bluuebunny/crossref_metadata_2025 huggingface dataset:
GLYCOPROTEIN IIB/IIIA ANTAGONISTS: DO THEY HAVE A ROLE IN THE MANAGEMENT OF UNSTABLE ANGINA?
Authors: Redwood S , Marber M , Jackson G
Published: April 2023

Plaque rupture, platelet aggregation and thrombosis have central roles in the pathogenesis of acute coronary syndromes. Despite several trials showing the benefit of aspirin and heparin in patients presenting with unstable angina and acute myocardial infarction, these patients are still at risk. This has prompted the development and evaluation of several new therapeutic agents including low molecular weight heparin, new antiplatelet drugs (e.g. ticlopidine and clopidogrel), direct thrombin inhibitors, and intravenous and oral glycoprotein IIb/IIIa antagonists. The IIb/IIIa receptor is the ‘final common pathway’ involved in platelet aggregation. Thus, whatever the stimulus for platelet activation, subsequent aggregation is mediated by the IIb/IIIa receptor binding fibrinogen. A variety of antibody, peptide and non‐peptide compounds that block the IIb/IIIa receptor have been developed, and several studies have investigated the role of these agents in patients with acute coronary syndromes both within and outside the setting of percutaneous intervention. This article summarises the studies to date using IIb/IIIa antagonists, and discusses their role in patients with non‐ST segment elevation acute coronary syndromes.
LOCAL ANAESTHETIC CIRCUMCISION IN ADULTS
Authors: Sobeh M , Junaid I , Marsh H , Fowler CG
Published: April 2023

Circumcision is a simple operation often performed under general anaesthesia. In this study, we assessed the suitability of local anaesthesia in 38 adult patients, 79.4% of whom suffered little or no discomfort. Infiltration of local anaesthesia caused moderate pain in 10 patients (29.4%) and severe pain in only one. The circumcision itself caused moderate pain in three patients and severe pain in another three (8.8%); 85% of patients expressed complete satisfaction.
IATROGENICALLY REVEALED MYASTHENIA GRAVIS
Authors: Gyawali P , Rangedara DC
Published: April 2023

Myasthenia gravis is rare. When it presents unusually, making a diagnosis is doubly difficult. We present an unusual case where an ‘everyday’ medication unfortunately precipitated a myasthenic crisis in an unsuspecting individual.
PREGNANCY OUTCOME IN WOMEN WITH TYPE 2 DIABETES MELLITUS NEEDS TO BE ADDRESSED
Authors: Brydon P , Smith T , Proffitt M , Gee H , Holder R , Dunne F
Published: April 2023

Maternal diabetes mellitus (types 1 and 2) is the most chronic prevalent medical condition affecting the pregnant population and is associated with a less satisfactory pregnancy outcome for both mother and infant when compared with the non‐diabetic population. Most reports have focused on women with type 1 disease, type 2 disease being perceived as a less serious condition. However, type 2 disease is far more common (and is increasing) in some areas of the UK, especially where there is a high proportion of women from the Indian subcontinent. This paper shows that pregnancy complicated by type 2 diabetes mellitus is a high‐risk state, with miscarriage and congenital malformations almost twice that seen in type 1 disease. These adverse outcomes are contributed to by poor attendance for pre‐pregnancy care, later booking for antenatal clinic and poor glycaemic control at booking. Offspring of pregnancies complicated by type 2 diabetes are more likely to be delivered before 37 weeks gestation and be large in size for gestational age. We must dispel the myth, in women of childbearing age and in their healthcare providers, that diabetes treated with diet and/or tablets (type 2) is a less serious problem than type 1 disease.
POST‐TONSILLECTOMY PATIENT CARE IN THE COMMUNITY
Authors: Ghufoor K , Frosh A , Sandhu G , Hamf J
Published: April 2023

Tonsillectomy is a frequently performed surgical procedure. Problems arising in the early postoperative period will have an important impact on community and hospital resources. We determined the type of problems that occur and the way these problems are managed. We monitored 203 patients undergoing routine tonsillectomy by a postoperative telephone survey and contacted their general practitioners, 164 in all. We found 46% of the patients experienced problems post‐discharge which led to early contact with a doctor. Infection was identified in 26% and secondary haemorrhage in 11%. Common symptoms associated with the prescribing of antibiotics were sore throat (74%) and secondary haemorrhage (41%). Each GP saw, on average, 2.4 post‐tonsillectomy patients per annum. The diagnosis of post‐tonsillectomy infection is difficult. This was reflected in the wide variation of clinical features used to diagnose post‐tonsillectomy infection by doctors. The vast majority (95%) of GPs expressed a desire for a framework for treating post‐tonsillectomy complications.
TRANSIENT ISCHAEMIC ATTACKS: EVALUATION AND MANAGEMENT
Authors: Hennessy MJ , Britton TC
Published: April 2023

Transient ischaemic attacks (TIAs) are temporary focal cerebral or retinal deficits that resolve within 24 hours. Attention should be given to the tempo and localisation of the clinical syndrome, as multiple and hemispheric TIAs are associated with the greatest incidence of early stroke. Evaluation of TIAs depends on the clinical symptoms, physical examination and investigations. Attention should be given to clinical evidence of generalised atherosclerotic disease, as death due to the complications of ischaemic heart disease is the commonest outcome in patients with TIA. Early attention should focus on risk factor modification, with emphasis on the treatment of hypertension and smoking cessation. Antiplatelet therapy should be instituted. Aspirin is the first‐line treatment but, if not tolerated, clopidogrel is effective in preventing vascular complications. Anticoagulants are generally reserved for patients with atrial fibrillation and are associated with a significant reduction of stroke risk. The use of statins is becoming more widespread, with emerging evidence of their efficacy in reducing stroke risk. The risk of stroke is greatest in the weeks following TIA and patients should be referred for carotid duplex ultrasonography. Carotid endarterectomy for symptomatic internal carotid artery high grade stenosis virtually abolishes stroke risk in that vascular territory over subsequent years. TIAs should be regarded as an emergency requiring early diagnosis and prompt referral.
COMPARISON OF TWO DIFFERENT FORMULATIONS OF MEBEVERINE HYDROCHLORIDE IN IRRITABLE BOWEL SYNDROME
Authors: Gilbody JS , Fletcher CP , Hughes IW , Kidman SP
Published: April 2023

