bluuebunny/crossref_metadata_2025 huggingface dataset:
CERVICAL METASTASIS IN PAPILLARY CARCINOMA OF THE THYROID: A HISTOPATHOLOGICAL STUDY
Authors: Coatesworth AP , Maclennan K
Published: April 2023

The tendency of well differentiated thyroid carcinoma to remain localised, and the slow progression of these tumours, have supported the belief that this disease behaves as a low grade malignancy. However, with differentiated carcinomas of the thyroid the incidence of nodal metastasis is highest in the papillary subgroup, and the importance of cervical metastases is being increasingly recognised. We have performed and prospectively analysed 17 neck dissections in 13 patients with clinically N+ve necks and papillary carcinoma of the thyroid. In all 17 neck dissections, metastatic deposits of papillary carcinoma of the thyroid were seen, with metastases found in all levels. Our findings of positive lymph nodes in all levels of the neck, with no predictable pattern of spread, and skip metastases, support an aggressive surgical approach to the treatment of cervical metastatic papillary carcinoma of the thyroid.
THE IMPORTANCE OF CODED RADIOGRAPHIC LABELLING IN CLINICAL PRACTICE
Authors: Harding IJ , Pearce O
Published: April 2023

Locating a particular radiograph from a radiographic envelope can be a frustrating and time‐consuming process. The aim of this study was to evaluate the role of colour and number coding of radiographs in reducing time taken to locate films and thereby improve efficiency. The time taken by clinicians to retrieve films from a radiographic envelope was measured. The radiographs were coded by number, number and colour or not at all. Results show a statistically significant reduction in time taken to find number coded versus non‐coded radiographs. A further benefit was gained by using colour coding in conjunction with number coding. We recommend the use of colour and number coding of radiographs in clinical practice.
MONITORING DIETARY COMPLIANCE IN COELIAC DISEASE USING RED CELL DISTRIBUTION WIDTH
Authors: Mitchell RMS , Robinson TJ
Published: April 2023

Red cell distribution width (RDW) as measured on modern blood analysers is a sensitive marker of nutritional deficiency affecting red blood cell production and maturation. Such deficiencies are common in coeliac disease and it may therefore be possible indirectly to assess response to a gluten‐free diet by monitoring the RDW. We measured RDW, iron, B12, folate and endomysial antibodies (EMA) in 46 newly diagnosed coeliac patients at diagnosis and after a gluten‐free diet. RDW was elevated in 76% of patients at diagnosis. There was a significant decrease in RDW (17.3% vs 13.8%) after 12 months of diet, corresponding to sero‐conversion of EMA and normalisation of serum iron, B12 and folate levels. We conclude that monitoring RDW is a simple indirect means of assessing response to a gluten‐free diet in coeliac disease.
EFFICACY AND SAFETY OF PIOGLITAZONE IN TYPE 2 DIABETES: A RANDOMISED, PLACEBO‐CONTROLLED STUDY IN PATIENTS RECEIVING STABLE INSULIN THERAPY
Authors: Rosenstock J , Einhorn D , Hershon K , Glazer NB , Yu S
Published: April 2023

The glycaemic and lipid effects of treatment with pioglitazone in combination with a stable insulin regimen were evaluated in patients with type 2 diabetes. Patients (n=566) receiving stable insulin regimens for ≥30 days yet who had HbA1c ≥8.0% and C‐peptide >0.7 μg/l were randomised to receive once‐daily 15 mg pioglitazone, 30 mg pioglitazone, or placebo in a 16‐week multicentre, double‐blind, placebo‐controlled trial. Per study protocol, the insulin dose was to remain unchanged, but could be decreased in response to hypoglycaemia. At the end of double‐blind treatment, patients receiving pioglitazone (15 mg or 30 mg) showed statistically significant mean decreases relative to baseline HbA1c (‐1.0 and ‐1.3, respectively; p<0.0001) and fasting plasma glucose (FPG) (‐34.5 mg/dl [‐1.92 mmol/l] and ‐48.0 mg/dl [‐2.67 mmol/l], respectively; p<0.0001); these differences compared with placebo were also significant (p<0.0001). Pioglitazone (15 or 30 mg) yielded significant increases in HDL‐C levels (mean increases ranging from +7.1% to + 9.3%) compared with baseline or placebo (p<0.01). The 30 mg dose also significantly reduced mean triglyceride levels (‐23.7%) compared with placebo (p=0.0218). No consistent changes in TC or LDL‐C levels were observed. The incidence of adverse events was similar in all treatment groups, although the incidences of weight increase, hypoglycaemia and oedema were higher among patients receiving insulin plus pioglitazone. There was no evidence of hepatotoxicity or drug‐induced elevations of serum ALT ≥3 x ULN. Pioglitazone, when added to stable insulin regimens, significantly improved HbA1c and FPG in type 2 diabetes. Pioglitazone treatment also provided significant benefit with respect to plasma HDL‐C and triglyceride levels. Whether these lipid changes have an impact on overall diabetic complications remains to be determined.
13. NEW BIOLOGICAL THERAPIES FOR BREAST CANCER
Authors: Plunkett TA , Miles DW
Published: April 2023

