bluuebunny/crossref_metadata_2025 huggingface dataset:
THE IMPACT OF DIRECT ACCESS ENDOSCOPY, HELICOBACTER PYLORI NEAR PATIENT TESTING AND ACID SUPPRESSANTS ON THE MANAGEMENT OF DYSPEPSIA IN GENERAL PRACTICE
Authors: Asante MA , Patel P , Mendall M , Jazrawi R , Northfield TC
Published: April 2023

Direct access endoscopy services, Helicobacter pylori infection and more effective acid suppression therapy have influenced the management of dyspepsia in the past decade. Three hundred and ten GPs in south London were surveyed via postal questionnaire to determine the impact of these factors on the management of dyspepsia in general practice. Ninety‐one per cent of GPs prescribed simple antacids as initial treatment for simple dyspepsia and referred only if symptoms did not improve. When acid suppresants were used, 41% used H2 antagonists compared with 11% for proton pump inhibitors (p=0.0001). Risk factors for underlying malignancy were the most frequent reason for hospital referral at first consultation. Long outpatient waiting times result in about 90% of GPs choosing direct access endoscopy as the route of referral for all patients with dyspepsia, while only 36% would refer patients with sinister symptoms to direct access endoscopy if waiting times were similar to that of outpatients. H. pylori near patient testing did not seem to influence the management of dyspepsia in general practice.
MECHANISMS OF HYPOPHOSPHATAEMIA IN ALCOHOLIC PATIENTS
Authors: Elisaf  , Siamopoulos KC
Published: April 2023

The aim of our study was to determine the possible pathophysiological mechanisms of hypophosphataemia in a group of 127 patients admitted to hospital for alcohol‐related causes. Blood and fresh urine specimens were taken to determine acid‐base and electrolyte parameters. Thirty‐seven patients (29.1%) had hypophosphataemia (serum phosphorus <0.77 mmol/l) with a range of serum phosphorus of 0.32‐0.74 mmol/l. In 17 hypophosphataemic patients inappropriate phosphaturia (FEP04 >20%, TmPO4/GFR<0.80 mmol/l) was evident, possibly due to hypomagnesaemia, metabolic acidosis, metabolic alkalosis, or a proximal tubular defect in phosphate transport. The causes of hypophosphataemia in the remaining 20 patients were alcohol withdrawal syndrome, respiratory alkalosis and diarrhoea. Patients with hypophosphataemia were more often found to have hypomagnesaemia and respiratory alkalosis than normophosphataemic patients. In conclusion, hypophosphataemia is frequently observed in alcoholic patients due to various pathophysiological mechanisms, such as inappropriate phosphaturia, increased phosphorus entry into cells and increased gastrointestinal loss of phosphate.
THE MEDICAL MANAGEMENT OF STROKE
Authors: Bath PMW
Published: April 2023

The management of stroke, so long a ‘Cinderella’ condition, is changing rapidly as new developments appear for acute treatment, rehabilitation and secondary prevention. Most patients with acute stroke now need rapid assessment at hospital following the onset of symptoms. Those needing admission should be managed on an acute stroke unit for stabilisation, CT scanning and other investigation, and diagnosis, and then referred, as appropriate, to a specialist stroke rehabilitation unit. Aspirin is now the recognised treatment for acute ischaemic stroke (once primary Intracerebral haemorrhage has been excluded), and can be continued for secondary prevention. Attention should be paid to risk factors to prevent recurrence, especially treatment of hypertension, atrial fibrillation, and severe ipsilateral carotid stenosis. Patients with mild cerebrovascular disease should be managed in a specialist stroke/TIA clinic. Stroke is no longer an untreatable or unpreventable condition, and It is vital that hospitals design appropriate systems to manage patients in an interdisciplinary environment.
OSTEOPETROSIS IN CHILDREN
Authors: Al‐Rasheed SA , Al‐Mohrij O , Al‐Jurayyan N , Al‐Herbish A , Al‐Mugeiren M , Al‐Salloum A , Al‐Hussain M , El‐Desouki M
Published: April 2023

