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Background: Supported self‐management can improve clinical and psychosocial outcomes in people with cancer; the considerations required to implement self‐management support (SMS) for people living with a lower‐grade glioma (LGG)—who often have complex support needs—are not known. We aimed to identify and understand these implementation considerations through the lens of normalisation process theory (NPT), from the perspectives of healthcare professionals (HCP) and people with LGG. Methods: We conducted semistructured interviews with HCPs who support adults with brain tumours (n = 25; 12 different healthcare professions), and people with LGG who had completed primary treatment (n = 28; male n = 16, mean age 54.6 years, mean time since diagnosis 8.7 years), from across the United Kingdom. Interviews were transcribed and inductive open coding conducted, before deductively mapping to constructs of NPT. We first mapped HCP data, then integrated data from people with LGG to explore alignment in experiences and perspectives. Results: We generated supporting evidence for all four NPT constructs and related subconstructs, namely: 'Coherence', 'Cognitive participation', 'Collective action' and 'Reflexive monitoring'. Data from HCPs and people with LGG clearly demonstrated that effective SMS constitutes a collective activity. Key implementation considerations included: ensuring awareness of, and access to, support; building strong HCP‐support recipient relationships; and careful inclusion of close family and friends. We identified pertinent challenges, such as identifying support needs (influenced by the extent to which those with LGG engage in help‐seeking), resistance to support (e.g., technology literacy), training for HCPs and HCP cooperation. Conclusions: This study demonstrates the collective nature of, and provides insight into the individual roles within, supported self‐management. We outline considerations to operationalise, sustain and appraise the implementation of SMS for people with LGG. Patient or Public Contribution: People with brain tumours, and informal caregivers, were involved in the development of information materials and topic guides to ensure accessibility and pertinence. They also had opportunities to comment on interview findings. [ABSTRACT FROM AUTHOR]

In 2015, a groundswell of brain tumour patient, carer and charity activism compelled the UK Minister for Life Sciences to form a brain tumour research task and finish group. This resulted, in 2018, with the UK government pledging £20m of funding, to be paralleled with £25m from Cancer Research UK, specifically for neuro‐oncology research over the subsequent 5 years. Herein, we review if and how the adult brain tumour research landscape in the United Kingdom has changed over that time and what challenges and bottlenecks remain. We have identified seven universal brain tumour research priorities and three cross‐cutting themes, which span the research spectrum from bench to bedside and back again. We discuss the status, challenges and recommendations for each one, specific to the United Kingdom. [ABSTRACT FROM AUTHOR]

To investigate how magnetic resonance imaging (MRI) examinations are protocolled in tertiary paediatric neuroradiology centres around the UK for some of the more common presentations encountered in paediatric neuroradiology, and to identify any variations of note. All 19 UK tertiary paediatric neuroradiology centres registered with the British Society of Neuroradiologists—Paediatric Group were contacted and asked if they could provide a copy of their standard MRI protocols. Twelve responded (63%) and 10 of the more common presentations were selected and the standard acquired sequences obtained at each participating centre were compared. Where available the collated protocols were also compared against current published guidance. The basic sequences carried out by centres around the UK are similar; however, there are lots of variations overall. The only standardised protocol currently being implemented nationally in paediatric imaging is that for brain tumours. Otherwise, chosen protocols are generally dependent on the preferences and technical capabilities of individual centres. Suggested published protocols also exist for non-accidental injury (NAI), multiple sclerosis, epilepsy, and head and neck imaging. The differences in MRI protocolling depend in part on technical capabilities and in part on the experience and preferences of the paediatric neuroradiologists at each centre. For most presentations, there is no consensus as to what constitutes the perfect protocol. The present results will be useful for specialist centres who may wish to review their current protocols, and for more generalist centres to use as a reference to guide their MRI protocolling. • Paediatric neuroradiology MRI protocols across the UK. • Standardisation of paediatric MRI protocols. • Paediatric neuroradiology guidelines for MRI imaging. [ABSTRACT FROM AUTHOR]

Objective: We sought to determine the 1-year survival following craniotomy for tumour resection in a public healthcare system and analyse the effect of indices of multiple deprivation (IMD) as well as smoking, alcohol, BMI, ASA grade and medical co-morbidities on post-operative morbidity and mortality. Methods: This is a retrospective, single-centre study in a high volume neurosurgical centre, over a 2-year period. All patients undergoing a craniotomy for a brain tumour were included. Data was collected from the neuro-oncology database and electronic patient records. Individual patient IMD data was obtained using their postcode from a national government database. Each English postcode being ranked from 1 to 32,844, with 1 being the most deprived and 32,844 the most affluent. Descriptive results are described along with further data analysis using multiple linear and logistic regression analyses. Results: 630 patients underwent an elective or urgent craniotomy for tumour. 10% of all patients underwent urgent surgery. 68% (95% CI: 64 to 71%) survived at least 1-year post-surgery. Our study found that social deprivation (IMD postcode rank) was not associated with mortality at 1 year after adjusting for potential confounding factors. Those from decile 1 had the lowest risk of death at 12 months for all tumour types (p = 0.0070). Previous smokers carried an increased risk of death at 12 months when compared with people who had never smoked RR 1.40 CI 1.10–1.78 (p = 0.006) but this risk was not evident in current smokers RR 0.92 CI 0.65–1.31 (p = 0.64). Increasing age and male gender were also found to be associated with higher mortality at 1 year (p = < 0.001). Conclusions: In the UK despite the discrepancy in the health of the general population between the north and south, social deprivation does not appear to be detrimental to neurooncological outcomes although smoking status, advancing age and male sex are. [ABSTRACT FROM AUTHOR]

A brain tumour can be a life-threatening illness and cause unique symptoms compared to other types of cancer, such as cognitive or language deficits, or changes in personality. It is an exceptionally distressing diagnosis which can affect quality of life, even for those with a low-grade tumour or many years after the diagnosis. This study sought to gain an in-depth understanding of the lived experience of adjustment to living with a brain tumour. Twelve individuals (83% female) with a primary brain tumour (83% low-grade) took part in the study. Participants were aged 29–54 years, on average 43 months following the diagnosis, and were recruited through the charitable support organisations in the United Kingdom. In-depth semi-structured interviews were conducted, transcribed verbatim, and analysed using interpretative phenomenological analysis (IPA). Six inter-related themes were identified: making sense of the diagnosis, seeking empowerment, feeling appreciative, taking charge of coping, learning to accept, and negotiating a new normality. Notions of empowerment, gratitude, and acceptance throughout the illness journey were prominent in the participants' narratives. Receiving sufficient information and initiating treatment were important in negotiation of control. The results highlighted what facilitates and hinders adaptive coping. Aspects which facilitated positive coping were as follows: trust in clinician, feeling in control, feeling grateful, or accepting. Participants on a 'watch and wait' approach, while feeling appreciative, perceived the lack of treatment as difficult and frustrating. Implications for patient–clinician communication are discussed, particularly for patients on a 'watch and wait' who might need additional support in adjusting. [ABSTRACT FROM AUTHOR]

