bluuebunny/crossref_metadata_2025 huggingface dataset:
INCREASED NAIL AND HAIR GROWTH IN A PATIENT WITH AIDS
Authors: Harindra V , Sivapalan S , Roy R Basu
Published: April 2023

SUMMARY A variety of nail and hair changes have been described in AIDS patients, but rapid nail growth has not previously been reported. A slowing of nail growth would be expected in these patients due to immunosuppression and possible malnutrition. We report a case of increased nail and hair growth in a man with AIDS.
THE INCIDENCE OF FIRST‐DOSE HYPOTENSION WITH QUINAPRIL IN PATIENTS WITH MILD TO MODERATE HYPERTENSION
Authors: MacLean D , Maton SM , Bibby AJ , Eminton Z
Published: April 2023

SUMMARY A total of 2242 patients with mild to moderate hypertension (diastolic pressure 95–120 mmHg) were randomised on a double‐blind basis to receive a single dose of placebo, 5 mg quinapril or 10 mg quinapril. Patients were identified who: (a) met the blood pressure (BP) criteria for first‐dose hypotension (sitting or standing systolic BP <100 mmHg, or a fall in systolic BP ≥20 mmHg on standing); (b) had symptoms suggestive of hypotension; and (c) met the BP criteria and had symptoms. In all three classifications there were no statistically significant differences between the incidences in placebo and combined active treatment groups, or between those in the two quinapril groups. No associated serious adverse events were reported. In the low‐risk population studied, it would appear that the incidence of first‐dose hypotension with quinapril is similar to placebo and is not dose‐related.
HEPATIC ARTERY ANEURYSM: AN UNUSUAL PRESENTATION
Authors: Alexander DJ , Madan M
Published: April 2023

SUMMARY The natural history of visceral artery aneurysms, and in particular those of the hepatic artery, is unclear. The clinical presentation can include upper abdominal pain, bleeding into the gastrointestinal tract, and obstructive jaundice. We present the case of a middle‐aged woman with right upper quadrant pain and a palpable mass, in whom a thrombosed hepatic artery aneurysm was found to be the cause.
COMMON FEMORAL ARTERY FENESTRATION IN THE TREATMENT OF THORACIC AORTIC DISSECTION
Authors: Andrews BT , Perry PM
Published: April 2023

SUMMARY Although dissection of the thoracic aorta is a common aortic emergency, little has been written about fenestration procedures to revascularise femoral arteries that have been occluded by dissecting aneurysms arising from as high as the thoracic aorta.
PARTIAL MALROTATION ASSOCIATED WITH PSEUDO‐OBSTRUCTION OF THE SMALL BOWEL
Authors: Singh G , Hershman MJ , Loft DE , Payne‐James J , Shorvon PJ , Lovell D , Misiewicz JJ , Menziesgow N
Published: April 2023

SUMMARY Intestinal pseudo‐obstruction is defined as a syndrome in which there are signs and symptoms of intestinal obstruction without an actual obstructing lesion.1,2 In many cases it is associated with other disease entities but may be idiopathic.3 We report a case associated with partial malrotation of the gut which has not been described in the literature before.
TWENTY YEARS' EXPERIENCE OF MYOCARDIAL INFARCTION: THE VALUE OF A HEART ATTACK REGISTER
Authors: Gray D , Hampton JR
Published: April 2023

SUMMARY Registers of disease serve a multitude of purposes, but are of particular importance to those interested in audit, in monitoring the introduction of new treatment or training programmes, in health service research, and in the planning of hospital services. The Nottingham Heart Attack Register has been in operation since 1973 and is proving to be an important data source. We present a brief history of the Register, describe how to set up a disease register and demonstrate how it can be of value to a wide range of health service staff using examples from our experience.
POSTMYOCARDIAL INFARCTION VENTRICULAR SEPTAL RUPTURE IN THE THROMBOLYTIC ERA: TWO‐YEAR EXPERIENCE AT A REGIONAL CENTRE
Authors: Martin PJ , McCance AJ
Published: April 2023

SUMMARY We review the 2‐year experience in one cardiology unit of postmyocardial infarction ventricular septal rupture. Between July 1990 and July 1992 there were 23 such patients for whom records were available, 20 of whom underwent surgical repair. The overall mortality was 48%, and the operative mortality was 40%. The mortality in patients who suffered septal rupture within 48 hours of acute myocardial infarction was 82%, while in those in whom rupture was delayed for more than 48 hours the mortality was 17% (P<0.001). Despite a local thrombolytic rate of 75% in acute myocardial infarction, only 5 out of 23 had received thrombolytic therapy. In this centre, postinfarction septal rupture is a common reason for emergency referral. Survival in those presenting more than 48 hours after infarction is good; in those presenting earlier the prognosis remains poor, despite surgery.
CEREBRAL ASPERGILLOSIS
Authors: Soub H Al , Iskander S , Uwaydah AK
Published: April 2023

SUMMARY A fatal case of cerebral aspergillosis is described in a patient with bronchial asthma maintained on beclomethasone inhalation therapy.
SPONTANEOUS CHOLECYSTCUTANEOUS FISTULAE SECONDARY TO CALCULOUS CHOLECYSTITIS
Authors: Mymin JS , Watkins RM
Published: April 2023

SUMMARY Spontaneous external biliary fistulae tend to occur in elderly patients, often those with systemic diseases. Cholecystectomy and fistulectomy is not always required or even appropriate.
LATE‐ONSET EPILEPSY
Authors: Hildick‐Smith M
Published: April 2023

SUMMARY The incidence of epilepsy rises progressively in old age. However, with good control of fits and sensible advice, elderly epileptic patients can be supported and helped to maintain an appropriate level of independence in their own homes.
PHARMACOLOGICAL TREATMENT OF DIABETIC PERIPHERAL NEUROPATHY: CHALLENGES AND POSSIBILITIES
Authors: Schoemaker JH
Published: April 2023