A total of 213 patients were recruited to a multicentre, randomised, double‐blind, double dummy, general practice study lasting eight weeks. The objectives of the study were (i) to demonstrate therapeutic equivalence of mebeverine hydrochloride 200 mg b.i.d. capsules (Colofac®MR) and 135 mg t.i.d. tablets (Colofac®) in the treatment of abdominal pain in irritable bowel syndrome (IBS) and (ii) to evaluate safety and physicians' and patients' assessments of therapeutic response. Patients were randomised at day 0 and assessments performed after four and eight weeks. Primary and secondary efficacy endpoints were number of responders (response being defined as 50% or more improvement in global mean visual analogue scale for abdominal pain); patients' and physicians' global assessment of therapeutic response; and physicians' global impression of patient symptoms. Safety was assessed from adverse event reports and routine laboratory tests. Therapeutic equivalence was proven statistically (difference <18%; p=0.003), with 65/92 (71%) of the 135 mg t.i.d. group and 64/92 (70%) of the 200 mg b.i.d. group classified as responders. The patients' evaluation of response (week 8) was that 75% of 135 mg t.i.d. and 81% of 200 mg b.i.d. improved; the physicians' assessment of therapeutic response (week 8) was that 64% of 135 mg t.i.d. and 70% of 200 mg b.i.d. had no or mild symptoms. In conclusion, Mebeverine hydrochloride 200 mg b.i.d. (Colofac®MR) was shown to be therapeutically equivalent to mebeverine hydrochloride 135 mg t.i.d. (Colofac®) in the treatment of abdominal pain in IBS. Results for the secondary efficacy variables were comparable. No safety concerns were identified.
ZOLMITRIPTAN PROVIDES EFFECTIVE MIGRAINE RELIEF IN ADOLESCENTS
Authors: Linder SL , Dowson AJ
Published: April 2023

Data from a subgroup of adolescents (12–17 years) entered into a one‐year open‐label phase of a large international study were analysed to evaluate response rates and tolerability of zolmitriptan for the acute treatment of migraine. In the open‐label phase of this study, the first two migraine attacks were treated with zolmitriptan 2.5 mg and subsequent attacks with zolmitriptan 2.5 mg or 5 mg, at the patient's discretion, for up to 12 months. Two‐hour headache and pain‐free responses were evaluated and adverse events were recorded. Thirty‐eight adolescents treated 276 migraine attacks of any intensity. The overall headache response at 2 hours was 80% (88% and 70% with zolmitriptan 2.5 mg and 5 mg, respectively), and the pain‐free response was 66% (76% and 52% for zolmitriptan 2.5 mg and 5 mg, respectively). Response rates were independent of whether or not migraine was associated with aura or menses. During prolonged use, patients learned to adjust the dose of zolmitriptan to effectively manage their migraine. Treatment was well tolerated. In conclusion, preliminary data indicate that zolmitriptan is effective in the acute treatment of migraine in adolescents and is well tolerated.
‘ACUTE ABDOMEN’ WITH A RASH
Authors: Lannon DA , Smyth YM , Waldron R
Published: April 2023

A previously fit and healthy 17‐year‐old male presented with the clinical symptoms and signs of an acute abdomen and with the secondary complaint of a rash. In view of the primary presenting complaint he was admitted to the surgical ward. The patient was initially booked for an emergency exploratory laparotomy, but after reassessment on the ward a clinical diagnosis of meningococcal septicaemia was made. The patient was treated medically with intravenous antibiotics and supportive therapy, and made a complete recovery. Medical causes of abdominal pain, as exemplified here, can be more life threatening than surgical causes and should be considered in all patients.
SYSTEMIC WEBER‐CHRISTIAN DISEASE COMPLICATED BY PARTIAL TRANSVERSE MYELOPATHY
Authors: Larner AJ , Marshall B , Ma RCW , Ball JA
Published: April 2023

Weber‐Christian disease is an inflammatory disorder of fatty tissue which usually presents with raised red tender nodules in the skin. Although there may be additional systemic upset, there are very few reports of neurological features associated with this condition. We report a patient with biopsy‐confirmed systemic Weber‐Christian disease in whom a transient partial myelopathy, of probable inflammatory origin, was the most prominent feature. Based on recent reports of the effects of immune mediators on neuronal function, a possible pathogenetic explanation for this syndrome is suggested.
THE DOGMA OF IDENTIFYING OCCULT BACTERIAL INFECTIONS IN YOUNG FEBRILE CHILDREN: A SURVEY OF PRIMARY‐CARE PHYSICIANS
Authors: Al‐Zamil FA
Published: April 2023