Unravelling the complex events driving grade-specific spatial distribution of brain tumour occurrence requires rich datasets from both healthy individuals and patients. Here, we combined open-access data from The Cancer Genome Atlas, the UK Biobank and the Allen Brain Human Atlas to disentangle how the different spatial occurrences of glioblastoma multiforme and low-grade gliomas are linked to brain network features and the normative transcriptional profiles of brain regions. From MRI of brain tumour patients, we first constructed a grade-related frequency map of the regional occurrence of low-grade gliomas and the more aggressive glioblastoma multiforme. Using associated mRNA transcription data, we derived a set of differential gene expressions from glioblastoma multiforme and low-grade gliomas tissues of the same patients. By combining the resulting values with normative gene expressions from post-mortem brain tissue, we constructed a grade-related expression map indicating which brain regions express genes dysregulated in aggressive gliomas. Additionally, we derived an expression map of genes previously associated with tumour subtypes in a genome-wide association study (tumour-related genes). There were significant associations between grade-related frequency, grade-related expression and tumour-related expression maps, as well as functional brain network features (specifically, nodal strength and participation coefficient) that are implicated in neurological and psychiatric disorders. These findings identify brain network dynamics and transcriptomic signatures as key factors in regional vulnerability for glioblastoma multiforme and low-grade glioma occurrence, placing primary brain tumours within a well established framework of neurological and psychiatric cortical alterations. [ABSTRACT FROM AUTHOR]

Background: The deleterious impact upon the cognitive development of survivors of pediatric brain tumors (PBT) is well documented. Impairment in cognitive function is associated with reduced health-related quality of life (HRQoL), such that survivors of PBT report difficulties in multiple distinct domains and an overall reduced quality of life. Studies of the use of methylphenidate in survivors of PBT to alleviate impairment in cognitive functions have shown some success. The current study aimed to explore the impact upon HRQoL in survivors of PBT of a trial of psychostimulant medication. Method: Data were collected from 12 pediatric neuro-oncology patients aged 7–17 years receiving methylphenidate treatment. HRQoL was measured using the PEDS QL quality of life self-report measure and a semi-structured questionnaire-based interview. Results: Analyses of data demonstrates benefit to five domains associated with HRQoL: social, emotional, academic, physical, and cognition. Conclusion: Survivors of PBT reported favorable views as to the subjective benefit of methylphenidate on post-treatment impairment of HRQoL. This medication may offer the potential for restoration of a sense of 'normality' of function following cancer treatment in this clinical population. [ABSTRACT FROM AUTHOR]

• The mitochondrial genome (mtDNA) is polymorphic in human populations. • Inherited variants in mtDNA may play a role in cancer risk and progression. • Array-based genotyping of mtDNA variants in 2 epidemiologic studies of glioma. • Selected mtDNA haplogroups and common mtDNA variants associate with glioma risk. • Complete mtDNA sequencing needed for study of rare and singleton variants. Malignant gliomas are the most common primary adult brain tumors, with a poor prognosis and ill-defined etiology. Mitochondrial DNA (mtDNA) sequence variation has been linked with certain cancers; however, research on glioma is lacking. We examined the association of common (minor allele frequency ≥ 5%) germline mtDNA variants and haplogroups with glioma risk in 1,566 glioma cases and 1,017 controls from a US case-control study, and 425 glioma cases and 1,534 matched controls from the UK Biobank cohort (UKB). DNA samples were genotyped using the UK Biobank array that included a set of common and rare mtDNA variants. Risk associations were examined separately for glioblastoma (GBM) and lower grade tumors (non-GBM). In the US study, haplogroup W was inversely associated with glioma when compared with haplogroup H (OR = 0.43, 95%CI: 0.23–0.79); this association was not demonstrated in the UKB (OR = 1.07, 95%CI: 0.47–2.43). In the UKB, the variant m.3010G > A was significantly associated with GBM (OR = 1.32; 95%CI: 1.01–1.73; p = 0.04), but not non-GBM (1.23; 95%CI: 0.78–1.95; p = 0.38); no similar association was observed in the US study. In the US study, the variant m.14798 T > C, was significantly associated with non-GBM (OR = 0.72; 95%CI: 0.53–0.99), but not GBM (OR = 0.86; 95%CI: 0.66–1.11), whereas in the UKB, a positive association was observed between this variant and GBM (OR = 1.46; 95%CI: 1.06–2.02) but not non-GBM (OR = 0.92; 95%CI: 0.52–1.63). None of these associations were significant after adjustment for multiple testing. The association of inherited mtDNA variation, including rare and singleton variants, with glioma risk merits further study. [ABSTRACT FROM AUTHOR]

New personalized immunotherapies hold considerable promise among cancer communities and are touted by many as the future of oncology. Described as a way to enhance the body's "natural defense" against cancer, they are made with antigens taken from patients' own tumor tissue. However, they also set up significant dilemmas for patients who are learning what it is like to participate in an emerging tissue economy and the stakes of exclusion from it. Taking brain tumors as my ethnographic case, I chart the valuations and exchanges that constitute this tissue economy as well as the dilemmas and disparities faced by patients. [ABSTRACT FROM AUTHOR]

