Treating Brain Metastases from Breast Cancer: Outcomes after Stereotactic Radiosurgery.

AIMS: Stereotactic radiosurgery (SRS) is an alternative to surgery or whole brain radiotherapy for the control of single or multiple brain metastases in patients with breast cancer. To date, there is no clear consensus on factors that might predict overall survival following SRS. The aim of this study was to assess the overall survival of breast cancer patients with brain metastases treated with SRS at a single centre and to examine the factors that might influence survival. MATERIALS AND METHODS: A retrospective analysis of consecutive patients with breast cancer and brain metastases, considered suitable for SRS by the regional neuro-oncology multidisciplinary team. All patients were treated at a single National Health Service centre. RESULTS: In total, 91 patients received SRS between 2013 and 2017, of whom 15 (16.5%) were alive at the time of analysis. The median overall survival post-SRS was 15.7 months (interquartile range 7.7-23.8 months) with no significant effect of age on survival (67 patients ≤ 65 years, 16.3 months; 26 patients > 65 years, 11.4 months, P = 0.129). The primary tumour receptor status was an important determinant of outcome: 31 oestrogen receptor positive (ER+)/human epidermal growth factor receptor 2 negative (HER2-) patients had a median overall survival of 13.8 months, 14 ER+/HER2+ patients had a median overall survival of 21.4 months, 30 ER-/HER2+ patients had a median overall survival of 20.4 months and 16 patients with triple negative breast cancer (TNBC) had a median overall survival of 8.5 months. A larger total volume of tumour treated (>10 cm3), but not the number of individual metastases treated, was associated with worse survival (P = 0.0002) in this series. Patients with stable extracranial disease at the time of SRS had improved overall survival compared with those with progressive extracranial disease (30 patients stable extracranial disease overall survival = 20.1 months versus 33 patients progressive extracranial disease overall survival = 11.4 months; P = 0.0011). Seventeen patients had no extracranial disease at the time of SRS, with a median overall survival of 13.1 months. CONCLUSIONS: This single-centre series of consecutive patients with brain metastases from breast cancer, treated with SRS, had a similar overall survival compared with previous studies of SRS. TNBC and ER+/HER2- histology, metastatic volumes >10 cm3 and progressive extracranial disease at the time of SRS were associated with worse survival.

Blood pressure in children aged 4-8 years: comparison of Omron HEM 711 and sphygmomanometer blood pressure measurements.

OBJECTIVE: To collect normal data on blood pressure (BP) in healthy children aged 4-8 and to compare measurements of BP made in the same subjects with a sphygmomanometer and a portable automated oscillometric BP monitor (Omron HEM 711 with child cuff). METHODS: Cross-sectional observational study of 764 children. BP measurements were made at school, using both a sphygmomanometer and an Omron HEM 711. Immediately after the BP measurement children were asked to state which device they preferred (if any). RESULTS: Children had no preference for whether the sphygmomanometer or the Omron was used. Bland-Altman plots showed a lack of consistency between the two methods of BP measurement. With systolic BP there was a trend for the Omron to underestimate when low and overestimate when high. CONCLUSIONS: Children were equally distributed in their preference for BP device. There was a wide variation between the two methods of BP measurement, which suggests that comparison of automated BP measurements with normative data obtained by sphygmomanometer is not valid.

Does initial spacing influence crown and hydraulic architecture of Eucalyptus marginata?

Long-term declines in rainfall in south-western Australia have resulted in increased interest in the hydraulic characteristics of jarrah (Eucalyptus marginata Donn ex Smith) forest established in the region's drinking water catchments on rehabilitated bauxite mining sites. We hypothesized that in jarrah forest established on rehabilitated mine sites: (1) leaf area index (L) is independent of initial tree spacing; and (2) more densely planted trees have less leaf area for the same leaf mass, or the same sapwood area, and have denser sapwood. Initial stand densities ranged from about 600 to 9000 stems ha(-1), and trees were 18 years old at the time of sampling. Leaf area index was unaffected by initial stand density, except in the most sparsely stocked stands where L was 1.2 compared with 2.0-2.5 in stands at other spacings. The ratio of leaf area to sapwood area (A(l):A(s)) was unaffected by tree spacing or tree size and was 0.2 at 1.3 m height and 0.25 at the crown base. There were small increases in sapwood density and decreases in leaf specific area with increased spacing. Tree diameter or basal area was a better predictor of leaf area than sapwood area. At the stand scale, basal area was a good predictor of L (r(2) = 0.98, n = 15) except in the densest stands. We conclude that the hydraulic attributes of this forest type are largely independent of initial tree spacing, thus simplifying parameterization of stand and catchment water balance models.

Evaluation of emergency medical services systems: a classification to assist in determination of indicators.

Emergency medical services (EMS) systems, and prehospital care are difficult to evaluate. Accordingly, the true efficacy and value of such systems are difficult to determine. The multitude of variations and combinations of involved factors makes standardisation and comparison difficult, and universal indicators are hard to develop. Various attempts have been made to determine valid indicators of effectiveness, but there has been little success. Prehospital care has been seen by some as a single entity. As a result, experience from well resourced first world trauma centres has been taken, by many, to be applicable to all prehospital situations. This article attempts to assist in the development of valid EMS indicators of performance and effectiveness by categorising prehospital scenarios into a classification reflecting the reality of their conditions of practice.