Management of undifferentiated febrile illness in young children continues to be a controversial issue among primary‐care physicians. A self‐administered questionnaire was mailed to 600 randomly selected physicians regarding their management of children with high fever and no focus of infection at various ages: 3 weeks, 7 weeks, 4 months and 20 months. Completed questionnaires were returned by 419 (70%) physicians. Nearly 77% of physicians would hospitalise a 3‐week old infant with fever and 70% would treat these infants empirically with antibiotics. Sixty‐one per cent of physicians would hospitalise a 7‐week‐old infant with fever and 46% would treat empirically with antibiotics. Approximately 80% and 93% of physicians, respectively, would not hospitalise 4‐ and 20‐month‐old infants with high fever and no focus of infection, but 72% and 59%, respectively, would treat such infants with antibiotics. There was considerable variation in the way physicians managed young febrile children with no focus of infection and the clinical approach of some physicians was remarkably different from current knowledge and recommendations.
RELIEF OF SORE THROAT WITH THE ANTI‐INFLAMMATORY THROAT LOZENGE FLURBIPROFEN 8.75 MG: A RANDOMISED, DOUBLE‐BLIND, PLACEBO‐CONTROLLED STUDY OF EFFICACY AND SAFETY
Authors: Watson N , Nimmo WS , Christian J , Charlesworth A , Speight J , Miller K
Published: April 2023

In this double‐blind study, 301 patients with subjective and objective signs of sore throat were randomly assigned to flurbiprofen 8.75 mg (n=129), flurbiprofen 12.5 mg (n=43) or placebo (demulcent lozenge without active drug [n=129]). Efficacy was assessed by changes in subjective rating scales primarily after a single dose and also over a 4‐day period. Flurbiprofen 8.75 mg was superior to placebo in a number of efficacy parameters, notably throat soreness. Throat soreness was significantly reduced after 15 minutes (p<0.05), with effects sustained for at least 2 hours (p<0.05). Multiple dosing with flurbiprofen 8.75 mg lozenges continued to provide effective symptomatic relief over the 4‐day treatment period. The small sample size was considered contributory to the variable results obtained with flurbiprofen 12.5 mg lozenges, but overall these were not inconsistent with previous trials. Both treatments were tolerated well. Flurbiprofen 8.75 mg lozenges provide an effective and well tolerated treatment for sore throat.
PROGNOSTIC VALUE OF CT SCAN FEATURES IN ACUTE ISCHAEMIC STROKE AND RELATIONSHIP WITH CLINICAL STROKE SYNDROMES
Authors: Sharma JC , Fletcher S , Vassallo M , Ross I
Published: April 2023

The aim of this prospective study was to investigate the value of CT scan in prognosis of acute ischaemic stroke patients as a variable additional to clinical stroke syndromes to develop a simple classification of CT scan features to provide a practical approach to prognosticate and manage such patients. One hundred and eight nine patients admitted with ischaemic stroke were investigated with a CT scan. CT scan features were classified into two groups: large infarct, LI (across more than one lobe) and non‐large infarcts (N‐LI) for all other features. Patients were also studied for clinical syndromes, analysing results for total anterior circulation syndrome (TACS). Outcome was measured as early post stroke Barthel index, acute phase and 3‐month mortality. Patients with LI had features of severe strokes and had a lower Barthel index (p<0.001), lower Glasgow coma score (p<0.001), more association with incontinence (p<0.001), pyrexia (p=0.007) and dysphagia (p<0.001). LI patients required higher level of care in acute wards and had a higher length of stay (p=0.01). Both the LI and TACS individually had a significantly higher mortality (p<0.001) and similar positive predictive value, sensitivity and specificity for 3‐month mortality. While the combined factor of ‘large infarct and TACS’ provided the highest likelihood ratio (3.1) for mortality, the factor of ‘large infarct or TACS’ was the most sensitive (85%) to identify majority of patients at a risk of mortality. N‐LI patients had a better prognosis. Classification of cerebral infarcts into large and non‐large categories identifies patients who require higher level of care in acute wards and have a higher mortality. Combined factor of ‘large infarct and/or TACS’ identifies the majority of patients at risk of 3‐month mortality as compared to either variable taken individually. CT scan features are complimentary to clinical syndromes for managing acute stroke patients.
AXILLARY ARCH AND ITS IMPLICATIONS IN AXILLARY DISSECTION — REVIEW
Authors: Babu ED , Khashaba A
Published: April 2023

Axillary arch is an anomalous muscular slip of latissimus dorsi muscle occasionally encountered in axillary dissection. A systematic review of medical literature published between 1966 to 1999 was performed regarding its incidence, clinical features and management. Its presence in axillary dissection should be recognised to avoid confusion in staging of lymph nodes and to prevent injury to axillary vessels and brachial plexus.
DIABETES KNOWLEDGE ‐ ARE PATIENTS GETTING THE MESSAGE?
Authors: Ford S , Mai F , Manson A , Rukin N , Dunne F
Published: April 2023

Diabetes knowledge in a multi‐ethnic population was assessed in 161 insulin treated diabetic patients using a 21‐point multiple choice questionnaire translated into the appropriate languages. Our data showed a significant difference in diabetes knowledge related to ethnicity, being less in Asians and Afro‐Caribbeans groups compared to Caucasians. In all groups there was a negative correlation with age, with older adults achieving lower scores. Gender and duration of disease did not appear to influence knowledge scores. This information has implications for the way in which we deliver our diabetes educational programme to ethnic minority groups and the elderly.
ESOMEPRAZOLE, A NEW PROTON PUMP INHIBITOR: PHARMACOLOGICAL CHARACTERISTICS AND CLINICAL EFFICACY
Authors: Thitiphuree S , Talley NJ
Published: April 2023

