The effect of anterior quadratus lumborum block on morphine consumption in minimally invasive colorectal surgery: a multicentre, double-blind, prospective randomised placebo-controlled trial.

We investigated the efficacy and safety of a bilateral anterior quadratus lumborum block in patients undergoing minimally invasive colorectal surgery. This was a two-centre, double-blind, prospective, randomised, placebo-controlled trial including 150 patients undergoing laparoscopic colorectal surgery (left- or right hemicolectomy, sigmoidectomy) who were enrolled in the institutional abdominal enhanced recovery programme. Before induction of anaesthesia, patients received a bilateral anterior quadratus lumborum block in the left and right lateral decubitus position under ultrasound guidance and were allocated randomly to receive 30 ml of ropivacaine 0.375% (n = 75) or placebo (saline 0.9%) (n = 75) bilaterally. Postoperatively, all patients received multimodal intravenous analgesia including paracetamol, ketorolac and patient-controlled analgesia with morphine. The primary outcome was morphine consumption during the first 24 h after tracheal extubation. Secondary outcomes included severity of pain; presence and extent of sensory block; incidence of postoperative nausea and vomiting; and hospital duration of stay. We also investigated the need for, and dose of, rescue analgesia. Safety outcomes included the incidence of adverse events. Mean (SD) 24-hour morphine consumption was no different between patients allocated to ropivacaine and placebo (28.6 (22.3) mg vs. 28.4 (22.5) mg, p = 0.966, respectively). While a sensory block could be detected in significantly more patients allocated to the ropivacaine group, no differences were detected in pain scores or other secondary or safety endpoints. Patient satisfaction scores were high in both groups. In laparoscopic colorectal surgery, adding a bilateral anterior quadratus lumborum block to a standard multimodal analgesia regimen did not reduce opioid consumption or improve pain scores.

Into the Wild, Out of the Woods: A Systematic Case Study on Facilitating Emotional Change.

Cognitive and behavioral treatment programs for individuals who have committed sexual offenses (ISOs) have shown significant but small effect sizes. A growing body of research points toward the importance of difficulties in affect regulation (AR) as a risk factor for sexual recidivism. On this basis, it seems important to target difficulties in AR in treatment. The current systematic case study investigates the potential contribution of emotion-focused therapy (EFT) to changing problematic AR in ISOs. Kevin was a high-risk offender with a traumatic history who met the diagnostic criteria of pedophilic and borderline disorders, with serious AR difficulties. Self-report outcome measures, observation measures, and a biomarker were used to track changes in AR, psychological symptoms, and distress during baseline (Phase A); treatment as usual (Phase B); treatment with an EFT component added (Phase C); and follow-up (Phase A). Statistically significant change was found in AR, psychological symptoms, and distress during treatment (Phase B + C); however, it is not possible to attribute these changes causally to EFT. An examination of the qualitative process data provides deeper insights into how the client reacted to specific EFT interventions. Verbatim clinical vignettes are included to clarify key interventions, hindrances, and mechanisms of change. This study provides preliminary support for the role of therapy to facilitate emotional change in ISOs.

Combined spatial and retrospective analysis of fluoroalkyl chemicals in fluvial sediments reveal changes in levels and patterns over the last 40 years.

