Brain metastasis is increasingly common, affecting 20%–40% of cancer patients. After diagnosis, survival is usually limited to months in these patients. Treatment for brain metastasis includes whole-brain radiation therapy, surgical resection, or both. These treatments aim to slow progression of disease and to improve or maintain neurologic function and quality of life. Although less common, primary brain tumours produce symptoms that are similar to those of brain metastasis. Glioblastoma, the most common malignant tumour of the brain, has a median survival of less than 12 months. Patients are often treated with surgical resection followed by radical radiation therapy and chemotherapy. Here, we present 2 separate cases of lesions in the brain radiologically compatible with brain metastasis. In both cases, no primary cancer site had been established, and neurosurgical intervention was sought to obtain a pathologic diagnosis. Both cases were pathologically confirmed as glioblastoma. These cases demonstrate the importance of differentiation between brain metastases and primary brain tumours to ensure that the appropriate management strategy is implemented.
The purpose of this study was to determine the extent of metastatic pelvic lymph nodes evident on bipedal lymphography in a group of patients under consideration for combined radiation therapy and chemotherapy as definitive treatment for carcinoma of the anal canal. Lymphography was attempted in 32 patients and successful bilateral cannulation and opacification of nodes was achieved in 28 (88%). Seven patients had lymphographic evidence of external iliac node metastases (25%). When patients were categorized according to the extent of clinically evident disease at presentation, 0/15 patients with T1/T2 tumours had positive lymphograms whereas 7/13 patients with T3/T4 tumours and/or positive inguinal or peri-rectal nodes had positive lymphograms (Fisher's exact test p = 0.0015). All patients with a positive lymphogram had undergone CT scanning of the pelvis and in only one patient was external iliac node involvement detected. In none of these patients was visceral or more extensive nodal metastases discovered. Subsequently, the external iliac nodes with radiological evidence of metastases on lymphography were included in the treatment volume taken to radical dosage. The projected cause specific actuarial 5 year survival for this cohort of patients is 86% (median follow-up 4 years). Since the prognosis for patients who relapse in pelvic nodes is poor, bipedal lymphography is advocated as a staging procedure in patients with advanced primary tumours and in all patients with clinically positive inguinal or peri-rectal lymph nodes who are being considered for curative therapy.
Abstract Background The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a ‘delayed’ operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease. Methods Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost–utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model. Results Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0–120 000). Conclusion Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs.
Abstract Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all-cause 30-day readmissions and complications in a prospective population-based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all-cause 30-day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics.
The central nervous system is a radiation-dose-limiting structure, and cellularity of the rat subependymal plate (a location of neuroglial stem cells) has been used as a model of radiation damage. In the present work, an attempt has been made to improve its radiation tolerance using 4-OH sodium butyrate (gamma OH). Adult rats received 10-Gy 250-kV (peak) x-rays or 3.5-Gy 15-MeV deuterons plus Be neutrons. Cell counts were obtained by histological examination of the subependymal plate. Photon and neutron irradiation alone resulted in a mean cell depletion of 62% and 58%, respectively, compared with sham-irradiated controls, which was not statistically significant; the relative biologic effectiveness was 2.9. In the absence of radiation, gamma OH did not significantly alter the cellularity of the subependymal plate, compared with that in controls treated with chloral hydrate. At doses greater than or equal to 1 g/kg, gamma OH was associated with a statistically significant reduction of subependymal plate cell depletion in animals treated with photon or neutron radiation, and the magnitude of the effect was similar. Arterial blood gas analysis failed to show a significant difference in arterial oxygen tension between control and test animals.
Abstract Background Day‐case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day‐case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same‐day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone‐related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day‐case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same‐day discharges following cholecystectomy.
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