Over a 10‐year period, 28 Arab children with autosomal recessive osteopetrosis were seen in two hospitals in Riyadh, Saudi Arabia. Eighteen (64%) had osteopetrosis associated with metabolic acidosis probably due to a renal tubular defect; nine (32%) had a malignant infantile form of osteopetrosis and one had a mild form with delayed onset. Parental consanguinity was 56% and 40% among patients with and without acidosis respectively. Somatic and psychomotor retardation and recurrent bone fractures were common in both groups. Dental caries, cerebral calcification and optic atrophy were more frequent in patients with acidosis, while anaemia, hepatosplenomegaly and deafness were more common in patients without acidosis. To guarantee optimal rehabilitation, children with this progressive disease require an early multiteam approach.
A STUDY OF CHEST INFECTIONS IN HIV SEROPOSITIVE PATIENTS IN KUALA LUMPUR
Authors: Wood E , Cheong I , Lee C
Published: April 2023

A retrospective study of 144 adults with HIV infection was conducted to investigate the prevalence of upper and lower respiratory tract infections (URTIs and LRTIs). The patients were divided into two groups: those with acquired HIV through intravenous drug abuse (IVDA), and those who had acquired HIV through ‘other’ risk behaviours. LRTIs were more prevalent than URTIs overall, and LRTIs were significantly more common (p<0.001) in IVDAs than in the other‐risk group. Tuberculosis (40%) and bacterial pneumonias (33%) comprised the majority of LRTIs among IVDAs, while Pneumocystis carinii pneumonia (40%) was the commonest LRTI in the other‐risk group. Analysis of CD4 T‐lymphocyte counts indicated that HIV‐seropositive IVDAs are at greater risk of developing chest infections at higher CD4 counts than other‐risk patients. The IVDAs were also found to have a much higher rate of co‐infection with hepatitis C and B, which may be a factor accelerating the progression from HIV infection to AIDS. The mean time averaged for the two groups from known seroconversion to development of respiratory tract infection is only 1.37 years, which suggests HIV‐infected patients are presenting late for treatment in Malaysia.
PAEDIATRIC XANTHOGRANULOMATOUS PYELONEPHRITIS
Authors: Goodman TR , McHugh K , Lindsell M
Published: April 2023

Xanthogranulomatous pyelonephritis (XGP) is a well recognised but rare type of chronic pyelonephritis classically occurring in middle‐aged women. It is increasingly being recognised in children in whom it can be mistaken for Wilms' tumour. Awareness of the possibility of this condition occurring in children may allow early recognition and possible treatment. Two cases of XGP in children are described and the literature reviewed.
INTRAVENOUS CONSCIOUS SEDATION WITH MIDAZOLAM IN PAEDIATRIC PATIENTS
Authors: Rosen DA , Rosen KR
Published: April 2023

Intravenous midazolam has been widely used in paediatric patients for conscious sedation in procedures such as endoscopy, oesophageal manometry, biopsy, bone marrow aspiration and lumbar puncture. Its advantages include quick onset and short duration of action, and haemodynamic stability which may be associated with improved patient acceptance. The pharmacokinetic profile of midazolam compares favourably with that of diazepam, permitting more controlled sedation with a quicker recovery time. Midazolam has been associated with shorter recovery room stays and less vomiting in children who undergo outpatient surgery. The safety and tolerability profile of midazolam in paediatric patients is comparable or superior to that observed in adults. Patients who are haemodynamically unstable, as well as pre‐term and term infants are at greater risk of hypotension while receiving sedation. Thus, the availability of IV midazolam for use in children provides an important additional option for providing IV conscious sedation.
CEREBRAL PTOSIS REVISITED
Authors: Nagaratnam N , Singh‐Grewal D , Chen E , Davies D
Published: April 2023