The exploitation of biological differences between normal and malignant cells is a logical approach to novel treatments for breast cancer. The potential targets for such therapy include the products of proto‐oncogenes and oncogenes, inhibition of growth factor receptor signalling and the immunological exploitation of antigenic differences between normal and malignant cells. Monoclonal antibody technology was heralded as a potential ‘magic bullet’ for cancer therapy following its discovery in the mid‐1970s, but it is only in the past few years that such technology has entered mainstream clinical practice. The humanised murine monoclonal antibody to HER2 (trastuzumab) has significant anti‐tumour activity but with minimal toxicity, and has been licensed for use in patients with advanced breast cancer. A different approach has been the use of enzyme inhibitors to interfere with the signalling pathways downstream of growth factor receptors (e.g. farnesyl transferase inhibitors). It is likely that effective targets for such therapies will be identified in the next few years. There have been significant advances in our understanding of human immunology which have coincided with the identification of so‐called tumour‐associated antigens (TAA). These developments have resulted in a resurgence of interest in tumour immunotherapy. Peptides derived from these TAAs have been used to generate tumour‐specific immune responses. An alternative strategy has been to immunise patients using viral vectors and plasmid cDNA encoding the TAA. In some studies, notably those in patients with advanced melanoma, significant clinical responses have been observed. Cell‐based strategies including autologous tumour cell vaccines, allogeneic tumour cell vaccines and dendritic cell vaccines have been used, and significant responses have been reported in several studies. Few of these methods have so far been applied to breast cancer, but the possible benefits and drawbacks of such an approach will be discussed.
MANAGEMENT OF ACUTE AND CUTANEOUS PORPHYRIAS
Authors: Badminton MN , Elder GH
Published: April 2023

The porphyrias comprise a group of disorders of the haem biosynthesis pathway that can present with acute neurovisceral symptoms, skin lesions or both. Acute porphyrias present with severe abdominal pain, confusion and seizures which may be life‐threatening. Specific treatment with haem preparations should be instituted as soon as possible following confirmation of increased excretion of porphobilinogen in the urine. Supportive treatment includes opiate analgesia, monitoring for and treating complications such as hypertension and hyponatraemia. Follow‐up should include counselling on lifestyle modification involving avoidance of alcohol, smoking and known porphyrogenic drugs and diet. Identification and counselling of at risk relatives is essential. The cutaneous porphyrias result from porphyrin‐induced photosensitivity and can present with either acute photosensitivity or skin fragility and blisters. All cutaneous porphyrias can be alleviated by avoidance of sunlight. Treatment of erythropoietic protoporphyria involves administering large doses of β‐carotene, which may improve tolerance to sunlight. Porphyria cutanea tarda can be effectively treated by phlebotomy or low dose chloroquine. Congenital erythropoietic porphyria is a rare, early onset, severe, photomutilating condition for which bone marrow transplantation has been shown to be successful.
TADALAFIL (CIALIS™) FOR MEN WITH ERECTILE DYSFUNCTION
Authors: Eardley I , Cartledge J
Published: April 2023

Tadalafil is an inhibitor of phosphodiesterase type 5, and is currently undergoing regulatory review in the US and in Europe. Its chemical structure is significantly different from sildenafil, and in vitro studies confirm significant potency for PDE5 inhibition, with little activity against most of the other isoforms of the enzyme including PDE6, which is the isoform of the enzyme found within the retina. The half‐life of tadalafil is 17.5 hours and clinical studies suggest significant activity 24 hours post‐dosing. As with sildenafil, efficacy depends upon a normal sexual stimulus, and the drug can taken be as required. Tadalafil is effective in the treatment of men with erectile dysfunction, and it appears to have a relatively mild side‐effect profile, with no visual side‐effects noted.
DISCHARGE AGAINST MEDICAL ADVICE: SOCIODEMOGRAPHIC, CLINICAL AND FINANCIAL PERSPECTIVES
Authors: Aliyu ZY
Published: April 2023

Discharge against medical advice (DAMA) presents healthcare providers with clinical, ethical and legal challenges. Patient factors – demographic, social and clinical – may determine the possibility of a hospitalisation ending against medical advice. All cases of DAMA from St Agnes Hospital, Baltimore, were identified from the computerised medical system. Patient factors including demographic, social and clinical variables relating to these discharges were analysed. Readmission data and cost of hospitalisation were also assessed. DAMA represented 1% of all discharges. The average length of stay was 2.3 days, at a cost of $3716.00. The average length of stay of 30‐day readmission was 4.7 days, making the cumulative cost of hospitalisation $10,761.56, 56% higher than expected. African Americans, males, lack of medical insurance and substance abuse were strongly associated with DAMA (p<0.01). Careful and proactive management strategies could mitigate the potential clinical, legal and economic implications of DAMA.
ACUTE EFFECT OF HAEMODIALYSIS ON SERUM MARKERS OF MYOCARDIAL DAMAGE
Authors: Tarakçioglu M , Erbagcl AB , Çekmen M , Usalan C , Çiçek H , Özaslan J , Camci C
Published: April 2023

Cardiac markers are more likely to be elevated in dialysis patients than in patients with renal failure not on dialysis. In this study, 31 patients (20 males, 11 females) undergoing chronic haemodialysis were enrolled. The effect of haemodialysis on cardiac troponin T (cTnT), I (cTnI), creatine kinase MB (CKMB) mass, CKMB activity and myoglobin assays was assessed by comparing pre‐ and post‐haemodialysis determinations. After correcting for haemoconcentration, significant differences were observed (mean ± SEM, pre‐ vs post‐dialysis) for myoglobin (178.9 ± 19.3 vs 225.0 ± 28.4 ng/ml; p=0.006) for cTnT (0.111 ± 0.028 vs 0.148 ± 0.037 ng/ml; p=0.004), for CKMB mass (2.75 ± 0.37 vs 2.59 ± 0.37 ng/ml; p=0.000) and CKMB activity (14.8 ± 0.9 vs 13.1 ± 0.9 U/l; p=0.000) assays. Our study questions the reliability of cardiac markers in dialysis patients and suggests that the clinical threshold value and diagnostic efficiency of each assay needs to be validated. Although these differences exceeded clinical threshold values in only a few patients, serum markers of myocardial damage in dialysis patients should be interpreted with caution.
RELATIONSHIP OF BONE TURNOVER PARAMETERS, ENDOGENOUS HORMONES AND VIT D DEFICIENCY TO HIP FRACTURE IN ELDERLY POSTMENOPAUSAL WOMEN
Authors: Erem C , Tanakol R , Alagöl F , Ömer B , Çetin Ö
Published: April 2023