SUMMARYPeripheral neuropathy is a well‐recognised late complication in both insulin‐dependent and non‐insulin‐dependent diabetes. However, its exact cause remains unknown. Various pathogenic mechanisms have been proposed as an explanation for the development of nerve fibre damage and associated sensory loss in this disease. As a result, many kinds of drugs are currently under evaluation for the treatment of diabetic peripheral neuropathy. This paper describes the rationale behind the usage of all these drugs and reviews major clinical and preclinical results published so far. Supplementary intake of such natural, non‐toxic compounds as vitamin constituents, linoleic acid and flavonoids is encouraged, as well as strict control of hyperglycaemia, until the efficacy of one or another experimental drug is established.
VERTEBRAL OSTEOMYELITIS IN QATAR
Authors: Soub H Al , Uwaydah AK , Hussain AH
Published: April 2023

SUMMARY Twenty‐eight cases of vertebral osteomyelitis were diagnosed at Hamad General Hospital in Qatar between January 1988 and December 1991:16 (57.2%) cases were tuberculous spondylitis, 6 (21.4%) Brucella spondylitis, 3 (10.7%) Staphylococcus aureus spondylitis, 2 (7.1%) Salmonella spondylitis, and 1 (3.6%) Pseudomonas cepacia spondylitis. Plain vertebral x‐ray films and CT scans were abnormal in all patients. Bone and gallium scans were abnormal in 87.5% and 64% of cases respectively. Clinical manifestations, haematological and radiological investigations were not able to differentiate between the causes. Serological tests were helpful in diagnosing Brucella spondylitis. CT‐guided needle biopsy was able to identify the aetiology in 90% of cases. We conclude that invasive tests are still needed to establish the microbiological diagnosis and to guide antimicrobial therapy in most cases of vertebral osteomyelitis.
DIAPHRAGMATIC PARALYSIS IN MOTOR NEURONE DISEASE: USE OF NON‐INVASIVE INVESTIGATIVE AND THERAPEUTIC TECHNIQUES
Authors: Sridhar MK , Anderson K , Weir A , Moran F , Banham SW
Published: April 2023

SUMMARY Two cases of bilateral diaphragmatic weakness are described in which the condition was the presenting feature of motor neurone disease. Inspiratory muscle strength was assessed by a non‐invasive technique involving measurements of pressures generated within the mouth. One patient with severe inspiratory muscle weakness is being treated with domiciliary nasal ventilation and has returned to a good‐quality life. The other patient with less severe weakness has thus far required no ventilatory support.
PROSTATIC CANCER PRESENTING AS DYSPHAGIA
Authors: Green JSA , Tomkinson A , Matanheua SS , Peeling WB
Published: April 2023

SUMMARY Neurological dysfunction from base of skull metastasis of prostate cancer is rare. In this case, dysphagia was the presenting symptom and relief occurred after orchidectomy. Improvement of neurological symptoms usually occurs only after local radiotherapy.
POSTOPERATIVE UPPER GASTROINTESTINAL BLEEDING ASSOCIATED WITH ISCHAEMIC ULCERATION OF THE DUODENUM
Authors: Yakubu A , Baildam A , Taylor TV
Published: April 2023

SUMMARY A rare case is reported of massive postoperative bleeding associated with ischaemic ulceration of the duodenum.
ISOTOPE RENOGRAPHY IN THE INVESTIGATION OF RENAL ARTERY STENOSIS IN HYPERTENSIVE PATIENTS
Authors: Prasad N , Wheeldon NM , MacDonald TM
Published: April 2023

SUMMARY Isotope renography is a commonly used investigation for the detection of renal artery stenosis (RAS) in hypertensive patients, although its predictive accuracy is poor in an unselected population with a low prevalence of RAS. The aim of the present study was to identify characteristics of hypertensive patients that raise the clinical suspicion of underlying RAS, and which are predictive of an abnormal isotope renogram. The characteristics of 75 patients who had undergone either conventional or ACE‐inhibitor‐enhanced renography were retrospectively assessed and correlated with the renogram results. The presence of a raised serum creatinine, severe systolic hypertension at presentation and the requirement for triple drug therapy best predicted abnormalities on renography. However, it would appear that the false‐positive rate of this investigation is high and its predictive accuracy is poor even in a highly selected group of patients. We conclude that isotope renography is of no practical value in the screening of hypertensive patients for RAS. Renal angiography remains the investigation of choice.
CEFUROXIME AXETIL IN THE TREATMENT OF BRONCHITIS: COMPARISON WITH AMOXYCILLIN IN A MULTICENTRE STUDY IN GENERAL PRACTICE PATIENTS
Authors: Shah SH , Shah IS , Turnbull G , Cunningham K
Published: April 2023

SUMMARY Cefuroxime axetil 250 mg twice daily and amoxycillin 250 mg three times daily were compared in an investigator‐blind, randomised, parallel group, multicentre study of acute or acute‐on‐chronic bronchitis. The two compounds had broadly similar efficacy. Analysis of patients on an intention‐to‐treat basis 24‐72 hours after completion of the course of study medication showed that amoxycillin afforded clinical cure or improvement in 123/153 (80.4%) of patients and cefuroxime axetil in 109/143 (76.2%). This result was not significantly different, but the amoxycillin cure rate was not sustained and there were significantly more clinical relapses during the 4‐week follow‐up period following the end of treatment. Only 4/68 (5.9%) of patients receiving cefuroxime axetil relapsed and required further treatment, whereas 16/77 (20.8%) of those receiving amoxycillin needed further treatment (P=0.016). These were all patients who had initially responded to treatment and had been adjudged clinically cured or improved. The significant difference in relapse rates suggests that the apparent clinical success with amoxycillin was not sustained. There were no differences between the two treatments in the numbers of patients experiencing adverse events, which were generally mild and transient.
OESOPHAGEAL FOREIGN BODY PRESENTING WITH PARADOXICAL RESPIRATORY SYMPTOMS
Authors: Martin‐Hirsch DP , Newbegin CJR
Published: April 2023

