Urgent 2-week referrals for CNS/brain tumours: a retrospective audit.

OBJECTIVE: To assess the effectiveness of the 2-week referral system for CNS/brain tumours and to contrast this with the number of patients with neurological cancers identified independently of this system. METHOD: Retrospective casenote review of patients referred to emergency neurology clinics pre-implementation of the 2-week referral system. Retrospective review of GP referral letters via this system and comparison to Department of Health referral guidelines. Review of corresponding casenotes to determine the actual neurological diagnosis. Identification of patients with CNS/brain tumours diagnosed independently of this system from a local CNS cancer register. RESULTS: Over a 3-month period pre-implementation of the referral system, of 12 patients referred as emergencies, none had CNS/brain cancer. Forty-three patients were referred via this system over a 9-month period to neurology departments of a teaching hospital and a district general hospital. Thirty per cent of the referrals did not follow the Department of Health guidelines. Only 9% actually had CNS tumours (two astrocytomas, two cerebral metastases). The remainder were diagnosed with chronic daily headache (10), epilepsy (5), migraine (3), demyelination (2), essential tremor (2), other (17). During this period at least 69 neurological cancers were identified independently of the 2-week system. CONCLUSION: These guidelines may increase diagnostic precision if adhered to rigidly. Inappropriate referrals have extended already lengthy outpatient waiting times in other specialities. We suggest early re-consideration of these guidelines and further study for earlier identification of CNS cancer.

An audit of the use of laser Doppler imaging (LDI) in the assessment of burns of intermediate depth.

This is the first report of an evaluation of the use of a laser Doppler imager (LDI) scanner in the assessment of burn depth in patients. It is based on a 6-month, prospective audit of 76 burns of intermediate depth. Clinical and LDI assessments of burn wound depth were recorded at 48-72 h post-injury. Histological confirmation of depth was obtained from those burns requiring surgery. A healing time of less than 21 days was taken as confirmation of the injury being an superficial dermal burn. The accuracy of LDI in the assessment of burn depth was 97%, compared with 60-80% for established clinical methods. This audit confirms that LDI is a very accurate measurement tool for the assessment of burn wound depth. We recommend that all burns of intermediate depth should be analysed in this way in order to ensure appropriate management of the burn, to avoid unnecessary surgery and to reduce hospital stay and costs.

Primary cerebral non-Hodgkin's lymphoma: problems with diagnosis and development of a protocol for management.

The prognosis for primary cerebral non-Hodgkin's lymphoma has improved markedly in the under-70 age group with the introduction of combined chemotherapy and radiotherapy. A review of our patients has revealed difficulty in obtaining definitive histology initially in 21% (9/43). We investigated the role of corticosteroids in these patients and found an idiosyncratic response in that there was no significance either of the cumulative dose (p > 0.424) or the length of treatment (p > 0.453) with the observed regression of lymphoma with corticosteroids. In order to avoid indiscriminate corticosteroid administration we have formulated a management protocol the entry point for which is a patient with enhanced computered tomography appearances of primary cerebral lymphoma.

Radical excision of sacrococcygeal tumours.

Large sacrococcygeal tumours are rare and remain a difficult management problem. Chordomas are one of the most common tumours in this region and may account for 30-40 per cent of postrectal tumours. Four patients aged between 22 and 66 years, three with chordomas and one with a schwannoma, are described. Each was managed by a combined general and neurosurgical approach. Major radical excision of the tumour involving high amputation of the sacrum and lower sacral nerve root division was performed. These large lesions can be radically excised with limited postoperative morbidity and excellent preservation of neurological function, including sphincter control, provided that one S2 nerve root is left intact.

Can photography be used to measure isodose distributions of space irradiance for laser photodynamic therapy?

The space irradiance isodose distribution of light delivered in tissue by an interstitial optical fibre may be determined by photographing the light diffusing out of the tissue. Provided that a plane of symmetry is photographed, it is shown that there is no significant distortion of the isodose distribution measured in this way. Two series of photographs were taken to test the method. In one set, a partially reflecting film was used to simulate the presence of the missing tissue. Isodose distributions obtained were in agreement with the predictions of diffusion theory. The isodoses were "scaled' by measuring the space irradiance at one point with a bulb-tipped optical fibre. Optical parameters are deduced from the measurements. The method, which is simple and fast in use, should be of wide applicability.

Carbon dioxide laser irradiation of bacterial targets in vitro.

Agar targets seeded with Escherichia coli and Staphylococcus aureus in roll tubes simulating the vaginal vault were irradiated with a CO2 laser at various power densities and durations. Viable bacteria were detected in the plume emissions in all instances. Staphylococcus aureus was found to be more resistant to the thermal effects of lasing than E. coli. This suggests that CO2 irradiation of cervical lesions could disseminate viable particles which may be a hazard for patients and operators.

Is the enuretic female bladder without instability normal?

Twenty-one females with a history of nocturnal enuresis were found to have stable bladders on cystometric testing. A stable detrusor is defined as one that is capable of contraction but does not develop abnormal contractions on filling inspite of provocative testing by rapid filling, standing, coughing and erect filling. A detailed assessment of 10 measurements revealed abnormalities in 19 of the 21 cases. This result strengthens the theory that for nocturnal enuresis to occur, two abnormalities are necessary: (a) failure of a full bladder to arouse from sleep, and (b) an abnormality of bladder/urethral function. Identifiable causes of nocturnal enuresis included a small functional bladder capacity, outlet obstruction, increased detrusor contractility and low urethral closure pressure.

Adult enuresis--a symptomatic and urodynamic assessment.

Sixty-five patients (33 females and 32 males) with adult enuresis have been assessed cystometrically. Patients with primary enuresis may have either nocturnal enuresis alone or diurnal symptoms as well. Abnormal cystometric patterns were found in a high percentage of both types of enuresis. There was a significant correlation between the presence of diurnal symptoms and bladder instability and between nocturia and instability.

Hyperthermia in the treatment of bladder tumours.

High temperature bladder irrigation was employed in 4 men as an alternative to cystectomy because of their age and frailty. Hyperthermic irrigation of the bladder from 63 degree C for 70 minutes to 82 degree C for 25 minutes caused partial, but not total, necrosis of the bladder. Transitional cell carcinoma appears to be resistant in vivo, in some cases, to heating at temperatures that destroy adjacent normal structures. Hyperthermic irrigation of the bladder at these high temperatures may be hazardous. In view of these findings we cannot recommend high temperature bladder irrigation as an alternative to cystectomy even in poor risk patients.