Hip fracture is one of the severest consequences of osteoporosis affecting elderly women, but abnormalities of bone turnover responsible for bone loss have not been clearly defined. This study evaluated the relationship of bone turnover parameters to hip fracture in postmenopausal elderly women. We also investigated the effects of endogenous hormones and vitamin D deficiency on osteoporotic hip fracture. The subjects were 21 osteoporotic patients with hip fracture (study group) and 20 healthy postmenopausal women (control group). We measured osteocalcin levels, total and bone alkaline phosphatase (T‐ALP and B‐ALP), calcitonin, intact parathyroid hormone (iPTH), serum 25 hydroxyvitamin D (25OHD), urinary free deoxypyridinoline (D‐pyr) and cross‐linked N‐telopeptides of type 1 collagen (NTx) levels. Serum T‐ALP and B‐ALP levels in the study group were lower than those of the control group. The mean serum 25OHD levels in the study group were not significantly different from the control group, but in five cases the mean serum iPTH level was increased. The mean urinary NTx levels were significantly increased in the study group compared with the control group (p<0.05). There was no significant increase in urinary free D‐pyr between the two groups. There was significant correlation between serum T‐ALP levels and B‐ALP levels and between serum iPTH levels and B‐ALP levels. The mean serum SHBG level in the study group was higher than in the control group (p<0.05). These data suggest that postmenopausal hip fracture patients have biochemical evidence of decreased bone formation and increased bone resorption compared with postmenopausal healthy subjects. We suggest these abnormalities play a role in the decrease of bone mass and the consequent increase in bone fragility that characterises osteoporotic hip fracture.
PATTERN OF BACTERIAL FLORA IN LOCAL GENITAL SKIN AND SURGICAL WOUNDS IN CHILDREN UNDERGOING HYPOSPADIAS REPAIR: A PRELIMINARY STUDY
Authors: Ratan SK , Sen A , Ratan J
Published: April 2023

To evaluate the pattern of bacterial flora in children undergoing hypospadias repair, the following swabs were sent for 60 consecutive subjects: perimeatal swabs at admission and immediately before surgical scrub, and intraoperative and postoperative wound swabs (after the first change of operative dressing). A pure or predominant growth of organism that was not part of the local flora was labelled ‘infection’. The peak incidence of infection (53%) was detected in swabs taken at admission. This decreased to 30% in immediately preoperative skin swabs, following local preparations. Coliforms and Staphylococcus aureus were the most commonly grown pathogens and were sensitive to cephalosporin and aminoglycoside. Proximity to the anus, poor personal hygiene in our study subjects (who were of low socioeconomic status) and the high temperature and humidity in our geographic region probably led to the high incidence of infection. The authors feel that the results of preoperative perimeatal swabs could help dictate antibiotic therapy in patients awaiting hypospadias repair.
SILDENAFIL FOR PRIMARY PULMONARY HYPERTENSION: SHORT AND LONG‐TERM SYMPTOMATIC BENEFIT
Authors: Jackson G , Chambers J
Published: April 2023

We report two cases of primary pulmonary hypertension (PPH) who benefited from oral sildenafil therapy. Both demonstrated a substantial improvement in exercise ability, which has been sustained at 3 and 6 months. Sildenafil acting as a phosphodiesterase 5 inhibitor may have an important role to play in the management of PPH and we believe further study to be of importance.
VIAGRA ON THE INTERNET: UNSAFE SEXUAL PRACTICE
Authors: Solomon H , Man J , Gill J , Jackson G
Published: April 2023

The vast majority of men who experience some form of erectile dysfunction (ED) do not seek medical advice, mainly due to embarrassment and social stigma. They often prefer to seek unorthodox and covert methods of treatment. Unprescribed medication for ED is dangerous because of the strong association between ED and coronary heart disease. Published guidelines already exist for the management of patients presenting with sexual dysfunction and cardiovascular risks. In this case report we highlight that ED itself is a risk factor for occult CHD and illustrate the need for careful medical assessment and adherence to published guidelines for the management of ED.
ANGIOTENSIN CONVERTING ENZYME GENE POLYMORPHISM AND GLOMERULAR FILTRATION RATE CHANGES IN TYPE 2 DIABETIC PATIENTS
Authors: Araz M , Okan V , Celen Z , Aynacioglu S
Published: April 2023

It has been suggested that an insertion/deletion (I/D) polymorphism in intron 16 of the angiotensin‐converting enzyme (ACE) gene may be associated with diabetic nephropathy. The aim of this study was to investigate whether an association exists between ACE I/D polymorphism and glomerular filtration rate (GFR) in type 2 diabetes mellitus. A total of 128 type 2 diabetic patients were included in the study with the following ACE genotype distribution: DD 40, ID 58, II 30. I/D polymorphism was determined by polymerase chain reaction (PCR). Mean GFR was not statistically different according to ACE genotype (DD: 89.9 ± 28.1 ml/min, ID: 99.5 ± 25.1 ml/min, II: 96.6 ± 19.6 ml/min). There was no significant difference in genotype distribution in normo‐, micro‐ and macroalbuminuric patients (DD:ID:II [%], normo‐ 35:46:19, micro‐28:55:17, macro‐ 31:55:14). ACE I/D polymorphism does not seem to be associated with GFR in type 2 diabetic patients.
COMPARISON OF MOMETASONE FUROATE ADMINISTERED BY METERED DOSE INHALER WITH BECLOMETHASONE DIPROPIONATE
Authors: Chervinsky P , Nelson HS , Bernstein DI , Rerkowitz RA , Siegel SC
Published: April 2023