Esomeprazole, the S‐isomer of omeprazole, is the first proton pump inhibitor synthesised as an optical isomer to become available for clinical use. Esomeprazole is optically stable in humans with negligible inversion to the R‐isomer. Esomeprazole has significantly higher oral bioavailability than omeprazole, resulting in greater acid suppression. In clinical studies, 4 weeks' treatment with 40 mg esomeprazole demonstrated greater healing of all grades of erosive oesophagitis, compared with 20 mg omeprazole (76–82% versus 69–71%) and higher rates of symptom resolution (65–68% versus 58–61%) Furthermore, esomeprazole maintained healing rates of up to 90% over 6 months in erosive oesophagitis. Comparisons with other proton pump inhibitors in oesophagitis are, as yet, unavailable. In patients with endoscopy‐negative gastro‐oesophageal reflux disease (GERD), on‐demand therapy with esomeprazole 20 mg has been shown to be very efficacious compared with placebo, and is well tolerated; however, comparisons with other proton pump inhibitors have not been performed. Long‐term use of esomeprazole for up to 12 months in patients with GERD have not raised any significant safety concerns with respect to the development of atrophic gastritis or clinically relevant changes in enterochromaffin‐like cells.
MESENCHYMAL HAMARTOMA OF THE LIVER IN AN ADULT: A REVIEW OF THE LITERATURE
Authors: Papastratis G , Margaris H , Zografos GN , Korkolis D , Mannika Z
Published: April 2023

Mesenchymal hamartoma of the liver is an unusual oncologic entity which occurs almost exclusively in infancy and childhood; fewer than 200 cases have been reported. We present the case of a 21‐year‐old female, who was admitted to our institution with a painful right subcostal mass lasting for 6 months, who had no evidence of generalised disease. Imaging procedures revealed a central solid lesion, 15 cm in diameter, in the right lobe of the liver, with cystic degeneration. The patient underwent a formal right hepatectomy The pathology report ascertained the presence of a benign mesenchymal hamartoma of the liver.
GROWTH FACTORS IN CLINICAL PRACTICE
Authors: Köveker GB
Published: April 2023

Wound repair consists of a complex interaction of cellular and bichemical events. Several growth factors have been identified as regulatory polypeptides co‐ordinating the healing process. Although it is not known precisely why chronic wounds do not follow the normal pattern of healing, diminished growth factor content and accelerated growth factor degradation may contibute to poor healing. Topical application of different factors exert stimulatory effects on wounds in animal models. Human data are limited but the most investigated compound is recombinant human platelet‐derived growth factor‐BB (rhPDGF‐BB). PDGF‐BB enhances granulation tissue formation and facilitates epithelialisation. Clinical trials in patients with ‘hard to heal’ diabetic foot ulcers demonstrated significant improvement in the ‘healing rate’ and the ‘time to healing’ compared with controls. Refinement of therapeutic strategies with growth factors will take place in the future.
STEROIDAL CONTRACEPTION FOR MEN
Authors: Sarkar NN
Published: April 2023

This article is a review of the development of male steroidal contraceptives during the past 25 years. Numerous studies have been conducted on male volunteers with oral and/or injectable preparations of single or combined steroids. Progestogen, androgen alone, or progestogen and androgen combinations have been used as weekly or monthly injectable formulations. Most of the studies involved small numbers of subjects. There was reversible suppression of spermatogenesis to oligospermia and/or azoospermia during the treatment period. Alteration of LH, FSH and testosterone levels in the blood was observed in most of these studies, depending on the steroid or combination of steroids used. There were reports about decreased or increased libido and weight gain during treatment with steroids. No other serious side‐effects were found. Attention has recently focused on developing an androgen‐only male contraceptive, because testosterone ester has shown promising results. The development of an effective and reliable steroidal contraceptive for men may be possible but this requires further research.
NEURAMINIDASE INHIBITORS: PROGRESS IN THE MANAGEMENT OF INFLUENZA
Authors: Woodhead M , Lavanchy D , Johnston S , Colman P , Fleming D
Published: April 2023

Influenza is a serious respiratory illness and represents a significant clinical burden. As well as being debilitating, influenza can often cause complications leading to hospitalisation and death. Prophylaxis by vaccination is the preferred method of disease management, but because influenza viruses are constantly changing their antigenic properties, influenza outbreaks occur regularly as epidemics. Neuraminidase inhibitors are a new class of anti‐influenza drugs designed to block influenza virus replication. Two neuraminidase inhibitors, zanamivir and oseltamivir, have been licensed for clinical use in the treatment of influenza. Both drugs significantly reduce the severity and duration of the illness when treatment is started within two days of the onset of symptoms. However, while zanamivir and oseltamivir have apparently similar efficacy, they differ in their modes of delivery and tolerability. Zanamivir is delivered direct to the lungs by inhalation and is well tolerated. Oseltamivir is taken in the form of a pill but has the side‐effect of producing nausea and vomiting in some patients. In the absence of a demonstrable difference in efficacy, uptake of the two drugs will depend on evaluation of the relative merits of mode of delivery and tolerability.
PIOGLITAZONE
Authors: Lawrence JM , Reckless JPD
Published: April 2023

Pioglitazone is a thiazolidinedione. As a PPAR‐γ agonist it alters the expression of a number of genes, resulting in a reduction in insulin resistance. Clinical trial data involving over 4500 patients with type 2 diabetes suggest it is effective both as monotherapy and in combination with sulphonylureas, metformin and insulin, producing both significant falls in HbA1c and favourable improvements in lipid parameters. It is well tolerated, with a low incidence of side‐effects. Unlike troglitazone, its use has not been associated with hepatotoxicity. It has recently been licensed in the US for use as monotherapy and in combination with insulin, metformin and sulphonylureas. Its European licence is more restrictive, allowing use in combination with metformin, and in combination with sulphonylureas in those intolerant of metformin. It provides a useful new option in the treatment of type 2 diabetes mellitus.
A CASE OF RECURRENT IMPETIGO HERPETIFORMIS WITH A POSITIVE FAMILY HISTORY
Authors: Erbagci Z , Erkiliç S
Published: April 2023

