bluuebunny/crossref_metadata_2025 huggingface dataset:
XELODA® IN COLORECTAL CANCER
Authors: Cassidy J
Published: April 2023

Xeloda® (capecitabine) is a rationally designed, oral pro‐drug of 5‐fluorouracil (5‐FU). It is rapidly and almost completely absorbed in the upper gastrointestinal tract. It is then catabolised in a three‐enzyme system, the last step being catalysed by thymidine phosphorylase, which is upregulated in many human cancers. Clinical pharmacology studies have confirmed that this preferential activation actually occurs in human colorectal cancer. Phase I and II trials were performed in colorectal cancer to define the optimal dose and schedule of capecitabine. In two large scale phase III studies this agent has been shown to be at least as effective as a standard regimen of bolus 5‐FU and leucovorin (Mayo regimen). Response was superior in the capecitabine arms of these studies with equivalence of progression‐free and overall survival. In addition the oral regimen was associated with significantly less toxicity. It seems likely that this agent will replace intravenous 5‐FU in the therapy of colorectal cancer and possibly in other cancers.
TREATMENT OF INSOMNIA WITH ZALEPLON, A NOVEL SLEEP MEDICATION
Authors: Doghramji PP
Published: April 2023

Insomnia is a highly prevalent sleep problem that often results in poor daily functioning of the affected patient. Unfortunately, sedative hypnotic agents prescribed in the past often resulted in residual sedation, as well as impairment of cognitive and psychomotor performance, throughout the day after use. Newer agents with relatively rapid elimination require administration regularly each night before bedtime if symptoms of insomnia are to be prevented and next‐day sedation is to be avoided. The availability of zaleplon challenges these standards of practice. The rapid elimination of zaleplon, combined with its unique receptor binding affinity, permits 10 mg of zaleplon to be taken at bedtime or later in the night with minimal concern for next‐day residual effects. Clinical studies of zaleplon also identified the low risk of withdrawal syndrome or rebound insomnia after the discontinuation of nightly use. If used only on the nights when symptoms actually occur, the occurrence of such problems with zaleplon will be minimal.
A HARD THYROID MASS DUE TO PLASMA CELL GRANULOMA
Authors: Chong JSW Li Voon , Burrows CT , Cave‐Bigley D , Macfarlane IA
Published: April 2023

Plasma cell granuloma involving the thyroid is very rare. A 29‐year‐old man with type 1 diabetes mellitus presented with a one‐week history of fever, sore throat, neck tenderness and dysphagia. Antibiotics were given but over the next two weeks a hard 8 cm mass in the left lobe of the thyroid developed. Fine needle aspiration was not diagnostic and surgical exploration revealed an inflammatory process arising from the left lobe of the thyroid involving the left sternothyroid muscle and parapharyngeal spaces. Histology of multiple biopsies showed plasma cell granuloma. Immunoperoxidase staining demonstrated the presence of IgG, IgM and IgA with predominance of IgG. The residual mass resolved and was impalpable after four weeks. Plasma cell granuloma should be suspected when there is a rapidly developing hard thyroid mass. Open biopsy/removal and histological confirmation are mandatory and residual disease may resolve within weeks.
LYMPHANGIOMA PRESENTING AS A NECK MASS IN THE ADULT
Authors: Moxo C De Casso , Lewis NJ Eynon , Rapado F
Published: April 2023

Lymphangiomas are uncommon congenital lesions of the lymphatic system which usually present in childhood. We report a case of adult lymphangioma, localised in the neck, and discuss the presentation, diagnosis and management of this tumour.
UNSTABLE ANGINA FOLLOWING ACUTE MI IN A PATIENT WITH BILATERAL CORONARY ARTERY FISTULAE: AN UNUSUAL PRESENTATION OF CORONARY STEAL?
Authors: Chin B , Spencer CGC , Lip GYH
Published: April 2023

We report a 57‐year‐old woman with acute myocardial infarction and cardiac arrest who subsequently developed unstable angina. The possibility of a coronary steal syndrome contributing to her unstable angina arises in view of the presence of bilateral coronary artery fistulae between two atherosclerotic coronary arteries and the main pulmonary artery.
AVASCULAR NECROSIS OF BONE: THE HIDDEN RISK OF GLUCOCORTICOIDS USED AS ANTIEMETICS IN CANCER CHEMOTHERAPY
Authors: Virik K , Karapetis C , Droufakou S , Harper P
Published: April 2023

The role of antiemetics is invaluable in allowing cancer patients to complete otherwise potentially intolerable chemotherapy. Corticosteroids have an established place in the prevention and treatment of nausea and vomiting due to emetogenic cytotoxic agents. Avascular necrosis of bone is a recognised complication of glucocorticoid treatment – the risk of this increasing with higher doses and longer duration of use. This report details a case of bilateral avascular necrosis of the femoral heads in a patient receiving ‘standard’ doses of dexamethasone as part of the antiemetic regimen used in cisplatin‐based combination chemotherapy.
THE PREVALENCE OF PRE‐ECLAMPSIA AND OBSTETRIC OUTCOME IN PREGNANCIES OF NORMOTENSIVE AND HYPERTENSIVE WOMEN ATTENDING A HOSPITAL SPECIALIST CLINIC
Authors: Lydakis C , Beevers M , Beevers DG , Lip GYH
Published: April 2023

