De Novo Skull Base Atypical Meningioma: Incidence and Outcome.

Objective Atypical meningiomas are uncommon in skull base practice and present a management challenge. We aimed to review all de novo atypical skull base meningioma cases within a single unit to analyze presentation and outcome. Methods A retrospective review of all patients undergoing surgery for intracranial meningioma identified consecutive cases of de novo atypical skull base meningioma. Electronic case records were analyzed for patient demographics, tumor location and size, extent of resection, and outcome. Tumor grading is based on the 2016 WHO criteria. Results Eighteen patients with de novo atypical skull base meningiomas were identified. The most common tumor location was the sphenoid wing in 10 patients (56%). Gross total resection (GTR) was achieved in 13 patients (72%) and subtotal resection (STR) in 5 patients (28%). There was no tumor recurrence recorded in patients who had undergone GTR. Patients with tumors >6 cm were more likely to undergo a STR as opposed to a GTR ( p < 0.01). Patients who had undergone a STR were more likely to have postoperative tumor progression and be referred for radiotherapy ( p = 0.02 and <0.01, respectively). On multiple regression analysis, tumor size is the only significant factor correlating with overall survival ( p = 0.048). Conclusion The incidence of de novo atypical skull base meningioma is higher in our series than currently published data. Tumor size was a significant indicator for patient outcome and extent of resection. Those undergoing a STR were more likely to have tumor recurrence. Multicenter studies of skull base meningiomas with associated molecular genetics are needed to guide management.

Pituitary xanthogranulomas: clinical features, radiological appearances and post-operative outcomes.

BACKGROUND: Xanthogranulomas are inflammatory masses most commonly found at peripheral sites such as the skin. Sellar and parasellar xanthogranulomas are rare and present a diagnostic challenge as they are difficult to differentiate from other sellar lesions such as craniopharyngiomas and Rathke's cleft cysts pre-operatively. Their radiological imaging features are yet to be clearly defined, and clinical outcomes after surgery are also uncertain. This study reviews clinical presentation, radiological appearances, and clinical outcomes in a cohort of patients with pituitary xanthogranulomas. METHODS: A prospectively maintained pituitary surgery database was screened for histologically confirmed pituitary xanthogranulomas between May 2011-December 2016. Retrospective case note assessments were then performed by three independent reviewers. Patient demographics, clinical presentations, imaging, and clinical outcomes were analysed. RESULTS: During the study period 295 endoscopic endonasal pituitary surgeries were performed. Six patients had confirmed pituitary xanthogranulomas (2%). Patients most commonly presented with visual field deficits and/or endocrine dysfunction. Common imaging features included: a cystic consistency, hyperintensity on T1-weighted MR images, and contrast enhancement either peripherally (n = 3) or homogenously (n = 3). The most common pre-operative endocrine deficits were hyperprolactinaemia and hypoadrenalism (at least one of which was identified in 4/6 patients; 66%). Thirty-three percent (2/6) of patients presented with diabetes insipidus. The most common post-operative endocrinological deficits were adrenocortical dysfunction (66%) and gonadotropin deficiency (66%). Visual assessments normalised in all six patients post-operatively. Gross total resection was achieved in all patients, and at median follow up of 33.5 months there were no cases of tumour recurrence. CONCLUSIONS: The prevalence of pituitary xanthogranulomas in our series is higher than that suggested in the literature. Surgery restored normal vision to all cases, however four patients (67%) required long-term hormonal replacement post-operatively. Imaging features such peripheral rim enhancement, a suprasellar tumour epicentre, and the absence of both calcification or cavernous sinus invasion were identified as potential indicators that together should alert clinicians to the possibility of pituitary xanthogranuloma when assessing patients with cystic sellar and parasellar tumours.

An evaluation of echo in life support (ELS): is it feasible? What does it add?