Use of computed tomography (CT) scanning has increased substantially since its introduction in the 1990s. Several authors have reported increased risk of leukemia and brain tumors associated with radiation exposure from CT scans. However, reverse causation is a concern, particularly for brain cancer; in other words, the CT scan may have been taken because of preexisting cancer and therefore not have been a cause. We assessed the possibility of reverse causation via a simulation study focused on brain tumors, using a simplified version of the data structure for recent CT studies. Five-year–lagged and unlagged analyses implied an observed excess risk per scan up to 70% lower than the true excess risk per scan, particularly when more than 10% of persons with latent cancer had increased numbers of scans or the extra scanning rate after development of latent cancer was greater than 2 scans/year; less extreme values of these parameters imply little risk attenuation. Without a lag and when more than 20% of persons with latent cancer had increased scans—an arguably implausible scenario—the excess risk per scan was increased over the true excess risk per scan by up to 35%–40%. This study suggests that with a realistic lag, reverse causation results in downwardly biased risk, a result of induced classical measurement error, and is therefore unlikely to produce a spurious positive association between cancer and radiation dose from CT scans. [ABSTRACT FROM AUTHOR]

Introduction The UK uses the 2-week-wait (2WW) pathway for rapid access to cancer services. It is unclear whether this is effective for brain cancer. Methods We retrospectively analysed all 2WW referrals for brain cancer between 2009 and 2016 in a district general neurology department. We compared clinical presentations to national guidelines and diagnoses of brain cancer. Results Of the 153 cases analysed, four brain cancers were identified: two glioblastomas and two metastases. Headaches were the most common referral. The end diagnosis was mostly migraine. The highest positive predictive value was for behavioural/personality change (5.3%) and sub-acute neurological deficit (3.2%). There was no significant association between any symptom(s) and brain cancer. Conclusion The 2WW pathway is not effective in the diagnosis of brain cancer. Resources are better directed towards clinical research and treatment trials. Headache remains the most common reason for referral although it is not yet a reliable indicator of brain cancer. [ABSTRACT FROM AUTHOR]

Though brain tumours are rare, survival rates are low, resulting in the most life-years lost of any cancer, according to the National Institute for Health and Care Excellence (NICE). They are also notoriously difficult to diagnose, with symptoms found in non-cancerous conditions such as migraine or epilepsy. [ABSTRACT FROM AUTHOR]

Background: Median survival for patients with glioblastoma is less than a year. Standard treatment consists of surgical debulking if feasible followed by temozolomide chemo-radiotherapy. The immune checkpoint inhibitor ipilimumab targets cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and has shown clinical efficacy in preclinical models of glioblastoma. The aim of this study is to explore the addition of ipilimumab to standard therapy in patients with glioblastoma.Methods/design: Ipi-Glio is a phase II, open label, randomised study of ipilimumab with temozolomide (Arm A) versus temozolomide alone (Arm B) after surgery and chemoradiotherapy in patients with recently diagnosed glioblastoma. Planned accrual is 120 patients (Arm A: 80, Arm B: 40). Endpoints include overall survival, 18-month survival, 5-year survival, and adverse events. The trial is currently recruiting in seven centres in the United Kingdom.Trial Registration: ISRCTN84434175. Registered 12 November 2018. [ABSTRACT FROM AUTHOR]

Over a third of brain tumour patients visit their general practitioner more than five times prior to diagnosis in the UK, leading to 62% of patients being diagnosed as emergency presentations. Unfortunately, symptoms are non-specific to brain tumours, and the majority of these patients complain of headaches on multiple occasions before being referred to a neurologist. As there are currently no methods in place for the early detection of brain cancer, the affected patients' average life expectancy is reduced by 20 years. These statistics indicate that the current pathway is ineffective, and there is a vast need for a rapid diagnostic test. Attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy is sensitive to the hallmarks of cancer, as it analyses the full range of macromolecular classes. The combination of serum spectroscopy and advanced data analysis has previously been shown to rapidly and objectively distinguish brain tumour severity. Recently, a novel high-throughput ATR accessory has been developed, which could be cost-effective to the National Health Service in the UK, and valuable for clinical translation. In this study, 765 blood serum samples have been collected from healthy controls and patients diagnosed with various types of brain cancer, contributing to one of the largest spectroscopic studies to date. Three robust machine learning techniques – random forest, partial least squares-discriminant analysis and support vector machine – have all provided promising results. The novel high-throughput technology has been validated by separating brain cancer and non-cancer with balanced accuracies of 90% which is comparable to the traditional fixed diamond crystal methodology. Furthermore, the differentiation of brain tumour type could be useful for neurologists, as some are difficult to distinguish through medical imaging alone. For example, the highly aggressive glioblastoma multiforme and primary cerebral lymphoma can appear similar on magnetic resonance imaging (MRI) scans, thus are often misdiagnosed. Here, we report the ability of infrared spectroscopy to distinguish between glioblastoma and lymphoma patients, at a sensitivity and specificity of 90.1% and 86.3%, respectively. A reliable serum diagnostic test could avoid the need for surgery and speed up time to definitive chemotherapy and radiotherapy. [ABSTRACT FROM AUTHOR]

Glioma is the most common malignant primary brain tumors with poor prognosis. Genome wide association studies (GWAS) of glioma in populations with Western European ancestry were completed in the US and UK. However, our previous results strongly suggest the genetic heterogeneity could be important in glioma risk. To systematically investigate glioma risk–associated variants in Chinese population, we performed a multistage GWAS of glioma in the Han Chinese population, with a total of 3,097 glioma cases and 4,362 controls. In addition to confirming two associations reported in other ancestry groups, this study identified one new risk‐associated locus for glioma on chromosome 12p11.23 (rs10842893, pmeta = 2.33x10‐12, STK38L) as well as a promising association at 15q15‐21.1 (rs4774756, pmeta = 6.12x10‐8, RAB27A) in 3,097 glioma cases and 4,362 controls. Our findings demonstrate two novel association between the glioma risk region marked by variant rs10842893 and rs4774756) and glioma risk. These findings may advance the understanding of genetic susceptibility to glioma. What's new? While very few brain tumors are attributed to familial risk factors, the previous identification of inherited genetic variants linked to glioma has raised new questions about the impact of genetics on brain tumor risk. In this genome‐wide association study in a Han Chinese population, two independent genetic variants, one on chromosome 12p11.23 and the second on 15q15‐21.1, were found to be significantly associated with glioma risk. In addition, two risk‐associated variants previously reported in other ancestry groups were also associated with glioma risk in Han Chinese patients. The findings may help advance understanding of genetic susceptibility to glioma. [ABSTRACT FROM AUTHOR]