To study the prevalence of pre‐eclampsia (PE) and other obstetric outcomes (growth restriction and fetal mortality) in pregnancies of normotensive and hypertensive women attending an antenatal hypertension clinic, we studied a cohort of 372 pregnancies from 267 women. The prevalence of PE in the groups of pregnancies of normotensive and chronic hypertensive women was 11.9% (19/159 cases) and 16.0% (34/213 cases) respectively (χ2=1.2, p=0.27). There were no significant differences in respect of ethnicity, being primi‐ or multigravida and smoking status or age. Treatment with antihypertensive drugs during pregnancy did not decrease the prevalence of PE. In pregnancies with hypertensive complications (with or without PE) there was a trend towards higher rates of pre‐term delivery (<37 weeks), caesarean section, small for gestational age babies, stillbirth and lower baby birth weight and ponderal index values. Pregnancies in women with uncomplicated hypertension had an increased risk for emergency caesarean section, pre‐term delivery (<37 weeks), birth weight <2500 g and stillbirth (relative risks [with confidence intervals] 2.5 [1.9–3.2], 2.3 [1.8–2.9], 3.1 [2.5–3.7] and 5.5 [2.6–11.9] respectively) compared with the general hospital obstetric population. After classification according to the type of hypertensive syndrome, a progressively higher risk for fetal growth restriction and adverse perinatal outcome was shown in the hypertensive and pre‐eclamptic groups. In chronic hypertension, this was irrespective of superimposed pre‐eclampsia or antihypertensive therapy. The high prevalence of PE in chronic hypertensive women (16.0%) was not statistically significant to that of normotensive women (11.9%), reflecting the referral selection of ‘high risk’ normotensive women to our clinic.
THE TOXIC OIL SYNDROME: 20 YEARS ON
Authors: Diggle GE
Published: April 2023

With hindsight, it is easy to criticise the standards of food regulation of two decades ago. Nevertheless, when the Spanish toxic oil syndrome (TOS) appeared in 1981, there were many who asked why aniline was permitted as an official adulterant for imported French rape seed oil, and why such adulterated oils were often illegally refined in Spain and marketed without difficulty. This review brings up to date a comprehensive survey of the ensuing research published in 1995 and concentrates on recent significant findings. These include the identification of the refinery that produced the toxic oil, and the detection of oil contaminants with possible aetiological significance. Possible chemical links have been found between oil contaminants and those detected in L‐tryptophan implicated in the eosinophilia‐myalgia syndrome (EMS). There is good evidence that the initial pathogenetic mechanism is immunological. On metabolic evidence, it is suggested that not one, but a group of, toxic agents was responsible for TOS.
RESEARCH INTO COMPLEMENTARY/ALTERNATIVE MEDICINE: AN ATTEMPT TO DISPEL THE MYTHS
Authors: Ernst E
Published: April 2023

The high level of popularity of complementary/alternative medicine (CAM) renders rigorous research into its efficacy and safety an important task. A House of Lords select committee called for more CAM research and for the establishment of UK centres of excellence to carry it out. In view of the otherwise dire funding situation, this would be a necessary step. This initiative should be complemented by CAM professional bodies setting up their own research budgets. Any central body overseeing CAM research has to be seen to be rigorous and impartial. Strong opinions which often dominate CAM can be a hindrance to good research. Evidence‐based CAM should no longer remain a contradiction in terms.
SUPERFICIAL RADIAL NEUROPATHY FOLLOWING VENEPUNCTURE
Authors: Sheu J‐J , Yuan R‐Y
Published: April 2023

A 42‐year‐old female suffered excruciating pain and paraesthesia on venepuncture of the cephalic vein in her left wrist. The left superficial radial nerve was injured. A flexed wrist during venepuncture renders the superficial radial nerve immobile and vulnerable to being punctured by the needle. To reduce the risk of nerve injury during venepuncture, the phlebotomist should choose a large and visible vein and insert the needle at a 5–15° angle with the skin. The wrist should be selected only if the veins in the antecubital area are deemed unsuitable. The feeling of an electric shock along the distribution of the nerve, or rupture of the vein during venepuncture, should alert the phlebotomist to the possibility of nerve injury and the procedure should be stopped immediately.
AGE OF SEIZURE ONSET IN ADULTS WITH DOWN'S SYNDROME
Authors: Puri BK , Ho KW , Singh I
Published: April 2023

In a cohort of 68 adults (35 males and 33 females) with Down's syndrome aged 29–83 years, a history of seizures was found in 26.5%. The overall mean age of onset of seizures was 37 years, males (22 years) being significantly younger than females (51 years). The age of onset was bimodally distributed, with the first peak occurring in the first two decades, and a late‐onset peak occurring in the fifth and sixth decades. A strong association between Alzheimer's disease and seizures was confirmed. Of those with a history of seizures, those aged over 45 years were significantly more likely to develop Alzheimer's disease than those younger than 45. It is suggested that late‐onset epilepsy in Down's syndrome is associated with Alzheimer's disease, while early‐onset epilepsy is associated with an absence of dementia.
STANDARD CARDIAC REHABILITATION IS LESS EFFECTIVE FOR DIABETICS
Authors: Suresh V , Harrison RA , Houghton P , Naqvi N
Published: April 2023

To assess clinical outcomes and lifestyle modifications in diabetic patients attending a standard cardiac rehabilitation programme following myocardial infarction (MI), a retrospective longitudinal study was undertaken in a district general hospital in the north west of England. A total of 1804 patients attended the cardiac rehabilitation programme over 10 years, of whom 223 (12.4%) had diabetes mellitus. Drugs were underprescribed in all patients, aspirin and beta‐blockers especially in diabetics (75.3% vs 90.3%, p<0.0001; 38.6% vs 60.8%, p<0.0001). Smoking cessation was poor in diabetics (54.2% vs 69.1%, p<0.003) and diabetics were less likely to attend at least one session of physiotherapy (26.9% vs 58.6%, p<0.0001). Diabetics had higher mortality at one year (15.7% vs 5.6%; p<0.0001), mostly associated with cardiovascular disease (13.4% vs 5.4%, p<0.0001). Standard cardiac rehabilitation programmes appear to be less effective for patients with diabetes mellitus. We suggest that patients presenting with an existing chronic condition need specialised programmes of rehabilitation to integrate the care of that condition with their recent MI. Aggressive drug therapy following acute MI should also be prescribed in all patients when not contraindicated by other evidence.
PRIMARY BRAIN TUMOURS: A REVIEW OF RESEARCH AND MANAGEMENT
Authors: Turini M , Redaelli A
Published: April 2023