Aide memoire for the management of gunshot wounds.

The hospitals in Johannesburg deal with about 4,000 gunshot wounds a year. Although most are from hand guns, a number are from high velocity, military-type weapons. Extensive experience has been built up and many lessons learned. Attention is directed to the actual damage inflicted rather than on theoretical predictions based on presumed velocity of the bullets involved, as this can often be misleading. Some patients are delayed in their presentation to emergency departments, in other cases several gunshot wound patients arrive at the same time, requiring appropriate triage and urgent management.

Growth hormone therapy in Noonan's syndrome: non-cardiomyopathic congenital heart disease does not adversely affect growth improvement.

Twenty-three children with Noonan's syndrome were treated with growth hormone (GH) and followed for at least three years. The presence of cardiomyopathy was a contraindication to treatment. Height SDS and velocity increased during treatment. None of the 23 children developed hypertrophic cardiomyopathy during GH treatment. Children with any cardiac abnormality at the start of treatment did not show a reduced growth trend when compared with patients with normal hearts.

Battle injuries of the rectum: options for the field surgeon.

Historically, battle wounds of the rectum have had high mortality and morbidity. This has improved greatly over several decades as a result of battle experience. This article highlights the value of civilian gunshot experience and its possible use in the military setting. The standard principles of rectal examination, followed by proctosigmoidoscopy after initial resuscitation, remain unchanged. Thereafter, the surgical decisions are made at laparotomy. Rectal injuries commonly have other injuries in association which must also be dealt with. In the stable patient rectal repair may be possible. Where repair is hazardous due to extensive injury (rectum or adjacent structures), the well-proven protective colostomy is used. A loop colostomy with or without distal closure is effective and is used to protect most injuries; possible exceptions being injuries dealt with early, in which there is minimal contamination and repair is easy. Presacral drainage can generally be reserved for severely destructive wounds or those in which repair has not been done. Rectal washout remains an option in patients with inspissated faeces. The basic military surgical principles remain valid, their extent and degree of implementation depending on the anatomical location of injury, degree of damage and any delay in presentation to surgery.

Primary closure of battle wounds of the colon: is it an option for the military surgeon?

The management of battle wounds of the colon has been safely established for many years, with primary closure of the wounds being discouraged. More recent work, involving large numbers of patients from civilian trauma centres, has challenged this. The appropriateness of these conclusions for the battle situation is discussed, including the nature of injury, the medical logistics and the combat scenario. Parameters are indicated and guide lines given, incorporating battle-proven military surgical principles and modern trauma experience. This includes damage control and possible primary closure of selected wounds. In this way the military surgeon can take an informed decision in providing optimal care for patients with battle wounds of the colon.

Growth hormone therapy and growth in children with Noonan's syndrome: results of 3 years' follow-up.

Growth data from the first 3 yr of a multicenter study examining the efficacy and safety of recombinant human GH [rhGH; 4 IU (1.3 mg)/m(2).day, sc] in children with Noonan's syndrome (NS) are reported for 23 subjects. Sixteen male and seven female patients (age, 9.3 +/- 2.6 yr at onset of GH therapy, mean +/- SD; range, 4.8-13.7) were each assessed at 1, 2, and 3 yr after starting treatment. Comparisons were made with a group of eight subjects (six males and two females, age, 9.0 +/- 4.1 yr; range, 4.1-14.8) with NS, not treated with rhGH, measured over the same period. All treated subjects underwent annual cardiac assessment. Height SD score increased from -2.7 +/- 0.4 at the start of GH therapy to -1.9 +/- 0.9 3 yr later (P < 0.001, two-tailed t test). This corresponded to an increase in height from 116.1 +/- 13.2 to 137.3 +/- 14.0 cm. Height velocity increased from 4.4 +/- 1.7 cm/yr in the year before treatment to 8.4 +/- 1.7 (P < 0.001), 6.2 +/- 1.7 (P < 0.001), and 5.8 +/- 1.8 (P = 0.01, two-tailed t test compared with baseline) during the first, second, and third years of GH treatment, respectively. Height acceleration was not significant during the second or third years when pubertal subjects were excluded. The comparison group showed an increase in height from 116.0 +/- 19.8 to 131.9 +/- 21.1 cm over the 3 yr (height SD score, -2.7 +/- 0.6 to -2.4 +/- 0.7, P = 0.3). None of the 23 children developed hypertrophic cardiomyopathy during GH treatment. The increase in growth rate in NS resulting from 1 yr of GH therapy seems to be maintained during the second year, although height velocity shows a less significant increase over pretherapy values. Possible abnormal anabolic effects of rhGH on myocardial thickness were not confirmed, and no treated patient developed features of hypertrophic cardiomyopathy.

Nurses' beliefs about the conditions that hinder or support evidence-based nursing.

