Modern management of head injuries

Management of the head-injured patient is designed to prevent secondary injury and to provide the neurosurgeon with a live patient who has some hope of recovery. This review sets out the background essentials for the non-neurosurgeon dealing with the initial care of a head-injured patient.

Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy

Background: This is an update of a Cochrane review first published in The Cochrane Library in Issue 3, 2010.
For many patients with head and neck cancer, oral nutrition will not provide adequate nourishment during treatment with radiotherapy or chemoradiotherapy due to the acute toxicity of treatment, obstruction caused by the tumour, or both. The optimal method of enteral feeding for this patient group has yet to be established.

Objectives: To compare the effectiveness of different enteral feeding methods used in the nutritional management of patients with head and neck cancer receiving radiotherapy or chemoradiotherapy using the clinical outcomes, nutritional status, quality of life and rates of complications.

Search methods: Our extensive search included the Cochrane ENT Group Trials Register, CENTRAL, PubMed, EMBASE, CINAHL, AMED and ISI Web of Science. The date of the most recent search was 13 February 2012.

Selection criteria:Randomised controlled trials comparing one method of enteral feeding with another, e.g. nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) feeding, for adult patients with a diagnosis of head and neck cancer receiving radiotherapy and/or chemoradiotherapy.

Data collection and analysis:Two authors independently assessed trial quality and extracted data using standardised forms. We contacted study authors for additional information.

Main results: One randomised controlled trial met the criteria for inclusion in this review. No further studies were identified when we updated the searches in 2012.
Patients diagnosed with head and neck cancer, being treated with chemoradiotherapy, were randomised to PEG or NG feeding. In total only 33 patients were eligible for analysis as the trial was terminated early due to poor accrual. A high degree of bias was identified in the study.
Weight loss was greater for the NG group at six weeks post-treatment than for the PEG group (P = 0.001). At six months post-treatment, however, there was no significant difference in weight loss between the two groups. Anthropometric measurements recorded six weeks post-treatment demonstrated lower triceps skin fold thickness for the NG group compared to the PEG group (P = 0.03). No statistically significant difference was found between the two different enteral feeding techniques in relation to complication rates or patient satisfaction. The duration of PEG feeding was significantly longer than for the NG group (P = 0.0006). In addition, the study calculated the cost of PEG feeding to be 10 times greater than that of NG, though this was not found to be significant. There was no difference in the treatment received by the two groups. However, four PEG fed patients and two NG fed patients required unscheduled treatment breaks of a median of two and six days respectively.
We identified no studies of enteral feeding involving any form of radiologically inserted gastrostomy (RIG) feeding or comparing prophylactic PEG versus PEG for inclusion in the review.

Authors' conclusions: There is not sufficient evidence to determine the optimal method of enteral feeding for patients with head and neck cancer receiving radiotherapy and/or chemoradiotherapy. Further trials of the two methods of enteral feeding, incorporating larger sample sizes, are required.

Dynamics of the Indonesian seas circulation. Part II – The role of pressure head

The aim of this paper is to analyze the role of the pressure head, i.e., the difference of total pressure forces acting on the Indonesian seas waters from the western Pacific and the eastern Indian Ocean, in driving the Indonesian Throughflow (ITF) and in determining the total transport of the ITF. These questions have been discussed in the literature but no consensus has been reached. A regional model of the Indonesian seas circulation has been developed that properly resolves all major topographic features in the region. The results of model runs have been used to calculate all components of the overall momentum balance. The estimates disclose that the dynamical balance is primarily between the volume integrated Coriolis acceleration, pressure gradient and the area integral of local wind stress. It is shown that consideration of components of momentum balance in the direction of the outflow through the Indian Ocean port leads to the formulation of a diagnostic relation between total inflow transports due to the Mindanao and New Guinea Coastal Currents and the external pressure head, internal pressure head, bottom form stress, and area integrated wind stress. Based on this relation, it is concluded that the external pressure head is not the major driving force of the ITF, which is why there is no unique relation between the total transport of the ITF and the external pressure head. However, Wyrtki's suggestion to monitor the variability of the total transport of the ITF by measurement of the sea-surface-height difference between the western Pacific and the eastern Indian Ocean is validated.

Human papillomavirus related head and neck cancer survival: A systematic review and meta-analysis

Human Papillomavirus (HPV) related oropharyngeal squamous cell carcinomas (OPSCCs) are reported to have improved prognosis and survival in comparison to other head and neck squamous cell cancers (HNSCCs). This systematic review and meta-analysis examines survival differences in HPV-positive HNSCC and OPSCC subtypes including tonsillar carcinoma in studies not previously investigated. Four electronic databases were searched from their inception till April 2011. A random effects meta-analysis was used to pool study estimates evaluating disease-specific (death from HNSCC), overall (all-cause mortality), progression-free and disease-free (recurrence free) survival outcomes in HPV-positive vs. HPV-negative HNSCCs. All statistical tests were two-sided. Forty-two studies were included. Patients with HPV-positive HNSCC had a 54% better overall survival compared to HPV-negative patients HR 0.46 (95% CI 0.37-0.57); the pooled HR for tonsillar cancer and OPSCC was 0.50 (95% CI 0.33-0.77) and HR 0.47 (95% CI 0.35-0.62) respectively. The pooled HR for disease specific survival was 0.28 (95% CI 0.19-0.40); similar effect sizes were found irrespective of the adjustment for confounders, HPV detection methods or study location. Both progression-free survival and disease-free survival were significantly improved in HPV-positive HNSCCs. HPV-positive HNSCCs and OPSCCs patients have a significantly lower disease specific mortality and are less likely to experience progression or recurrence of their cancer than HPV-negative patients; findings which have connotations for treatment selection in these patients.

Anther Extrusion and Fusarium Head Blight Resistance in European Wheat

Anther extrusion has been widely discussed as a factor influencing fusarium head blight (FHB) resistance in wheat. This is despite a paucity of quantitative information on its importance, between cultivars, in contrast to that for heading date and plant height. We describe a method applicable to a plant breeding
situation at 10 days postanthesis, for assessing the distinct characteristics of anther retention (anthers held within the spikelet) and trapped anthers (partially
extruded and trapped between the lemma and palea of the wheat spikelet). FHB resistance was tested in field experiments in 2004 and 2005. In these experiments designed to resemble applications to a plant breeding selection scheme anther retention was significantly correlated with FHB in 2004 (r = 0.26; P < 0.05) and 2005 (r = 0.26; P < 0.05). A higher proportion of anthers retained relating, albeit weakly, with increased FHB susceptibility in European wheat.

Head injury from a bungee run

An adaptation of bungee jumping, 'bungee running', involves participants attempting to run as far as they can whilst connected to an elastic rope which is anchored to a fixed point. Usually considered a safe recreational activity, we report a potentially life-threatening head injury following a bungee running accident.