Criteria for cure in acromegaly: report of a case apparently cured in which persisting tumor was found at autopsy.

A 49-year-old man with acromegaly underwent the apparently complete removal of a pituitary microadenoma by the transsphenoidal route. There was complete remission of the biochemical abnormalities for 2 1/2 years, with basal plasma growth hormone (GH) levels of less than 1 ng/ml and normal somatomedin levels. The patient then died after the rupture of a cerebral aneurysm. Serial sections of the pituitary fossa showed persistent tumor with a volume of about 6% of the remaining normal gland. It is concluded that current endocrine tests are limited in their ability to detect residual GH-secreting tumor. Their sensitivity is likely to depend on the mass of tumor and on the GH secretion rate. Predictions of long term cure based on these tests are only tentative.

The development of a concept of mild head injury.

Medical and literary sources have described head injury and its effects from early Egyptian times. Though milder injury - concussion - must have been familiar, there was little specific written about it until the latter part of the 18th century. Descriptions of persisting symptoms appear in the 19th century, and discussion of their origin and management has continued and intensified since then. There have been several major issues. How does mechanical trauma produce a temporary loss of neurological function and is there some lasting damage? When symptoms persist do they follow a pattern which we recognise as occurring with structural lesions, or are the symptoms a functional reaction to the injury and other life events? Are they both?Over the last 50 years these issues have been debated, often with heat. Whatever the final judgment the present task would seem to be to provide a service to deal with the clinical situation.

Acromegaly: factors affecting the long term outcome after surgical treatment.

Survival and clinical status in 105 acromegalic patients followed for up to 24 years after surgery is assessed against serum growth hormone (GH) levels and other factors. Primary treatment was at first (90)Yttrium implants or craniotomy, later transsphenoidal operation. GH levels were similar for each method, and the results were combined. Relief of presenting symptoms and tumour clearance related to early post-operative GH levels. Although the level at the last follow-up influenced clinical status at 10 years (P = 0.01), the major contributor was the age at diagnosis (P = 0.0002). Ten year survival was more likely when the final GH level was less than 5mug/l and at this level no tumour recurred. With GH less than 2 mug/l survival rate was higher and clinical status better. With GH between 2 and 5 mug/l radiotherapy may be indicated; levels of Insulin-like Growth Factor I help in this decision. A plan of management is suggested.

Mild head injury in New Zealand: incidence of injury and persisting symptoms.

AIMS: To define mild head injury and determine its incidence and that of persisting symptoms. METHODS: Analysis of an eight week sample of all patients with head injury passing through the Emergency Departments of the four Auckland Hospitals, and of a five year sample of patients attending a clinic for management of symptoms persisting after head injury. RESULTS: Mild head injury was defined by the acute management needed--care out of hospital or not more than 48 hours admission, corresponding reasonably with a definition using post-traumatic amnesia. Incidence in those seen at hospital was 437/10(5) whole population/year for ages 15 and over, and 252/10(5) for ages under 15. Age specific incidences were 1769/10(5)/year for 15 and over, and 2920/10(5) for ages under 15, the major causes being road accidents (RTA) and falls, respectively. For 100 cases seen at hospital approximately 60 were treated by general practitioners alone. Referrals in patients 15 years and over because of persisting symptoms occurred in 5% (95%, CI 3-7), 69% in the first four months and 6% after a year. Referrals were equally likely after RTA, sports injuries and assaults, more frequent after objects striking the head. Older people were marginally more likely to be referred and the probability was significantly greater in women injured in sport and in minor RTA not needing admission to hospital. CONCLUSIONS: Mild head injuries are economically important and deserve efficient management.

Attitudes to concussion in young New Zealand men.

Sixty-three men aged 17 to 48 who had been concussed were asked 90 days later if it had affected them, if they knew of others who had been affected, and if they would take action to prevent further injury. Twenty percent still had symptoms, mostly impairment of intellectual function. Sixty percent expressed concern about the injury, though only 19 percent intended realistic measures to prevent recurrence, such as giving up football or selling their motorcycle. Concern was commoner after sports than road accidents. Sixty percent had friends who had been concussed, and a third of these had given up sport because of the effects. It is concluded that there is considerable awareness, particularly amongst sportsmen, of the effects of concussion, and that sports administrators would find considerable support for rules to reduce the risk of brain damage from repeated concussion.

Surgery for temporal lobe epilepsy.

Twenty-six patients were subjected to temporal lobectomy for complex partial seizures resistant to anticonvulsant control. The criteria for selection were simple. There should be EEG evidence of epileptiform activity arising predominantly in one temporal lobe. It was desirable that psychometric tests should confirm the localisation by showing defects of function in this lobe, and necessary that they should demonstrate normal function in the other. There should be no radiological evidence of a gross structural lesion. Twenty-four patients have been followed for 5 to 17 years, two being lost at 3 and 4 years. After operation, 50% were completely free from seizures, and in a further 38% seizures were reduced in frequency by at least 75%. There was no mortality, and the only morbidity was a minor quadrantic hemianopia, usually unnoticed by the patient. A significant improvement in mental state was noted in many patients. It is concluded that to use simple criteria for selection of patients for temporal lobectomy gives worthwhile results. There are many patients in the community who could be selected for surgery on these criteria with a high probability that their condition would be improved.

Dural invasion by pituitary tumours.

In 12 cases of pituitary tumour the dura mater of the sella turcica or diaphragma sellae in contact with the tumour was examined histologically. In nine cases tumour cells were found lying deep in the substance of the dura. Dura from the sella of seven subjects without pituitary disease, obtianed at autopsy, showed no inclusions of pituitary tissue. Four of the cases studied were known before death to suffer from an invasive pituitary adenoma. Of eight surviving cases operated upon in the last two years, five showed dural invasion by tumour. The present report suggests that the condition may be more frequent than expected and that with more study it may provide an index of prognosis. It also defines a requirement for the surgeon aiming to prevent recurrence of tumour after operation or to achieve a complete endocrine ablation.

