A standardised pathway for the surveillance of stable vestibular schwannoma.

Introduction Conservative management of patients with a stable vestibular schwannoma (VS) places a significant burden on National Health Service (NHS) resources and yet patients' surveillance management is often inconsistent. Our unit has developed a standardised pathway to guide surveillance imaging of patients with stable VS. In this article, we provide the basis for our imaging protocol by reviewing the measurement, natural history and growth patterns of VS, and we present a cost analysis of implementing the pathway both regionally and nationally. Methods Patients with an extrameatal VS measuring ≤20mm in maximal diameter receive magnetic resonance imaging (MRI) six months after their index imaging, followed by three annual MRI scans, two two-year interval MRI scans, a single three-year interval MRI scan and then five-yearly MRI scans to be continued lifelong. Patients with purely intrameatal tumours follow the same protocol but the initial six-month imaging is omitted. A cost analysis of the new pathway was modelled on our unit's retrospective data for 2015 and extrapolated to reflect the cost of VS surveillance nationally. Results Based on an estimation that imaging surveillance would last approximately 25 years (+/- 10 years), the cost of implementing our regional surveillance programme would be £151,011 per year (for 99 new referrals per year) and it would cost the NHS £1,982,968 per year if implemented nationally. Conclusions A standardised surveillance pathway promotes safe practice in the conservative management of VS. The estimated cost of a national surveillance programme compares favourably with other tumour surveillance initiatives, and would enable the NHS to provide a safe and economical service to patients with VS.

Treatment of Trombicula autumnalis infestation in dogs and cats with a 0.25 per cent fipronil pump spray.

To evaluate the efficacy of fipronil in controlling trombiculid infestations, 18 dogs and three cats infested with Trombicula autumnalis larvae were treated monthly from examination to the end of the Trombicula season (range one to four months) with a 0.25 per cent fipronil spray applied to the whole body, with particular emphasis on the feet, face, ears, perineum and tail. No other antiparasite measures were used. Follow-up was by clinical examination and telephone interview until the end of the Trombicula season (range one to four months). No adverse effects were seen. Monthly treatment controlled trombiculids in 15 dogs. In two dogs localised pedal reinfestations were controlled with additional local application of fipronil to the feet every 14 days. In one dog therapy was of no benefit. In the three cats, treatment was initially effective, but generalised infestations recurred after seven to 10 days. Fipronil is a safe and effective treatment for trombiculid infestations in dogs. Residual activity lasts for 14 to 30 days. Further studies are required to examine the apparent short duration of efficacy in cats.

5-Hydroxyindole-secreting rectal carcinoid tumour.

A patient with a 5-hydroxyindole-secreting rectal carcinoid tumour is described, the second on record. There was no clinical evidence of carcinoid syndrome. Prostaglandin-like substances were isolated from hepatic metastases.