Bed sediments and a dated sediment core were collected upstream and downstream from the city of Lyon (France) to assess the spatial and temporal trends of contamination by per- and polyfluoroalkyl substances (PFASs) in this section of the Rhône River. Upstream from Lyon, concentrations of total PFASs (ΣPFASs) in sediments are low (between 0.19 and 2.6 ng g-1 dry weight - dw), being characterized by a high proportion of perfluorooctane sulfonate (PFOS). Downstream from Lyon, and also from a fluoropolymer manufacturing plant, ΣPFASs concentrations reach 48.7 ng g-1 dw. A gradual decrease of concentrations is reported at the coring site further downstream (38 km). Based on a dated sediment core, the temporal evolution of PFASs is reconstructed from 1984 to 2013. Prior to 1987, ΣPFASs concentrations were low (≤2 ng g-1 dw), increasing to a maximum of 51 ng g-1 dw in the 1990s and then decreasing from 2002 to the present day (∼10 ng g-1 dw). In terms of the PFAS pattern, the proportion of perfluoroalkyl sulfonic acids (PFSAs) has remained stable since the 1980s (∼10%), whereas large variations are reported for carboxylic acids (PFCAs). Long chain- (C > 8) PFCAs characterized by an even number of perfluorinated carbons represent about 74% of the total PFAS load until 2005. However, from 2005 to 2013, the relative contribution of long chain- (C > 8) PFCAs with an odd number of perfluorinated carbons reaches 80%. Such changes in the PFAS pattern likely highlight a major shift in the industrial production process. This spatial and retrospective study provides valuable insights into the long-term contamination patterns of PFAS chemicals in river basins impacted by both urban and industrial activities.

Dose-response relationship of perineural dexamethasone for interscalene brachial plexus block: a randomised, controlled, triple-blind trial.

Perineural dexamethasone has a ceiling dose of 4 mg for prolongation of analgesia duration after injection of long-acting local anaesthetic for peripheral nerve block, but evidence for doses < 4 mg is lacking. This randomised controlled triple-blind trial tested the hypothesis that increasing doses of perineural dexamethasone between 1 mg and 4 mg would prolong the duration of analgesia in a dose-dependent manner. Eighty ASA physical status 1-2 patients scheduled for shoulder arthroscopy under general anaesthesia with ultrasound-guided interscalene brachial plexus block were randomly allocated to receive saline (control), dexamethasone 1 mg, 2 mg, 3 mg and 4 mg, together with 20 ml ropivacaine 0.5%. Postoperative analgesia consisted of paracetamol, diclofenac and oxycodone on request, using a pre-defined protocol. The primary outcome was the duration of analgesia, defined as the time between the block procedure and the first analgesic request. Secondary outcomes included rest and dynamic pain scores, and analgesic consumption at 2 h, 24 h and 48 h postoperatively. An analysis of the dose-response relationship was performed using multiple comparison procedure-modelling. The median (IQR [range]) duration of analgesia was significantly prolonged in a dose-dependent manner: control 685 (590-860 [453-1272]) min; 1 mg 835 (740-1110 [450-1375]) min; 2 mg 904 (710-1130 [525-1365]) min; 3 mg 965 (875-1025 [730-1390]) min; 4 mg 1023 (838-1239 [518-1500]) min (p = 0.03). There were no significant differences between the secondary outcomes. Perineural administration of dexamethasone with doses between 1 mg and 4 mg, combined with ropivacaine for interscalene brachial plexus block, prolongs duration of analgesia in a dose-dependent manner.

The influence of propofol and sevoflurane on intestinal motility during laparoscopic surgery.

BACKGROUND: Volatile anaesthetics have an influence on small bowel peristalsis during laparoscopic surgery. A recent study concluded that desflurane increased intestinal motility compared to sevoflurane. Hence, a desflurane-based anaesthesia protocol may reduce surgical exposure during intestinal suturing or stapling due to small bowel hyperperistalsis. The effect of propofol on intestinal motility is not well studied. We tested the hypothesis that a propofol-remifentanil anaesthesia increases intestinal contractions in comparison with a sevoflurane-remifentanil anaesthesia. METHODS: Patients scheduled for laparoscopic gastric bypass surgery were randomized in this single blind randomized controlled trial to receive remifentanil combined with sevoflurane or propofol (ISRCTN 12921661). Bispectral index monitoring was used to guide depth of anaesthesia. Visual observation of peristaltic waves was performed during 1 min at the planned site of the jejunostomy. Statistical analysis was performed using Wilcoxon two-sample test. RESULTS: After obtaining written informed consent 50 patients were included. Groups were similar for demographic variables, and depth of anaesthesia during the observations. The median number of peristaltic waves was lower in the sevoflurane-remifentanil group compared to the propofol-remifentanil group (0 vs. 6, P < 0.001). CONCLUSION: Propofol-remifentanil increases intestinal motility compared with sevoflurane-remifentanil during laparoscopic gastric bypass surgery. A sevoflurane-based protocol can help to avoid disturbing peristalsis.