Impetigo herpetiformis is a rare non‐infectious pustular dermatosis of pregnancy. A few non‐gestational cases due to oral contraceptive use have also been reported. Although the disorder is not thought to have a genetic background, there are some familial case reports in the literature. We describe a case of recurrent impetigo herpetiformis in an 18‐year‐old pregnant woman who had normal serum calcium levels and responded well to prednisolone therapy. Interestingly, the patient's mother had also experienced a generalised pustular dermatosis associated with hypocalcaemia during oral contraceptive use, which was diagnosed clinically and histologically as impetigo herpetiformis.
RECURRENT ENCEPHALOPATHY AND GENERALISED SEIZURES ASSOCIATED WITH RELAPSES OF THYROTOXICOSIS
Authors: Chong JSW Li Voon , Leckt BRF , Macfarlane IA
Published: April 2023

Seizures or encephalopathy associated with thyrotoxicosis are very rare. A 30‐year‐old man with thyrotoxicosis and strongly positive thyroid antibodies presented with generalised seizures preceded by an encephalopathic illness of a few days duration. CSF protein was raised and EEG showed bilateral slowing of activity. Antithyroid drug treatment rendered him biochemically euthyroid, his cognitive state returned to normal and his seizures stopped. Subsequently he had a recurrence of both encephalopathy and seizures on two occasions, coinciding with relapses of the thyrotoxicosis. This supports the view that the hyperthyroid state caused this serious neurological condition. Treatment with 131I caused hypothyroidism and he has remained seizure free and well for six years on thyroxine replacement. Corticosteroids may have been helpful in the management of his encephalopathy.
A CASE OF ISOLATED ACTH DEFICIENCY PRESENTING WITH HYPERCALCAEMIA
Authors: Wong RKM , Gregory R , Lo TCN
Published: April 2023

A 76‐year‐old man presented with a subacute history of weight loss, malaise and anorexia. Laboratory investigations revealed serially increasing hypercalcaemia, correlating with deterioration in his clinical status. He was subsequently shown to have hypocortisolaemia, which improved with the administration of intravenous steroids. Subsequent biochemical testing revealed the endocrinological defect to be one of isolated ACTH deficiency, which, unlike Addison's disease, does not classically include hypercalcaemia in its presentation.
TRANSOESOPHAGEAL ECHOCARDIOGRAPHY: ITS ROLE IN THE MANAGEMENT OF PATIENTS IN A DISTRICT GENERAL HOSPITAL
Authors: Fragakis N , Patel S , Lloyd G , Lambert G , Robson D , Shakespeare C
Published: April 2023

The aim of this study was to assess the value of a transoesophageal echocardiography (TOE) service in a district general hospital (DGH). A series of 151 consecutive cases was analysed retrospectively to determine the relative additional benefit of TOE over transthoracic echocardiography (TTE) in establishing diagnoses and making therapeutic decisions. Of the 151 cases, 140 were suitable for the two procedures to be compared. In 56%, TOE provided useful information for patient management. This consisted of the detection of new major findings (33%) and the exclusion of significant abnormalities (23%), suspected either clinically or by TTE. TOE made a minor clinical contribution in 8% of cases, while in 30% there was concordance between the two studies. Finally, in 6% both examinations were inconclusive. We conclude that TOE has a significant complementary role to TTE in terms of clinical diagnosis and patient management in the DGH setting.
A CROSS‐SECTIONAL SURVEY OF THE CLINICAL AND PSYCHOLOGICAL FEATURES OF LOW BACK PAIN AND CONSEQUENT WORK HANDICAP: USE OF THE QUEBEC TASK FORCE CLASSIFICATION
Authors: Frank AO , De Souza LH , McAuley JH , Sharma V , Main CJ
Published: April 2023

A hospital‐based cross‐sectional study examined 657 consecutive referrals with low back pain over two years to a district rheumatology service serving a population of about 250,000 people. Five hundred and thirty‐eight had mechanical/degenerative low back pain. The mean age was 48.6 (range 18–80 SD 15.3) years; 64% were women. Patients with radiating pain or neurological deficit (Quebec Task Force classification) were significantly more disabled (Roland disability score p<0.001) and depressed (Modified Zung score p<0.05) than those without radiating pain. Women were more impaired (p=0.02) than men but had similar disabilities (mean Roland score 11.7, range 0–24 SD 6.5). Fifty‐three per cent of patients were receiving benefits and were significantly more likely to have musculoskeletal comorbidities than those in work (p<0.025). It is concluded that the Quebec Task Force classification of low back pain impairment is a helpful descriptor and related to both physical and psychological disability and handicap in employment.
A VALIDATION STUDY OF THE SIRIRAJ STROKE SCORE
Authors: Kan CH , Lee SK , Low CS , Velusamy SS , Cheong I
Published: April 2023

A cross‐sectional study was conducted on 160 Malaysian patients to validate the usefulness of the Siriraj Stroke Score (SSS) for differentiating intracerebral haemorrhage and infarction following acute strokes. Our results indicate that the score lacks sensitivity and specificity. It should thus not be used in epidemiological studies to determine stroke types in a community. More importantly, in the absence of information from neuroimaging of the brain, it cannot be used safely by physicians to assess the need or otherwise of thrombolytic and/or anticoagulant therapy after an acute stroke.
MYOCARDIAL STUNNING AND HIBERNATION IN CLINICAL PRACTICE
Authors: Rinaldi CA , Hall RJC
Published: April 2023