This study compared the efficacy and safety of mometasone furoate (MF) administered by metered dose inhaler (MDI) 56, 200 or 500 μg b.i.d., with beclomethasone dipropionate (BDP) 168 μg b.i.d. and placebo. Adult patients (n=395), with moderate persistent asthma (FEV1 50–90% of predicted normal), previously maintained on inhaled corticosteroids, were enrolled at 16 centres in a four‐week, randomised, double‐blind, double‐dummy, multicentre, dose‐ranging trial. At endpoint, FEV1 was significantly improved (p<0.01) with MF‐MDI 56, 200 and 500 μg b.i.d., as well as with BDP (6%, 13%, 14% and 4%, respectively), compared with placebo (‐12%). Mean change in FVC, FEF25–75%, and a.m. and p.m. peak expiratory flow rate (PEFR) were also significantly improved for all active treatment groups at endpoint compared with placebo. Asthma symptoms and quality of life (SF‐36) related to physical functioning improved with active treatments relative to placebo. All doses of MF‐MDI were well tolerated. Treatment with MF‐MDI 200 μg b.i.d. was superior to BDP MDI 168 μg b.i.d. or MF‐MDI 56 μg b.i.d., with no additional benefit derived from a higher MF‐MDI 500 μg b.i.d. dose. MF‐MDI was well tolerated, with superior efficacy compared with BDP MDI in these patients with moderate persistent asthma.
BUDESONIDE/FORMOTEROL (SYMBICORT®) IS WELL TOLERATED AND EFFECTIVE IN PATIENTS WITH MODERATE PERSISTENT ASTHMA
Authors: Rosenhall L , Heinig JH , Lindqvist A , Leegaard J , Ståhl E , Bergqvist PBF
Published: April 2023

The aim of this study was to compare the safety and efficacy of budesonide/formoterol 160/4.5 μg, two inhalations twice daily, with that of the mono‐products administered at the same daily doses via separate inhalers. A total of 586 patients (mean age 45 years) was included in this six‐month, open, randomised, multicentre study. Patients received either budesonide/formoterol (n=390) or budesonide plus formoterol (n=190). Safety was assessed by adverse events, vital signs and laboratory values. Efficacy was evaluated using spirometry tests, the Mini Asthma Quality of Life Questionnaire and the Asthma Control Questionnaire. Both treatments were well tolerated, with no differences in safety parameters between the groups. Mean FEV1 increased by 5–6% over baseline in both groups. There was no significant difference in the change from baseline between the groups using the disease‐specific questionnaires. Asthma exacerbations occurred with low frequency in both groups. Withdrawal rates were also comparable between the groups (p=0.085). Budesonide/formoterol in a single inhaler was as effective and as well tolerated as budesonide plus formoterol via separate inhalers.
A MULTINATIONAL, RANDOMISED, 12‐WEEK, COMPARATIVE STUDY OF DONEPEZIL AND RIVASTIGMINE IN PATIENTS WITH MILD TO MODERATE ALZHEIMER'S DISEASE
Authors: Wilkinson DG , Passmore AP , Bullock R , Hopker SW , Smith R , Potocnik FCV , Maud CM , Engelbrecht I , Hock C , Ieni JR , Bahra RS
Published: April 2023

This 12‐week, multinational study compared the tolerability and cognitive effects of donepezil (up to 10 mg once daily) and rivastigmine (up to 6 mg twice daily) in 111 patients with mild to moderate Alzheimer's disease. Both medications were administered open label according to recommended dosing regimens from the respective product labelling available during the conduct of the study. More patients in the donepezil group (89.3%) completed the study compared with the rivastigmine group (69.1%; p=0.009), and 10.7% of the donepezil group and 21.8% of the rivastigmine group discontinued due to adverse events (AEs); 87.5% of donepezil‐treated patients and 47.3% of rivastigmine‐treated patients remained on the maximum approved dose of each drug at the last study visit. Both groups showed comparable improvements on the ADAS‐cog administered by raters blind to study medication at weeks 4 and 12. Thus, using the recommended dosing schedules, donepezil was better tolerated with fewer discontinuations due to AEs, and both agents improved cognition to a similar extent.
TREATMENT OF PARKINSON'S DISEASE AND RESTLESS LEGS SYNDROME WITH CABERGOLINE, A LONG‐ACTING DOPAMINE AGONIST
Authors: Porter M‐C , Appiah‐Kubi LS , Chaudhuri KR
Published: April 2023

Dopamine agonists have diverse chemical and physical properties that can directly stimulate the dopamine receptors, unlike levodopa which undergoes presynaptic breakdown to dopamine before dopaminergic effects in Parkinson's disease (PD). Cabergoline, a dopamine agonist effective given once daily, is being used as treatment for PD. In theory, therapy with cabergoline provides striatal intrasynaptic dopamine replacement of PD in a physiological manner because of its long half‐life and the resultant sustained rather than pulsatile dopaminergic stimulation. Several placebo‐controlled trials using cabergoline as adjunctive therapy in PD have shown that cabergoline significantly reduces ‘off’ time, improves motor function and reduces levodopa requirement. Cabergoline has also been used as monotherapy in PD and has been shown to be as effective as other dopamine agonists in improving motor function and to be superior to levodopa in reducing dyskinesias over a five‐year period. Work from our group and others have also demonstrated the efficacy of cabergoline in PD patients with nocturnal disabilities and those with restless legs syndrome (RLS). More recently we have reported that cabergoline is a well‐tolerated dopamine agonist in both young and elderly patients and has an acceptable side‐effect profile.
FRACTURED LATERAL EPICONDYLE WITH ASSOCIATED ELBOW DISLOCATION
Authors: Murnaghan JM , Thompson NS , Taylor TC , Cosgrove AP , Ballard J
Published: April 2023