Dynamics of metallic contaminants at a basin scale--Spatial and temporal reconstruction from four sediment cores (Loire fluvial system, France).

From the 19th century, the Loire basin (France) presents potentially pollutant activities such as mining and heavy industries. This paper shows spatio-temporal distribution of trace elements in sediments at a basin-scale, based on a comparison of archived temporal signals recorded in four sedimentary cores. Anthropogenic sources contributing to sediment contamination are also characterized, using geochemical signatures recorded in river bank sediments of the most industrialized tributaries. This study highlights upstream-downstream differences concerning recorded contamination phases in terms of spatial influence and temporality of archiving processes. Such differences were related to (i) various spatial influences of contamination sources and (ii) polluted sediments dispersion controlled by transport capacity of metal-carrier phases and hydrosedimentary dynamics.

Storage and source of polycyclic aromatic hydrocarbons in sediments downstream of a major coal district in France.

During the 20th century, the local economy of the Upper Loire Basin (ULB) was essentially based on industrial coal mining extraction. One of the major French coal districts with associated urban/industrial activities and numerous coking/gas plants were developed in the Ondaine-Furan subbasins, two tributaries of the upper Loire main stream. To determine the compositional assemblage, the level and the potential sources of contamination, the historical sedimentary chronicle of the 16 US EPA priority polycyclic aromatic hydrocarbons (PAHs) has been investigated. PAH concentrations were determined using gas chromatography/mass spectrometry (GC/MS) in a dated core, sampled in the Villerest flood-control reservoir located downstream of the Ondaine-Furan corridor (OFC). The most contaminated sediments were deposited prior to 1983 (Σ16PAHs ca. 4429-13,348 ng/g) and during flood events (Σ16PAHs ca. 6380 ng/g - 1996 flood; 5360 ng/g - 2003 flood; 6075 ng/g - 2008 flood), especially in medium and high molecular weight PAHs. Among them, typical pyrogenic PAHs such as FLT, PYR, BbF and BaP were prevalent in most of the core samples. In addition, some PAHs last decade data is available from the Loire Bretagne Water Agency and were analyzed using high-performance liquid chromatography with postcolumn fluorescence derivatization (HPLC/FLD). These results confirm that the most highly contaminated sediments were found downstream of OFC (Σ16PAHs ca. 2264-7460 ng/g). According to the observed molecular distribution, PAHs are originated largely from high-temperature pyrolytic processes. Major sources of pyrogenic PAHs have been emphasized by calculation of specific ratios and by comparison to reported data. Atmospheric deposition of urban and industrial areas, wood combustion and degraded coal tar derived from former factories of coking/gas plants seem to be the major pyrogenic sources. Specifically, particular solid transport conditions that can occur during major flood events lead us to emphasize weathering of former contamination sources, such as more preserved coal tar.

A randomised controlled trial of intravenous dexamethasone combined with interscalene brachial plexus blockade for shoulder surgery.