We studied nine patients with cerebral ptosis and gaze deviation following an acute stroke. The brains of all nine showed an extensive lesion in the fronto‐parieto‐temporal regions. In five the stroke was left hemispheric. The assumption is that cerebral ptosis may have a bihemispheric representation and results from damage to the connections rather than to a specific area.
A COMPARISON OF A COMMUNITY MENTAL HEALTH CENTRE‐BASED PSYCHIATRIC SERVICE WITH ONE BASED IN AN OUTPATIENT DEPARTMENT AT THE SAME HOSPITAL
Authors: Singh MB , Puri BK
Published: April 2023

Referrals and response to referrals of two psychiatric services with similar catchment areas of the same hospital, one with a Community Mental Health Care (CMHC) centre and the other based at an outpatient department, were compared over a five‐month period. While the service with a CMHC had an increased number of referrals, which may reflect the aims of the CMHC of making mental health services more accessible and less stigmatised, most referrals were from general practitioners and therefore likely to be appropriate. In spite of its increased workload, the time from referral to assessment for the CMHC‐based service was significantly shorter than for the outpatient‐based service.
ANTIPLATELET DRUGS IN SECONDARY PREVENTION OF STROKE
Authors: Diener H‐C
Published: April 2023

Stroke is a leading cause of long‐term disability and death in developed countries. The primary medical strategy for secondary prevention of stroke is antiplatelet therapy. Although the clinical value of acetylsalicylic acid (ASA) is well recognised for preventing secondary stroke, several questions remain. What is the optimal dose of ASA to prevent stroke? Would combining ASA with another antiplatelet drug increase efficacy? Do new agents currently under development offer additional benefits? Many of the recent clinical trials address these questions. This review article summarises the results of these trials in the context of evolving strategies for stroke prevention, including the management of recurrent transient ischaemic attacks (TIAs), side‐effects of ASA, and economic issues.
CONTRACEPTION: A REVIEW
Authors: Kubba AA
Published: April 2023

Recent years have seen a dual development in contraception: on the one hand, advances in technology have widened the choice for women; on the other, the right of women to informed and free choice has been reaffirmed. The need to provide contraceptive users with impartial and up‐to‐date advice was highlighted by the pill scare of 1995. The extreme safety of the pill when used by low risk women was confirmed in several reports. However, interest in long‐acting systemic non‐oral methods continues to increase as providers seek methods with minimal compliance requirement and therefore higher efficacy which, in the case of the hormone releasing intrauterine system (IUS) and injectable progestogens, approach the efficacy of female sterilisation. Globally the intrauterine device (IUD) had topped the league of reversible contraceptives for many years but had had mixed fortunes in some developed countries, especially the US. A revival of the IUD is on the way, mainly because of the impressive performance of the IUS and the recent introduction of a frameless device, the GyneFix.
OBSTRUCTIVE SLEEP APNOEA SYNDROME: CARDIOPULMONARY AND DIFFUSE MANIFESTATIONS
Authors: Lalloo MT
Published: April 2023

Obstructive sleep apnoea syndrome mainly affects males over 40 and is thought to occur as a result of soft tissue laxity in the buccal and pharyngeal musculature. It is associated with changes in blood oxygen saturation and may lead to pulmonary hypertension and cardiac arrhythmias. Investigations should include routine haematological tests and, if possible, polysomnography. The main aim of therapy is to reverse as many risk factors as possible, i.e. alcohol consumption, obesity and smoking. Nasal continuous positive airway pressure is a useful tool in treatment but patient compliance may be poor, so surgery may be indicated. The surgical intervention of choice is uvulopalatopharyngoplasty, which is of most benefit to the patient with an upper airway laxity with an obstruction only at this level.
TREATMENT OF PAIN WITH SUSTAINED‐RELEASE TRAMADOL 100, 150, 200 MG: RESULTS OF A POST‐MARKETING SURVEILLANCE STUDY
Authors: Nossol S , Schwarzbold M , Stadler Th
Published: April 2023