We describe a case series involving a very unusual injury in children, i.e. a Milch 1 fracture of the lateral condyle with an associated dislocation of the elbow. This fracture configuration is normally stable as the intact capitellotrochlear groove serves as a lateral buttress for the coronoid‐olecranon ridge of the ulna. In this series, however, each patient had an associated dislocation. These injuries usually present as a clinical dislocation and if the elbow is manipulated before radiographic imaging, the fracture line can be difficult to see on the post‐reduction films. We recommend that all patients with a dislocated elbow should have elbow stability assessed under general anaesthesia, because a missed lateral condylar injury can lead to abnormalities in carrying angle, epiphyseolysis or an unstable elbow.
EFFICACY OF LASER PALATOPLASTY: FOUR‐YEAR RESULTS
Authors: Maheshwar AA , Gomez KG , Obilanade M , Evans RA
Published: April 2023

There are few reports on the long‐term results of laser‐assisted uvulopalatoplasty (LAUP), with some casting doubt about its long‐term efficacy. We report satisfactory results in patients with more than four years' follow‐up. We conducted a retrospective study of patients who underwent LAUP at the Princess of Wales Hospital over a period of five years. Thirty‐three patients underwent LAUP as a day case procedure. They had had a mean follow‐up period of four years and five months. Twenty‐eight of these were asked details of their pre‐ and postoperative levels of snoring regarding frequency, volume and disturbance to their partners. There was a 50% reduction in frequency of snoring, a 51.85% reduction in volume and a 53.7% reduction in disturbance to their partners. All these figures are statistically significant (p<0.001). Overall, 60.8% of the patients felt the surgery was successful and had reduced their snoring to acceptable levels. We conclude that LAUP is an effective treatment for snoring, even in the long term.
REVERSIBLE HYPERTENSION IN A YOUNG FEMALE: URETERIC OBSTRUCTION DUE TO ENDOMETRIOSIS
Authors: Aldington S , Gujral S , Sibley GNA
Published: April 2023

We present the case of a young female who, upon investigation for hypertension, was found to have a ureteric stricture secondary to endometriosis. After excision of the stricture and an end‐to‐end ureteric anastomosis the patient's blood pressure returned to normal. This case highlights the need to investigate fully hypertension in young people and to consider the possibility of endometriosis in any female who presents with obstructive uropathy.
THE ROLE OF BOTULINUM TOXIN A IN THE MANAGEMENT OF LOWER LIMB SPASTICITY IN PATIENTS WITH CEREBRAL PALSY
Authors: Dursun N , Dursun E , Alican D
Published: April 2023

This study aimed to determine the effects of botulinum toxin‐A (btA) on spasticity in children with cerebral palsy (CP). Thirty‐five children with spastic CP were evaluated. The injection group consisted of 25 patients who were injected with btA and received conventional physical therapy The control group consisted of 10 patients who were treated with conventional physical therapy only In the injection group, btA was applied to the lower extremity spastic muscles at a total dose of 8–10 lU/kg. Spasticity was measured by the Ashworth scale. Gait function was evaluated by clinical gait assessment in all patients and temporal distance factors in 16 patients. All the parameters were recorded before treatment, after three days and after one month of therapy. Following injection of btA, significant improvement in all parameters was observed. No statistically significant progression was noted in the control group except clinical gait analysis scores. Comparing the three‐day and one‐month measurements of spasticity of the two groups, statistically significant results were obtained in favour of the injection group in all parameters except for clinical gait analysis scores. The findings of this study showed btA injection to be an effective treatment for reducing spasticity and improving gait function in patients with spastic CP
AGT AND AT1R GENE POLYMORPHISM IN HYPERTENSIVE HEART DISEASE
Authors: Mettimano M , Romano‐Spica V , Ianni A , Specchia ML , Migneco A , Savi L
Published: April 2023

Left ventricular hypertrophy in patients with hypertension is a main clinical prognostic entity. The aim of this study was to evaluate the association between mutations at genes of the renin‐angiotensin system (RAS) and the development of left ventricular hypertrophy. Genetic polymorphism in angiotensinogen (AGT) and angiotensin ll‐type 1 receptor (AT1R) genes was examined in a group of well‐selected essential hypertensive Caucasians with left ventricular involvement (n=40) and a group of healthy unrelated Caucasians (n=150). Cardiac morphology and function were assessed by M‐mode echocardiography. Molecular variants were analysed by amplified fragment length polymorphism. We observed a statistically significant difference both for AGT and AT1R genotype distribution in patients with left ventricular hypertrophy compared with controls (p<0.05). A 0.49 and 0.225 frequency was detected among cases for T and C mutant alleles at AGT and AT1R genes. Mutations in RAS genes are involved in the pathophysiology of target‐organ damage in essential hypertension. Evaluation of molecular factors conferring a risk of developing heart involvement may lead to better identification of patient subgroups and more effective control of the clinical course.
15. IMAGE‐GUIDED BREAST BIOPSY
Authors: Ralleigh G , Michell MJ
Published: April 2023