• Glioblastoma is an infiltrative brain tumor type. • T98 G is a well-known Glioblastoma cell line. • We assessed the phenotypic characterization of the T98 G cells using spheroids. • The invasion of the T98 G spheroids is collective with sporadic proliferation. • The T98 G cells can be used as a control Glioblastoma cell line. Major Glioblastoma's hallmarks include proliferation, invasion and heterogeneity. Biological 3D tumor spheroid models can serve as intermediate systems between traditional 2D cell culture and complex in vivo models. Tumor spheroids have been shown to more accurately reproduce the spatial organization and microenvironmental factors of in vivo micro-tumors, such as relevant gradients of nutrients and other molecular agents, while they maintain cell-to-cell and cell-to-matrix interactions. In vitro 3D assays are useful to monitor these properties. Here, we test the suitability of the well-known T98 G Glioblastoma cell line in such a 3D assay. The doubling time and death rate parameters of T98 G are estimated, as well as their spheroidal growth-expansion curves with and without the presence of basement membrane substrate. The T98 G invasive profile is characterized by collective morphology and proliferation-associated invasion. We show that the T98 G secondary GB cell line exhibits both invasive and proliferative capabilities in 3D and thus, can serve as control cell line for the 3D in vitro study of primary GB cell cultures. [ABSTRACT FROM AUTHOR]

Background Brain cancer has a strong impact on health-related quality of life (HRQoL), and its evaluation in clinical practice can improve the quality of care provided. The aim of this project was to integrate routine collection of HRQoL information from patients with brain tumor or metastasis in 2 specialized United Kingdom tertiary centers, and to evaluate the implementation process. Methods Since October 2016, routine collection of electronic self-reported HRQoL information has been progressively embedded in the participating centers using standard questionnaires. During the first year, the project was implemented, and the process evaluated, through regular cycles of process evaluation followed by an action plan, monitoring of questionnaire completion rates, and assessment of patient views. Results Main challenges encountered included reluctance to change usual practice and limited resources. Key measures for success included strong leadership of senior staff, involvement of stakeholders in project design and evaluation, and continuous strategic support to professionals. Final project workflow included 6 process steps, 1 decision step, and 4 outputs. Questionnaires were mostly self-completed (75.1%), and completion took 6-9 minutes. Most patients agreed that the questionnaire items were easy to understand (97.0%), important for them (93.0%), and helped them think what they wanted to discuss in their clinical consultation (75.4%). Conclusions Integrating HRQoL information as a routine part of clinical assessments has the potential to enhance individually tailored patient care in our institutions. Challenges involved in innovations of this nature can be overcome through a systematic approach involving strong leadership, wide stakeholder engagement, and strategic planning. [ABSTRACT FROM AUTHOR]

Background: To determine if filtration-histogram based texture analysis (MRTA) of clinical MR imaging can non-invasively identify molecular subtypes of untreated gliomas.Methods: Post Gadolinium T1-weighted (T1+Gad) images, T2-weighted (T2) images and apparent diffusion coefficient (ADC) maps of 97 gliomas (54 = WHO II, 20 = WHO III, 23 = WHO IV) between 2010 and 2016 were studied. Whole-tumor segmentations were performed on a proprietary texture analysis research platform (TexRAD, Cambridge, UK) using the software's freehand drawing tool. MRTA commences with a filtration step, followed by quantification of texture using histogram texture parameters. Results were correlated using non-parametric statistics with a logistic regression model generated.Results: T1+Gad performed best for IDH typing of glioblastoma (sensitivity 91.9%, specificity 100%, AUC 0.945) and ADC for non-Gadolinium-enhancing gliomas (sensitivity 85.7%, specificity 78.4%, AUC 0.877). T2 was moderately precise (sensitivity 83.1%, specificity 78.9%, AUC 0.821). Excellent results for IDH typing were achieved from a combination of the three sequences (sensitivity 90.5%, specificity 94.5%, AUC = 0.98). For discriminating 1p19q genotypes, ADC produced the best results using unfiltered textures (sensitivity 80.6%, specificity 89.3%, AUC 0.811).Conclusion: Preoperative glioma genotyping with MRTA appears valuable with potential for clinical translation. The optimal choice of texture parameters is influenced by sequence choice, tumour morphology and segmentation method. [ABSTRACT FROM AUTHOR]

Background Surgery for lesions in eloquent brain areas remains challenging owing to the risk of permanent neurological deficits. To date, direct electrical stimulation (DES) and intraoperative neuromonitoring represent the reference standard. Recently, navigated transcranial magnetic stimulation (nTMS) has emerged as a mapping tool to optimize surgical planning. Our aim was to correlate nTMS with the intraoperative findings and assess its effects on surgical decision-making. Methods We retrospectively reviewed our series of patients who had undergone craniotomy for removal of a brain tumor at our institution with preoperative nTMS, intraoperative neuromonitoring, and DES from February 2017 to February 2018. Demographic data, tumor entity and location, extent of resection, change in surgical approach, and neurological outcome were collected. Results Of 35 patients, 24 (68.6%) had undergone preoperative motor mapping and 11 (31.4%) had undergone mapping for language. Histopathological examination demonstrated glioma in 88.6% (high grade, n = 24; low grade, n = 6), metastasis (n = 2), epidermoid cyst (n = 1), and cavernoma (n = 1). nTMS resulted in change in the surgical strategy in 31.5% (craniotomy size, n = 7; access pathway, n = 3; surgical indication, n = 1). The specificity of nTMS for language was 66.7%, with a negative predictive value of 74.1%. nTMS motor mapping correlated with DES in all cases, with a mean abductor pollicis brevis hotspot distance of 3.50 ± 0.66 mm (n = 9). Conclusions nTMS is a safe, noninvasive adjunctive tool for preoperative mapping of brain tumors in eloquent areas. Furthermore, nTMS can influence the surgical decisions in up to one third of patients in our experience. [ABSTRACT FROM AUTHOR]

When investigating the association between brain tumors and use of mobile telephones, accurate data on tumor position are essential, due to the highly localized absorption of energy in the human brain from the radio-frequency fields emitted. We used a point process model to investigate this association using information that included tumor localization data from the INTERPHONE Study (Australia, Canada, Denmark, Finland, France, Germany, Israel, Italy, Japan, New Zealand, Norway, Sweden, and the United Kingdom). Our main analysis included 792 regular mobile phone users diagnosed with a glioma between 2000 and 2004. Similar to earlier results, we found a statistically significant association between the intracranial distribution of gliomas and the self-reported location of the phone. When we accounted for the preferred side of the head not being exclusively used for all mobile phone calls, the results were similar. The association was independent of the cumulative call time and cumulative number of calls. However, our model used reported side of mobile phone use, which is potentially influenced by recall bias. The point process method provides an alternative to previously used epidemiologic research designs when one is including localization in the investigation of brain tumors and mobile phone use. [ABSTRACT FROM AUTHOR]