SUMMARY Two cases are described of oesophageal foreign body impaction presenting with respiratory symptoms.
REVERSAL OF VASECTOMY AND THE GENERAL SURGEON
Authors: White AET , Sheridan WG , Crosby DL
Published: April 2023

SUMMARY Reversal of vasectomy is a difficult procedure. Most surgeons still perform a macroscopic vasovasostomy. However, there is a little guidance in the current literature on the results that can be expected from such procedures. Patients may therefore be given unrealistic expectations preoperatively. Our study shows the results of macroscopic reversals of vasectomy performed over a 9‐year period. A survey of Welsh surgeons is also presented concerning their preferred techniques and estimated success rates for reversals. The study clearly shows that a macroscopic vasovasostomy is the commonest method employed, with a wide variation in estimated success rates. Patients considering a macroscopic reversal of vasectomy should be warned of a less than 20% success rate.
DOCTORS, NURSES, AND TRAINING IN THE ADMINISTRATION OF INTRAVENOUS DRUGS
Authors: Hardern R , Sutcliffe J , Catto A , Pope R
Published: April 2023

SUMMARY To assess the knowledge of staff and the effect of formal training on house officers we conducted telephone questionnaires of 40 house officers and 18 nurses. The following points were assessed: knowledge of dilution of drugs; knowledge of the rate at which drugs should be given; and the rate at which drugs were given. Appropriately trained nurses had greater knowledge than ‘untrained’ house officers. In all, 17/18 (94%) nurses compared with 9/18 (50%) house officers knew the correct rate at which to give ampicillin (P=0.0036, Fisher's exact test); 14/18 (78%) nurses and 1/18 (6%) house officers said they gave ampicillin at the correct rate (P<0.001); 13/18 (72%) nurses and 7/18 (39%) house officers said they gave ranitidine at the correct rate (P=0.037).

Only 1 of the 10 house officers who knew how rapidly to administer ampicillin said they took the correct length of time; 6 of the 10 who knew how rapidly to give ranitidine said they gave it at the correct rate. Training improves the knowledge of house officers, but other factors besides lack of knowledge (possibly lack of time) adversely affect delivery of intravenous drugs.
SURVEY OF CARDIAC ARRESTS AND CARDIAC ARREST TROLLEYS IN A DISTRICT GENERAL HOSPITAL
Authors: King D , Davies KN , Cope CS , Silas JH
Published: April 2023

SUMMARY In a 12‐month period there were 137 cardiac arrests in a district general hospital. Cardiopulmonary resuscitation was instituted within 3 minutes in 82%. Delay in 18% was due to equipment failure. Survival at 6 months was 12%. Of the 18% of inappropriate arrests, 42% had ‘do‐not‐resuscitate’ orders in the casenotes. Survival did not depend on age, sex, location, presence of an anaesthetist, experience of house officer, time of day or admission diagnosis. Survival was more likely in the presence of ventricular fibrillation and absence of intubation. Of the 32 arrest trolleys, 66% were geographically acceptable to the area they served and 9% had significant deficiencies (these were situated in patient waiting areas and were infrequently checked).
PHARMACOTHERAPY OF THE DEPRESSED PATIENT WITH CARDIOVASCULAR AND/OR CEREBROVASCULAR ILLNESS
Authors: Lane RM , Sweeney M , Henry JA
Published: April 2023

SUMMARY Cardiovascular and cerebrovascular disease are associated with a high incidence of depressive disorder. Despite this high level of co‐morbidity, depressive disorders appear to go largely unrecognised and remain untreated. This may have serious consequences, as concomitant depression worsens the prognosis in patients with cardiovascular or cerebrovascular disease, increases medical costs, and delays return to work. Treatment with traditional tricyclic antidepressants is difficult in these patients because of the known cardiac effects. The favourable side‐effect profiles of the 5‐HT reuptake inhibitors suggest that they may offer therapeutic advantages, as they have little or no effect on cardiac conduction, do not cause orthostatic hypotension, and lack serious sequelae in overdose. The pharmacological profiles and the reduced potential of these newer antidepressant drugs to cause drug interaction show important differences that may be of clinical relevance in this patient population.
ASSESSING DYSPEPSIA IN GENERAL PRACTICE
Authors: Cann PA , Gleeson MH , Robinson TJ , Wicks ACB
Published: April 2023

SUMMARY The value of the symptom pattern in achieving an accurate diagnosis in dyspeptic disease is still controversial. A number of investigators have used it to distinguish those patients who are at a high risk of serious disease (ulcer or cancer) from those who are not. Such findings have important implications for patient management, both in clinical and economic terms.
RECTUS SHEATH HAEMATOMA: DIAGNOSIS IS ESSENTIAL
Authors: Johnson RC , Fligelstone LJ , Boyce DE , Salaman JR
Published: April 2023

SUMMARY Three cases of rectus sheath haematoma are treated conservatively with apparent success.
REVERSIBLE HEART BLOCK IN LYME DISEASE
Authors: Clesham GJ , Grant A , Waller D , Davies GJ
Published: April 2023

SUMMARY A case is described of a young man who was referred to a cardiology department with heart block which was found to be due to Lyme disease.
CROHN'S AND SARCOIDOSIS: DIFFERENT MANIFESTATIONS OF THE SAME DISEASE PROCESS?
Authors: Kiely PDW , Rees DHE , Axford JS
Published: April 2023

SUMMARY A case of sarcoidosis manifesting with granulomatous renal impairment is described.
ENCEPHALITIS — AN ADVERSE REACTION TO FENBUFEN
Authors: Crosse BA , Stanley PJ
Published: April 2023

SUMMARY A young woman presenting with encephalitis and a generalised skin rash was thought to have an enteroviral infection. No infectious agent was identified. An adverse reaction to fenbufen, on a background of mixed connective tissue disease, was considered to be the cause of the illness.
DOXAZOSIN IN HYPERTENSION: RESULTS OF A GENERAL PRACTICE STUDY IN 4809 PATIENTS
Authors: Langdon CG , Packard RS
Published: April 2023