The brain is an incredibly complex organ that contains some 10 billion working cells. Brain tumours can arise from the brain itself, the meninges, the nerves at the base of the brain, or even from outside the brain. The frequency of brain tumours directly reflects the relative proportion of each cell type present at the site of the initial tumour. Symptoms produced by a brain tumour often mimic the symptoms of other diseases and vice versa. Because symptoms can develop gradually, and can be subtle, there may well be a long delay between symptom onset and diagnosis. Treatment of brain tumour depends on the type and stage of the disease, and the patient's age and overall state of health. Treatment options fall into three categories: surgery, radiotherapy and chemotherapy. Biological therapy is also being studied in clinical trials. Primary brain tumours occur in all age groups, but are significantly more frequent in children and adolescents under 15 years old and the elderly. For every person diagnosed with a brain tumour (over 100,000 people annually in the US), an average of 22 years of life expectancy is lost. The estimated annual cost, direct and indirect, of the disease in the US is $104 billion.
THALAMIC TUMOUR PRESENTING AS FRONTAL LOBE DYSFUNCTION
Authors: Nagaratnam N , Ting A , Jolley D
Published: April 2023

A 64‐year‐old man presented with a change in personality and behaviour but with no neurological deficits. He exhibited impaired executive functions, apathy, unsteadiness of gait and falling; he lacked insight and exhibited purposeless behaviour, making loud grunting noises. A CT scan at 6 months revealed no abnormality, but at 9 months CT and MRI showed a bilateral thalamic tumour. The presenting symptoms had similarities to frontal lobe dysfunction progressing to dementia.
EPIDEMIOLOGY, MORBIDITY, MORTALITY AND TREATMENT OF LIGHTNING INJURIES IN A TURKISH BURNS UNITS
Authors: Aslar A Kessaf , Soran A , Yildiz Y , Isik Y
Published: April 2023

Deaths from lightning injuries are infrequent – 0.2–0.8 per million per year. The victims are mostly young, active people who are struck during various outdoor activities in the summer months. From November 1975 to October 1998; 22 lightning burns were treated in Ankara Numune Teaching and Research Hospital. The mean age of the patients was 32.9 (12–65) years, the female/male ratio 9/13 and the mean duration of hospital stay 15.4 (1–62) days. The commonest clinical symptoms were confusion, amnesia (5 patients), neurological dysfunction (2 patients), cystitis (4 patients), and cardiac arrhythmias (1 patient). There were no deaths. Sixteen surgical procedures were carried out on 14 patients; this was significantly fewer than from any other cause of burns. The commonest long‐term complication was chronic pain. Because complications are frequently seen in lightning injuries, our results revealed that patients should be hospitalised and treated as soon as possible after the accident with fluid resuscitation, cardiac resuscitation, tetanus prophylaxis and antibiotics where necessary.
DOUBLE‐BLIND STUDY COMPARING THE LONG‐TERM EFFICACY OF THE COX‐2 INHIBITOR NIMESULIDE AND NAPROXEN IN PATIENTS WITH OSTEOARTHRITIS
Authors: Kriegel W , Korff KJ , Ehrlich JC , Lehnhardt K , Macciocchi A , Moresino C , Pawlowski C
Published: April 2023

This double‐blind one‐year study compares the long‐term efficacy and safety of nimesulide with naproxen in patients with osteoarthritis (OA) of the knee or hip. Patients were randomised to nimesulide 100 mg twice daily (n=183) or naproxen 250 mg morning, 500 mg evening (n=187). The primary efficacy variable was change in pain intensity (WOMAC A scale) at 6 months. Nimesulide tablets showed at least equivalent efficacy to naproxen tablets in reducing pain intensity at 6 and 12 months (nimesulide ‐22.5% at 6 and 12 months; naproxen ‐22.4% at 6 months, ‐19.9% at 12 months; non‐inferiority proven). At 6 months the investigator assessed efficacy as ‘good’ or ‘excellent’ in 59.3% of nimesulide and 56.4% of naproxen‐treated patients, with corresponding values for patient assessment of 57% and 52.7%. Both treatments were well tolerated, with fewer related gastrointestinal adverse events reported with nimesulide (77 cases, 47.5%) than with naproxen (96 cases, 54.5%). This study shows nimesulide to be as effective as naproxen in the long‐term treatment of OA and to be associated with fewer gastrointestinal side‐effects.
TREATMENT GOALS IN IRRITABLE BOWEL SYNDROME
Authors: Kellow JE
Published: April 2023

Irritable bowel syndrome (IBS) carries a considerable economic and social impact which may, in part, be due to inefficient diagnosis and inappropriate treatment choice leading to continued patient ill health and absenteeism. Even assuming that IBS can be diagnosed positively, using well‐established symptom‐based criteria, management difficulties remain. Thus, pharmacological treatment choice is still based on the single predominant symptom, and many currently available treatments are ineffective in the long term. A greater understanding of the pathophysiology of IBS may lead to the development of more effective treatments that can target the multiple symptoms present in IBS. A new understanding of the role of serotonin (5‐HT) and specific receptors (5‐HT3 and 5‐HT4) found in the gastrointestinal (GI) tract has led to the development of serotonergic agents which have potential clinical benefits. Recent clinical trials suggest that 5‐HT4 receptor partial agonists, in particular, may have the ability to offer multiple symptom relief, without the risk of significant adverse reactions.
PATIENT SATISFACTION WITH RIZATRIPTAN VERSUS OTHER TRIPTANS: DIRECT HEAD‐TO‐HEAD COMPARISONS
Authors: Gerth WC , McCarroll KA , Santanello NC , Vandormael K , Zhang Q , Mannix LK
Published: April 2023

