Clinical audit effectively bridges the evidence-practice gap in chronic subdural haematoma management.

BACKGROUND: Placement of a subdural drain after drainage of chronic subdural haematoma (CSDH) has been shown to reduce the rate of recurrence in several randomised controlled trials (RCT). The most recently published RCT was from Cambridge, UK, in 2009. Despite class I evidence for the use of subdural drains, it is unclear whether these results have been translated into clinical practice. In this clinical audit we review the use of subdural drains in our institution before and after the publication of the 2009 RCT results. METHODS: A longitudinal retrospective study was performed on all adults having burr holes for CSDH between January 2009 and January 2014. Case notes were analysed to determine subdural drain use, re-operation for CSDH recurrence and post-operative complications. The audit loop was closed with data collected from August 2015 to January 2016. RESULTS: Thirty-one per cent of patients had subdural drains placed at operation. Drain placement was associated with lower reoperation rates (8% vs. 17%, p = 0.021) without increasing complication rates. Drain usage doubled after publication of the Santarius et al. (2009) trial but we observed persisting and significant variability in drain utilisation by supervising consultants. The use of drains in the department increased from 35% to 75% of all cases after presentation of these results. CONCLUSIONS: The use of subdural drains in our unit reduced recurrence rates following drainage of CSDH and reproduced the results of a 2009 clinical trial. Although the use of subdural drains doubled in the post-trial epoch, significant variability remains in practice. Clinical audit provided an effective tool necessary to drive the implementation of subdural drain placement in our unit.

Time-resolved contrast-enhanced MR angiography of spinal vascular malformations.

BACKGROUND AND PURPOSE: The diagnosis of spinal vascular malformations may be challenging on conventional MR imaging because neither the location of the signal abnormality in the spinal cord nor the level of the abnormal flow voids correlates with the level of the fistula. We conducted a retrospective evaluation of the utility of using a time-resolved imaging of contrast kinetics sequence in the diagnosis, characterization, and localization of spinal vascular malformations, comparing it with the criterion standard of spinal DSA. MATERIALS AND METHODS: Fifty-five consecutive patients with a suspected diagnosis of spinal vascular malformation underwent time-resolved imaging of contrast kinetics followed by spinal DSA. All scans were performed on a 1.5T scanner by using a standard 8-channel spine coil and were reported by a neuroradiologist before the DSA was performed. RESULTS: Forty-seven lesions were confirmed on time-resolved imaging of contrast kinetics and classified as spinal dural arteriovenous fistulas (n = 33, with 1 patient having a type Ib fistula), perimedullary spinal cord arteriovenous fistulas (n = 10), and intramedullary arteriovenous malformations (n = 3). One patient had an extradural spinal vascular malformation. Time-resolved imaging of contrast kinetics identified the location of the arterial feeder to within 1 vertebral level in 27/33 patients (81.8%) with spinal dural arteriovenous fistulas and correctly predicted the side in 22/33 (66.6%) patients. Perimedullary spinal cord arteriovenous fistulas were erroneously considered to represent spinal dural arteriovenous fistulas before spinal DSA. The anatomy of the arterial supply to intramedullary arteriovenous malformations was also poorly characterized on time-resolved contrast-enhanced MR angiography. CONCLUSIONS: It has been our experience that time-resolved imaging of contrast kinetics is a useful confirmatory tool when a spinal vascular malformation is suspected on the basis of clinical and conventional MR imaging findings. As experience with the technique grows and sequences are refined, it may be possible to rely on time-resolved imaging of contrast kinetics as a screening tool for the diagnosis of spinal vascular malformations.

Thromboembolism in brain tumors.