BACKGROUND: Emergency physicians were trained to perform echo in life support (ELS)--that is, limited transthoracic echocardiography during advanced life support (ALS) management of cardiac arrest. METHODS: Data were collected on the adequacy of views obtained and timing of the scan, as well as the clinical findings of pericardial effusion and ventricular wall motion. Any intervention performed as a result of the scan was also noted. ELS was performed on 50 patients during cardiac arrest. RESULTS: Adequate views were obtained in 47 (94%) scans, and 45 (90%) were obtained within the 10 s rhythm check. Twenty patients (40%) had ventricular wall motion (VWM), three (6%) had pericardial effusions and six patients (12%) had an intervention performed as a direct result of the scan. These included pericardiocentesis, thrombolysis and insertion of a chest drain. The presence of VWM had a positive predictive value of 55%. The absence of VWM resulted in a negative predictive value of 97% for predicting return of spontaneous circulation (ROSC). CONCLUSION: It is concluded that ELS is feasible and that the scan findings may guide further interventions.

Short communication: Genetic and nongenetic factors influencing Ostertagia ostertagi antibodies in UK Holstein-Friesian cattle.

The purpose of this study was to estimate and discuss the genetic variation, heritability, and effects of nongenetic factors on the ability of Holstein-Friesian cows to produce an immune response by producing IgG antibodies to Ostertagia ostertagi. Total IgG (IgG(1) and IgG(2)) antibody levels were determined using an ELISA and measured using optical density ratio (ODR=OD(sample) - OD(negative control)/OD(positive control) - OD(negative control)) from milk samples collected from 1,276 Holstein-Friesian cattle in 229 commercial dairy farms from 2002 to 2004 during their first (82%) and other (2 to 12) lactations. A sire (n=461) model was fitted to the ODR data using ASREML software, and variance components were estimated. The ability to produce O. ostertagi antibodies as measured by ODR had a heritability of 0.13+/-0.12, and both season of sample and herd had a significant effect on total IgG levels. To conclude, this study has ascertained that genetic variation is present in the ability of dairy cows to mount an immune response to the parasite O. ostertagi. Inasmuch as evidence exists that IgG is linked to protective immunity against the parasite via a reduction in its reproductive ability, this trait may be of potential interest to genetic selection programs as an aid to reduce the effect of O. ostertagi in dairy herds.

How have changes to out-of-hours primary care services since 2004 affected emergency department attendances at a UK District General Hospital? A longitudinal study.

BACKGROUND: The delivery of out-of-hours primary medical care in the United Kingdom has changed substantially since 2004, and there has been little examination of the effect that this has on secondary care. AIM: The authors aimed to quantify the change in patient type presenting to our emergency department. METHODS: In this study, routinely collected coding data before, during and after the changes were analysed. Each September and October between 1999 and 2006 were included. RESULTS: There was a steady increase in all attendances at our emergency department. The number and proportions of patients with non-traumatic conditions rose steadily throughout the study period. The number of patients presenting with traumatic conditions stayed the same. The number of patients presenting with non-traumatic conditions out-of-hours rose after the changes were implemented. INTERPRETATION: The changes to the provision of out-of-hours primary care have been associated with an increase in patients with non-traumatic attendances presenting to our emergency department. This effect is most marked outside of office hours.

Genetic variation of metabolite and hormone concentration in UK Holstein-Friesian calves and the genetic relationship with economically important traits.

The decline of dairy cattle fertility worldwide remains a major concern, with conception rates to first service commonly below 40%. The length and severity of negative energy balance postpartum are unfavorably correlated with fertility, suggesting that the length and severity of negative energy balance and fertility are linked via several hormones or metabolites. These compounds therefore have the potential to predict fertility at a genetic level. The addition of a predictor trait for fertility into present fertility indices would accelerate genetic gain, particularly if it was expressed before adulthood. The objective of this work was to estimate the genetic variation in several metabolites and hormones in calves, and to determine their genetic relationships with fertility and production through sire predicted transmitting abilities (PTA; sires of calves sampled). Circulating concentrations of free fatty acids (FFA), glucose, growth hormone (GH), insulin, and insulin-like growth factor 1 (IGF-1) in male and female UK Holstein-Friesian dairy calves (average age +/- SD; 126 +/- 12.7 d) were analyzed during 2 studies: data set 1 (n = 496 females; 1996-2001; 7 commercial dairy herds) and data set 2 (n = 326 females, n = 256 males; 2002-2006; multiple ovulation and embryo transfer breeding scheme). Univariate mixed models were fitted to the data using ASREML. Basal concentrations of FFA, glucose, GH, insulin and total IGF-1 were all moderately heritable in both sexes (heritability range +/- SE; 0.09 +/- 0.05 to 0.66 +/- 0.14). The sire PTA for protein percentage had significant regression coefficients and approximate genetic correlations with FFA and insulin, and the sire PTA for calving interval had significant regression coefficients and approximate genetic correlations with GH. Additive genetic variance seems responsible for a moderate proportion of the phenotypic variation in important metabolites and regulatory hormones in male and female UK Holstein-Friesian dairy calves, therefore supporting further investigation into their use as juvenile predictors for fertility in the mature female.