SUMMARY The safety and efficacy of the selective α1‐adrenoceptor antagonist doxazosin were evaluated in a 10‐week open, non‐comparative multicentre trial in 4809 hypertensive patients (sitting diastolic blood pressure 95–114 mmHg) in general practice. Multiple coronary risk factors were present in the study population (mean age 58.4 years, 1486 patients ≥65 years) on entry: mean blood pressure was 173/103 mmHg, 21% were cigarette smokers, and baseline blood cholesterol (mean 6.84 mmol/l) exceeded 6.5 mmol/l in 56% and 5.2 mmol/l in 88% of patients. In all, 4385 patients (91%) completed the study, including 89% of those ≥65 years. Blood pressure was controlled (diastolic BP ≤90 mmHg or a reduction ≥10 mmHg) in 81% of patients with a mean reduction of 21/15 mmHg and a mean final daily dose of 2.9 mg doxazosin. Adverse events were reported in 827 patients (17%), were severe in 72 (1.5%), and led to withdrawal in 269 patients (5.7%). Dizziness and related symptoms (6%; severe 1.1%), headache (3.8%) and fatigue (2.6%) were most frequent; dizziness led to study withdrawal in 1.3% of patients. Fainting or syncope occurred in 13 patients (0.3%). Differences in adverse event frequency between younger (<65) and older patients were small (dizziness: younger 5.1%, older 8.1%). Troublesome postural hypotension was uncommon as a clinical problem. Modest but statistically significant reductions occurred in blood total (4.09%) and LDL (5.13%) cholesterol. These results are in accord with those of controlled studies, and help confirm the suitability of doxazosin as part of a multiple risk factor approach to the management of hypertension.
EVALUATING THE USE OF A SEMIAUTOMATED CUFF‐OSCILLOMETRIC SPHYGMOMANOMETER IN THE HYPERTENSION CLINIC
Authors: Prasad N , Wheeldon NM , MacDonald TM
Published: April 2023

SUMMARY Measuring blood pressure in the clinic setting is confounded by ‘white coat’ hypertension, observer bias and digit preference. In this study a semiautomatic blood pressure measuring device (the UA‐751) was tested for its use as a reliable assessment of blood pressure and improved patient management in the hypertension clinic. Blood pressures were recorded in 156 patients and compared with physicians' readings measured using a standard mercury sphygmomanometer. The mean blood pressure differences between the two methods showed that the device gave consistently higher readings for both systolic (1.4‐3.6 mmHg) and diastolic (3.6‐3.8 mmHg) pressure, whether it was used before or after physician consultation. No reduction in ‘white coat’ hypertension was thus apparent. There was considerable variability between recordings made by the two methods on the same individual. Digit preference was apparent with physician readings, with zero recorded in 57.8% of systolic readings compared with 12.2% using the machine. Different management decisions would have been taken in 20 (13.6%) patients had the UA‐751 recordings been used. The device is thus of no value in patient management in the setting of the hypertension clinic.
SELF‐INFLICTED IM INJECTION OF AIR INTO THE HAND
Authors: Kay PR , Paul A , Kurdy NM , Kenny NW
Published: April 2023

SUMMARY A case is presented of deliberate and repeated self‐injection of air into the deep tissues of the hand, leading to the consideration of a diagnosis of gas gangrene and to subsequent hyperbaric oxygen therapy and surgical exploration.
COMMUNITY CARE OUTCOMES
Authors: Black DA , Foster CJ , Maitland N
Published: April 2023

SUMMARY A community care scheme was designed to provide an alternative to residential care by the flexible use of informal paid carers to supplement or replace formal care. We report details of client problems and dependency, outcomes and use of hospital inpatient beds for the first 92 clients. The mean age was 83 years (28 men, 64 women). In all, 88/92 suffered from dementia. The CAPE survey dependency of the clients was A 2%, B 8%, C 23%, D 40%, E 27%. The 1‐year outcome was 50% at home, 25% died, 10% part III, 15% long‐term care; at 3 years: 24% at home, 64% died, 7% part III, 6% long‐term care. In the year before admission to the scheme, 58% were admitted to hospital, totalling 139 patient months in hospital, and in the first year of the scheme 55% were admitted, spending 82 patient months in hospital. Frail elderly people supported at home have a significant mortality and morbidity rate, and continue to need a high use of NHS inpatient resources.
CLINICOPATHOLOGICAL PROFILE OF ABDOMINAL TUBERCULOSIS
Authors: Singh V , Jain AK , Agrawal AK , Gupta S , Khanna S , Khanna AK , Gupta JP
Published: April 2023

SUMMARY The clinical and histopathological profile is presented of 145 patients with abdominal tuberculosis studied prospectively over a period of 5 years. The study highlights the role of various investigations and therapeutic response in this condition.
TRANSDERMAL NON‐STEROIDAL ANTI‐INFLAMMATORY AGENTS
Authors: Grahame R
Published: April 2023

SUMMARY Concern over the scale of morbidity associated with the use of oral non‐steroidal anti‐inflammatory drugs (NSAIDs), particularly in the elderly, has led to the development of alternative strategies for the relief of musculoskeletal and joint pain. One such is to explore the possibility of formulations that bypass the gastrointestinal tract that has proved so vulnerable to the prostaglandin inhibitory effects of NSAIDs. The success of transdermal absorption of such drugs as nicotine, oestrogens, nitrates, clonidine and hyoscine into the bloodstream has added a new dimension to drug therapy. Over the past 15 years some six topical non‐steroidals (T/NSAIDs) have been licensed in the UK, and a number of others are available in other countries or are under investigation. Unlike the case with the drugs mentioned above, where the aim is to achieve a high blood level, comparable to that obtained with the oral formulation, with T/NSAIDs the desired goal is a high local concentration at the site of the lesion with, at the same time, as low a plasma concentration as possible, in order to minimise adverse GI tract or systemic effects. This paper reviews the pharmacokinetic data and the evidence for efficacy and safety, and attempts to assess the place of T/NSAIDs in current medical practice.
ALL THAT WHEEZES IS NOT ASTHMA
Authors: Scott PMJ , Glover GW
Published: April 2023