Venous thromboembolism commonly affects patients receiving treatment for primary and secondary cerebral tumors. We review the recent literature on the molecular mechanisms underlying this hypercoagulable state and clinical studies of antithrombotic prophylaxis and therapy in this population. A computerized search of the MEDLINE database for articles from 1966 to the present day. Keywords/search terms used were glioma, astrocytoma, glioblastoma multiforme, cerebral tumor, primary brain tumour, secondary brain tumour, venous thromboembolism, thromboprophylaxis, heparin, warfarin, anticoagulants, and caval filters. Although neurological deficit has been identified as an independent risk factor for thrombosis it is also clear that malignant brain tumors induce changes in the makeup of circulating blood, making it more likely to clot. Concern for the perceived risk of perioperative intracranial bleeding with antithrombotic prophylaxis appears not to be justified by the available evidence. Prospective assessment of low molecular weight heparins for prophylaxis and treatment of established thrombosis is required. Antithrombotic therapy may also offer advantages over intracaval devices in prevention of secondary pulmonary embolism in patients with brain tumors.

Thromboprophylaxis in the cancer patient.

Cancer patients not undergoing treatment and without a history of venous thrombosis do not, as a general rule, require prophylaxis. However, venous thromboembolism is of sufficient magnitude in patients undergoing treatment for cancer for thromboprophylaxis to be routinely employed. The mainstay of primary prevention is low molecular weight heparin, while secondary prevention may require warfarin and in some instances vena cava filters. The duration of prophylaxis should usually last for the period of treatment, except in the case of pelvic or cerebral radiotherapy where it is continued for 4-12 months beyond the treatment period. The principal role for vena cava filters is on occasions where recurrent thrombosis or haemorrhage complicates anticoagulation.

Refuse incinerator particulate emissions and combustion residues for New York City during the 20th century.

Refuse incineration data for New York City (NYC) have been compiled as a function of time during the 20th century to assess the historical significance of this pollutant source in a densely populated area. Thirty-two municipal and 17,000 apartment house refuse incinerators were identified. Approximately 1.1 x 10(8) t of refuse (wet weight) were combusted in NYC incinerators between 1908 and 1993, producing 3.4 x 10(7) t(dryweight) of combustion residue disposed in local landfills. Refuse incinerators were operated for most of this period without air pollution control and emitted 1.0 x 10(6) t of particles (a total of 120 mg for each cm2 of land in NYC). Incinerator particle emission (PE) rates per unit area of land were highest in Manhattan (equivalent total deposition of 530 mg cm(-2)). Incinerator PE exceeded 1.2 x 10(4) t yr(-1) between 1930 and 1975, with maximum emission rates (>2.2 x 10(4) t yr(-1)) in the late 1930s and 1960s. These and other factors support the conclusion that refuse incineration without air pollution control was an important source of airborne, respirable pollutants in NYC for many decades during the 20th century. Rates of particle emissions from Manhattan incinerators estimated here correlate stronglywith Pb accumulation rates as a function of depth (time) in Central Park Lake sediments, consistent with refuse incineration emitting large amounts of atmospheric lead in NYC for many decades afterthe 1920s.

The role of the coagulation system in tumour angiogenesis.

The coagulation system, which is activated in most cancer patients, has an important role in tumour biology. It may make a substantial contribution to tumour angiogenesis, which represents an imbalance in the normal mechanisms that allow organised healing after injury. The recently recognised, but steadily growing, knowledge of the relationship between the coagulation and angiogenesis pathways has research and clinical implications. Manipulation of these systems may minimise both the neoangiogenesis essential for tumour growth and associated thromboembolic complications. However, since surgery is the primary treatment for most cancers, the angiogenesis of wound healing and haemostatic competence must be maintained. In this article, we summarise the complex interactions between the coagulation system and the angiogenic process that occur in cancer growth. We focus upon the contributions of the vascular endothelium, platelets, and coagulation factors to the angiogenic process and explore the coagulation system as a therapeutic target.

Tumour-specific distribution of BRCA1 promoter region methylation supports a pathogenetic role in breast and ovarian cancer.