Brain tumours are the commonest cancer cause of death in children. Early diagnosis is crucial in preventing worse neurological outcome in survivors, however diagnosis is difficult as presenting symptoms can be non-specific. In 2006 the median total diagnostic interval was more than three months in the UK, three times more than in the USA. “HeadSmart: Be Brain Tumour Aware” was launched in 2011 to amplify the impact of the RCPCH diagnostic guidelines published in 2008. By providing high quality guidance on assessment, investigation and referral as well as distributing symptom cards, signposting the website and providing e-learning resources, we have successfully enhanced awareness in health professionals and the public. Moreover, since the guidance, there has been a statistically significant reduction in the UK's total diagnostic interval from 14.4 weeks in 2006 to one of the shortest in the world at 6.7 weeks. This article reviews the progress that has been made and aims to highlight the advice that has proved useful in reducing the total diagnostic interval. [ABSTRACT FROM AUTHOR]

Background: Primary malignant brain tumours are rare but represent a serious health burden due to their poor survival. This manuscript describes the survival of malignant brain tumours in adults diagnosed 2000-2007 in Europe. Methods: For this study we analysed patients archived in 86 European population-based cancer registries, followed up to 31st December 2008. Only primary malignant neuroepithelial brain tumours (with pathological confirmation) and primary malignant unspecified brain tumours without pathological confirmation were included. We estimated 1-year and 5-year relative survival (RS) weighted by age group and country. We also estimated country-specific and age-specific survival, together with survival differences between time periods (for 1999-2001, 2002-2004 and 2005-2007). Results: Glioblastoma represents 49% of all brain tumours, followed by other/unspecified astrocytoma (18%), oligodendroglioma/oligoastrocytoma (9%), ependymoma (1.5%) and embryonal tumours (1%). Five-year RS was 20% for all tumours combined, but ranged from 58% for ependymoma to only 6% for glioblastoma and sharply decreased with increasing age. Differences between countries were relatively small, but generally RS in Ireland/United Kingdom (UK) and Eastern Europe was below the average. An increase in 1-year RS (up to 10-12%) was noted over time, being largest in Central and Northern Europe in patients between 45 and 74 years of age. Conclusions: Despite an increase in 1-year RS in most European regions, the survival of primary malignant brain tumours is still poor. Disparities between countries were evident, being even larger at the end of the study period than at the beginning, suggesting differences in availability of the latest treatment modalities. [ABSTRACT FROM AUTHOR]

Background: Spiritual needs of cancer patients should be assessed and discussed by healthcare professionals. Neurosurgical nurses need to be able to assess and support neuro-oncology patients with their spiritual needs from diagnosis and throughout their hospital stay. Methods: Data were collected through questionnaires using a Critical Incident Technique (CIT) from neurosurgical nurses, findings were analysed using thematic analysis. Results: Nurses reported some awareness of their patients' spiritual needs during their stay on neurosurgical units although some used expressions approximating what could be described as spiritual needs. Patients' spiritual needs were identified as: need to talk about spiritual concerns, showing sensitivity to patients' emotions, responding to religious needs; and relatives' spiritual needs included: supporting them with end of life decisions, supporting them when feeling being lost and unbalanced, encouraging exploration of meaning of life, and providing space, time and privacy to talk. Participants appeared largely to be in tune with their patients' spiritual needs and reported that they recognised effective strategies to meet their patients' and relatives' spiritual needs. However, the findings also suggest that they don't always feel prepared to offer spiritual support for neuro-oncology patients. Conclusions: There is a need for healthcare professionals to provide spiritual care for neuro-oncology patients and their relatives. Although strategies were identified that nurses can use to support patients with spiritual needs further research is required to explore how effective nurses are at delivering spiritual care and if nurses are the most appropriate professionals to support neuro-oncology patients with spiritual care. [ABSTRACT FROM AUTHOR]

People with intellectual disabilities (ID) are enjoying increasing longevity, but are simultaneously having to cope with the additional health problems associated with ageing. Even though people with ID are reported to have worse health than the rest of the population, resulting in greater health-care needs, they also have poorer health care than the average person, including including-end-of-life care. The aim of this paper is to explore the challenges to providing effective end-of-life care for a person with an ID by using critical reflection from a nursing care perspective on an illustrative case study. Death never occurs in a vacuum but rather occurs in a social context, and the social context here was crucial to providing appropriate end-of-life care. It is hoped that the paper will promote discussion both around end-of-life care generally and in relation to this marginalized population. [ABSTRACT FROM AUTHOR]

Primary brain tumours account for less than 2% of cancer diagnoses in the UK but more people under 40 die from a brain tumour than from any other cancer. Despite developments in some treatment options, survival remains poor and patients suffer with considerable functional and cognitive deficits. Rehabilitation for patients with primary brain tumours produces statistically and clinically significant improvements in function. When compared, similar functional gains are made following rehabilitation for brain tumour patients and for those following stroke and traumatic brain injury. There have been very few studies looking at access to rehabilitation for this group of patients as a primary objective. However, existing studies and clinical experience suggest that patients with brain tumours do not access rehabilitation services frequently or easily, either locally or nationally. Therefore, this qualitative study addressed the reasons for this through semi-structured interviews of healthcare professionals, investigating their experiences of rehabilitation for this patient group and describing commonly identified barriers under key themes. The interviews gauged the views of eight healthcare professionals representing three professions in different settings, including hospital and community based. The resultant barriers fell under the following themes: professional knowledge and behaviours; services and systems; and the disease and its effects. Suggested solutions were wide ranging and included education, multidisciplinary meetings and specialist clinicians to co-ordinate care. The barriers to accessing rehabilitation for this group of patients are complex, but some of the solutions could be reached through education and co-ordination of services. Further research into the benefits of, and access to, rehabilitation for this group of patients is essential to ensure that patients with brain tumours are given opportunity to gain from the benefits of rehabilitation in the same way as other diagnoses, both cancer and non-cancer. [ABSTRACT FROM PUBLISHER]