This study summarises the impact of treatment with rizatriptan 10 mg versus other 5‐HT1B/1D receptor agonists (triptans) on patient satisfaction with medication. Rizatriptan is a potent, selective 5‐HT1B/1D receptor agonist shown to be fast, effective and well tolerated in the acute treatment of migraine. We investigated patients' overall satisfaction with treatment in studies in which direct comparisons with other triptans were made. Data from five double‐blind, placebo‐controlled trials in which rizatriptan 10 mg was compared with another triptan were included in the analysis. Rizatriptan 10 mg was compared with sumatriptan 100 mg in one parallel study (n=916), sumatriptan 50 mg in two crossover studies (n=1599), naratriptan 2.5 mg in one parallel study (n=502), and zolmitriptan 2.5 mg in one parallel study (n=701). Satisfaction was reported by patients on a seven‐point scale ranging from ‘completely satisfied, couldn't be better’ to ‘completely dissatisfied, couldn't be worse’ at 2 hours after dosing. The percent of patients in the top two ‘satisfied’ categories (completely or very satisfied) were analysed. More patients on rizatriptan 10 mg were completely or very satisfied compared with sumatriptan 100 mg (33% vs 26%, p<0.05), sumatriptan 50 mg (40% vs 35%, p<0.05), naratriptan 2.5 mg (33% vs 19%, p<0.01), and zolmitriptan 2.5 mg (38% vs 30%, p<0.05). In all five studies more patients treated with rizatriptan 10 mg or other triptans were completely or very satisfied with treatment than patients receiving placebo (p<0.001, except naratriptan vs placebo p=0.004). The results, combined with the superior efficacy profile (fast, effective, well tolerated) of rizatriptan 10 mg, should enhance the treatment of migraine headache and lead to improved therapeutic intervention in clinical practice.
EICOSAPENTAENOIC ACID IN TREATMENT‐RESISTANT DEPRESSION ASSOCIATED WITH SYMPTOM REMISSION, STRUCTURAL BRAIN CHANGES AND REDUCED NEURONAL PHOSPHOLIPID TURNOVER
Authors: Puri BK , Counsell SJ , Hamilton G , Richardson AJ , Horrobin DF
Published: April 2023

The n‐3 essential fatty acid eicosapentaenoic acid (EPA) was added to the conventional antidepressant treatment of a treatment‐resistant severely depressed and suicidal male patient with a seven‐year history of unremitting depressive symptoms. The niacin skin flush test and cerebral magnetic resonance scanning were carried out at baseline and nine months later. The addition of ethyl‐EPA led to a dramatic and sustained clinical improvement in all the symptoms of depression, including a cessation of previously unremitting severe suicidal ideation, within one month. Symptoms of social phobia also improved dramatically. During the nine‐month period the volumetric niacin response increased by 30%, the relative concentration of cerebral phosphomonesters increased by 53%, and the ratio of cerebral phosphomonesters to phosphodiesters increased by 79%, indicating reduced neuronal phospholipid turnover. Registered difference images showed that the EPA treatment was accompanied by structural brain changes including, in particular, a reduction in the lateral ventricular volume.
SUPRAVENTRICULAR TACHYCARDIA WITH HYDROPS IN A 27‐WEEK PREMATURE BABY
Authors: Abraham P
Published: April 2023

A 27‐week baby with antenatally diagnosed supraventricular tachycardia (SVT) and hydrops fetalis was delivered by emergency caesarean section because of severe fetal bradycardia. The mother was on flecanide to control the fetal SVT. The baby was hydropic at birth and required prolonged ventilatory support. On day 6, he developed acute renal failure for which peritoneal dialysis was done. On day 23, he developed several episodes of supraventricular tachycardia (SVT) which did not respond to intravenous adenosine and amiodarone and ultimately required intravenous flecanide. This case report highlights the management of a critically ill premature hydropic baby with resistant SVT, and the successful outcome.
SEAT‐BELT SYNDROME REVISITED
Authors: Thompson NS , Date R , Charlwood AP , Adair IV , Clements WDB
Published: April 2023

This report describes a complex syndrome of injuries occurring in a young female who was a back seat passenger wearing a lap‐belt restraint in a high‐speed road traffic accident. As a consequence of the forced flexion distraction injury of her lumbar spine, she sustained a fracture‐subluxation of the first lumbar vertebra in association with a jejunal perforation and extensive small intestinal mesenteric laceration. She also had a large traumatic hernia of the anterior abdominal wall, which was overlooked at primary laparotomy. This report highlights collectively the classical combination of injuries associated with the lap‐belt syndrome and demonstrates the importance of carefully inspecting the anterior abdominal wall for deficiencies, because traumatic herniation may be easily overlooked.
THE RELATIONSHIP BETWEEN EXPRESSION OF P53/BCL‐2 AND HISTOPATHOLOGICAL CRITERIA IN BREAST INVASIVE DUCTAL CARCINOMAS
Authors: Gursan N , Karakök M , Sari I , Gursan
Published: April 2023

Seventy‐five cases of invasive ductal carcinoma (IDC) on whom axillary lymph node dissection and mastectomy were performed between 1996 and 2000 were reviewed histopathologically. The slides were stained immunohistologically with p53 and Bcl‐2. In 40 cases we observed 53% Bcl‐2 and 69% p53 positivity. There were correlations between p53 and tumour grade, and also between p53 and Bcl‐2. We did not observe any connection between the main histopathological prognostic factors – lymph node metastasis, tumour size, tubule formation, pleomorphism – and p53/Bcl‐2. In our study, IDC with a high mitotic index and poor differentiation showed mutant p53 positive staining. Expression of Bcl‐2 is associated with low nuclear grade and absence of mutant p53. This study was designed to reveal the correlation between histopathological findings and the expression of p53/Bcl‐2 on prognosis.
CONVULSIVE SYNCOPE IN YOUNG ADULTS: THINK OF A CARDIAC CAUSE
Authors: Patel SJ , Jackson G , Marshall A
Published: April 2023

