare the symptomatic effects of two different regimens of palliative radiotherapy for lung cancer. Two hundred and sixteen patients needing palliation were randomized to receive either a 17 Gy mid-point dose in two fractions 1 week apart or 22.5 Gy in five daily fractions. Both toxicity and efficacy were evaluated by postal questionnaires. This small study was intended to identify any clinically important differences in toxicity or efficacy between the two regimens. We detected no such difference, although there was a tendency for iatrogenic dysphagia and improvement in chest pain and cough to be more common with the two-fraction regimen. The only symptom that was improved in over 50% of patients for 8 weeks or more was haemoptysis. Haemoptysis and chest pain appeared to be the best indications for treatment. The relief of other symptoms was disappointing in both degree and duration.

Comparison of mitozantrone and epirubicin in advanced breast cancer.

Forty chemotherapy naive patients with metastatic or locally advanced breast cancer were treated in a randomized trial comparing mitozantrone 14 mg/m2 with epirubicin 75 mg/m2 given intravenously at 3-weekly intervals. There was a 40% (95% confidence interval (CI) 8-72; P = 0.013) higher partial response rate with epirubicin (11/18) than with mitozantrone (4/19). Epirubicin caused significantly more alopecia (difference 76%; 95% CI 57-96; P < 0.0001) and nausea/vomiting (difference = 38%; 95% CI 10-67; P = 0.01). Three patients who received long courses of epirubicin experienced cardiac failure; two were proved to have cardiomyopathy. The median survival for the epirubicin and mitozantrone groups were 9.5 and 8 months respectively. Thus, although epirubicin gave a higher response rate it also caused more toxicity.

Economic evaluation of new treatments: haematopoietic growth factors.

The clinical benefits of new healthcare interventions usually receive considerable attention, but their impact on the economic aspects of care provision are not so well considered. Among the issues that different audiences will want to see addressed are: how clinical benefits translate into resource use savings in practice; the extent to which clinical trial outcomes can be said to be representative or normal practice and the value of the economic impact to purchasers and providers. In this review we consider these elements using the haematopoietic growth factors as an example.

Does dexamethasone leucocytosis facilitate full dosage adjuvant chemotherapy for breast cancer?

This is a retrospective analysis of breast cancer patients given adjuvant 'CMF' cytotoxic chemotherapy. It examines the impact on full blood counts of introducing dexamethasone as a prophylactic antiemetic the day before injections. Dexamethasone reduced leucopenia on injection due days. Twelve of 13 patients treated before the introduction of prophylactic dexamethasone, but only eight of 21 patients treated after, experience dose reduction or delay due to leucopenia (P < 0.01). Dexamethasone facilitated the administration of chemotherapy according to schedule.

Assessing the benefits of anti-emetic innovation.

This paper reviews recent anti-emetic developments, with particular reference to the 5-HT3 receptor antagonists. These drugs are at least as effective as conventional regimens for controlling acute nausea and vomiting in patients receiving highly or moderately emetogenic chemotherapy and abdominal radiotherapy. They have less side effects than do alternative drugs. Improved control of acute nausea and vomiting by 5-HT3 receptor antagonists seems to reduce anticipatory symptoms in subsequent cycles. Dexamethasone enhances activity of 5-HT3 receptor antagonists in highly emetogenic chemotherapy. Improved control of acute nausea and vomiting by 5-HT3 receptor antagonists may remove one obstacle to offering palliative chemotherapy.

Clinical oncology services to district general hospitals: report of a working party of the Royal College of Radiologists.

We conducted a survey of multidisciplinary non-surgical cancer services in district general hospitals without departments of radiotherapy and oncology. All consultants in clinical oncology (radiotherapy and oncology) in the United Kingdom were sent a questionnaire. This report is based on the analysis of information on 235 district general hospitals, which have an average of 450 acute or general beds. Non-surgical medical care for cancer patients at these hospitals is mainly provided by consultants in clinical oncology based at cancer centres. Initial assessment and follow-up, and some investigations and drug treatment, are organized at the district general hospitals, but radiotherapy and a substantial proportion of cytotoxic chemotherapy is administered at the cancer centres. The principal finding of the survey is that the average total weekly commitment of consultants in clinical oncology at district general hospitals is just under two sessions. We estimate that for each session at present provided at these hospitals there are five new cancer patients who would benefit from a specialized oncological opinion. For each new patient consultation there is a need for 5-10 times as many follow-up consultations. It is clear that the time available for cancer patients at district general hospitals, which on average are 22 miles away from the cancer centres, is far from adequate. We believe that it is correct to continue to base cancer services at cancer centres. This helps to ensure the maintenance of high standards and continuity of care. There is no need to alter the system, but there is a need to increase substantially specialist oncological presence at district general hospitals through the appointment of additional visiting consultants.

Influence of parasternal radiotherapy for breast carcinoma on thoracic vertebral metastases.

A retrospective study was performed of 109 women who had died with breast carcinoma metastatic to bone. Both radiologically demonstrated metastases and the requirement for palliative radiotherapy to the upper two thirds of the thoracic spine occurred significantly less in those patients who had received exit dose irradiation to this region from parasternal radiotherapy given for apparently localised disease. This finding is in agreement with a previous report that such low dose irradiation can exert a clinically important effect on minimal metastatic disease. Systemic (double hemi-body) radiotherapy might be an effective and quick adjuvant treatment for patients with breast carcinoma.

Paediatric anaesthesia--past, present and future.

On 27th August 1986, the 5th David Vervat Lecture was presented in Rotterdam by Professor emeritus Gordon Jackson Rees, M.B., Ch. B. (Liverpool). For his pioneering work Professor Jackson Rees may be called the father of paediatric anaesthesia, which is now conquering the world as a specialty of anaesthesia (Fig. 1). Mr. David Vervat is likewise a legend in his own lifetime for his pioneering work in paediatric surgery in the Netherlands, during which he felt so deeply the need for paediatric anaesthesia for his patients. As such this lecture represented a real tribute to David Vervat.

Changes in helper and suppressor T lymphocytes following radiotherapy for breast cancer.

Changes in total lymphocyte, T lymphocyte, T helper and T suppressor lymphocyte numbers were studied in 22 patients with breast cancer before and after radiotherapy. T lymphocyte subsets were measured using monoclonal antibodies and fluorescence microscopy. After treatment the total lymphocyte count fell significantly and was still reduced 9 months later, but the proportion of cells labelled as T lymphocytes was unchanged during this period. The helper-suppressor ratio, which was within the normal range before radiotherapy, was significantly reduced at 3 months and 9 months after. Following treatment both T helper and T suppressor cell numbers were significantly reduced. T helper cell numbers remained reduced throughout the study period but T suppressor cell numbers showed a recovery to normal values 9 months after radiotherapy.