Myocardial stunning and hibernation are both clinically important causes of myocardial dysfunction and are caused by episodes of myocardial ischaemia. Stunning tends to occur acutely and may produce transient but clinically important reductions in left ventricular function in the setting of myocardial infarction, post coronary artery bypass grafting and even following episodes of effort induced angina. Hibernation refers to a chronic down‐regulation of myocardial function in response to chronic myocardial ischaemia. Hibernating myocardium may be present in up to 50% of patients with significantly impaired left ventricular function and evidence of heart failure. Importantly, both these entities can be either prevented or ameliorated by preventing or lessening ischaemic burden. There is also evidence that there may be an overlap between these two entities and that hibernating myocardium may result from repeated episodes of myocardial ischaemia causing chronic stunning.
PHARMACOLOGY AND EFFICACY OF ELETRIPTAN FOR THE TREATMENT OF MIGRAINE ATTACKS
Authors: Diener H‐C , McHarg A
Published: April 2023

Sumatriptan, a 5‐HT1B/1D agonist, was introduced 10 years ago and was the most effective therapy for migraine attacks at that time. Eletriptan is a new 5‐HT1B/1D agonist with high potency and selectivity at 5‐HT1B/1D receptors. It is effective in animal models in which the vascular and neurogenic mechanisms implicated in migraine were measured. Eletriptan is selective for the intracranial blood vessels over other extracranial vasculature, in particular coronary arteries. Eletriptan has a rapid and complete oral absorption and a good oral bioavailability in migraineurs. In comparative trials 20 mg, 40 mg and 80 mg eletriptan, 100 mg sumatritpan and placebo were compared for the treatment of migraine attacks. All three doses of eletriptan were statistically superior to placebo for headache response and headache‐free patients. The 80 mg dose of eletriptan was also superior to sumatriptan 100 mg. Headache recurrence, defined as return of moderate or severe headache within 24 hours of dosing and following a headache response at two hours after initial dosing, occurred in 33% of the patients following 100 mg sumatriptan and in 28%, 34% and 32% after 20 mg, 40 mg and 80 mg eletriptan. In another large trial, headache response rates were significantly higher for both doses of eletriptan (64% for 40 mg and 67% for 80 mg) than for two doses of sumatriptan (50% for 50 mg and 53% for 100 mg). Eletriptan 40 mg or 80 mg was also superior to ergotamine plus caffeine (Cafergot). In summary, eletriptan is a highly effective and fast‐acting drug for the treatment of acute migraine attacks.
EXTRACRANIAL ARTERIAL ANEURYSMS: A CAUSE OF CRESCENDO TRANSIENT ISCHAEMIC ATTACKS
Authors: Paterson HM , Holdsworth RJ
Published: April 2023

Crescendo transient ischaemic attacks (TIAs) should be regarded as a medical emergency. Patients require hospitalisation with urgent assessment and symptom control with anticoagulant therapy. We report on three patients, all of whom had atherosclerotic aneurysmal disease of the extracranial arterial circulation who presented with crescendo TIAs. The possibility of extracranial aneurysmal disease should always be considered and excluded.
INTERFERON TREATMENT FOR THROMBOCYTOPENIA ASSOCIATED WITH CHRONIC HCV INFECTION
Authors: Uygun A , Kadayifci A , Ercin N , Bagci S , Dagalp K
Published: April 2023

Thrombocytopenia is commonly seen in patients with chronic liver disease, due mainly to hypersplenism secondary to portal hypertension. We report a case of chronic hepatitis C admitted with thrombocytopenia of unknown cause. The patient's symptoms and platelet count improved markedly with interferon treatment. We conclude that interferon treatment in chronic C hepatitis may improve HCV‐induced thrombocytopenia.
METASTATIC TUMOUR OF THE TUNICA VAGINALIS TESTIS FROM CARCINOMA OF THE STOMACH
Authors: Wai HPS , Yau T‐K , Sze W‐M , Yeung M‐W , Moe F , Lee AWM
Published: April 2023

A 50‐year‐old man with advanced inoperable gastric adenocarcinoma and diffuse peritoneal metastasis received six cycles of palliative chemotherapy and responded clinically with weight gain. Two months after the completion of chemotherapy, however, he developed a left hydrocele. Aspiration yielded 70 ml of yellowish hydrocele fluid, which contained metastatic adenocarcinoma cells, consistent with a gastric primary tumour. A diagnosis of malignant hydrocele was made. Two weeks later, he developed a painful recurrent left hydrocele with increasing pain and swelling. Left orchidectomy was performed. Tiny white mural nodules measuring 1 mm in size were noted on the tunica vaginalis. No focal lesion was noted in the testis. On microscopic examination, the tunica vaginalis showed reactive mesothelial hyperplasia and extensive lymphatic permeation by poorly differentiated adenocarcinoma, consistent with a gastric primary tumour.
TRAUMATIC RUPTURE OF THE DIAPHRAGM
Authors: ÇubukÇu A , Paksoy M , Gönüllü NN , Sirin F , Dülger M
Published: April 2023