Hindbrain decompression for Chiari-syringomyelia complex: an outcome analysis comparing surgical techniques.

The natural history of Chiari malformation and our ability to alter it is poorly understood, and reported results of hindbrain decompression show high recurrence rates. We report 11 years of experience of hindbrain decompression, to evaluate long-term outcome related to surgical technique. The results of patients who underwent hindbrain decompression between 1994 and 2005 were retrospectively analysed. We identified 96 patients from operative records and reviewed all clinical records for presenting symptomatology and examination findings. Decompression technique includes traditional decompression, duraplasty and bone--only decompression. Symptoms at the last available follow-up visit were defined by the assessing clinician as resolved, improved, unchanged or worse. There were 35 males and 61 females with a mean age of 33 years (range 6 - 62 years). The mean length of follow-up is 3.6 years with a range of 6 months to 9 years. Postoperative resolution or improvement in symptoms was seen in 75 patients (78%). Drop attacks and headaches were the most likely to respond to hindbrain decompression, showing improvement or resolution in 100 and 92% of cases. Dysaesthetic arm pain and weakness carried the worse prognosis with only 20% having symptom resolution. Sixteen patients had only bony decompression leaving the dura intact. In eight patients (66%) the headaches resolved following bony decompression alone. However the headaches were unchanged in 25% of cases. Dysaesthetic pain and weakness was unchanged in 60%. Restoration of CSF flow dynamics at the foramen magnum by surgical decompression does not consistently result in resolution of symptoms in all patients. Identification of predictors of successful outcome following decompression, coupled with early intervention and appropriate choice of procedure may result in improved outcomes. Although this is a retrospective study it suggests that bone only decompression should be reserved for patients with isolated headache.

Metabolic regulation in Danish bull calves and the relationship to the fertility of their female offspring.

The objective of this work was to estimate the genetic variation of free fatty acids (FFA), glucose, growth hormone (GH), and insulin in juvenile male dairy calves and to assess the relationships, if present, with the fertility of their female offspring. This study used data from 1,498 (269.5 d of age +/- 11.1) male calves from a multiple ovulation and embryo transfer breeding scheme (data collected from 1997 to 2002). Calves were Danish Holstein (n = 1,047), Danish Jersey (n = 200), and Red Dane (n = 251), and were sampled following an overnight fast at approximately 9 mo of age. Plasma samples were assayed for basal FFA, glucose, GH, and insulin. Estimated breeding values of female fertility (high values indicating better fertility), based on progeny-test results for approximately 100 daughters per sire, were available for a subset (n = 810) of the male calves as adult sires. Data from Danish Holstein alone or Danish Holstein, Red Dane, and Danish Jersey combined (all breeds) were analyzed for each trait. In both data sets, the estimates of heritabilities of glucose (0.27 +/- 0.06), FFA (0.11 +/- 0.05), and insulin (0.21 +/- 0.06) were moderate, and that of GH (0.09 +/- 0.05) was low. Correlations of estimated breeding values for fertility traits with glucose and FFA breeding values were negative, indicating that male calves with high glucose or FFA had female offspring with reduced fertility. Selection for bull calves with lower concentrations of glucose and FFA following an overnight fast could result in female offspring with genetically better fertility. Glucose and FFA may therefore be of interest to enhance selection for improved female fertility, as a measurement in young bulls.

The role of endoscopic third ventriculostomy in the management of hydrocephalus associated with cerebellopontine angle tumours.