In a post‐marketing‐surveillance study the use of a sustained‐release tramadol preparation (Tramal® long 100, 150, 200 mg) was investigated in 3153 patients. The intention was to comply with the legal obligation to carry out product surveillance and to collect data on prescribing behaviour. We focused our attention on drug safety and efficacy. Tramal long was used mainly for severe and very severe pain. The most frequently reported causes of pain were diseases of the locomotor system (49.9%), tumours (24.3%), traumas and fractures (10.1%), and neurogenic (9.3%). The mean daily dose was 235.7 mg, usually divided into two doses. The analgesic effect was described as very good or good by 82.5% of the patients. Adverse events occurred in 6.5% of the patients, mostly in the form of typical opioid side‐effects such as nausea (3.4%), dizziness (1.5%) and vomiting (1.1%). Severe or unknown side‐effects were not reported.
SAVED BY A HERNIA: AN UNUSUAL PRESENTATION OF OVARIAN CANCER
Authors: Matthews SJ , Mcclelland HR
Published: April 2023

A lump in the groin of a 75‐year‐old woman co‐existed with a single ovarian cyst. It was eventually diagnosed as a solitary necrotic omental metastasis from a cystadenocarcinoma of the ovary which had herniated through the femoral canal.
SUDDEN ONSET DEAFNESS: TWO CASES ASSOCIATED WITH PREGNANCY
Authors: Lavy JA
Published: April 2023

Sudden onset sensorineural deafness is an otological emergency; subsequent recovery of hearing has been shown to correlate with early treatment. There have been few documented reports of this occurring in pregnancy, although the increased thrombogenic risk of the pregnant state is a proposed aetiological factor. The wide variation in outcome is demonstrated by these two cases, which are presented to raise awareness of this condition.
FIBROUS CONTRACURE OF THE ELBOW FOLLOWING CANNULATION OF THE ANTECUBITAL FOSSA VEIN
Authors: Saab M , Kurdy NMG , Birkinshaw RI
Published: April 2023

A case of flexion contracture of the elbow resulting from thrombophlebitis is described. Thrombophlebitis is a recognised complication following cannulation of the antecubital fossa vein. In severe cases a tender fibrous band is palpable. There are no previous reports of a contracture deformity occurring from such a fibrous band. This case therefore presents an unusual clinical manifestation of thrombophlebitis not previously described.
ENT MANIFESTATIONS OF PSEUDOMONAS AERUGINOSA INFECTION IN HIV AND AIDS
Authors: Hern JD , Ghufoor K , Jayaraj SM , Frosh A , Mochloulis G
Published: April 2023

In acquired immunodeficiency syndrome (AIDS), opportunistic infections occur which are usually related to defects in cell‐mediated immunity. However, there has also been an increase in the incidence of bacterial infections in this population, including infections caused by Pseudomonas species. This study reveals the wide range of ear, nose and throat manifestations which can be caused by Pseudomonas aeruginosa in patients with HIV and AIDS and illustrates the need for a high index of clinical suspicion combined with accurate microbiological data for treating these potentially life‐threatening infections. In addition, treatment using combination chemotherapy, such as ciprofloxacin and ceftazidime, is advised, as it has been shown that dual therapy results in a significantly lower mortality.
COMPARATIVE EFFICACY AND SAFETY OF THE NONSTEROIDAL ANTI‐INFLAMMATORY DRUGS NIMESULIDE AND DICLOFENAC IN PATIENTS WITH ACUTE SUBDELTOID BURSITIS AND BICIPITAL TENDINITIS
Authors: Wober W , Rahlfs VW , Büchl N , Grässle A , Macciocchi A
Published: April 2023