Incidence of infection after caesarean section: a study.

This article reports a study of the incidence of infection in patients undergoing Caesarean section in a district general hospital maternity unit. A literature review was carried out and data were collected on operating circumstances, catheterisation, rates of infection, antibiotic therapy and post-discharge infection surveillance. A high incidence of infection was discovered and there was no evidence of a systematic approach to antibiotic therapy. The author highlights the need for further research on a larger group of patients and describes changes in practice which have occurred locally since completion of the study.

Accountability in urinary catheter management.

Catheterisation is traditionally considered an area of nursing expertise. Patient involvement in decision-making is important. Although considered autonomous, community nurses appear to encourage a large degree of medical involvement in decision-making related to catheterisation.

Conservative removal of small pituitary tumours: is it justified by the pathological findings?

Operation by the trans-sphenoidal route allows removal of small pituitary adenomata with conservation of normal gland. Histological examination of tissue obtained at operation and necropsy in 73 cases showed that surgical methods at present in use are likely to leave tumour behind in the pituitary gland and in the dura mater of the pituitary fossa. The clinical significance of these findings will only become evident after following patients for an extended period, but there appears to be a strong indication for routine postoperative radiotherapy.

Time off work and symptoms after minor head injury.

A carefully controlled prospective study was made of 66 men aged 17 to 48 with minor head injuries. The mean time off work was 4.7 days, range 0 to 26 days. Time off work was longer: in older patients; after road traffic accidents compared with sports injuries; in patients who had taken alcohol and in 5 who had needed admission to hospital. Post-traumatic amnesia alone did not relate to time off work but was longer in these groups of patients. Sixty per cent of patients had symptoms on return to work and 46 per cent could not do their job as well as usual for a mean time of 14 days. Leisure activities were affected for a similar period and fatigue was common. Ninety days after the accident 20 per cent still had symptoms, mostly defects of memory, concentration and work capacity. Four patients still had symptoms 2 years later. Though describing symptoms, all patients were back at their usual work and non had any claim for compensation outstanding. Major points emerging are the limitations of post-traumatic amnesia as an index of the severity of a minor head injury, and the high incidence of symptoms on return to work and later, in patients who were at work and without compensation claims. The importance is stressed of an effective programme for the management of minor head injuries.

Memory and information processing capacity after closed head injury.

The relation between duration of post-traumatic amnesia (PTA), performance on memory tests, and the Paced Auditory Serial Addition Task (PASAT) was examined in two samples of young adult closed head injury patients. Three different effects were isolated: (1) an attention and concentration factor, related to PASAT scores, (2) a deficit in the ability to place material into long-term memory storage, related to PTA durations, and (3) an impairment in the ability to retrieve material once it has been stored, which was not predicted by either PTA or PASAT.

Cumulative effect of concussion.

Twenty young adults were studied after a second concussion. The rate at which they were able to process information was reduced more than in controls who had been concussed only once, and they took longer to recover than the controls. The effects of concussion seem to be cumulative, and this has important implications for sports where concussion injury is common.

Effect of mild head injury during the preschool years.

This article examines the evidence that the effect of head injury on young children may differ from that in adults, in that while in the latter the pattern is of deficits that recover with time since the accident, this is not necessarily the case with very young children. In this group, there may be no evidence of any deficit in the early days or weeks after injury, but the children may fail to develop some skills as quickly as children who have not had a head injury. Results from a series of studies of MHI in preschool children carried out over a more than 10-year period from Auckland Hospital and recently published studies of pediatric MHI from other groups are reviewed. It is concluded from a comparison of these data that there is a need for long-term prospective studies designed within a developmental framework to clarify the issue.

Mild head injury in preschool children: evidence that it can be associated with a persisting cognitive defect.

This study describes the effect of mild head injury in preschool children on aspects of their cognitive performance in the year after injury and at the age of 6.5 years, with particular reference to the development of reading skills. Mild head injury was defined by diagnosis at a hospital emergency department of a head injury which was not severe enough to need admission for observation. Seventy eight such children were compared with a group of 86 with a minor injury elsewhere. The groups had similar developmental, family, and socioeconomic status. There were no differences in cognitive tests soon after the injury, but at six months and one year children with mild head injury scored less than controls on one test, solving a visual puzzle (visual closure); they were also more likely to have had another mild head injury. At 6.5 years of age they still scored less than controls, reading ability was related to their visual closure score at one year, and they were more likely to have needed help with reading. Mild head injury seems to be able to produce subtle but significant changes which can affect school performance.

The natural history and the influence of surgical treatment in syringomyelia.

A retrospective analysis was made of the natural history and treatment of 44 patients with syringomyelia, followed for a median interval of 10 years after diagnosis. Twenty-four patients were treated surgically. Four of 12 patients who had a laminectomy with aspiration of the syrinx or syringostomy, and 7 of 15 patients who underwent decompression and exploration of the cervicomedullary junction, showed sustained improvement or stabilisation of their neurological deficits. When symptoms had been present for more than 2 years, when there was a moderate or severe neurological disability, and when the patient was more than 40 years old, the long-term outlook of posterior fossa surgery was usually poor. Of the 20 patients who did not have an operation, 7 had no further progression in symptoms after presentation and prolonged survival was usual. It is concluded that in many cases syringomyelia is compatible with prolonged survival, and although improvement can follow surgery, its influence on the disease in the long-term is uncertain.