SUMMARY Insidious upper airway obstruction may be misdiagnosed as asthma. This study illustrates such a case, highlighting the reason for confusion between asthma and upper airway obstruction and discussing investigations to differentiate between the two.
DEEP HAND INFECTION COMPLICATING CHICKENPOX IN AN OTHERWISE HEALTHY INFANT
Authors: Newey ML , Magnussen PA
Published: April 2023

SUMMARY Chickenpox is a common childhood infection, and complications are rare in the healthy child. This report describes a significant complication of varicella in an otherwise healthy infant.
THE METABOLIC AND CARDIOVASCULAR CONSEQUENCES OF HRT
Authors: Stevenson JC
Published: April 2023

SUMMARY Hormone replacement therapy comprises natural oestrogen and, when appropriate, progestogen given to postmenopausal women. Population studies have shown that postmenopausal oestrogen administration results in a marked reduction in cardiovascular disease, particularly coronary heart disease, an effect that does not appear to be lost when cyclical progestogen is also included. The way in which the hormones confer this protection has not been fully elucidated, but it includes effects on metabolic processes that contribute to atheroma formation as well as direct effects on the arteries themselves. Oestrogens and progestogens can produce beneficial changes in lipids and lipoproteins, glucose and insulin metabolism, body fat distribution, and coagulation and fibrinolysis. Oestrogen acts directly on blood vessels through both endothelium‐dependent and calcium‐dependent mechanisms to improve arterial function. More widespread use of HRT could result in a major beneficial impact on cardiovascular disease, the leading cause of death in women.
MILLER FISHER SYNDROME AND ANTI‐GQ1b ANTIBODIES
Authors: Bourke JP , Rogers S , Castleden CM
Published: April 2023

SUMMARY A case is presented of Miller Fisher syndrome in a 77‐year‐old woman. The diagnosis was confirmed by the presence of serum IgG antibody to ganglioside GQ1b. Miller Fisher syndrome, although uncommon, enters the differential diagnosis of brainstem stroke.
RECURRENT CEREBRAL ABSCESSES 20 YEARS BEFORE RECOGNITION OF MULTIPLE PULMONARY ARTERIOVENOUS MALFORMATIONS
Authors: Suresh CG , Coupe MO , Jegarajah S
Published: April 2023

SUMMARY A case is presented of a patient with multiple pulmonary arteriovenous malformations, which were successfully treated by embolisation.
CUTANEOUS SCC: METASTASES WITH A PREDILECTION FOR LUNGS 6 YEARS AFTER EXCISION OF THE PRIMARY TUMOUR
Authors: Panayiotou BN , Aravindan N , Sinha SK , Ryatt K
Published: April 2023

SUMMARY An 80‐year‐old woman developed an ulcerated, moderately differentiated squamous cell carcinoma (SCC) on the lower leg. Despite local excision and radiotherapy, the patient presented 6 years later with multiple lung metastases which were histologically indistinguishable from the original skin tumour. There was no evidence of metastases to lymph nodes or other viscera.
Candido albicans INFECTION COMPLICATING PERCUTANEOUS GASTROSTOMY IN CYSTIC FIBROSIS
Authors: Bell SC , Elborn JS , Campbell IA , Shale DJ
Published: April 2023

SUMMARY Three cases are reported of young adults with cystic fibrosis who had deep fungal infections associated with percutaneous gastrostomy tubes.
NEW THERAPIES FOR RHEUMATOID ARTHRITIS
Authors: Richardson C , Emery P
Published: April 2023

SUMMARY There are two major thrusts in the development of effective treatments in RA: the use and development of entirely new drugs; and the more effective usage of the currently available drugs. This represents a comprehensive review of the pharmacological agents that have been recently developed or will be available in the near future.
FIRST‐LINE TREATMENT IN ACUTE NON‐DYSENTERIC DIARRHOEA: CLINICAL COMPARISON OF LOPERAMIDE OXIDE, LOPERAMIDE AND PLACEBO
Authors: Hughes IW
Published: April 2023

SUMMARY The use of antimicrobial agents for the treatment of acute diarrhoea has become more common with the introduction of quinolone compounds, which are active against most types of bacterial pathogens. Despite the fact that such drugs have been used for empirical therapy or even for prophylaxis, current opinion would restrict their use to specific groups of patients who are likely to show particular benefit from them. Non‐specific therapy seems a more appropriate initial treatment for cases of acute, non‐dysenteric diarrhoea. Clinical trial data are presented here comparing the effects of loperamide oxide 1 and 2 mg to those of placebo and loperamide 2 mg in this condition. All the drug preparations were significantly superior to placebo, in particular reducing the time to complete relief of symptoms to about 24 hours, as opposed to 45 hours on placebo treatment. Of these preparations, loperamide oxide 1 mg is to be preferred, as it produces fewer constipation‐like episodes after treatment. The introduction of loperamide oxide 1 mg represents a useful advance in the non‐specific treatment of acute, non‐dysenteric diarrhoea.
DOES HAEMOSTATIC THERAPY IMPROVE THE PROGNOSIS IN UPPER GASTROINTESTINAL BLEEDING?
Authors: Nikolopoulou V , Katsakoulis E , Thomopoulos K , Tsiotos P
Published: April 2023