The efficacy and tolerability of nimesulide, a non‐steroidal anti‐inflammatory drug (NSAID) 100 mg twice daily were compared with diclofenac 75 mg b.i.d. in short term treatment of acute shoulder (acute subdeltoid bursitis and bicipital tendinitis) in adult patients. In this double‐blind (double‐dummy), randomised, parallel group study over two weeks, 122 patients were included. The Mann‐Whitney statistics revealed therapeutic equivalence of both treatments with a slight superiority for nimesulide. The tolerability of nimesulide, judged by investigators and patients and analysed statistically, was superior to that of diclofenac. Thus, the benefit‐risk relationship was better for the test drug than for the reference drug.
BIOCHEMICAL TESTING OF ADRENOCORTICAL FUNCTION
Authors: Rosalki SB
Published: April 2023

Disturbed adrenal function may present in various ways. Here are outlined some of the functions of the adrenals and the clinical effects of adrenal disorder, followed by a more detailed consideration of the application of laboratory tests to the identification of adrenocortical hypo‐ and hyperfunction.
METASTATIC RENAL CELL CARCINOMA OF THE PAROTID GLAND PRESENTING AS A NECK MASS
Authors: Gangopadhyay K , Abuzeid MO , Martin JM , Saleem M
Published: April 2023

Metastatic tumours in major salivary glands are uncommon, with a higher incidence of primary sites from the head and neck. Renal cell carcinoma often exhibits unusual behaviour causing both clinical and pathological confusion. Renal cell carcinoma initially presenting as a metastatic swelling in the parotid gland or elsewhere in the head and neck is rare. We report a case of renal cell carcinoma metastatic to the parotid gland where the neck swelling was the first sign of the tumour, with a comprehensive review of the literature.
TELEPHONE FOLLOW‐UP: AN EXTENSION OF THE SURGICAL OUTPATIENT DEPARTMENT
Authors: Scott NA , Hughes S , Wright S
Published: April 2023

A total of 112 surgical patients took part in telephone follow‐up, conducted by non‐medical staff, after discharge home. Successful telephone follow‐up was achieved in 93% of patients at 6 weeks, 91% at 3 months and 79% at 12 months. Telephone follow‐up by non‐medical staff is a practical method of assessing patient outcome after surgery. Wider use of this technique would free up time in the surgical clinics, without compromising audits of outcome and purchaser demands for evidence of efficacy.
MANAGEMENT OF VULVAL PAIN – WHOSE RESPONSIBILITY?
Authors: Kundu A , Riley AJ
Published: April 2023

Vulval pain can be acute or chronic. Usually patients present to their general practitioner when the pain is acute but, when specialist advice is required, vulval pain can present a real dilemma over to whom to refer patients. Genitourinary medicine, gynaecology, dermatology and sexual dysfunction clinics all play an important part in the holistic management of this symptom. Consultation in a sympathetic environment with appropriate investigations and collaboration between different disciplines may provide a diagnosis and management.
REVERSIBLE LEFT VENTRICULAR DYSFUNCTION: DOES IT AFFECT CLINICAL PRACTICE AND DOES IT MATTER?
Authors: Redwood SR , Ferrari R , Marber
Published: April 2023

There is substantial evidence that many patients with impaired left ventricular function secondary to coronary artery disease may have hibernating or stunned myocardium. The identification of these patients is important, as revascularisation is associated with an improvement in function, and there is some evidence that revascularisation of these patients will actually improve prognosis. The most useful investigations for the identification of reversible left ventricular dysfunction are dobutamine echocardiography, thallium scanning and, although not available in many centres, PET scanning.
BIOCHEMICAL MARKERS OF BONE TURNOVER
Authors: Rosalki SB
Published: April 2023