Convulsive syncope is often misdiagnosed as epilepsy because of its similarity in clinical presentation. We present the case of a patient who had several such episodes before a definitive diagnosis was made. The diagnosis of prolonged sinus arrest was finally made with the valuable assistance of cardiac monitoring during a witnessed episode of convulsive syncope. Appropriate therapy was prompty introduced, i.e. temporary then permanent cardiac pacing. It is possible that any further delay in reaching the correct diagnosis and delivering appropriate treatment might have carried a significant risk of morbidity and mortality. Continuous electrocardiographic monitoring performed at an early stage is therefore crucial in the initial assessment of a young adult presenting with convulsive syncope, as a significant proportion may have a cardiovascular aetiology, particularly arrhythmias, for their syncopal episodes.
CONCURRENT MYELITIS AND GUILLAIN‐BARRÉ SYNDROME AFTER VARICELLA INFECTION
Authors: Chua HC , Tjia H , Sitoh YY
Published: April 2023

Myelitis and Guillain‐Barré syndrome occurring concurrently after varicella infection is very rare. A 34‐year‐old man presented with progressive flaccid tetraparesis, facial palsy, respiratory failure, sensory loss and urinary incontinence one week after varicella infection. Clinical, imaging and electrodiagnostic studies supported the diagnosis of myelitis and Guillain‐Barré syndrome. He improved with intravenous acyclovir and gammaglobulin.
THE USE OF INTRAVASCULAR ULTRASOUND IMAGING FOR THE ASSESSMENT OF LEFT MAIN STEM CORONARY DISEASE BEFORE BYPASS SURGERY
Authors: Skyrme‐Jones RAP , Mottram P , Meredith IT
Published: April 2023

Coronary angiography has well‐known limitations in the assessment of coronary artery disease, many of which are overcome using intravascular ultrasound (IVUS). While these limitations are particularly pronounced in the left main stem coronary artery, it is in this anatomical location that a correct decision regarding treatment modality has the most prognostic relevance to the patient. In this case report we demonstrate the importance of considering IVUS imaging in patients with apparent ostial and proximal left main stem disease before coronary bypass surgery.
CORONARY BYPASS GRAFTING IN SOUTH THAMES: THE CORRELATION BETWEEN CLINICAL SCORES AND WAITING TIMES
Authors: Chambers JB , Buckle R , Smeeton N
Published: April 2023

To determine waiting times before surgery and their correlation with clinical need, we examined the files of 1049 patients on the waiting list for coronary bypass grafting in 1996. The total waiting time to bypass grafting was 279 (SD 209) days (range 1–1579 days). Waiting time to specialist consultation was 36 (SD 43) days, and time on the waiting list for coronary angiography was 85 (SD 89) days. The mean time on the surgical waiting list was 133 (SD 134) days. Patients with a Birmingham clinical score below 10 waited between 27 and 879 days, and patients with scores above 35 waited between 3 and 282 days. Total waiting time was weakly associated with the priority score (Pearson correlation = ‐0.51). We conclude that waiting times were long with wide variation at every stage between referral and coronary bypass grafting. There was little correlation between clinical scores and waiting times.
THE SAFETY AND EFFICACY OF FORMOTEROL (OXIS®) TURBUHALER® PLUS BUDESONIDE (PULMICORT®) TURBUHALER IN MILD TO MODERATE ASTHMA: A COMPARISON WITH BUDESONIDE TURBUHALER ALONE AND CURRENT NON‐CORTICOSTEROID THERAPY IN RUSSIA
Authors: Chuchalin AG , Ovcharenko SI , Goriachkina LA , Sidorenko IV , Tsoi AN ,   Epoch Study Group
Published: April 2023

Current therapy in Russia for long‐term management of asthma is mainly non‐steroidal. This provided the opportunity to compare the efficacy and safety of formoterol (Oxis®) Turbuhaler® plus budesonide (Pulmicort®) Turbuhaler with budesonide Turbuhaler alone in adults (n=338) with mild to moderate asthma who had little previous exposure to inhaled corticosteroids. The 12‐week study followed a randomised, double‐blind, parallel group design and included an open control group of patients who were treated with conventional non‐corticosteroid therapy. Patients treated with formoterol plus budesonide benefited from a significantly greater improvement in their pulmonary function and asthma symptoms compared with budesonide alone (95% CI of difference in mean morning peak expiratory flow [PEF] 8.7–36.3 l/min, p=0.0015). Non‐corticosteroid treatment was significantly less effective than formoterol plus budesonide and budesonide alone (95% CIs of differences in mean morning PEF were 36.4–63.6 l/min and 14.1–41.1 l/min, respectively, both p=0.0001). Although the incidence and frequency of adverse events was not significantly different between the groups, formoterol plus budesonide and budesonide alone were better tolerated than non‐corticosteroid treatment, and there were fewer incidences of asthma deterioration. Overall, formoterol Turbuhaler plus budesonide Turbuhaler was the safest and most effective treatment.
THE MANAGEMENT OF METASTATIC BONE PAIN IN A DEVELOPING COUNTRY: THE ROLE OF RADIOTHERAPY AS AN ADJUNCT TO WEAK OPIOIDS
Authors: Adenipekun A , Alonge TO , Campbell OB , Oyesegun AR , Elumelu TN
Published: April 2023