The introduction of mammographic screening has led to an increased number of impalpable in situ and invasive breast cancers. Image‐guided percutaneous biopsy in these patients has advantages over surgical biopsy, primarily cost savings and reducing the number of operations required for definitive treatment. Image‐guided breast biopsy is also useful in palpable lesions. Image‐guided biopsy should be used in conjunction with full clinical and imaging work‐up as part of the triple assessment protocol. Techniques available include fine needle aspiration, automated needle‐gun core and vacuum assisted large core biopsy. Lesions visible on ultrasound are preferentially biopsied using ultrasound guidance, while those seen only mammographically are biopsied using stereotactic guidance. Major complications are rare following image‐guided biopsy. In most cases further management can be decided based on the biopsy result. If there is discordance between clinical and imaging features and the biopsy result, image‐guided percutaneous biopsy should be repeated or surgical biopsy may be required.
FONDAPARINUX (ARIXTRA®): A NEW ANTICOAGULANT
Authors: Giangrande PLF
Published: April 2023

Fondaparinux is a promising new antithrombotic agent. This pentasaccharide selectively and specifically inhibits coagulation factor Xa, and requires antithrombin as co‐factor. It is entirely synthetic, in contrast to conventional heparin and low molecular heparins which are derived from animal tissues. Fondaparinux exhibits a high bioavailability and is convenient to use as it only needs to be given once daily by subcutaneous injection. Peak plasma levels are achieved within two hours of dosing and the plasma half‐life of fondaparinux is approximately 17 hours. There is no specific antidote for fondaparinux: it is not neutralised by protamine sulphate. Fondaparinux shows no cross‐reactivity with antibodies associated with heparin‐induced thrombocytopenia. Several randomised, double‐blind studies have demonstrated superiority with respect to a low molecular weight heparin (enoxaparin) in preventing venous thromboembolism in the setting of orthopaedic surgery. The results of clinical trials of fondaparinux in the treatment of deep vein thrombosis and acute coronary syndrome are also presented.
SLOW DECOMPRESSION OF THE BLADDER USING AN INTRAVENOUS GIVING SET
Authors: Perry A , Maharaj D , Ramdass MJ , Naraynsingh V
Published: April 2023

Rapid decompression of the bladder has been associated with complications such as diuresis, hyperkalaemia, haematuria and hypotension. Although these complications are easily managed and rarely clinically significant, clinicians still practise slow decompression using a ‘clamping’ technique. Slow decompression using a giving set provides a more convenient and less time‐consuming way of achieving this goal.
HORNER'S SYNDROME FOLLOWING EXCISION OF A VAGAL PARAGANGLIONOMA
Authors: Clements DM , Hedges AR , Tudor GR
Published: April 2023

We report a case of excision of a vagal paraganglionoma resulting in Horner's syndrome. The case was initially misdiagnosed as a carotid body tumour and demonstrates the need for adequate preoperative imaging and patient counselling for likely complications of surgery.
KNOWLEDGE OF STROKE SYMPTOMS AND RISK FACTORS AMONG AT‐RISK ELDERLY PATIENTS IN THE UK
Authors: Gupta A , Thomas P
Published: April 2023

Assessing patient knowledge can help healthcare providers in planning measures directed at prevention, early identification and referral of patients. An incorrect understanding of stroke symptoms may delay patients seeking emergency help, thus missing the benefits of acute stroke treatments. Insufficient knowledge about stroke risk factors may affect risk factor control. We conducted a questionnaire‐based interview among elderly patients at risk of stroke and assessed their baseline knowledge of stroke symptoms and risk factors. A large proportion were found to have an improper understanding of stroke symptoms and risk factors. Stress was considered the commonest risk factor for stroke. Most patients did not consider themselves to be at further risk of stroke. Further education is needed as part of stroke prevention strategies to remove misconceptions. Improved recognition of stroke symptoms when they occur will help when seeking emergency medical help.
PUBLIC PERCEPTIONS OF CARDIOVASCULAR RISK IN FIVE EUROPEAN COUNTRIES: THE REACT SURVEY
Authors: Erhardt L , Hobbs FDR
Published: April 2023

Little is known of the attitudes and behaviours of the general public with regard to their general and personal risk factors for coronary heart disease (CHD), particularly in relation to cholesterol. This study attempted to determine patient perceptions of general population and personal risks regarding cardiovascular disease. Face‐to‐face interviews were conducted with 5104 members of the public in five countries (France, Germany, Italy, Sweden and the UK). Main results showed only 45% of the public correctly identified CHD as the leading cause of death in their country, and only 51% were aware that high cholesterol increases CHD risk. The presence of cardiovascular disease or risk factors in respondents did not appear to alter perceptions of risk compared with the public who had no existing disease. Of the different nationalities interviewed, the Swedes and the Germans appeared to be most aware of CHD risk factors. Awareness and knowledge of LDL‐C and HDL‐C were very poor in all countries except Italy. Half of the general public (50%) reported they had never discussed their cholesterol levels with a physician and only 33% knew what their target level was. Despite this, the most common source of information on CHD and cholesterol was the physician (60%). Only 9% of the total sample reported that they were currently taking medication for high cholesterol, compared with 20% for hypertension. In summary the general public in several European countries has major lack of awareness of the risks of CHD. This gap in knowledge is particularly marked over the risks of high cholesterol. Significant public health education is required.
PERCUTANEOUS TRANSLUMINAL RENAL ARTERY ANGIOPLASTY: WHO BENEFITS MOST?
Authors: Ziakka S , Belli A‐M , Kong TK , Macgregor GA , Missouris CG
Published: April 2023

