Second surgery for progressive glioblastoma: a multi-centre questionnaire and cohort-based review of clinical decision-making and patient outcomes in current practice.

PURPOSE: Glioblastoma prognosis is poor. Treatment options are limited at progression. Surgery may benefit, but no quality guidelines exist to inform patient selection. We sought to describe variations in surgical management at progression, highlight where further evidence is needed, and build towards a consensus strategy. METHODS: Current practice in selection of patients with progressive GBM for second surgery was surveyed online amongst specialists in the UK and Europe. We complemented this with an assessment of practice in a retrospective cohort study from six United Kingdom neurosurgical units. We used descriptive statistics to analyse the data. RESULTS: 234 questionnaire responses were received. Maintaining or improving patient quality of life was key to decision making, with variation as to whether patient age, performance status or intended extent of resection was relevant. MGMT methylation status was not important. Half considered no minimum time after first surgery. 288 patients were reported in the cohort analysis. Median time to second surgery from first surgery 390 days. Median overall survival 815 days, with no association between time to second surgery and time to death (p = 0.874). CONCLUSIONS: This is the most wide-ranging examination of contemporaneous practice in management of GBM progression. Without evidence-based guidelines, the variation is unsurprising. We propose consensus guidelines for consideration, to reduce heterogeneity in decision making, support data collection and analysis of factors influencing outcomes, and to inform clinical trials to establish whether second surgery improves patient outcomes, or simply selects to patients already performing well.

Characteristics of Pelargonium radula as a mercury bioindicator for safety assessment of drinking water.

Identification of Pelargonium radula as bioindicator for mercury (Hg) detection confers a new hope for monitoring the safety of drinking water consumption. Hg, like other non-essential metals, inflicts the deterioration of biological functions in human and other creatures. In the present study, effects of Hg on the physiology and biochemical content of P. radula were undertaken to understand the occurrence of the morphological changes observed. Young leaves of P. radula were treated with different concentrations of Hg-containing solution (0.5, 1.0 and 2.0 ppb) along with controls for 4 h, prior to further analysis. Elevated Hg concentration in treatment solution significantly prompted an increased accumulation of Hg in the leaf tissues. Meanwhile, total protein, chlorophyll and low molecular mass thiol contents (cysteine, glutathione and oxidized glutathione) decreased as Hg accumulation increased. However, phytochelatin 2 productions were induced in the treated leaves, in comparison to the control. Based on these findings, it is postulated that as low as 0.5 ppb of Hg interferes with the metabolic processes of plant cells, which was reflected from the morphological changes exhibited on P. radula leaves-the colour of the Hg-treated leaves changed from green to yellowish-brown, became chlorosis and wilted. Changes in the tested characteristics of plant are closely related to the Hg-induced morphological changes on P. radula leaves, a potential bioindicator for detecting Hg in drinking water.

No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma.

INTRODUCTION: Neurosurgical trainees should achieve competency in chronic subdural haematoma (CSDH) drainage at an early stage in training. The effect of surgeon seniority on recurrence following surgical drainage of CSDH was examined. METHODS: All CSDH cases performed at St George's Hospital in London between March 2009 and March 2012 were analysed. Recurrence was defined as clinical deterioration with computed tomography evidence of CSDH requiring reoperation within six months. The following risk factors were considered: seniority of primary and supervising surgeons, timing of surgery (working hours, outside working hours), patient related factors (age, antiplatelets, warfarin) and operative factors (general vs local anaesthesia, burr holes vs craniotomy, drain use). For recurrent cases, we examined the distance of the cranial opening from the thickest part of the CSDH. RESULTS: A total of 239 patients (median age: 79 years, range: 33-98 years) had 275 CSDH drainage operations. The overall recurrence rate was 13.1%. The median time between the initial procedure and reoperation was 16 days (range: 1-161 days). The only statistically significant risk factor for recurrence was antiplatelets (odds ratio: 2.62, 95% confidence interval: 1.13-6.10, p<0.05). Warfarin, grade of surgeon, timing of surgery, type of anaesthesia, type of operation and use of drains were not significant risk factors. In 26% of recurrent CSDH cases, the burr holes or craniotomy flaps were placed with borderline accuracy. CONCLUSIONS: CSDH drainage is a suitable case for neurosurgical trainees to perform without increasing the chance of recurrence.

Paediatric head injury admissions over a 10-year period in a regional neurosurgical unit.

Traumatic brain injury is a leading cause of death and disability in childhood. A retrospective study of all paediatric head injuries admitted to the neurosurgical unit for the West of Scotland over a 10-year period was performed to assess the impact of the National Institute for Health and Clinical Excellence head injury guidelines on the admission rate and to determine the associated risk factors, causes, severity and outcomes of these injuries. There were 564 admissions between 1998 and 2007. The median age at presentation was nine years and two months. There was no change in the admission rate, injury mechanism or severity of head injury admitted over the period studied. A relationship was observed between the Scottish Index of Multiple Deprivation Score and the incidence of head injury (P = 0.05). Alcohol was reported as a causative factor in only a small number of cases, and moderate to severe head injuries were more commonly identified as a result of road traffic accidents.