Diaphragmatic rupture following trauma is often an associated and missed injury. The diagnosis is difficult, so is usually made intraoperatively. Twenty‐one patients with traumatic rupture of the diaphragm (TRD) who presented between 1995 and 1998 were retrospectively analysed: 12 had penetrating injuries and nine had blunt injuries. Right‐sided defects exceeded left (12 vs 9). Only seven patients had signs and symptoms directly referrable to rupture of the diaphragm. All patients were operated on through a midline laparotomy. Diaphragmatic hernia was seen in six patients (28.5%); 20 (95%) patients had concomitant injuries. The liver was the most commonly injured organ (10 patients). The aim of this study was to report our experiences with TRD and review the literature. We conclude that correct preoperative diagnosis of TRD needs a high index of suspicion. It can be diagnosed intraoperatively by explorative laparotomy. Most ruptures can be repaired by the abdominal approach. (Int J Clin Pract 2000; 54(1): 19‐21)
IMAGING ASSESSMENT OF UNCOMPLICATED BLADDER OUTFLOW OBSTRUCTION
Authors: Probert JL , Mills R , Persad RA , Sethia KK
Published: April 2023

To assess the impact of the use of plain X‐ray films and ultrasound examinations on clinical decision‐making in patients referred with symptoms of bladder outflow obstruction. Patients with symptoms of bladder outflow obstruction were recruited prospectively. After clinical assessment they underwent standard investigations of plain X‐ray of the kidneys, ureters and bladder, and upper and lower urinary tract ultrasound. A management decision was made on the basis of all results. These decisions were then reviewed with specific reference to radiological findings to assess the role of imaging in the decision‐making process. A total of 320 men were recruited for the study. X‐ray of the kidneys, ureters and bladder detected 10 upper tract calculi, none of which has required active intervention to date. Four bladder calculi were detected. Two of these were also seen on ultrasound scan: one was small and insignificant, the other had caused microscopic haematuria, necessitating cystoscopy regardless of the X‐ray findings. Upper tract ultrasound revealed abnormalities and anatomical variants which did not affect management. Four patients had upper tract dilatation but these had already had surgery planned on the basis of other investigations, including residual urine volume determination by lower tract ultrasound. Lower urinary tract ultrasound should be the only routine imaging used in the initial assessment of patients with bladder outflow obstruction, with consequent implications of reduced patient stress and reduced investigation cost. (Int J Clin Pract 2000; 54(1): 22‐24)
SOCIAL DRIFT IN FORENSIC PSYCHIATRIC INPATIENTS WITH SCHIZOPHRENIA
Authors: Treasaden IH , Lekh SK , Puri BK
Published: April 2023

The highest social class before admission of 27 forensic psychiatric inpatients in a regional secure unit who suffered from schizophrenia was found to be significantly lower than that of their fathers. This is the first report of social drift in this group of patients. (Int J Clin Pract 2000; 54(1): 28‐29)
V. THE STIGMA OF ANXIETY DISORDERS
Authors: Davies B
Published: April 2023

People with genuine anxiety disorders can be misdiagnosed and mismanaged, because of negative public and professional attitudes to anxiety and the ‘worried well’. Misdiagnosis includes not taking symptoms seriously and giving patients pejorative labels such as ‘personality disorder’ or ‘inadequate’. This can lead to mismanagement such as reluctance to investigate symptoms fully, with regard to both physical and psychological aetiologies. Also, poor understanding of appropriate treatments can lead to mismanagement of these disorders. This paper reviews sources of stigma in dealing with anxiety disorders and ways in which this stigma might be avoided. (Int J Clin Pract 2000; 54(1): 44‐47)
SAFE AND EFFECTIVE MANAGEMENT OF HYPERTENSION WITH FIXED‐DOSE COMBINATION THERAPY: FOCUS ON LOSARTAN PLUS HYDROCHLOROTHIAZIDE
Authors: Benedict CR
Published: April 2023

Treatment of hypertensive patients with fixed‐dose combination therapy consisting of losartan and hydrochlorothiazide (HCTZ) has several potential benefits over monotherapy with each of the individual components: more effective blood pressure control, a reduction in the likelihood of adverse effects, and facilitation of patients staying on therapy due to a simple once‐daily regimen. Losartan plus HCTZ fixed‐dose combination therapy lowers blood pressure in mild to moderate or severe hypertensive patients to a level comparable with other classes of antihypertensive drugs in combination with HCTZ. Fixed‐dose combination therapy with losartan plus HCTZ is therefore an excellent choice for hypertensive patients in whom combination therapy is necessary to achieve additional blood pressure reductions. (Int J Clin Pract 2000; 54(1): 48‐54)
A RANDOMISED COMPARISON OF SIMVASTATIN VERSUS SIMVASTATIN AND LOW CHOLESTEROL DIET IN THE TREATMENT OF HYPERCHOLESTEROLAEMIA
Authors: Thuraisingham S , Tan KH , Chong KS , Yap SF , Pasamanikam K
Published: April 2023

There is little evidence to show that strict dietary modification alone confers any significant impact on cardiac events in primary and secondary prevention of coronary heart disease. Given the efficacy of the statins, the need for strict dietary modification in patients on statin therapy has been questioned. This study was performed to assess 1) the added benefit on serum lipid levels of a strict low‐fat dietary regimen in patients with hypercholesterolaemia already treated with simvastatin; 2) the efficacy of simvastatin on the lipid profile of our sample Asian population; and 3) the tolerability and side‐effect profile of simvastatin. This study was a prospective evaluation of 60 patients with hypercholesterolaemia treated with simvastatin who were subjected to either a normal diet or a dietitian guided low‐fat diet. Assessment of the effects on serum lipid levels, side‐effects, biochemical and haematological markers were performed. After 24 weeks of treatment, a strict dietitian guided low‐fat diet conferred no additional benefit over and above what was achieved by simvastatin alone. Furthermore, a higher dose of simvastatin was needed in the dietitian guided diet group to achieve the target LDL‐cholesterol level. Simvastatin resulted in a significant positive alteration of lipid profiles in all patients. The drug was well tolerated, with no significant change in either haematological or biochemical indices. Simvastatin is a highly effective cholesterol‐lowering drug with a beneficial effect on the entire lipid spectrum in a cross‐section of Asian patients, and is well tolerated. A dietitian guided dietary approach confers no additional advantage once statin therapy has been initiated. (Int J Clin Pract 2000; 54(2): 78‐84)
DOES COMBINATION THERAPY WITH A CALCIUM CHANNEL BLOCKER AND AN ACE INHIBITOR HAVE ADDITIVE EFFECTS ON BLOOD PRESSURE REDUCTION?
Authors: Edelman DA , Paul RA
Published: April 2023