Since bone markers may reflect different aspects of bone disorders and cell function, and osteolytic and osteoblastic activities may be individually or concomitantly altered, determination of more than one marker type is generally appropriate. Also, the individual markers of a particular type do not necessarily show parallelism. For example, in osteomalacia from vitamin D deficiency, bone‐specific alkaline phosphatase may be grossly elevated because of enhanced osteoblastic activity, whereas the vitamin D dependent osteocalcin may be decreased. With the exception of measurement of the bone enzymes, bone‐specific alkaline phosphatase and tartrate‐resistant acid phosphatase, bone marker measurements require complex and expensive immunoassays. As a general rule, the simple enzyme measurements can precede other investigation in most bone disorders. Bone‐specific alkaline phosphatase measurement alone is generally adequate for the investigation of osteomalacia, Paget's disease and hyperparathyroidism but should be combined with measurement of tartrate‐resistant acid phosphatase in suspected metastatic disease, and in multiple myeloma. Determination of both enzymes together may also be of value in the investigation of osteoporosis but in this disorder added benefit may be obtained by the addition of other bone markers, particularly urine deoxypyridinoline and possibly serum collagen telopeptide.
CONGENITAL DOUBLE UTERUS AND CONGLUTINATIO CERVIX IN LABOUR
Authors: As AK , Antoniou AV
Published: April 2023

An interesting case of congenital double uterus and the intrapartum events associated with it are described. In view of the rarity of the condition, its implication to the patient, her general practitioner and the obstetrician/gynaecologist is discussed, with special reference to contraception, cervical smear and operative surgical technique.
CHICKEN FANCIER'S SPLEEN
Authors: Morris‐Stiff G , Foster M
Published: April 2023

Splenic epidermoid cysts are rare congenital lesions which usually present insidiously with non‐specific symptoms such as dull left upper quadrant pain, or as incidental findings on clinical examination. We present a chicken breeder who presented as an emergency with a tender left upper quadrant mass and septicaemia secondary to zoonotic infection of a primary spienic cyst with Salmonella enteritidis. The cystic nature of the swelling was confirmed by ultrasound and the anatomy assessed with computed tomography. She was aggressively resuscitated and underwent laparotomy and splenectomy, after which she made an uncomplicated recovery. The importance of early diagnosis and surgical treatment is discussed, together with the measures required as prophylaxis against overwhelming post‐splenectomy sepsis.
HORMONE REPLACEMENT THERAPY: WHY ARE GENERAL PRACTITIONERS NOT PRESCRIBING MORE?
Authors: Dunne FP , Sadler GJ , Crampton JA
Published: April 2023

Recent statistics suggest hormone replacement therapy (HRT) is prescribed by only a small number of general practitioners (GPs), despite its use being widely discussed and advocated in the literature. In March 1997, we sent a questionnaire to 200 randomly selected practices in the south Birmingham area to try to find the reason. Eighty‐one (40.5%) completed questionnaires were returned from 57 (70%) male and 24 (30%) female GPs respectively. Seventy (86.4%) claimed they actively prescribed HRT as a prophylaxis for osteoporosis; 76% felt doctors were well informed about the risks and benefits of HRT. However, male and female GP opinions differed as to the most effective duration of HRT use. Comparison of the ethnic backgrounds of male prescribers and non‐prescribers revealed significant differences, and the ethnic group predominating in the catchment areas of prescribers and non‐prescribers was also different.
THE DIFFICULTIES ENCOUNTERED IN COMPLETING AN AUDIT CYCLE IN A DISTRICT GENERAL HOSPITAL
Authors: Ong CC , Chorbachi R
Published: April 2023

Clinical audit has brought about tremendous improvements in the quality of clinical, practice in all aspects of health care. However, completing an audit cycle presents many obstacles. We present our experience in the difficulties encountered in implementing changes to current practice. The factors involved are discussed.
RESPIRATORY MUSCLE FUNCTION IN PATIENTS WITH NEUROMUSCULAR DISORDERS AND CARDIOPULMONARY DISEASES
Authors: Syabbalo N
Published: April 2023

