A controlled, prospective study comparing streptokinase and heparin treatment has been completed in 51 patients presenting with acute proximal venous thrombosis of less than 8 days' clinical duration. Patients were studied by means of pre-treatment, post-treatment, 3- and 12-monthly phlebography and pulmonary perfusion scanning and were followed up at 3-monthly intervals. Of the 26 patients randomized to receive streptokinase, therapy was stopped in 3 because of complications. Phlebography 5 days after starting treatment showed 80--100 per cent lysis in 17 of the 23 patients who completed the course of streptokinase. Two patients later developed partial rethrombosis. One patient developed an asymptomatic pulmonary embolus during treatment. During follow-up (mean 19 months) only 1 of the 17 patients with 80--100 per cent lysis developed postphlebitic symptoms, 3 patients died of unrelated causes and 1 patient was lost to follow-up. In patients randomized to heparin therapy no significant lysis was achieved in any of the 25 patients and only 2 of these patients were found to have asymptomatic legs on follow-up. Two patients in this group died and autopsy confirmed massive pulmonary embolus during treatment. These data suggest that streptokinase is superior to heparin in the treatment of acute proximal venous thrombosis of less than 1 week's clinical duration especially if the thrombus is largely non-occlusive. It must be stressed that in order to avoid the bleeding complications of thrombolytic therapy, streptokinase must not be used within 10 days of major surgery, or even longer after vascular, neurosurgical or eye operations.

Hirschsprung's disease is a rare condition in the adult. The case reports of 39 patients managed by the Duhamel procedure were reviewed. One-third of the patients underwent at least one abdominal surgical procedure before the correct diagnosis was made. The operative mortality of the Duhamel procedure was zero. In 29 patients no defunctioning procedure was used to protect the anastomosis. The incidence of anastomotic dehiscence was 13 per cent. Thirty-six of the thirty-nine patients have excellent functional results.

Conventional wisdom has been that hard, resilient surfaces resuspend fewer particles than carpeted surfaces, however, exceptions to this have been demonstrated and uncertainty remains about the factors that lead to this resuspension, notably, the effect of vacuum cleaning on either increasing or reducing resuspension from flooring. The purpose of this study was to determine how resuspension of house dust by aerodynamic size or particle type, including cat allergen and bacterial endotoxin, is affected by flooring, dust loading, embedding dust, and walking/cleaning activities. House dust was blown in and allowed to settle in a walk-in chamber after overnight deposition followed by walking or a vacuum cleaning procedure. Using an aerosol particle sizer and large-volume air samplers at different heights in the chamber, concentrations of airborne particles, resuspension rates, and fractions were computed for four types of flooring conditions during six walking activities. Carpeting resulted in significantly more airborne cat allergen and airborne endotoxin than a laminate floor. Height does have an effect on measured allergen over carpet and this is apparent with concentrations at the infant and adult air samplers. Walking on laminate flooring resuspends less house dust than walking on an equally dusty carpeted floor, where dust is entirely on the surface of the carpet. However, vacuum cleaning a laminate floor resuspended more dust than vacuum cleaning carpets, at large particle sizes of 5 µm and 10 µm. Activities following a deep cleaning of hard resilient or a carpeted surface is likely to leave no differences in resuspended particles between them.

A case of giant condyloma of Buschke and Loewenstein is presented. The clinical course and pathology of these tumors are reviewed. This case illustrates the delay in establishing the diagnosis in spite of numerous biopsies. It is emphasized that the only effective treatment is wide local excision.