We recruited patients scheduled for shoulder rotator cuff repair or subacromial decompression under general anaesthesia and interscalene brachial plexus blockade (30 ml ropivacaine 0.5%). We allocated 240 participants into four groups of 60 that were given pre-operative saline 0.9% or dexamethasone 1.25 mg, 2.5 mg or 10 mg, intravenously. We recorded outcomes for 48 h. The median (IQR [range]) time to first postoperative analgesic request after saline was 12.2 (11.0-14.1 [1.8-48]) h, which was extended by intravenous dexamethasone 2.5 mg and 10 mg to 17.4 (14.9-21.5 [7.2-48]) h, p < 0.0001, and 20.1 (17.2-24.3 [1.3-48]) h, p < 0.0001, respectively, but not by dexamethasone 1.25 mg, 14.0 (12.1-17.7 [2.1-48]) h, p = 0.05. Postoperative analgesia was given sooner after rotator cuff repair than subacromial decompression, hazard ratio (95% CI) 2.2 (1.6-3.0), p < 0.0001, but later in older participants, hazard ratio (95% CI) 0.98 (0.97-0.99) per year, p < 0.0001.

Influence of fluvial environments on sediment archiving processes and temporal pollutant dynamics (Upper Loire River, France).

Floodplains are often cored to build long-term pollutant trends at the basin scale. To highlight the influences of depositional environments on archiving processes, aggradation rates, archived trace element signals and vertical redistribution processes, two floodplain cores were sampled near in two different environments of the Upper Loire River (France): (i) a river bank ridge and (ii) a paleochannel connected by its downstream end. The base of the river bank core is composed of sandy sediments from the end of the Little Ice Age (late 18th century). This composition corresponds to a proximal floodplain aggradation (<50 m from the river channel) and delimits successive depositional steps related to progressive disconnection degree dynamism. This temporal evolution of depositional environments is associated with mineralogical sorting and variable natural trace element signals, even in the <63-µm fraction. The paleochannel core and upper part of the river bank core are composed of fine-grained sediments that settled in the distal floodplain. In this distal floodplain environment, the aggradation rate depends on the topography and connection degree to the river channel. The temporal dynamics of anthropogenic trace element enrichments recorded in the distal floodplain are initially synchronous and present similar levels. Although the river bank core shows general temporal trends, the paleochannel core has a better resolution for short-time variations of trace element signals. After local water depth regulation began in the early 1930s, differences of connection degree were enhanced between the two cores. Therefore, large trace element signal divergences are recorded across the floodplain. The paleochannel core shows important temporal variations of enrichment levels from the 1930s to the coring date. However, the river bank core has no significant temporal variations of trace element enrichments and lower contamination levels because of a lower deposition of contaminated sediments and a pedogenetic trace elements redistribution.

I.V. and perineural dexamethasone are equivalent in increasing the analgesic duration of a single-shot interscalene block with ropivacaine for shoulder surgery: a prospective, randomized, placebo-controlled study.

BACKGROUND: Interscalene brachial plexus block (ISB) provides excellent, but time-limited analgesia. Dexamethasone added to local anaesthetics prolongs the duration of a single-shot ISB. However, systemic glucocorticoids also improve postoperative analgesia. The hypothesis was tested that perineural and i.v. dexamethasone would have an equivalent effect on prolonging analgesic duration of an ISB. METHODS: We performed a prospective, double blind, randomized, placebo-controlled study. Patients presenting for arthroscopic shoulder surgery with an ISB were randomized into three groups: ropivacaine 0.5% (R); ropivacaine 0.5% and dexamethasone 10 mg (RD); and ropivacaine 0.5% with i.v. dexamethasone 10 mg (RDiv). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first analgesic request. Standard hypothesis tests (t-test, Mann-Whitney U-test) were used to compare treatment groups. The primary outcome was analysed by Kaplan-Meier survival analysis with a log-rank test and Cox's proportional hazards regression. RESULTS: One hundred and fifty patients were included after obtaining ethical committee approval and patient informed consent. The median time of a sensory block was equivalent for perineural and i.v. dexamethasone: 1405 min (IQR 1015-1710) and 1275 min (IQR 1095-2035) for RD and RDiv, respectively. There was a significant difference between the ropivacaine group: 757 min (IQR 635-910) and the dexamethasone groups (P<0.0001). CONCLUSIONS: I.V. dexamethasone is equivalent to perineural dexamethasone in prolonging the analgesic duration of a single-shot ISB with ropivacaine. As dexamethasone is not licensed for perineural use, clinicians should consider i.v. administration of dexamethasone to achieve an increased duration of ISB.