SUMMARY A study was conducted of 816 patients with peptic ulcer haemorrhage, comparing outcome before and after the introduction of endoscopic therapy. The control group comprised 505 patients admitted with bleeding due to benign peptic ulcer over a 5‐year period before endoscopic therapy, and 311 patients after introduction of endoscopic therapy were studied prospectively. The two groups were well matched for age, sex, shock, endoscopic findings and use of ulcerogenic drugs. The introduction of endoscopic therapy was associated with a reduction in surgical intervention and mortality rates for gastric and duodenal ulcer. The beneficial effects of endoscopic therapy appear to be due to a reduction in the need for surgical intervention in patients with an ulcer base visible vessel. The authors suggest that endoscopic injection therapy may result in an improved outcome from peptic ulcer haemorrhage. Adrenaline injection treatment seems to be the treatment of choice in view of its simplicity, low cost and availability.
IMPROVING OUTCOME AFTER ACUTE MYOCARDIAL INFARCTION: WHAT IS THE ROLE OF ACE INHIBITORS?
Authors: Purcell H , Coats A , Fox K , Campbell R
Published: April 2023

SUMMARY Acute myocardial infarction continues to be the number 1 killer in industrialised countries. While the more widespread use of thrombolytic therapy has made a dramatic impact on patient survival, changes in long‐term prognosis after discharge from hospital have not improved radically and 5‐year mortality remains at over 30%. The single most important determinant of survival in the long term is left ventricular function. The process of ventricular dilatation and remodelling begins early after infarction. While such changes may initially go unrecognised clinically, without intervention progressive functional impairment will ensue and the majority of patients will develop signs and symptoms of heart failure, which carries a worse prognosis than many forms of cancer. ACE inhibitors act on both the haemodynamic and neurohormonal mechanisms in heart failure. Several large‐scale clinical trials have clearly demonstrated that early use of these agents in stable patients who are not hypotensive or in cardiogenic shock can reduce significantly the development of heart failure and death. A strategy for the early initiation of ACE inhibitor therapy is proposed to improve survival in AMI patients.
HEART FAILURE IN THE ELDERLY PATIENT
Authors: Valacio R , Lye M
Published: April 2023

SUMMARY Both prevalence and incidence of heart failure rise with age. Diagnosis of heart failure in the older patient may be difficult because of atypical symptoms or the acceptance of symptoms as manifestations of old age. Heart failure is not a diagnosis but a syndrome. Echocardiograms should be obtained in most elderly patients to aid diagnosis and assessment. Loop diuretics, taking into account the altered homoeostasis of old age and presence of co‐morbidity, are the mainstay of symptomatic treatment. ACE inhibitors are likely to benefit survival, although formal trials have failed to include many older patients. Digoxin and direct vasodilators are less well tolerated in elderly patients.
FOLLOW‐UP OF PATIENTS WITH SUSPECTED VENOUS THROMBOSIS BUT NEGATIVE RADIONUCLIDE VENOGRAPHY
Authors: Murphy JJ , Chandler ST
Published: April 2023

SUMMARY A retrospective review of the outcome of patients presenting to one district general hospital with suspected deep vein thrombosis (DVT) but normal radionuclide venogram. Of 387 scans, 141 (36%) were reported as positive, 81 (21%) as equivocal, and 165 (43%) as negative. The casenotes of 150 (91%) of those with negative scans were reviewed of which 124 were performed as part of the investigation of suspected DVT. During the next 3 months there were 13 DVTs and 7 with pulmonary emboli in this group, 4 of the latter proving fatal (confirmed at postmortem in 3). From a review of the initial clerking, the pre‐venogram likelihood of DVT was graded as low in 54 (43%), medium in 23 (18%), and high in 45 (36%). DVT or PE occurred in none of those with a low probability, 9% of those with medium, and 38% of those with high probability. The results suggest that radionuclide venography is insufficient to exclude DVT when suspected clinically.
EFFECT OF ALCOHOL ON BODY CORE TEMPERATURE DURING COLD‐WATER IMMERSION
Authors: Roeggla G , Roeggla M , Binder M , Roeggla H , Muellner M , Wagner A
Published: April 2023

SUMMARY This study investigates the influence of alcohol on body core temperature during cold‐water immersion in human volunteers. In this randomised, double‐blind, placebo‐controlled crossover trial, 8 healthy male volunteers were randomised to drink 1 litre of beverage containing 50 g alcohol or placebo before 20°C cold‐water immersion for 1 hour. Body core temperature was measured before cooling and after 1 hour of immersion with an infrared ear thermometer. After a 1‐week interval subjects crossed to the other study branch. In the placebo test, mean temperature decreased after immersion by 0.66°C; after the alcohol mean temperature decreased by 1.0°C (mean difference 0.34, 95% CI 0.14‐0.53, P=0.002).
HEPATITIS AND HIV: INTERRELATIONSHIP AND INTERACTIONS
Authors: Newell A , Francis N , Nelson M
Published: April 2023

SUMMARY Hepatitis in the context of HIV infection is commonplace, but the causative agent is not always readily identifiable. This review highlights the differential diagnosis of hepatitis in that context, examining the interrelationships and interactions between the four main hepatitis viruses and HIV.
DRUGS AFFECTING THE LEUKOTRIENE PATHWAY IN ASTHMA
Authors: Barnes NC , Kuitert LM
Published: April 2023

SUMMARY Drugs affecting the leukotriene pathway are emerging as a new class of asthma treatment — the first for more than 20 years. Development of these leukotriene antagonists should lead to greater understanding of the underlying processes in asthma and may result in a safe, oral, anti‐asthmatic drug to benefit particular groups of asthmatic patients.
C. albicans SEPTIC ARTHRITIS IN A PATIENT WITH AIDS
Authors: Smith NA , Keat ACS , Barton SE
Published: April 2023

SUMMARY This is the first case reported of recurrent Candida albicans septic arthritis in an HIV‐positive man who was not an injecting drug user.
FAT ARMS, OBESITY AND CHOICE OF BLOOD PRESSURE CUFF SIZE IN DIABETIC PATIENTS
Authors: Feher MD , Cox A , Foxton J , Lant AF
Published: April 2023