Reports in the medical literature have suggested that the effects on blood pressure (BP) of calcium channel blockers (CCBs) and angiotensin‐converting enzyme (ACE) inhibitors are additive. Most reports have provided neither a definition of ‘additive’ nor the necessary information to determine whether the effects are additive. In this review of the medical literature, the effects of combination therapy were defined as additive if the sum of the mean reductions in BP following monotherapy with a CCB and an ACE inhibitor was not significantly different from the mean reduction in BP of combination therapy. The review generally showed that combination therapy is more effective than treatment with either monotherapy alone, based on mean decreases in either diastolic or systolic BP. The studies provided no clear evidence that the effects of combination therapy were either additive or less than additive. (Int J Clin Pract 2000; 54(2): 105‐109)
VI. STIGMA AND ALZHEIMER'S DISEASE: CAUSES, CONSEQUENCES AND A CONSTRUCTIVE APPROACH
Authors: Jolley DJ , Benbow SM
Published: April 2023

The term ‘Alzheimer's disease’ has entered the vocabulary of ordinary people. This has been useful, encouraging patients and families to seek medical help for conditions that were previously neglected as inevitable consequences of old age. Yet Alzheimer's itself can carry negative connotations. Some people who believe they have Alzheimer's disease are suffering from less sinister and more easily treated conditions. Even when the diagnosis is confirmed, many months of happy and worthwhile life continue for most patients and families if they are given appropriate information and support. It is important that neither families nor clinicians see life with presumed Alzheimer's disease as of no value. (Int J Clin Pract 2000; 54(2): 117‐119)
HOME MANAGEMENT OF FEVER IN CHILDREN: RATIONAL OR RITUAL?
Authors: Al‐Eissa YA , Al‐Zamil FA , Al‐Sanie AM , Al‐Salloum AA , Ai‐Tuwaijri HM , Al‐Abdali NM , Al‐Azzam SA
Published: April 2023

Fever is extremely common in childhood. Parents have been shown to have unrealistic fears, resulting in inappropriate management of fever in their children. This study was conducted to survey parents about their knowledge concerning home management of fever in children in their care. Parents of 560 febrile children were randomly recruited and interviewed in the waiting areas of the outpatient clinics or emergency room in four hospitals in Riyadh city using a standard questionnaire. Most of the interviewees were mothers, aged within 20‐39 years. Although more than one‐half of fathers and one‐third of mothers in the study were well educated, most were misinformed about recognition and definition of fever. Most parents had poor knowledge regarding minimum temperatures for administering correct doses of antipyretic drugs or for sponging/bathing with water of the correct temperature. Most parents demonstrated a poor understanding of the appropriate frequency for checking the child's temperature and administering antipyretics. Only one‐third of parents indicated a reasonable educational imprint by health‐care providers. Considerable efforts will be required to educate parents about fever and its management. (Int J Clin Pract 2000; 54(3): 138‐142)
RAPID DIAGNOSIS OF MASSIVE PULMONARY EMBOLISM IN A DISTRICT GENERAL HOSPITAL
Authors: Ong Y E , Crowther A , Miller A
Published: April 2023

Effective treatment of massive pulmonary embolism is more likely if diagnostic tests are rapidly available, including during out‐of‐hours. An agreed protocol was implemented in November 1997, which allowed initiation of thrombolysis by junior doctors within an hour of clinical suspicion of the diagnosis of massive pulmonary embolism in six patients in the subsequent year. A similar approach could be considered by other acute hospitals. (Int J Clin Pract 2000; 54(3): 144‐146)
MANAGEMENT OF SEPTICAEMIC INFANTS DURING LONG‐TERM PARENTERAL NUTRITION
Authors: Page S , Abel G , Stringer MD , Puntis JWL
Published: April 2023

Young infants, particularly following gastrointestinal surgery, are at high risk of septicaemia during parenteral nutrition. Febrile illness in the absence of focal infection inevitably raises suspicion of central venous catheter sepsis and poses the following dilemma: remove the catheter (which may then prove uninfected) and lose venous access, or leave the catheter and risk clinical deterioration? We examined retrospectively the isolates from blood culture during febrile episodes in 13 children who received long‐term (>2 months) parenteral nutrition via a central venous catheter, and assessed the effectiveness of through‐catheter antibiotic treatment during 76 episodes of blood culture positive sepsis. Coagulase‐negative Staphylococci accounted for only 16% of positive isolates, with yeasts accounting for 5%, and Gram‐negative organisms accounting for 46%, suggesting that infection was often associated with bacterial translocation from the gastrointestinal tract. Treatment with the central venous catheter left in situ was successful in resolving infection in 53 (70%) of septic episodes. These findings indicate that, in this specific group of patients, through‐catheter antibiotic treatment is often effective in treating septicaemia. When long‐term venous access is essential, this approach should be tried before recourse to central venous catheter removal. (Int J Clin Pract 2000; 54(3): 147‐150)