Background: Immunodeficiency in ataxia telangiectasia (A-T) is less severe in patients expressing some mutant or normal ATM kinase activity. We, therefore, determined whether expression of residual ATM kinase activity also protected against tumour development in A-T.Methods: From a total of 296 consecutive genetically confirmed A-T patients from the British Isles and the Netherlands, we identified 66 patients who developed a malignant tumour; 47 lymphoid tumours and 19 non-lymphoid tumours were diagnosed. We determined their ATM mutations, and whether cells from these patients expressed any ATM with residual ATM kinase activity.Results: In childhood, total absence of ATM kinase activity was associated, almost exclusively, with development of lymphoid tumours. There was an overwhelming preponderance of tumours in patients <16 years without kinase activity compared with those with some residual activity, consistent with a substantial protective effect of residual ATM kinase activity against tumour development in childhood. In addition, the presence of eight breast cancers in A-T patients, a 30-fold increased risk, establishes breast cancer as part of the A-T phenotype.Conclusion: Overall, a spectrum of tumour types is associated with A-T, consistent with involvement of ATM in different mechanisms of tumour formation. Tumour type was influenced by ATM allelic heterogeneity, residual ATM kinase activity and age. [ABSTRACT FROM AUTHOR]

Background: Brain tumours account for <2% of all primary neoplasms but are responsible for 7% of the years of life lost from cancer before age 70 years. The latest survival trends for patients with CNS malignancies have remained largely static. The objective of this study was to evaluate the change in practice as a result of implementing the Improving Outcomes Guidance from the UK National Institute for Health and Clinical Excellence (NICE).Methods: Patients were identified from the local cancer registry and hospital databases. We compared time from diagnosis to treatment, proportion of patients discussed at multidisciplinary team (MDT) meetings, treatment received, length of inpatient stay and survival. Inpatient and imaging costs were also estimated.Results: Service reconfiguration and implementation of NICE guidance resulted in significantly more patients being discussed by the MDT--increased from 66 to 87%, reduced emergency admission in favour of elective surgery, reduced median hospital stay from 8 to 4.5 days, increased use of post-operative MRI from 17 to 91% facilitating early discharge and treatment planning, and reduced cost of inpatient stay from £2096 in 2006 to £1316 in 2009. Patients treated with optimal surgery followed by radiotherapy with concomitant and adjuvant temozolomide achieved outcomes comparable to those reported in clinical trials: median overall survival 18 months (2-year survival 35%).Conclusions: Advancing the management of neuro-oncology patients by moving from an emergency-based system of patient referral and management to a more planned elective outpatient-based pattern of care improves patient experience and has the potential to deliver better outcomes and research opportunities. [ABSTRACT FROM AUTHOR]

Background: Recent UK clinical guidance advises against continuing trastuzumab (T) beyond disease progression (PD) in the absence of brain metastases in patients with HER-2 positive (+ve) advanced breast cancer .We have retrospectively evaluated the outcome of patients with HER-2+ve locally advanced (LA) or metastatic breast cancer (MBC) who continued T beyond PD, treated in our unit.Methods: All HER-2+ve patients on our prospectively maintained database with LA or MBC who received T beyond PD after adjuvant or one line of T for advanced disease were assessed for response and outcome. From the timepoint of T continuation beyond PD, we calculated the overall disease control rate, time to progression (TTP), and overall survival (OS).Results: One hundred and fourteen patients with HER-2+ve LA or MBC treated with T beyond PD were identified. The main site of disease was visceral in 84 (74%) patients. Seventy-six (66%) had one line of chemotherapy before continuation of T beyond PD and 21 (19%) had two or more. Post-progression, 66 (58%) received T combined with chemotherapy. Of the 93 (82%) patients with documented clinical or radiological response evaluation, 67 (59%) were considered as having stable disease or better. The median TTP was 24 weeks (95% CI: 21-28) and the median OS was 19 months (95% CI: 12-24).Conclusion: Our results from an unselected group of patients provide additional evidence that continuation of T beyond PD is of clinical benefit. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To compare the frequency of brain tumor signs and symptoms in children with and without brain tumors. METHODS: This was a UK population-based retrospective analysis of primary care records. Participants were 195 children (1-14 years) newly diagnosed with brain tumors and 285 controls matched by age, gender, and region. Comparisons included total number of prediagnosis consultations, number with ⩾1 symptom suggestive of a brain tumor, total number of symptoms, number of different symptoms, and number of visits with specific combinations of symptoms. RESULTS: On average, cases consulted more often than controls between birth and diagnosis/pseudodiagnosis with brain tumor signs and symptoms. Their consultation rate with ⩾1 suggestive symptom escalated in the 2 years before diagnosis. Symptom prevalence was higher among cases than controls, a relative difference of 3.29 times as many consultations with ⩾1 suggestive symptom (95% confidence interval [Cl]: 2.82-3.83) and 7.01 as many with more than 1 (95% Cl: 5.38-9.13). In each 6-month period in the 4 years before diagnosis, cases had at least twice as many consultations with ⩾1 suggestive symptom (20.81 times as many in the 6 months before diagnosis [95% Cl: 14.29-30.301) and 2-3 times more records of suggestive symptoms (28.35 times more in the 6 months before diagnosis [95% Cl: 19.05- 42.19]). Symptoms rarely or not observed among control children included head tilt, odd head movements, odd posture, back or neck stiffness, and unsteadiness without obvious cause. CONCLUSION Key to identifying the 1 child among many who merits prompt investigation is recognition of unusual symptoms, or specific symptom patterns. [ABSTRACT FROM AUTHOR]

Background: Epigenetic silencing of O(6)-methylguanine-DNA-methyltransferase (MGMT) by promoter methylation is associated with improved survival in glioblastomas treated with alkylating agents. In this study, we investigated MGMT promoter methylation in glioblastomas treated with temozolomide and radiotherapy in a single UK treatment centre.Methods: Quantitative methylation data at individual CpG sites were obtained by pyrosequencing for 109 glioblastomas.Results: Median overall survival (OS) was 12.4 months with 2-year survival of 17.9%. Pyrosequencing data were reproducible with archival samples yielding data for all glioblastomas. Variation in methylation patterns of discrete CpG sites and intratumoral methylation heterogeneity were observed. A total of 58 out of 109 glioblastomas showed average methylation >non-neoplastic brain in at least one clinical sample; 86% had homogeneous methylation status in multiple samples. Methylation was an independent prognostic factor associated with prolonged progression-free survival (PFS) and OS. Cases with methylation more than 35% had the longest survival (median PFS 19.2; OS 26.2 months, 2-year survival of 59.7%). Significant differences in PFS were seen between those with intermediate or high methylation and unmethylated cases, whereas cases with low, intermediate or high methylation all showed significantly different OS.Conclusions: These data indicate that MGMT methylation is prognostically significant in glioblastomas given chemoradiotherapy in the routine clinic; furthermore, the extent of methylation may be used to provide additional prognostic stratification. [ABSTRACT FROM AUTHOR]