Bone pain secondary to metastatic cancer is the commonest intractable pain and is a major concern in most oncology units the world over. Cancer pain management is multidisciplinary in approach, so there is no universal or singular modality of treatment. In a developing country like Nigeria, only external radiotherapy and adjuvant weak opioids are readily available, so it is of interest to review the response of these patients to this management option. This is a retrospective review of 92 patients aged 16–80 years with radiologically confirmed metastatic bone disease associated with pain who received external radiotherapy and weak analgesics. The results showed that 23 (25%) patients had a complete response and 67 (73%) had a partial response within four weeks of treatment. Total response was over 90%, which suggests external radiotherapy has an effective palliative role. The study also demonstrated the pattern of bony involvement among the common cancers seen in our environment. The availability of strong opioids (e.g. morphine and pethidine) will obviously consolidate the gains achieved with external radiotherapy in the management of metastatic bone pain in our environment.
TEGASEROD: A NOVEL, SELECTIVE 5‐HT4 RECEPTOR PARTIAL AGONIST FOR IRRITABLE BOWEL SYNDROME
Authors: Beglinger C
Published: April 2023

Irritable bowel syndrome (IBS) is a common functional bowel disorder of unknown aetiology. It is defined by the presence of gastrointestinal (GI) symptoms including abdominal pain/discomfort, bloating and bowel motor dysfunction. No available therapy is yet effective against all the symptoms of the disorder. Current treatments therefore target individual symptoms but may be accompanied by unpleasant side‐effects. Tegaserod is a novel selective serotonin receptor type‐4 (5‐HT4) partial agonist with structural similarity to 5‐HT. Tegaserod stimulates small bowel and colonic motility and helps to normalise GI function. Clinical trials using a patient's assessment of efficacy demonstrate that tegaserod significantly improves key symptoms of IBS: abdominal pain/discomfort, bloating and constipation. Tegaserod is well tolerated with an excellent safety profile and represents a significant treatment advance in this difficult‐to‐treat disorder.
THE MRC/BHF HEART PROTECTION STUDY: PRELIMINARY RESULTS
Authors: Owen Olwen Glynn
Published: April 2023

The Heart Protection Study (HPS), with over 20,500 subjects, is the largest trial of statin therapy ever conducted. It provides important and definitive new information on women, the elderly, diabetics, and people with low baseline cholesterol pre‐treatment and those with prior occlusive non‐coronary vascular disease. It is a prospective double blind randomised controlled trial with a 2×2 factorial design investigating prolonged use (>5 years) of simvastatin 40 mg and a cocktail of antioxidant vitamins (650 mg vitamin E, 250 mg vitamin C and 20 mg beta‐carotene). The HPS specifically included patients with high risk for coronary heart disease (CHD) but characteristics that excluded them from participation in previous statin trials. Simvastatin 40 mg treatment showed benefit across all patient groups regardless of age, gender or baseline cholesterol value and proved safe and well tolerated. Results show a 12% reduction in total mortality, a 17% reduction in vascular mortality, a 24% reduction in CHD events, a 27% reduction in all strokes and a 16% reduction in non‐coronary revascularisations. Among high‐risk patients in this western population (with a minimum total cholesterol [TC] ≥3.5 mmol/l at entry) there appears to be no threshold cholesterol value below which statin therapy is not associated with benefit; even among those with pre‐treatment cholesterol levels below current national recommended targets. Over the 5.5 year study period patients and their doctors were encouraged to add an active non‐study statin to the study regimen if they wished to do so. Thus the trial eventually had only two‐thirds complying with the original intention‐to‐treat design. Nevertheless, results were highly significant for the study statin – simvastatin 40 mg once daily. Preliminary results of the HPS are negative for the antioxidant vitamin cocktail but provide reassurance that vitamins do no harm.
EFFECT OF VERAPAMIL IN ELDERLY PATIENTS WITH LEFT VENTRICULAR DIASTOLIC DYSFUNCTION AS A CAUSE OF CONGESTIVE HEART FAILURE
Authors: Hung MJ , Cherng WJ , Kuo LT , Wang CH
Published: April 2023

Fifteen elderly patients with normal left ventricular (LV) systolic function and New York Heart Association functional class II‐III were studied. The effect of verapamil on LV diastolic function was assessed by congestive heart failure (CHF) score, treadmill exercise test, and Doppler echocardiography at baseline, and after each three‐month treatment period (placebo or verapamil 120 mg once daily), separated by a one‐week washout period before crossover. Blood pressure, heart rate, LV ejection fraction, LV mass, and cardiac output were unaltered by placebo or verapamil. Verapamil treatment significantly improved CHF score at 3 months (3.5 ± 0.5, p<0.05) compared with baseline (5.6 ± 0.5) or placebo (5.5 ± 0.5). The exercise time was similar at baseline (7.4 ± 1.2 min) and after placebo (7.4 ± 1.3 min) treatment but significantly (p<0.05) increased after verapamil (8.3 ± 1.2 min) treatment. The ratio of mitral A wave duration/pulmonary venous atrial systolic reversal duration increased after verapamil (1.11 ± 0.08) treatment compared with placebo (0.91 ± 0.07, p<0.05) and baseline (0.89 ± 0.08) which had similar durations. The isovolumic relaxation time was significantly (p<0.05) decreased from 84 ± 12 ms at baseline and 86 ± 13 ms with placebo to 73 ± 9 ms with verapamil. The results of this study suggest that in elderly patients with Doppler evidence of diastolic dysfunction as the cause of CHF, three months treatment with verapamil can improve CHF, increase exercise tolerance and improve LV diastolic function.
SEIZURE RECURRENCE IN TEMPORAL LOBE EPILEPSY
Authors: Hui ACF , Ma RCW , Ozaki R , Kay R , Cockram CC
Published: April 2023

We report on a patient with clinical, electroencephalographic and radiological features of temporal lobe epilepsy, whose seizures were initially controlled with antiepileptic treatment. Five years after the onset of seizures, he developed more frequent and prolonged episodes of confusion, which were misinterpreted as secondary to temporal lobe epilepsy. Further investigation revealed the presence of hypoglycaemia and the eventual diagnosis of metastatic insulinoma.
RECURRENT LENTIGO MALIGNA MELANOMA: REGRESSION ASSOCIATED WITH LOCAL AZELAIC ACID 20%
Authors: Vereecken P , Heenen M
Published: April 2023