Multiple organ failure and granulomatous hepatitis following intravesical bacillus Calmette-Guérin instillation.

Intravesical instillations of Bacillus-Calmette Guérin are widely used in the treatment of superficial bladder carcinoma. Although relatively safe, it has potentially lethal systemic side effects. In this case report a 68 year old patient presented with septic shock and multiple organ failure three days after instillation with Bacillus Calmette-Guérin. After treatment with fluid, vasopressors, broad spectrum antibiotics and antimycobacterial drugs the patient's condition improved. Ten days after admission there was a dramatic increase in bilirubin levels. A liver biopsy revealed granulomatous hepatitis. After the initiation of methylprednisolone the overall condition of the patient improved and serum bilirubin levels returned to normal.

Randomized clinical trial on the influence of anaesthesia protocol on intestinal motility during laparoscopic surgery requiring small bowel anastomosis.

BACKGROUND: Hyperperistalsis of the small bowel during laparoscopic surgery may cause mucosal prolapse and reduce exposure, making laparoscopic suturing or stapling more demanding for the surgeon. Although it is commonly accepted that both opioids and volatile anaesthetics induce intestinal paralysis, intestinal hyperactivity during anaesthesia is not uncommon. This randomized trial investigated the effect of different volatile anaesthetics on intestinal motility and the impact on surgeon satisfaction. METHODS: Patients scheduled for laparoscopic gastric bypass surgery were randomized to receive sevoflurane or desflurane in a balanced anaesthetic regimen. After surgical exposure peristaltic waves were counted over 1 min in a segment of the jejunum. Following evaluation of intestinal motility, N-butylhyoscine, an antimuscarinic anticholinergic agent that relaxes bowel smooth muscle cells, could be administered if the surgeon judged the intestinal motility as disturbing. The endpoints were number of peristaltic waves and incidence of N-butylhyoscine administration, a surrogate for surgeon satisfaction. RESULTS: Twenty-two patients were randomized to each group. The groups were similar in age, sex and body mass index. There was a statistically significant difference in intestinal motility between the desflurane and sevoflurane groups: median (range) 7 (0-12) versus 1 (0-10) waves counted over 1 min respectively (P < 0·001). A higher proportion of patients in the desflurane group received N-butylhyoscine (10 of 22 versus 1 of 22 in the sevoflurane group; P = 0·004). CONCLUSION: Desflurane increased intestinal motility and decreased surgeon satisfaction compared with sevoflurane during laparoscopic gastric bypass surgery. A sevoflurane-based anaesthetic protocol can help to avoid disturbing hyperperistalsis. REGISTRATION NUMBER: B39620097060 (http://www.clinicaltrials.be).

First trimester anesthesia exposure and fetal outcome. A review.

Approximately 0.5-2% of all pregnant women undergo nonobstetric surgery during their pregnancy. This percentage does not include patients who are in the early phase of gestation and are not aware of it at the time of surgery. When pregnancy is diagnosed, the concern raises whether surgery and anesthesia during early gestation pose hazard to the developing fetus, by increasing the risk of congenital anomalies and spontaneous abortion. Literature review suggests that there is no increase in congenital anomalies at birth in women who underwent anesthesia during pregnancy. However, first trimester anesthesia exposure does increase the risk of spontaneous abortion and lower birth weight. This is more likely due to surgical manipulation and the medical condition that necessitates surgery than to the exposure to anesthesia.

Abolition of cost-sharing is pro-poor: evidence from Uganda.