BACKGROUND: Progressive hydrocephalus secondary to cerebellopontine angle tumours has been traditionally managed with ventriculo-peritoneal shunting. Endoscopic third ventriculostomy provides an alternative treatment option and the success rate in this patient group has not previously been reported. METHODS: We report a retrospective series of 11 patients with cerebello-pontine angle tumours who presented with symptomatic hydrocephalus, or developed hydrocephalus following radiosurgery, who underwent endoscopic third ventriculostomy. RESULTS: Seven patients (63.6%) remain shunt free. There were no complications following endoscopy in any patient. Where the ventriculostomy failed there was no additional morbidity. CONCLUSIONS: Endoscopic third ventriculostomy is a low morbidity procedure, which avoids the inherent problems of shunts, particularly infection and should be considered for patients with hydrocephalus and cerebello-pontine angle tumours.

Stereotactic radiosurgery and vestibular schwannoma: hydrocephalus associated with the development of a secondary arachnoid cyst: a report of two cases and review of the literature.

Stereotactic radiosurgery for vesibular schwannoma requires long-term follow-up with complete MR imaging. We report two cases of a large secondary arachnoid cyst developing in the cerebellopontine angle following stereotactic radiosurgery. In one case this was associated with progressive ventriculomegaly and the onset of symptomatic hydrocephalus requiring emergency treatment. The second patient had ventriculomegaly at diagnosis, but developed an arachnoid cyst following treatment. Although both arachnoid cysts and hydrocephalus may also occur spontaneously in patients with vestibular schwanomma, the incidence is higher after stereotactic radiosurgery. As both complications may be associated with sudden clinical deterioration, follow-up with full cranial T1 and T2 weighted MR imaging is required to reveal these complications, in addition to assessing tumour response.

Elevated, straight-arm traction for supracondylar fractures of the humerus in children.

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age. Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.

Can a senior house officer's time be used more effectively?

OBJECTIVES: To determine the amount of time senior house officers (SHO) spent performing tasks that could be delegated to a technician or administrative assistant and therefore to quantify the expected benefit that could be obtained by employing such physicians' assistants (PA). METHODS: SHOs working in the emergency department were observed for one week by pre-clinical students who had been trained to code and time each task performed by SHOs. Activity was grouped into four categories (clinical, technical, administrative, and other). Those activities in the technical and administrative categories were those we believed could be performed by a PA. RESULTS: The SHOs worked 430 hours in total, of which only 25 hours were not coded due to lack of an observer. Of the 405 hours observed 86.2% of time was accounted for by the various codes. The process of taking a history and examining patients accounted for an average of 22% of coded time. Writing the patient's notes accounted for an average of 20% of coded time. Discussion with relatives and patients accounted for 4.7% of coded time and performing procedures accounted for 5.2% of coded time. On average across all shifts, 15% of coded time was spent doing either technical or administrative tasks. CONCLUSION: In this department an average of 15% of coded SHOs working time was spent performing administrative and technical tasks, rising to 17% of coded time during a night shift. This is equivalent to an average time of 78 minutes per 10 hour shift/SHO. Most tasks included in these categories could be performed by PAs thus potentially decreasing patient waiting times, improving risk management, allowing doctors to spend more time with their patients, and possibly improving doctors' training.

Developments in vapour cloud explosion blast modeling.

TNT Equivalency methods are widely used for vapour cloud explosion blast modeling. Presently, however, other types of models are available which do not have the fundamental objections TNT Equivalency models have. TNO Multi-Energy method is increasingly accepted as a more reasonable alternative to be used as a simple and practical method. Computer codes based on computational fluid dynamics (CFD) like AutoReaGas, developed by TNO and Century Dynamics, could be used also in case a more rigorous analysis is required. Application of the Multi-Energy method requires knowledge of two parameters describing the explosion: a charge size and a charge strength. During the last years, research has led to an improved determination of the charge strength (i.e., the class number or source overpressure) to be chosen to apply the blast charts. A correlation has been derived relating the charge strength to a set of parameters describing the boundary conditions of the flammable cloud and the fuel in the cloud. A simple approach may not be satisfactory in all situations. The overpressure distribution inside a vapour cloud explosion is generally not homogeneous and the presence of obstructions causes directional blast propagation in the near field. A CFD approach, in which the actual situation is modeled, supplies case-specific results. An overview of the key aspects relevant to the application of the Multi-Energy method and CFD modeling is provided. Then the application of the two methods is demonstrated for an example problem involving the calculation of the explosion blast load on a structure at some distance from the explosion in an offshore platform complex.