We set out to assess the long‐term benefits of renal percutaneous transluminal angioplasty (PTA) in 107 consecutive hypertensive patients with atheromatous renal artery stenosis. During 12‐month follow‐up, blood pressure fell to normal levels in 10 (8.8%) patients and improved in 76 (67.3%); renal function improved or remained stable in 74% of patients. In patients with atheromatous disease, renal angioplasty was most successful in those with stenosis in a single functioning kidney, and in nine patients who presented with symptoms and signs of heart failure, in the absence of overt ischaemic or valvular heart disease. In the latter group, renal PTA resulted in a large loss of sodium and water, resolution of the ‘apparent’ heart failure, and a marked improvement in blood pressure and renal function. It is suggested that all hypertensive patients with haemodynamically significant renal artery stenosis (and/or mild to moderate impairment in renal function), should be considered for renal PTA. Patients with atheromatous stenosis in a single functioning kidney, and those who present with signs of sodium and water retention, are likely to benefit most.
COMBINED SPINAL AND EPIDURAL ANAESTHESIA IN ELDERLY PATIENTS
Authors: Tahtaci N , Neyal M
Published: April 2023

The study was designed to investigate the effects of simultaneously combined spinal‐epidural anaesthesia in elderly patients and to evaluate the problems encountered during and after performing spinal block following epidural blockade. Nineteen ASA grade III elderly patients (mean age 75.8 years) were included in the study. The first 10 patients (group 1) were given 0.5% hyperbaric bupivacaine 2 ml (10 mg) and fentanyl 0.25 ml (12.5 μg) intrathecally. The remaining nine patients (group 2) received 0.5% hyperbaric bupivacaine 1 ml (5 mg) intrathecally; following the spinal block fixation (about 15 min), fentanyl 1 ml (50μg) in saline 10 ml was injected into the epidural catheter. The highest sensory block was achieved at T6 and T9 in groups 1 and 2, respectively. None of the patients experienced respiratory depression, sedation, vomiting, shivering or headache. In conclusion, simultaneous combination of subarachnoid and epidural blockade may provide sufficient anaesthesia with fewer complications.
17. PSYCHOSOCIAL PROBLEMS FOLLOWING A DIAGNOSIS OF BREAST CANCER
Authors: Griffin M , Fentiman IS
Published: April 2023

Most breast cancer patients are not ill but have to cope with major life changes, in the knowledge that they have a potentially life‐threatening illness. Additionally they have to withstand multiple physical and psychological demands of local and systemic treatment. The role of the specialist breast care nurse is to reinforce information, discuss treatment options, and if the patient has further questions to arrange additional appointments with the appropriate member of the breast team. Approximately 20% of newly diagnosed patients will experience long‐term psychological problems, and those at greater risk are cases with a previous psychiatric history, lack of support and low expectations of the benefit of treatment, sometimes from a previous adverse experience with a family member. The breast care nurse is in a good position to identify those at risk and to advise on the benefits of surgery and breast reconstruction. Clarification of the benefits and side‐effects of other treatments such as chemotherapy and radiotherapy are also part of the breast care nurse's remit. Patients in need can receive support including coping strategies which will improve their psychological well‐being during the cancer journey.
MANAGEMENT OF PATIENTS WITH INTERMITTENT CLAUDICATION
Authors: Olin JW
Published: April 2023

Intermittent claudication, the most common symptomatology of peripheral arterial disease, is characterised by lower‐extremity discomfort induced by exercise and relieved by rest. The most serious potential outcome of the condition is increased morbidity and mortality from cardiovascular disease, with which it is often associated, thus prompt diagnosis and management are crucial. Therapy consists of structured exercise and reduction of cardiovascular risk factors, followed by or together with pharmacological interventions with anticlaudicants (cilostazol or pentoxifylline) and specific antiplatelet agents (aspirin, clopidogrel). Revascularisation procedures are indicated in those with limb‐threatening or lifestyle disabling disease.
ACUTE MYOCARDIAL INFARCTION ASSOCIATED WITH MYOCARDIAL BRIDGE AND CORONARY ARTERY VASOSPASM
Authors: Sakuma M , Kamishirado H , Inoue T , Ichihara M , Takayanagi K , Hayashi T , Morooka S
Published: April 2023

A 65‐year‐old man was admitted to our hospital with acute myocardial infarction (Ml). Emergency coronary angiography showed no significant organic lesions, but a myocardial bridge was found at the mid‐left anterior descending artery. An acetylcholine provocation test revealed 90% spastic stenosis just proximal to the myocardial bridge. His acute Ml could have been caused by both a coronary spasm and the myocardial bridge.
TWELVE‐YEAR EXPERIENCE IN THE INVESTIGATION AND TREATMENT OF PARAGANGLIOMAS
Authors: Tormey WP , Fitzgerald RJ , Davis WG , Thompson CJ
Published: April 2023

We report a 12‐year laboratory experience in the diagnosis of 37 patients with phaeochromocytoma, one with malignant paraganglioma and one with ganglioneuroblastoma. Surgery was performed in eight different hospitals, which underlines the difficulty of ensuring uniformity of investigations. Of the 37 with phaeochromocytoma, 15 were in the right adrenal gland, 12 were on the left, seven were bilateral and three were extra adrenal. Twenty‐three were male and 15 were female; the median age was 36 years. Four of five patients with von Hippel‐Lindau disease had bilateral adrenal tumours and four had neurofibromatosis. None had multiple endocrine neoplasia. Using essential hypertensive patients as a reference population, diagnostic sensitivity was 80% for noradrenaline, 54.4% for adrenaline, 19.1% for dopamine, 93.3% for total normetanephrine, 33.3% for total metanephrine, 78.7% for 3‐methoxy‐4‐hydroxymandelic acid (HMMA) and 23.5% for homovanillic acid (HVA). However, if each patient's results were taken as a package, the sensitivities were 100% for noradrenaline, 63.6% for adrenaline, 30.3% for dopamine and 89% for HMMA. Seven recent patients had gene analysis. There were six (15.4%) deaths due directly or indirectly to the paraganglioma. Postoperative blood pressures were normal in 74%. The decrement in catecholamine values post‐surgery is shown. Urinary noradrenaline values fell by a mean of 94.5% and the use of urinary noradrenaline as a tumour marker is also demonstrated.
THE PHYSIOLOGY AND EMERGING ROLES OF ANTIDIURETIC HORMONE
Authors: Ranger G Singh
Published: April 2023