Primary tumours of the meninges occur extremely rarely in children and young people (less than five new cases annually in the UK) and have remained a poorly defined group compared with the common diagnosis of meningiomas in adults. Because of the rarity in children, paediatric meningiomas are often treated according to the adult practice. This may lead to inappropriate treatment considerations since paediatric meningiomas exhibit peculiarities that distinguish them from their adult counterpart. Striking the balance between late toxicities of adjuvant radiotherapy on the growing brain versus the risk of repeated recurrences necessitating surgical interventions in young patients is of importance and will require a clinical decision making process in the paediatric neuro-oncological/neurosurgical MDT tailored to each patient's age and clinical setting. The paediatric literature is based on small, single institution retrospective studies over extensive time periods during which the imaging facilities, pathological criteria and surgical advances have led to shifts in definitions of disease making comparison of results difficult to interpret. These guidelines have been developed following a comprehensive appraisal of the literature. Primary treatment is surgical resection. Careful pathological review and multidisciplinary discussions should be undertaken before considering postoperative treatment, such as radiotherapy for histologically anaplastic or clinically aggressive, relapsing meningioma. [ABSTRACT FROM AUTHOR]

A model assessment of the poorly controlled adolescent with asthma was expected to be completed in 10 minutes but in practice would take at least 30 minutes.[11] SP , sp [12] Primary care paediatricians could revolutionise the workforce in child health Primary care paediatricians would be a popular option for many doctors who enjoy paediatrics and child health but who do not want to pursue the long programme (8 years) of hospital-based training to become a paediatrician. 9 European Confederation of Primary Care Paediatricians, Curriculum in primary care paediatrics. [Extracted from the article]

Neurofibromatosis type 1 (NF1) is an autosomal dominant condition affecting around one in 3000 live births. The manifestations of this condition are extremely variable, even within families, and genetic counselling is consequently difficult with regard to prognosis. Individuals with NF1 are acknowledged to be at increased risk of malignancy. Several studies have previously attempted to quantify this risk, but have involved relatively small study populations. We present prospective data from 448 individuals with NF1 with a total of 5705 years of patient follow-up. These data have been collected via the UK NF1 association for patients. Demographic information on the affected individuals was cross-referenced with UK cancer registry data by the UK Office of National Statistics. The overall risk of cancer was 2.7 times higher in this cohort of NF1 patients than in the general population (95% confidence interval (CI) 1.9-3.7). The cumulative risk of a malignancy by age 50 years was 20% (95% CI 14-29%); beyond this age, the risk of cancer was not significantly elevated (P=0.27). The most frequent types of cancer were connective tissue (14% risk by age 70, 95% CI 7.8-24%) and brain tumours (7.9, 95% CI 3.9-16%). There was no statistically significant excess of cancers at other sites (P=0.22). [ABSTRACT FROM AUTHOR]

Objective: To determine the presenting features of brain tumours in children. Design: Retrospective case note review. Setting: Paediatric and neurosurgical services at the Wessex Neurology Centre and Southampton General Hospital, UK. Patients: 200 patients presenting with a CNS tumour between 1988 and 2001. Results: The commonest first presenting symptoms were headache (41%), vomiting (12%), unsteadiness (11%), visual difficulties (10%), educational or behavioural problems (10%), and seizures (9%). The commonest symptoms occurring at any time were headache (56%), vomiting (51%), educational or behavioural problems (44%), unsteadiness (40%), and visual difficulties (38%). Neurological signs were present at diagnosis in 88%: 38% had papilloedema, 49% cranial nerve abnormalities, 48% cerebellar signs, 27% long tract signs, 11% somatosensory abnormalities, and 1 2% a reduced level of consciousness. The median symptom interval was 2.5 months (range 1 day to 120 months). A short symptom interval was significantly associated with high grade tumours and patient age of 3 years or younger. Conclusions: The well known predominance of headache in children with CNS tumours is confirmed. Visual, behavioural, and educational symptoms were also prominent. With the exception of seizures, every initial symptom was accompanied by other symptoms or signs by the time of diagnosis. Questions about visual symptoms and educational or behavioural difficulties, as well as the more widely recognised symptoms of raised intracranial pressure and motor dysfunction, are important in the diagnosis of brain tumours, as are vision assessment and the appropriate plotting of growth and head size. [ABSTRACT FROM AUTHOR]

The management of malignant brain tumours comprises a huge financial burden to any health care system. The referral pattern and initial management of this condition has not been widely investigated. Our main aim was to investigate and compare the referral patterns between two tertiary referral centres in Birmingham, UK, and Toronto, Canada, which have similar health care provision structures, but different financial resources, in order to examine whether there are any significant delays in the pathway of either system. The investigation consisted of a retrospective analysis of case records of patients identified as having malignant brain tumours who had been operated on at the two centres during the period 1997 - 1998. Data were collected on patient demographics, symptomatology at presentation, referral pattern, and time intervals between presentation, investigations, neurosurgical consultation and operation. Mann - Whitney U-tests of statistical significance were used to compare the two centres. Sixty-eight and 100 patients in Birmingham and Toronto, respectively, were identified from the registers following exclusion of patients with benign or low-grade tumours. Both centres were found to be similar with respect to sociodemographic factors of patients with malignant brain tumours. Referral patterns were analysed for presenting symptoms of neurological deficit and seizure, and found to be similar for both centres. Time intervals from presentation to investigation and from investigation to neurosurgical consultation were not significantly different between the two centres. Significant differences were found from neurosurgical consultation to operation (Birmingham, 3 days, and Toronto, 6 days, p 0.006), and the duration of stay in hospital (Birmingham, 11 days, and Toronto, 2 days, p < 0.001). Although there are differences in the financial resources of the two tertiary centres our study reveals no significant differences in the referral pathway to operation. [ABSTRACT FROM AUTHOR]