OBJECTIVE: To document the effects of the abolition of user fees on utilization of health services in Uganda with emphasis on poor and vulnerable groups. METHODS: A longitudinal study using quantitative and qualitative methods was carried out in 106 health facilities across the country. Health records were reviewed to determine trends in overall utilization patterns and use among vulnerable groups. A modification of wealth ranking as defined by the Uganda Poverty Participatory Assessment Project was used to categorize households by socio-economic status in order to compare utilization by the poor against that of other socio-economic groups. FINDINGS: There was a marked increase in utilization in all population groups that was fluctuating in nature. The increase in utilization varied from 26% in public referral facilities in 2001, rising to 55% in 2002 compared with 2000. The corresponding figures for the lower level facilities were 44% and 77%, respectively. Increase in utilization among the poor was more than for other socio-economic categories. Women utilized health services more than men both before and after cost-sharing. Higher increases in utilization were noted among the over-five age group compared with the under-fives. There were no increases in utilization for preventive and inpatient services. With respect to quality of care, there were fewer drug stock-outs in 2002 compared with 2000 and 2001. There was no deterioration of other indicators such as cleanliness, compound maintenance and staff availability reported. CONCLUSION: The study suggests that there is a financial barrier created by cost-sharing that decreases access to services, especially among the poor in Uganda. However, further studies are needed to clarify issues of utilization by age and gender.

A 300 year history of lead contamination in northern French Alps reconstructed from distant lake sediment records.

Lead concentrations and isotopic ratios were measured along two well-dated sediment cores from two distant lakes: Anterne (2100 m a.s.l.) and Le Bourget (270 m a.s.l.), submitted to low and high direct human impact and covering the last 250 and 600 years, respectively. The measurement of lead in old sediment samples (>3000 BP) permits, in using mixing-models, the determination of lead concentration, flux and isotopic composition of purely anthropogenic origin. We thus show that since ca. 1800 AD the regional increase in lead contamination was mostly driven by coal consumption ((206)Pb/(207)Pb approximately 1.17-1.19; (206)Pb/(204)Pb approximately 18.3-18.6), which peaks around 1915 AD. The increasing usage of leaded gasoline, introduced in the 1920s, was recorded in both lakes by increasing Pb concentrations and decreasing Pb isotope ratios. A peak around 1970 ((206)Pb/(207)Pb approximately 1.13-1.16; (206)Pb/(204)Pb approximately 17.6-18.0) corresponds to the worldwide recorded leaded gasoline maximum of consumption. The 1973 oil crisis is characterised by a drastic drop of lead fluxes in both lakes (from approximately 35 to <20 mg cm(-2) yr(-1)). In the late 1980s, environmental policies made the Lake Anterne flux drop to pre-1900 values (<10 mg cm(-2) yr(-1)) while Lake Le Bourget is always submitted to an important flux (approximately 25 mg cm(-2) yr(-1)). The good match of our distant records, together and with a previously established series in an ice core from Mont Blanc, provides confidence in the use of sediments as archives of lead contamination. The integration of the Mont Blanc ice core results from Rosman et al. with our data highlights, from 1990 onward, a decoupling in lead sources between the high elevation sites (Lake Anterne and Mont Blanc ice core), submitted to a mixture of long-distance and regional contamination and the low elevation site (Lake Le Bourget), where regional contamination is predominant.

Pharmacokinetics of intravenous alendronate.

Alendronate is a potent bisphosphonate that has been studied for the treatment of osteoporosis and Paget's disease of the bone. To examine the pharmacokinetics of this drug, several groups of postmenopausal women were dosed intravenously in several studies. Twelve patients with metastatic bone disease were administered an intravenous dose of 10 mg of 14C-labeled alendronate (approximately 26 muCi), and plasma, feces, and urine samples were collected for 72 hours. Radioactivity was excreted almost exclusively in urine, and all of it was accounted for by alendronate. Overall recovery accounted for 47% of dose, with the remainder presumed to be retained in bone. Metabolism of alendronate was not observed. Renal clearance of alendronate was 71 mL/min. An additional 10 subjects were given repeated i.v. administrations of alendronate to demonstrate that previous exposure does not alter the pharmacokinetic behavior of the drug. Examination of the findings from these and other studies in which alendronate was administered intravenously revealed that disposition of single doses is linear in the range of 0.125 to 10 mg. With the possible exception of a somewhat greater skeletal retention of a systemically administered dose, the pharmacokinetics of i.v. alendronate were found to be similar to those of other bisphosphonates.