The antidiuretic hormone (ADH) vasopressin is a simple peptide hormone with a number of complex, essential physiological actions. It is becoming clear that this hormone is developing an important therapeutic role in a number of different conditions. These include vasodilatory shock due to sepsis or cardiac surgery, cardiac arrest, and prolonged/excessive bleeding caused by, for example, variceal haemorrhage. This article reviews the physiology of ADH relevant to these actions and scrutinises the evidence for its therapeutic applications.
RIVASTIGMINE IN PATIENTS WITH ALZHEIMER'S DISEASE AND CONCURRENT HYPERTENSION
Authors: Erkinjuntti T , Skoog I , Lane R , Andrews C
Published: April 2023

Rivastigmine has demonstrated significant benefits in patients with mild to moderate Alzheimer's disease (AD). We aimed to confirm whether rivastigmine was effective in patients with or without concurrent vascular risk factors (VRF), as previously suggested. We chose to stratify the 725 patients involved in an international dose‐ranging study according to the presence of arterial hypertension (a marker of VRF) at baseline. Efficacy in each subgroup was assessed using the ADAS‐cog, a measure of cognitive performance, the Progressive Deterioration Scale (PDS) and the Clinician's Interview‐Based Impression of Change (CIBIC) with caregiver input. Patients receiving rivastigmine 6–12 mg/day showed better outcomes on the ADAS‐cog than those receiving placebo, in both the hypertensive and non‐hypertensive subgroups. Hypertensive patients receiving rivastigmine 6–12 mg/day also showed improvement over those receiving 1–4 mg/day (p=0.023). Rivastigmine 6–12 mg/day also provided better outcomes than placebo on the PDS in the hypertensive (p=0.031) and non‐hypertensive (p=0.035) subgroups. All patients receiving rivastigmine 6–12 mg/day had superior CIBIC‐plus scores than those receiving placebo. There was a trend for lower incidences of nausea and vomiting in rivastigmine‐treated patients with hypertension than in those without hypertension. No cardiac adverse events or drug‐drug interactions were reported. Our data support the hypothesis that rivastigmine provides benefits to patients with or without hypertension, and contribute to the evidence that particular benefits may be observed in those with vascular risk factors.
UPPER AIRWAY OBSTRUCTION RESULTING FROM AN ANTIEMETIC
Authors: Barclay GA , Giridharan W , Guntis E , Karagama Y , Williams RS
Published: April 2023

Stridor and stertor can both be the cause of medical and surgical emergencies. The management of these conditions is largely dependent upon the underlying aetiology. This case report describes dystonia following prochlorperazine resulting in stridor and stertor.
CLINICAL GUIDELINES VERSUS CLINICAL PRACTICE IN THE MANAGEMENT OF LOW BACK PAIN
Authors: Armstrong MP , McDonough S , Baxter GD
Published: April 2023

To date, there have been limited data on the implementation of evidenced‐based clinical guidelines for low back pain (LBP). The aim of this study was to assess current management of LBP and evaluate to what extent clinical practice now reflects clinical guidelines. This survey involved the collection and analysis of data from the records of 200 patients who had been referred to a large teaching hospital with LBR Analysis indicated a high use of X‐rays, with little evidence of initial biopsychosocial assessment. The most popular treatments were advice, active exercises and McKenzie therapy. Manipulation was rarely used. Overall, a low use of electrotherapy was recorded. The results emphasise how little the clinical guidelines have influenced the decisions of clinicians, and highlight the need to address the barriers to adopting an evidence‐based approach in this area.
EPIDEMIOLOGICAL, CLINICAL AND LABORATORY FEATURES OF BRUCELLOSIS: A PROSPECTIVE EVALUATION OF 120 ADULT PATIENTS
Authors: Namiduru M , Gungor K , Dikensoy O , Baydar I , Ekinci E , Karaoglan I , Bekir NA
Published: April 2023

This prospective study was carried out in the department of infectious diseases of Gaziantep University between January 1997 and December 1999 to evaluate the epidemiological, clinical and laboratory features of brucellosis in south‐eastern Turkey. One hundred and twenty consecutive patients with active brucellosis were enrolled. The commonest way of transmission was ingestion of milk products from diseased animals.Brucella melitensiswas isolated in the specimens of 31 (45.5%) of 68 patients. The commonest abnormalities on physical examination were fever (66.6%), hepatomegaly (63.3%) and splenomegaly (56.6%). Osteoarticular involvement was found in 34 patients (28.3%). Fifteen (12.5%) patients had ocular involvement. Hepatitis, orchiepididymitis, pulmonary involvement and meningitis were found in one (0.8%), four (6.8%), three (2.5%) and one (0.8) patient, respectively. The commonest haematological abnormalities were relative lymphomonocytosis (71.6%) and anaemia (36.6%). In conclusion, brucellosis continues to be a common health problem in communities where the consumption of unpasteurised dairy products is common. Since prevention is as important as early diagnosis in reducing the morbidity of brucellosis, we suggest that improving current health policies with additional educational programmes is essential.