Abstract: Brain tumours account for about 20 cases per 100,000 population per year in the UK. The largest group are metastatic tumours from common primary tumours, such as lung, breast, kidney, thyroid, and, increasingly, melanoma. The incidence of brain tumours in the UK has increased over the last 10 years. Intrinsic tumours (7–10 per 100,000 population per year in the UK) arise from glial cells (e.g. astrocytes, oligodendrocytes) and give rise to gliomas. Some patient groups have genetic abnormalities that give a lifelong risk of glial or other tumours (e.g. neurofibromatosis, tuberous sclerosis). Most tumours, however, occur sporadically. Commonly, glial tumours in young patients arise as low-grade tumours that accumulate more chromosomal mutations with a more aggressive phenotype over time. Older patients tend to present with high-grade glial tumours (usually glioblastoma, Figure 1). [Copyright &y& Elsevier]

The aim of the study was to determine current U.K. neuro-oncology practice. A questionnaire was sent to all U.K. clinical oncologists who treat primary brain tumours. Results were distributed to these doctors with an invitation to attend a workshop in September 2000 to debate areas of differing practice and to review the existing related evidence. A further workshop was held in May 2002. The questionnaire responses and discussion of controversial areas, including the management of high-grade gliomas, low-grade gliomas, meningiomas, pituitary adenomas and multiple-brain metastases are included in this paper. [Copyright &y& Elsevier]

Studies the developing adjuvant therapies in the treatment of brain tumors in Great Britain. Clinical features of brain tumors; Citations of common occurred tumors; Improvements in treatments and its clinical outcome.

The article focuses on intracranial tumors of childhood in Great Britain. Here, the biological and clinical spectrum of tumors occurring in early life have been investigated. Furthermore, some of the implications for treatment in these diseases will be reviewed. Among the tumors that are discussed in this article are craniopharyngioma, optic pathway gliomas and cerebellar astrocytomas.

The article presents case studies of frontal brain tumor with psychiatric diagnosis in Great Britain. Cases on frontal brain tumor were presented with psychiatric and neurological symptoms. The first case study depicts on the case of a 43-year-old Czechoslovakian man with progressive dementia of presenile type, his case was presented as reactive depression because of marital discord. Second case study shows the case of a 56-year-old women who was diagnosed to have a large olfactory groove meningioma on both frontal lobes. The third case history demonstrates the case of a 49-year-old woman with a four-week history of right frontal headache. Furthermore, the need of general practitioner, social worker, mental welfare officer plays a vital role in the diagnosis and treatment of these cases.

This work proposes a novel framework for brain tumor segmentation prediction in longitudinal multimodal MRI scans, comprising two methods; feature fusion and joint label fusion (JLF). The first method fuses stochastic multi-resolution texture features with tumor cell density feature to obtain tumor segmentation predictions in follow-up timepoints using data from baseline pre-operative timepoint. The cell density feature is obtained by solving the 3D reaction-diffusion equation for biophysical tumor growth modelling using the Lattice-Boltzmann method. The second method utilizes JLF to combine segmentation labels obtained from (i) the stochastic texture feature-based and Random Forest (RF)-based tumor segmentation method; and (ii) another state-of-the-art tumor growth and segmentation method, known as boosted Glioma Image Segmentation and Registration (GLISTRboost, or GB). We quantitatively evaluate both proposed methods using the Dice Similarity Coefficient (DSC) in longitudinal scans of 9 patients from the public BraTS 2015 multi-institutional dataset. The evaluation results for the feature-based fusion method show improved tumor segmentation prediction for the whole tumor(DSC WT = 0.314, p = 0.1502), tumor core (DSC TC = 0.332, p = 0.0002), and enhancing tumor (DSC ET = 0.448, p = 0.0002) regions. The feature-based fusion shows some improvement on tumor prediction of longitudinal brain tumor tracking, whereas the JLF offers statistically significant improvement on the actual segmentation of WT and ET (DSC WT = 0.85 ± 0.055, DSC ET = 0.837 ± 0.074), and also improves the results of GB. The novelty of this work is two-fold: (a) exploit tumor cell density as a feature to predict brain tumor segmentation, using a stochastic multi-resolution RF-based method, and (b) improve the performance of another successful tumor segmentation method, GB, by fusing with the RF-based segmentation labels. [ABSTRACT FROM AUTHOR]

The article discusses methods for diagnosing adult primary brain tumors. Topics include a Great Britain House of Commons Select Committee report indicating impact of brain tumors on patients and their families; lower success of prognosis for primary brain tumors; multiple primary care consultations of adults diagnosed with cancer; and a 2015 National Institute for Health and Care Institute (NICE) guideline on the diagnosis.

Background: Glioblastomas (GB) are the most common and lethal primary brain tumors. Significant progress has been made toward identifying potential risk factors for GB and diagnostic and prognostic biomarkers. However, the current standard of care for newly diagnosed GB, the Stupp protocol, has remained unchanged for over a decade. Large-scale translational programs based on a large clinicobiological database are required to improve our understanding of GB biology, potentially facilitating the development of personalized and specifically targeted therapies. With this goal in mind, a well-annotated clinicobiological database housing data and samples from GB patients has been set up in France: the French GB biobank (FGB).Methods: The biobank contains data and samples from adult GB patients from 24 centers in France providing written informed consent. Clinical and biomaterial data are stored in anonymized certified electronic case report forms. Biological samples (including frozen and formalin-fixed paraffin-embedded tumor tissues, blood samples, and hair) are conserved in certified biological resource centers or tumor tissue banks at each participating center.Results: Clinical data and biological materials have been collected for 1087 GB patients. A complete set of samples (tumor, blood and hair) is available for 66%, and at least one frozen tumor sample is available for 88% of the GB patients.Conclusions: This large biobank is unique in Europe and can support the large-scale translational projects required to improve GB care. Additional biological materials, such as peritumoral brain zone and fecal samples, will be collected in the future, to respond to research needs. [ABSTRACT FROM AUTHOR]

This article discusses findings from a report by the Brain Tumour Charity on the experiences of treatment and care in the UK of more than 1,000 people with low and high-grade tumours. The report highlights the positive effects of access to clinical nurse specialists on symptom management, mental health and wellbeing. However, it notes that patients with low-grade tumours do not receive equity of access. The survey recommends that the government and health bodies review the number of nurses specialising in the care of patients with brain tumours. [ABSTRACT FROM AUTHOR]