The role of BRCA1 in sporadic breast and ovarian cancers remains elusive. Direct involvement of BRCA1 in the development of breast and ovarian cancer is suggested by the finding that the BRCA1 promoter region CpG island is methylated in a proportion of breast and ovarian cancers. The aim of this study was to compare the incidence of BRCA1 promoter region methylation in tumours in which loss of BRCA1 has been shown to play a role in pathogenesis (breast and ovarian carcinomas) with the incidence in tumours in which BRCA1 is unlikely to play a role in pathogenesis. Promoter region hypermethylation was significantly more common (P < 0.008) in breast and ovarian cancer (6/38 tumours methylated) than in colon cancer (0/35 tumours methylated) or in leukaemias (0/19 samples methylated). The restriction of BRCA1 promoter region hypermethylation to breast and ovarian cancer is consistent with a pathogenetic role of BRCA1 promoter methylation in these tumours. We suggest that the rarity of observed BRCA1 mutations in sporadic breast and ovarian cancer is due to the greater likelihood of BRCA1 inactivation by non-mutational mechanisms such as methylation.

Life threatening epistaxis complicating extended maxillotomy for chordoma.

Postoperative hemorrhagic complications of the "open-door" maxillotomy approach to the skull base and clivus are uncommon. We report a case of maxillary artery pseudoaneurysm and discuss the management of this condition.

Stump appendicitis--a potential problem after laparoscopic appendicectomy.

Appendicitis is now commonly diagnosed and treated using laparoscopic techniques. Laparoscopic appendicectomy has the potential to result in incomplete removal of the appendix stump and subsequent risk of stump appendicitis. This article reports such a case, requiring laparotomy 5 months after the original appendectomy.

Subcutaneous metastases after laparoscopic resection of malignancy.

Following the introduction and widespread acceptance of laparoscopic cholecystectomy, laparoscopic techniques have been applied to an increasing variety of general surgical procedures. Recently, laparoscopic procedures for resection of malignancy have begun to emerge, in particular laparoscopic assisted colectomy for carcinoma of the colon. In the cases reported here, metastatic tumour in the laparoscopy port sites is described as a potentially serious complication of laparoscopic procedures for resection of malignancy.

Schools as healthful environments: prerequisite to comprehensive school health?

The development of healthy schools to support and nature the well-being of students, teachers, and staff is proposed as a first step toward the goal of comprehensive health education. A focus on healthy schools incorporates elements of an expanded concept of comprehensive health education that demands careful consideration of the physical, psychological, and social environment of the nation's schools--worksite to 51 million (students, teachers, and staff). The active participation of all stakeholders in environmental assessments, health and safety audits, and restructuring of schools is an essential part of the school reform movement. A healthy worksite concept supports the transformation of the school environment to increase "productivity" by enhancing the ability of teachers, staff, and students to function well.

Researching and preventing alcohol problems at work: toward an integrative model.

PURPOSE OF PROPOSAL. A consolidated framework is proposed to highlight modifiable factors in work organizations that may contribute to alcohol-related problems. This research model serves to organize existing knowledge, highlight pathways for new research initiatives, and offer insights into the design of primary and secondary preventive strategies. CONTRIBUTING INFLUENCES. Current research on problem drinking in the workplace either locates problems in individual drinkers or looks to the social environment to understand how drinking problems unfold. There is a clear need for a more complete theoretical model which incorporates social, cultural, organizational, and personal factors. PROPOSAL SUMMARY. This article elaborates on a model for examining problem drinking at work which integrates policy, normative, and psychosocial influences. It emphasizes the structures within which health-related decisions and actions are contained and constrained. The focus here on the connections between alcohol use and work builds on the premise that health is socially produced.

Social marketing for public health.

Marketing techniques and tools, imported from the private sector, are increasingly being advocated for their potential value in crafting and disseminating effective social change strategies. This paper describes the field of social marketing as it is used to improve the health of the public. A disciplined process of strategic planning can yield promising new insights into consumer behavior and product design. But the "technology" cannot simply be transferred without some translation to reconcile differences between commercial marketing and public health.

PIP: While the administration of US President Bill Clinton is trying to reform the US health care system, less attention is being given to changing behavior. The problems caused by excessive alcohol drinking, poor diets, and the use of tobacco products and other harmful substances often tend to be more related to a country's health status than are acute, short-lived illnesses. Private sector-derived marketing techniques and tools are increasingly being used to create and disseminate effective social change strategies. The authors describe how social marketing can be used to improve public health. They draw from information obtained from major textbooks, conference proceedings, telephone interviews with more than 30 practitioners and scholars in the field, and data on the application of social marketing in maternal and child health and nutrition in developing countries, family planning in developing countries, the anti-smoking campaign in the US, cardiovascular disease risk reduction, and substance abuse prevention among adolescents. Sections consider the historical convergence of marketing and health promotion; the essential elements of a social marketing approach to health; lessons learned from applications of social marketing to health; and limitations, caveats, and issues for the future.