Azelaic acid has been used to treat different hyperpigmentary disorders because of its antimelanocyte activity. The efficacy of azelaic acid in the treatment of lentigo maligna and melanoma has already been described and this local treatment is considered by some as an alternative agent when other forms of therapy are not realisable. Here we report a case of a patient with local recurrence of a stage IV lentigo maligna melanoma of the cheek which cleared after treatment with azelaic acid cream 20%.
GRANULOCYTE COLONY STIMULATING FACTOR TREATMENT FOR DELAYED RECOVERY OF TICLOPIDINE‐RELATED NEUTROPENIA
Authors: Hung MJ , Wang CH , Cherng WJ
Published: April 2023

We describe the case of a patient who developed neutropenia associated with sepsis and endophthalmitis after ticlopidine therapy for coronary stenting. The neutropenia did not resolve until granulocyte colony stimulating factor (G‐CSF) was given. This uncommon case brings to attention the need for the immediate use of G‐CSF in patients with delayed recovery from drug‐related neutropenia and severe infection.
COMPARISON OF NON‐INVASIVE VENTILATION AND STANDARD MEDICAL THERAPY IN ACUTE HYPERCAPNIC RESPIRATORY FAILURE: A RANDOMISED CONTROLLED STUDY AT A TERTIARY HEALTH CENTRE IN SE TURKEY
Authors: Dikensoy O , Ikidag B , Filiz A , Bayram N
Published: April 2023

This study was designed in a tertiary health centre in south‐eastern Turkey to compare the effectiveness of non‐invasive ventilation (NIV) plus standard medical therapy (ST) to ST alone, in acute hypercapnic respiratory failure (AHRF) due to chronic obstructive pulmonary disease (COPD) exacerbation. Thirty‐four consecutive patients were randomly assigned to receive either NIV plus ST or ST alone. NIV was applied with a simple non‐invasive ventilator through a full face mask in the general ward. Initial settings for inspiratory and expiratory positive airway pressures were 9 cm HO2, and 3 cm HO2, respectively. We observed statistically significant improvements in the first hour of NIV regarding respiratory rate (p<0.001), pH (p<0.05), PaO2 (p<0.05), and PaCO2 (p<0.001). PaO2 (p<0.05) showed significant improvement only in the first hour of ST The intubation rate and duration of hospitalisation in the NIV group were significantly shorter than those in the ST group (p<0.05). We conclude that NIV provides adjunctive therapeutic benefits compared with ST alone, and should be the choice of first step treatment in the AHRF due to COPD exacerbation in the appropriate setting and in selected patients.
UNDERSTANDING PATIENT PERCEPTIONS OF ASTHMA: RESULTS OF THE ASTHMA CONTROL AND EXPECTATIONS (ACE) SURVEY
Authors: Jones K Gruffyd , Bell J , Fehrenbach C , Pearce L , Grimley D , McCarthy TP
Published: April 2023

In spite of support among UK healthcare professionals for asthma guidelines, studies continue to show that many patients fail to reach the suggested management goals. Patient expectations and poor communication may be factors in this failure. This survey assessed patients' asthma control, expectations in respect of asthma and communication with healthcare professionals. A structured questionnaire, designed for self‐completion, was developed and distributed to asthma patients at participating pharmacies. A total of 1031 questionnaires were returned. Most of the respondents, even among those feeling well, reported lifestyle restrictions because of asthma. These restrictions were not generally discussed with healthcare professionals. One‐third did not perceive the benefits of inhaled corticosteroids. Low expectation may be a major contributor to the poor control seen in this survey. The failure to discuss lifestyle restrictions and symptom levels with healthcare professionals gives little scope for recommendation of appropriate and adequate treatment. Improved communication between healthcare professionals and patients may help such understanding and raise patient expectations.
9. ARM LYMPHOEDEMA FOLLOWING BREAST CANCER TREATMENT
Authors: Sparaco A , Fentiman IS
Published: April 2023

Lymphoedema of the upper limb can be a devastating consequence of breast cancer treatment. A wide range of incidence has been reported but the generally accepted rate is around 12%. The exact pathophysiological mechanisms remain unclear. Agreed working definitions are required in order to standardise future research in this area. The psychosocial importance and management is fundamental in limiting the impact of this phenomenon. Furthermore, it remains that the primary cause is dissection of the axilla. Therefore, active investigation into potential tools that may eliminate or reduce the extent of dissection without compromising prognosis is warranted.
SELECTIVE CHOLESTEROL ABSORPTION INHIBITION: A NOVEL STRATEGY IN LIPID‐LOWERING MANAGEMENT
Authors: Leitersdorf E
Published: April 2023

Many individuals throughout Europe have risk factors for coronary heart disease (CHD) and are non‐compliant with recommended treatments, despite guidelines for the reduction of low‐density lipoprotein cholesterol (LDL‐C) and the prevention of CHD. Significant numbers who should receive pharmacotherapy for hypercholesterolaemia do not, and one‐third of treated patients do not achieve recommended target LDL‐C levels. Optimum doses of statins, which have demonstrated undisputed efficacy in the treatment of hypercholesterolaemia in clinical trials, are seldom used; the inconvenience of dosage adjustments and safety concerns, particularly myalgia, may constitute obstacles to their optimal use for LDL‐C reduction in clinical practice. Ezetimibe is the first selective cholesterol absorption inhibitor that has demonstrated clinical benefits when used as either monotherapy or in combination with other lipid‐modifying agents.
AN OVERVIEW OF THE PHARMACOLOGY, EFFICACY, SAFETY AND COST‐EFFECTIVENESS OF LANSOPRAZOLE
Authors: Bown RL
Published: April 2023