SUMMARY Four hundred consecutive diabetic patients had their mid‐arm circumference (AC) measured and body mass index (BMI) calculated to determine the proportion of an unselected clinic group who would require a larger than standard adult blood pressure (BP) cuff and whether or not BMI could be used to predict AC and hence choice of appropriate BP cuff size. More than 75% of both men and women had an AC ≥29cm, justifying a larger than standard adult cuff for their BP measurement. When patients were classified according to their BMI, at least 80% with a BMI ≥30 and more than 70% with a BMI of 25‐29 had a measured AC ≥29cm, while less than a third of patients with a BMI ≥25 had an AC ≥29cm. These results indicate that, in a diabetic clinic, most patients with a BMI ≥25 are likely to require an alternative adult BP cuff if their blood pressure is to be measured precisely.
USE OF ANTIBIOTICS AFTER COMPLEX OPEN HAND INJURY
Authors: Drew PJ , Titley OG
Published: April 2023

SUMMARY A prospective study undertaken to examine bacterial contamination at presentation, frequency and type of antibiotic prescribed, and outcome, in 50 patients presenting with hand injuries of varying severity, is reported. Results of a national survey of trends in antibiotic prescribing for similar wounds in plastic surgery units are also recorded. Preoperative swabs cultured normal flora or no growth. Forty‐eight patients received antibiotics with little consistency in the agent used, route of administration, or length of treatment. Clinical wound infection occurred in three crush injuries. No significant difference in the numbers of surgeons using antibiotics for clean and crushed injuries of all types was demonstrated. The state of the wound, rather than the tissue damaged, seemed to dictate antibiotic use. In dirty wounds, however, damage to deep structures appeared to be an indication for antibiotics — significantly fewer respondents treated dirty injuries of the skin alone. The authors believe that antibiotic use in open hand injury is of no proven benefit, and that this aspect of hand surgery requires further investigation.
HYPOVITAMINOSIS D IN THE HEALTHY ELDERLY
Authors: Keane EM , Healy M , O'Moore R , Coakley D , Walsh JB
Published: April 2023

SUMMARY Hypovitaminosis D is a common finding in the healthy elderly population and has significant sequelae. No clear dietary or sunlight‐related risk factors were identified by dietary assessment and modified outdoor score. Fortified liquid milk and vitamin supplements were associated with significantly higher serum 25‐hydroxyvitamin D levels. These results emphasise the need for foodstuff fortification and supplement use in the healthy elderly, as well as the ‘high‐risk’ housebound and institutionalised elderly.
FALSE‐NEGATIVE LAPAROSCOPY: A PITFALL IN THE DIAGNOSIS OF EARLY ECTOPIC PREGNANCY
Authors: Edozien LC , Pandiarajan T , Ali SW
Published: April 2023

SUMMARY This case highlights the problems and possibilites in the early diagnosis of ectopic pregnancy.
NORMALISATION OF SLOW‐RELAXING TENDON REFLEXES (WOLTMAN'S SIGN) AFTER CARDIAC PACING FOR COMPLETE HEART BLOCK
Authors: Larner AJ
Published: April 2023

SUMMARY A patient whose slow‐relaxing tendon reflexes returned to normal after cardiac pacing for complete heart block is reported. Since the patient was euthyroid, these observations add further weight to previous suggestions that intrinsic catecholaminergic mechanisms, as well as thyroid status, may play a role in the pathogenesis of slow‐relaxing reflexes.
THE LIMA SUCCESS STORY — WHITHER OTHER ARTERIAL GRAFTS — ARE VEIN GRAFTS OBSOLETE ?
Authors: Cooper GJ , Underwood MJ , Deverall PB
Published: April 2023

SUMMARY The long‐term benefit of myocardial revascularisation depends largely upon the continued patency of bypass grafts, but the long‐term patency of vein grafts is poor. To improve the results of myocardial revascularisation, either measures to increase the patency of saphenous vein grafts or alternative conduits are required. Use of the left internal mammary artery as a graft is known to increase survival, and this has prompted wider use of other arterial grafts in the expectation that they will further enhance the long‐term results of coronary artery bypass. This policy is based upon sound theory, but convincing evidence that it improves survival is lacking. Meanwhile, advances in the understanding of the pathology of vein graft occlusion have given rise to new methods of increasing vein graft patency. While these techniques are, as yet, only experimental, if translated into clinical practice, the places of arterial and venous grafts may require further assessment.
STERILE PYURIA: CONSIDER CHLAMYDIAL INFECTION
Authors: Tayal SC , Pattman RS
Published: April 2023

SUMMARY We report the cases of two men referred to a genitourinary medicine clinic with sterile pyuria and subsequently found to have their urethras infected with Chlamydia trachomatis. Chlamydial infection should be considered in the differential diagnosis of sterile pyuria, particularly in young, sexually active males. We discuss the consequences of inadequate treatment of the index case.
TWO‐LEVEL INTERVERTEBRAL DISC HERNIATION IN AN ADOLESCENT
Authors: Schindler OS , Fairbank JCT
Published: April 2023

SUMMARY A two‐level intervertebral disc prolapse is a rare circumstance in adolescents. We describe the case of a 19‐year‐old man who suffered a deceleration trauma and developed simultaneous large intervertebral disc herniations at L4/5 and L5/S1. The aetiology is discussed and, in accordance with the current literature, it is pointed out that clinical findings due to intervertebral disc herniations in young people do not necessarily correspond with the extent of the disease.
HEPATOCELLULAR CARCINOMA PRESENTING AS A SEPTICAEMIA‐LIKE ILLNESS IN AN AFRICAN ADOLESCENT
Authors: Olubodun JOB , Talabi OA
Published: April 2023