The aim of this study was to identify the conditions that Australian nurses believe support or hinder the development of evidence-based nursing. A survey instrument was developed from the results of content analysis of the UK and the USA research and of interviews with 12 Australian nurses. Eight hundred and sixteen nurses working in three large hospitals responded representing a response rate of 65%. Principal axis factor analysis of the survey results revealed six conditions that the participants believed were necessary for evidence-based nursing to take place. The results of this study may be used to develop models for the improvement of evidence-based nursing in Australia.

Hyperbaric oxygen and surgery.

Hyperbaric oxygen (HBO) therapy, that is the administration of 100% oxygen delivered under pressure, has a beneficial effect in several surgical conditions. Its use has been assessed and audited and its pharmacological effects demonstrated. It is appropriate for use in several surgical conditions as evidence-based therapy. These are: (i) gas gangrene; (ii) crush injuries, compartment syndromes and acute traumatic ischemias; (iii) enhancement of healing in selected problem wounds; (iv) exceptional blood loss anaemia; (v) necrotising soft-tissue infections; (vi) refractory osteomyelitis; (vii) radionecrosis; (viii) compromised skin grafts and flaps; (ix) thermal burns; (x) intracranial abscess. HBO therapy has been used inappropriately in the past; there is also lack of knowledge regarding its application, and scarce hyperbaric facilities. Hyperbaric therapy, when properly supervised by a physician trained in its use, working closely with a surgeon, and ethically used for appropriate indications, can be a useful adjunct to surgical practice.

Hyperbaric oxygen in trauma and surgical emergencies.

Hyperbaric oxygen therapy (HBO), that is the administration of 100% oxygen delivered under pressure, has a beneficial effect in several surgical conditions. Its use has been assessed and audited and its pharmacological effects demonstrated. It is appropriate for use in several acute surgical conditions as evidence-based therapy. These are: Gas Gangrene Crush Injuries, Compartment Syndromes & Acute Traumatic Ischaemias Enhancement of Healing in Selected Problem Wounds Exceptional Blood loss Anaemia Necrotising Soft Tissue Infections Compromised Skin Grafts & Flaps Thermal Burns HBO therapy suffers from previous inappropriate use, lack of knowledge, and scarce hyperbaric facilities. Hyperbaric therapy, when properly supervised by a physician trained in its use, working closely with a surgeon, and ethically used for appropriate indications, can be a useful adjunct to surgical practice. Military surgeons may be in a situation in which they can utilize HBO in acute surgical conditions and trauma. They are urged to identify HBO facilities, both fixed and portable, and to establish communication with hyperbaric therapy colleagues.

A rapid and simple method for processing wood to crude cellulose for analysis of stable carbon isotopes in tree rings.

For analysis of carbon isotope discrimination in wood, cellulose or holocellulose is often preferred to whole tissue because of the variability in isotopic composition of different wood components and the relative immobility of cellulose. Most currently used methods for the preparation of wood components for stable isotope analysis (e.g., the Jayme-Wise method) produce a residue of holocellulose. The Jayme-Wise method was initially developed to extract holocellulose from small (~1 g) samples of wood, and, despite subsequent modifications, the method requires specialized glassware, considerable time and entails the risk of sample loss. For carbon isotope analysis, we adapted an acid-catalyzed solvolytic method for preparing crude cellulose by treating wood meal with acidified di-glycol methyl ether (diglyme). The one-step process requires no special glassware, is complete within 24 hours and enables over 100 samples to be processed in a day. This method gives similar delta(13)C values to the Jayme-Wise method for wood of Eucalyptus globulus Labill., Pinus radiata D. Don and Pinus pinaster Ait. The relationship between delta(13)C of wood and crude cellulose is as strong as that observed between wood and alpha-cellulose and stronger than that observed between wood and holocellulose in other species. These relationships suggest that variation in delta(13)C of wood may result from hemicellulose and that analysis of stable carbon isotopes in crude cellulose is preferable. If the consistent -0.3 bias in the value of delta(13)C of cellulose resulting from residual lignin is corrected for, then the relationship between delta(13)C of wood and crude cellulose may be used to predict delta(13)C of cellulose from a small sub-sample. The method is well suited to species with low concentrations of extractives, but further testing is needed to assess its general applicability.

Management of gunshot wounds: the Johannesburg experience.

The Johannesburg hospitals see large numbers of gunshot wounds and there is, therefore, considerable experience in their management. Historically, management has been dictated by experimental theories of wounding mechanisms. More modern work has indicated that some of these theories have been somewhat misleading, and some traditional means of management have changed. The basic military surgical lessons of the excision of dead tissue, delayed primary suture remain valid, it is the understanding of tissue damage and the more logical response which has changed. It is the wound as encountered which is managed, irrespective or the theoretical velocity of the bullet. The Johannesburg practice is outlined with regard to regions of the body, with discussion of, among others, the conservative management of gunshot wounds of the abdomen, primary repair of the colon, non operative management of certain limb wounds. The practice is summarised, based on considerable experience and the logistic implications of large numbers and may be useful to surgeons less experienced in gunshot wound management.