Lansoprazole is a proton pump inhibitor that reduces gastric acid secretion in a dose‐dependent manner via inhibition of H+/K+‐adenosine triphosphatase in gastric parietal cells. It also exhibits antibacterial activity againstHelicobacter pyloriin vitro. During almost 10 years of clinical use, lansoprazole has proved effective and well tolerated in a wide range of acid‐related disorders, including gastro‐oesophageal reflux disease (GORD), duodenal ulcers, gastric ulcers, non‐steroidal anti‐inflammatory drug‐related ulcers, as well as non‐ulcer dyspepsia and acid hypersecretion. It is also used, in combination with antibiotics, forH. pylorieradication. In the above indications, lansoprazole has generally proved to be superior to the histamine H2‐receptor antagonists, and is at least as effective as the other currently available proton pump inhibitors. This review aims to evaluate the pharmacology, efficacy, safety and cost‐effectiveness of lansoprazole in acid‐related disorders, with particular emphasis on its use in GORD andH. pylorieradication regimens.
ADVERSE CUTANEOUS REACTION TO NAPROXEN: A MISSED DIAGNOSIS FORTUITOUSLY RESOLVED
Authors: Bandyopadhyay P , Butler JV , Patel CU
Published: April 2023

A 91‐year‐old man presented with a one‐month history of swollen legs and dyspnoea. He also complained of a 16‐year chronic rash that had caused him considerable morbidity and cosmetic problems. He had been taking naproxen for several years for osteoarthritis. Clinical examination demonstrated bilateral pitting oedema of the leg and a widespread excoriated rash that affected most of his body. A clinical diagnosis of fluid retention secondary to naproxen was made. Stopping naproxen led not only to the resolution of his leg oedema and dyspnoea, but also to the prompt and complete remission of the rash. Reviewing the patient's history revealed that the rash had almost certainly first appeared when naproxen was started many years previously.
ANAL INCONTINENCE AMONG IGBO (NIGERIAN) WOMEN
Authors: Okonkwo JEN , Obionu CN , Okonkwo CV , Obiechina NJA
Published: April 2023

Anal incontinence in patients who present to the gynaecology clinic for symptoms other than pelvic organ prolapse dysfunction is fairly common. A structured pre‐tested 41‐item pelvic organ prolapse questionnaire was administered by doctors to 3963 gynaecological patients, recruited from three states of south‐eastern Nigeria, who were in the clinic for reasons other than pelvic organ prolapse dysfunction. This report considers only anal incontinence. We found a prevalence of 6.96% for anal incontinence. Of these, 2.67% were incontinent for liquid stool, 2.17% for solid stool and 2.12% for flatus. There appears to be a higher frequency of flatus incontinence in the reproductive years: 36.6% of primiparas aged <30 years had faecal incontinence. Flatus incontinence was present in 28 (43.7%) of 198 para 4 and below, and in 36 (56.3%) of 78 para 5 and above. There was thus a significant association between flatus incontinence and parity (χ2=32.4; p<0.001). Spontaneous vaginal delivery had a significant effect on anal incontinence (p=0.04). Physicians should, be able to detect this embarrassing condition and be alert to factors that may avert or ameliorate it.
MANAGEMENT OF CHRONIC OSTEOMYELITIS IN A DEVELOPING COUNTRY USING CEFTRIAXONE‐PMMA BEADS: AN INITIAL STUDY
Authors: Alonge TO , Ogunlade SO , Omololu AB , Fashina AN , Oluwatosin A
Published: April 2023

Chronic osteomyelitis is a debilitating disease that is fairly common in developing countries. Various operative techniques have been adopted in the management of this disease but there have been few reports of their use in Africa. In this report, we present our experience of the use of a modified two‐staged Belfast operation in patients with chronic osteomyelitis in Ibadan, Nigeria. An important modification of the procedure was the substitution of gentamicin beads (Septopal) with ceftriaxone‐polymethylmethacrylate (PMMA) beads at the saucerised segment of bone at the first stage. Thirty‐four patients with chronic osteomyelitis had the two‐stage Belfast operation in 35 long bones; of these, 32 patients had ceftriaxone‐PMMA antibiotic beads inserted at the saucerised segment of bone at the first stage, while the other two patients had gentamicin beads inserted. One of the two patients who had gentamicin beads had a residual collection of pus at second stage surgery but, following a repeat debridement, the cavity was rid of infection. There was recurrence of infection in three patients (8.6%) who had a suction drain inserted at the first stage and in six patients (17.1%) who had no suction drain at the first stage. The locally produced ceftriaxone‐PMMA beads were found to be as efficient as the commercially available gentamicin beads in eluting antibiotics locally, thereby eliminating the residual infection in the bone cavities after the first stage. Another important outcome was a fourfold saving in cost in choosing to use ceftriaxone‐PMMA beads rather than gentamicin beads.
12. TIMING OF SURGERY FOR BREAST CANCER
Authors: Fentiman IS
Published: April 2023

Several studies have now shown that premenopausal women with early breast cancer have a significantly better prognosis if their tumours are excised during the luteal phase of the cycle. The 10‐year survival for node positive cases undergoing follicular phase surgery was 33% compared with 78% in those having surgery at other times of the menstrual cycle. Further work has shown that there is an improved survival in those with plasma progesterone levels >4 ng/ml‐1, associated with the luteal phase. Luteal phase surgery is also associated with a decreased risk of vascular invasion, implying that the tumour is more cohesive at that time. Similarly, in the heaviest quartile of postmenopausal patients, with the highest endogenous oestrogen levels, there was vascular invasion around tumours in 45% compared with only 11% of the lightest quartile. Changing the hormonal milieu at the time of surgery for breast cancer may have the ability to improve the prognosis for some patients with early breast cancer.