Correspondence to: Mr R. J. Aitken, University Department of Clinical Surgery, The Royal Infirmary, Edinburgh EH39YW. UK Psoas abscesses are an unusual complication of Crohn's disease that originate from a communication with adherent bowel. We report a patient with Crohn's disease in whom a psoas abscess led to a spinal extradural abscess that required emergency laminectomy. Case reportA 36-year-old man with Crohn's disease underwent an intersphincteric excision of the anorectum with end sigmoid colostomy because of unremitting perianal fistulas with associated pelvic sepsis. The perineal wound was closed primarily over a suction and irrigation drain. He made an uneventful recovery, but during the subsequent 6 months was admitted with three episodes of subacute small bowel obstruction, all of which settled with conservative management. During the seventh month he was admitted with septicaemia (temperature 39°C) and pain in his right iliac fossa. A prominent and distressing feature was severe unremitting low lumbar back pain. Urgent radiological investigations, including ultrasonography but not computerized tomography (CT), were unhelpful but an indium-labelled white cell scan demonstrated a hot focus in the pelvis. Following recuscitation and the administration of antibiotics he underwent surgery and a large pelvic inflammatory mass was found. Thirty-five centimetres of terminal ileum was resected with a segment of sigmoid colon adherent to the pelvic mass. Pelvic and bilateral psoas abscesses were drained. A Brooke ileostomy was constructed and the right colon was closed and returned to the peritoneal cavity. Histology of the terminal ileum confirmed Crohn's disease. One week later a pulmonary embolus was confirmed by chest Xray and ventilation/perfusion scan and he was heparinized. His severe backache persisted; spinal X-rays and CT scan did not demonstrate a focal cause although a bone scan showed increased uptake in the area of the right sacro-iliac joint. One week later a further laparotomy was required for recurrent septicaemia but no intra-abdominal focus was found. His presumed sacro-iliitis was treated symptomatically with nonsteroidal anit-inflammatory drugs and he was discharged. Three weeks later he was admitted with worsening of back pain and sudden onset of paralegia. Urgent myelogram demonstrated a spinal extradural abscess and decompressive L,-L, laminectomy was performed (Figure I). The bacteriology of mixed faecal flora was similar to that obtained from his psoas abscess. Laminectomy provided immediate relief from backache and allowed resolution of the paragraphs of the paraplegia. Further laminectomy of L,-SI was required one month later for osteitis.He was finally discharged 9f months after his presentation with a psoas abscess and remains well 6 months later. DiscussionA literature search in 1982 revealed only 28 reported cases of psoas abscess complicating Crohn's disease. Previous reports have emphasized the difficult clinical course that these patients follow' -3 . The majority present ...

Summary Radiation therapy is often considered the treatment of choice for low-grade gliomas. However, given the long-term effects of radiation on the developing brain, the appropriate use of radiation therapy in pediatric patients remains controversial. The purpose of this study was to evaluate progression-free survival (PFS) of pediatric low-grade glioma patients treated with radiation therapy. Data were obtained through a retrospective chart review of patients treated between 1991 and 2008 from a single tertiary care center in the midwest. The study population consisted of 17 patients, of whom 8 (47%) had tumor recurrence after radiation therapy. The median follow-up time was 8.2 years, with a range of 2.3 to 17.2 years. The median age at diagnosis was 5.4 years, and the median age at radiation therapy was 9.4 years. The 3- and the 10-year PFS were 69% ± 11.7% and 46% ± 13.3%, respectively. A significant difference in PFS was seen when comparing brainstem tumors with hypothalamic/optic pathway tumors (P = 0.019). Differences in PFS based on the age at diagnosis, the extent of initial surgery, and indication for radiation therapy were not significant. A larger multicenter study is needed to better assess PFS in these patients.

Familial adenomatous polyposis (FAP), is a genetic premalignant condition which, if untreated, will ultimately manifest with the development of colorectal carcinoma. It is a disease of young adulthood. Rectal and colonic polyps are seldom seen before 10 years of age. Screening of clinically asymptomatic relatives thus generally starts during the teenage years. Carcinoma of the colon is exceedingly rare in children with FAP. While all adult patients should be surgically treated before the appearance of any carcinoma, early detection of dysplasia is paramount. The present case history relates to an 8-year-old boy with FAP who was found to have a significant degree of dysplasia in a polyp. This case remains the exception and a uniform approach to the screening and treatment of patients with FAP is still encouraged.

Case reports of three teenage patients with nonfamilial diffuse juvenile polyposis are presented to illustrate the considerable morbidity and significant growth retardation that may occur. Although generally considered to have no malignant potential, histologic findings revealed features ranging from adenomatous change to severe dysplasia. It is suggested that a conservative approach may not always be appropriate in this condition.