The potential for social mobilisation in Bangladesh: the organisation and functioning of two health insurance schemes.

Health insurance schemes are usually assessed according to technical indicators. This approach, however, neglects the dynamic perspective of insurance schemes as an element of people's mobilisation for participation in organising and managing health care delivery and financing. The first part of this paper describes the technical performance and the level of community involvement in management of the two largest health insurance schemes in Bangladesh, both in the rural areas and in the non-government sector. Part two discusses these achievements in light of the schemes' potential role as a mechanism for people's management of health care. A review of documents and key-informant interviews were conducted. Key findings include that (1) subscribers currently are not actively participating in scheme management. However, existing family groups, involved in credit programmes may serve as entry-points for interaction. This is sustained by the 'natural link' between health insurance as a means of spreading the risks of treatment costs and credit programmes as a means of decreasing the relative impact of illness on household income. (2) The schemes' role could be further enhanced, by improving their technical performance and applying health care systems elements with the input of all partners involved. These issues are avoidance of service duplication with other providers; better protection of the poorer households; inclusion of hospital care in the coverage package; simplification of scheme administration by introduction of episode-based co-payments instead of the current itemised ones and concentrating the schemes at the level of community-based services, which may be self-financed and also self-managed by the community, given available sensitisation, training and interaction. A shift to episode-based co-payments would also introduce solidarity among patients and among individuals at higher risk, such as pregnant women and under-fives. Finally, action-research is needed to document the process of increased community involvement.

Phase II trial of chemotherapy alone for primary CNS and intraocular lymphoma.

PURPOSE: Primary CNS lymphoma (PCNSL) and primary intraocular lymphoma (IOL) are usually treated with radiation therapy alone or in combination with chemotherapy. The neurotoxicity of these treatments can be substantial. This study attempts to define the toxicity and efficacy of the treatment of this disease with chemotherapy alone. PATIENTS AND METHODS: Fourteen nonimmunocompromised patients were accrued to a chemotherapy regimen that incorporated a 24-hour infusion of high-dose methotrexate total dose of 8.4 g/m2 with leucovorin rescue; thiotepa 35 mg/m2; vincristine 1.4 mg/m2; dexamethasone; and intrathecal cytarabine (Ara-C) and methotrexate (MTV) administered in 21-day cycles. Seven patients were prospectively followed up with formal neuropsychologic assessments for evidence of CNS toxicity. RESULTS: The response rate was 100% with 11 (79%) complete responses and three (21%) partial responses. Cumulative survival and progression-free survival rates at more than 4.5 years were 68.8% and 34.3%, respectively. Median survival has not been reached, and median progression-free survival was 16.5 months. Toxicity included severe leukoencephalopathy that was clearly attributable to chemotherapy (two patients), grade 3 or 4 neutropenia in 50% of the cycles administered, ileus (one patient), and seizures (two patients). Mucositis and renal and hepatic toxicity were mild and not therapy limiting. CONCLUSION: The MTV regimen is generally well tolerated and produces a high complete response rate. Chemotherapy alone should be investigated further in this disease to assess the necessity of initial radiation therapy, either alone or in combined modality regimens, for the achievement of optimal response and survival.

Epidural dextran 40 patch for postdural puncture headache.

We report a case where two consecutive blood patches failed to relieve postdural puncture headache and hearing loss following inadvertent dural puncture. Initial conservative therapy with analgesics, fluids and later two blood patches had no effect and the patient's symptoms only resolved after an epidural dextran 40 patch performed 8 weeks after the dural tap. Two months later, the patient is still asymptomatic.