SUMMARY Although primary hepatocellular carcinoma (PHC) is quite common in adults in Africa, it is very rare in those under 25. The clinical diagnosis is usually straightforward by the time patients present and it is unusual to encounter differential diagnostic problems. We report an unusual clinical manifestation of PHC at the very young age of 15 years. The case presented clinically as a septicaemia‐like illness that was initially thought to be typhoid. The patient died within 72h of presentation and the true diagnosis was only made at post‐mortem. This case simultaneously highlights several problems commonly encountered in medicine in the developing world: late presentation, self‐medication, and investigative and diagnostic difficulties related to inadequate facilities.
SEVEN COMMON DUCT STONES AT CHOLECYSTECTOMY AFTER A CLEAR DUCT ON ERCP
Authors: Payne SPK , Cohen AS , Mee AS , Ross HB
Published: April 2023

SUMMARY A clear common bile duct at ERCP does not guarantee a clear common bile duct when laparoscopic cholecystectomy is performed at a later date.
A LARGE TRANSMURAL THORACIC LIPOMA EASILY MISTAKEN FOR PULMONARY MALIGNANCY
Authors: Vassallo M , Rana Z , Allen S
Published: April 2023

SUMMARY Lipomas in the thorax are very rare. Most such lesions are asymptomatic and discovered by accident on a chest radiograph. However, radiographic features are non‐specific and can mimic malignancy. We describe the case of an 82‐year‐old woman whose history and chest radiograph suggest a malignant lung tumour. A computed tomography scan of the chest eventually determined the fatty nature of her chest lesion.
SURGERY FOR ASYMPTOMATIC CAROTID ARTERY STENOSIS
Authors: Panayiotopoulos YP , Padayachee ST , Taylor PR
Published: April 2023

SUMMARYThe recent European Carotid Surgery Trial (ECST) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) have clearly defined a population who benefit from carotid artery endarterectomy (CAE). However these trials used different criteria to identify >70% stenosis of the internal carotid artery (ICA). The role of CAE in asymptomatic ICA stenosis has been investigated by the Carotid Artery Stenosis with Asymptomatic Narrowing Operation Versus Aspirin (CASANOVA) study, the Veterans Administration Asymptomatic Carotid Study (VAACS) and the Asymptomatic Carotid Artery Stenosis (ACAS) trials, all of which have design limitations. The Asymptomatic Carotid Stenosis Trial (ACST) is still recruiting patients but until the natural history of asymptomatic ICA disease is understood, the role of surgical intervention will continue to be controversial.
AN ATYPICAL CASE OF ATYPICAL PNEUMONIA
Authors: Lawrence IG , Dalby RJ , Lad NR , Shepherd RJ
Published: April 2023

SUMMARY A 23‐year‐old man, previously fit and well, presented with an atypical pneumonia, associated with microangiopathic anaemia, thrombocytopenia, rhabdomyolysis and renal impairment. Despite administration of intravenous fluids and antibiotics, his condition rapidly deteriorated, and the possibility of an aggressive connective tissue disorder was raised. Thus he was treated with high‐dose oral steroids and plasma exchange until autoantibodies were shown to be negative. At this stage it transpired that the patient had swallowed water from a stream three weeks earlier, and leptospira antibody titres were subsequently found to be elevated. Antibiotics were continued, and after a protracted course he made a full recovery. Leptospirosis should be remembered as a rare cause of atypical pneumonia, particularly if there is associated hepatic or renal impairment.
ACUTE PSYCHOSIS ASSOCIATED WITH ABRUPT WITHDRAWAL OF CARBAMAZEPINE FOLLOWING INTOXICATION
Authors: Darbar D , Connachie AM , Jones AM , Newton RW
Published: April 2023

SUMMARY Carbamazepine is regularly used in the treatment of trigeminal neuralgia. Although exacerbation of psychosis has been described following abrupt discontinuation of carbamazepine in chronic schizophrenics, a withdrawal syndrome has not been reported previously in patients treated for trigeminal neuralgia. The case presented here suggests that abrupt withdrawal of toxic concentrations of carbamazepine may precipitate a withdrawal reaction, which is manifest some days after discontinuation of the drug. Therefore it may be advisable to withdraw therapy slowly in these situations.
ANTIDEPRESSANT THERAPY AND BEHAVIOURAL COMPETENCE
Authors: O'Hanlon JF
Published: April 2023

SUMMARY Major depression can impair an individual's motivation to perform routine daily activities and cause a deterioration in cognitive and psychomotor function. Some antidepressants add to pathological dysfunction through unwanted side‐effects. Although most patients eventually recover as a simultaneous consequence of tolerance and therapeutic response, some may not. Where side‐effects continue to retard normal recovery they can be called behaviourally toxic, which can be classified as disruptive, inhibitory or provocative. Disruptive behavioural toxic effects are measured using either psychometric tests or simulations of real‐life activities (for example, a driving test). There are no widely‐accepted tests for inhibitory or provocative behavioural toxicity, and assessments of antidepressants are made on the basis of case studies. This review summarises the results of psychometric and real‐life simulation tests and compares the effects of antidepressants on behaviour competence. The purpose is to identify those drugs that seem to be the most and least likely to produce behavioural toxicity.
A POST‐MARKETING SURVEILLANCE STUDY OF ®VOLTAROL 75 mg SR IN THE PRIMARY CARE SETTING
Authors: Jones CW
Published: April 2023

SUMMARY A total of 7438 patients suffering from a wide variety of painful conditions was included in the final analysis of a post‐marketing surveillance (PMS) study monitoring the use of Voltarol 75 mg SR in a primary care setting. Follow‐up data were collected at visits conducted one, four and 12 months after the initial consultation. Improvement of symptoms was the most common reason for discontinuation of treatment (47% of patients who discontinued). Adverse events led to the withdrawal of 18% of patients overall. The rate of serious gastrointestinal complications was low (0.4%) and deleterious hepatic or renal effects were not apparent. There were significantly more events experienced by female patients and there was a significant effect of age on severe gastrointestinal events. In this PMS study Voltarol 75 mg SR was used successfully once or twice daily without any unexpected adverse effects in a manner consistent with current recommendations for the use of non‐steroidal anti‐inflammatory drugs.