The impact of a physician's warning on recovery after alcoholism treatment.

OBJECTIVE: To study whether alcoholic workers had seen physicians during the year they were identified by their company, whether they recalled physicians' warnings about drinking, and whether such warnings affected outcomes 2 years later. DESIGN: Workers were interviewed at intake and 2 years later: subgroups who did and did not see physicians and who did and did not recall warnings were compared. SETTING: A company-union employee assistance program. PARTICIPANTS: Two hundred problem drinkers, newly identified on the job, predominantly male, blue-collar workers. OUTCOMES: Drinking, drunkenness, average daily alcohol consumption, and impairment score. RESULTS: Among the 200 participants, 74% saw physicians in the index year; only 22% recalled warnings. Recall of a warning was associated with liver disease, continued drinking while ill, supervisors' job warnings, older age, and marijuana use. Two years later, those warned were more likely to be abstaining, and sober, and were less impaired. CONCLUSIONS: Recalling a physician's warning at intake into alcoholism treatment was associated with better prognosis 2 years later. However, among this group of employees whose drinking was serious enough to be identified on the job, fewer than a quarter recalled physicians' warnings, even though more than three quarters had seen physicians in the year preceding intake.

The new corporate health ethic: lifestyle and the social control of work.

A corporate health ethic, forged in U.S. industry in the 20th century, clearly demarcated boundaries between private and workplace health concerns. This article advances evidence that the boundary is blurring, and argues that trends in workplace initiatives, including employee assistance, wellness programs, and drug screening, are giving shape to a new corporate health ethic. The new ethic emphasizes workers' lifestyles on and off the job, engendering a shift in corporate jurisdiction over employee health and behavior. Economic arguments such as "health care cost containment" are commonly offered as explanations for these new health initiatives. But the authors see the new ethic as a deeper response to a changing corporate environment and, more fundamentally, as emblematic of changes in the social control of work and productivity. They argue that the new health ethic may be a harbinger of new forms of social control in the workplace.

A randomized trial of treatment options for alcohol-abusing workers.

BACKGROUND: Employee-assistance programs sponsored by companies or labor unions identify workers who abuse alcohol and refer them for care, often to inpatient rehabilitation programs. Yet the effectiveness of inpatient treatment, as compared with a variety of less intensive alternatives, has repeatedly been called into question. In this study, anchored in the work site, we compared the effectiveness of mandatory in-hospital treatment with that of required attendance at the meetings of a self-help group and a choice of treatment options. METHODS: We randomly assigned a series of 227 workers newly identified as abusing alcohol to one of three rehabilitation regimens: compulsory inpatient treatment, compulsory attendance at Alcoholics Anonymous (AA) meetings, and a choice of options. Inpatient backup was provided if needed. The groups were compared in terms of 12 job-performance variables and 12 measures of drinking and drug use during a two-year follow-up period. RESULTS: All three groups improved, and no significant differences were found among the groups in job-related outcome variables. On seven measures of drinking and drug use, however, we found significant differences at several follow-up assessments. The hospital group fared best and that assigned to AA the least well; those allowed to choose a program had intermediate outcomes. Additional inpatient treatment was required significantly more often (P less than 0.0001) by the AA group (63 percent) and the choice group (38 percent) than by subjects assigned to initial treatment in the hospital (23 percent). The differences among the groups were especially pronounced for workers who had used cocaine within six months before study entry. The estimated costs of inpatient treatment for the AA and choice groups averaged only 10 percent less than the costs for the hospital group because of their higher rates of additional treatment. CONCLUSIONS: Even for employed problem drinkers who are not abusing drugs and who have no serious medical problems, an initial referral to AA alone or a choice of programs, although less costly than inpatient care, involves more risk than compulsory inpatient treatment and should be accompanied by close monitoring for signs of incipient relapse.