Respiratory muscle dysfunction frequently occurs in patients with neuromuscular disorders, cardiopulmonary diseases and in patients in intensive care units. Respiratory muscle weakness and/or fatigue is responsible for dyspnoea, reduced exercise tolerance, nocturnal 'desaturation, and prolonged weaning from mechanical ventilation. Chronic respiratory muscle weakness may also be associated with poor quality of life and increased mortality. Patients with severe respiratory muscle weakness are at increased risk of respiratory failure due to respiratory infections, electrolyte imbalance, sedation or uncontrolled inspired oxygen therapy. Although respiratory muscle weakness is often seen in clinical practice, the consequences and the precise point at which respiratory muscle fatigue occurs remain elusive. This article reviews the pathophysiology of respiratory muscle weakness and fatigue, and therapeutic interventions for enhancing respiratory muscle function in patients with neuromuscular and cardiopulmonary diseases.
RECENT DEVELOPMENTS IN THE DIAGNOSIS AND TREATMENT OF LUNG CANCER
Authors: Gilligan D
Published: April 2023

Lung cancer is responsible for 25% of all cancer deaths in the UK and it is estimated that over 80% of lung cancers are related to smoking. Despite numerous health education campaigns, large numbers of young people take up smoking, particularly girls. In the past there has been a somewhat nihilistic attitude to the management of lung cancer, but this is changing due to the emergence of sub‐specialisation in oncology and the development of new techniques and treatment, which are beginning to show promise.
ANOMALOUS ORIGIN OF THE LEFT CORONARY ARTERY
Authors: Felmeden D , Lip GYH
Published: April 2023

We report on a rare case of both left and coronary arteries originating from a common origin in the right coronary sinus.
COBB'S COLLAR AND SYRINGOCELE WITH STONE
Authors: Mutlu N , Çulha M , Mutlu B , Acar O , Turkan S , Gokalp A
Published: April 2023

We report a case of unusual syringocele with a stone and Cobb's collar. Tubular or cystic dilatation of Cowper's gland duct has been called a syringocele. Congenital urethral narrowing is known as Cobb's collar. This paper presents a rare case of adult syringocele with stone and Cobb's collar. We analysed the clinical, radiological and therapeutic aspects of this entity.
DEEP VEIN THROMBOSIS AS A PRESENTING SYMPTOM OF CONGENITAL INTERRUPTION OF THE INFERIOR VENA CAVA
Authors: Timmers GJ , Falke THM , Rauwerda JA , Huijgens PC
Published: April 2023

Intrahepatic interruption of the inferior vena cava is a congenital anomaly, resulting in venous drainage of the lower extremities by way of a compensatory enlarged vena azygos system. We report the case of a 37‐year‐old male who presented with symptoms of deep vein thrombosis of the entire right lower extremity. A right‐sided mediastinal mass on the chest X‐ray was mistaken for a haematological malignancy but proved later to represent an enlarged azygos vein. The case illustrates that in a case of deep vein thrombosis, especially in younger patients, interruption of the inferior vena cava should be considered. A right‐sided paratracheal mass on the chest X‐ray may give a clue in making the correct diagnosis.
AN UNUSUAL CASE OF ILEOCAECAL TUBERCULOSIS IN AN 80‐YEAR‐OLD CAUCASIAN MALE
Authors: Kelly J , Warren K , Coutts M , Jenkins A
Published: April 2023

An 80‐year‐old Caucasian male presented with a seven‐week history of diarrhoea and weight loss. Distal duodenal biopsies showed partial villous atrophy but he failed to respond to a gluten‐free diet. Subsequently he developed a right iliac fossa mass associated with radiological evidence of ileocaecal ulceration. Colonoscopic biopsies from the caecum showed non‐caseating granulomata and Ziehl‐Neelsen (ZN) staining and culture for acid‐fast bacilli (AFB) were negative. Crohn's disease was diagnosed and he was started on steroids. Although he showed an initial response, his condition then deteriorated and he died after six weeks. ZN staining of tissue at postmortem showed AFBs. Although a rare diagnosis in the UK, a high index of suspicion should be maintained for ileocaecal TB in patients with appropriate clinical features, even if classical risk factors for TB are absent.
A FOREIGN BODY IN THE BRONCHUS STILL PRESENTS PROBLEMS
Authors: Tariq M , Beg MHA
Published: April 2023

Aspiration of a foreign body in young children is rare but can still cause considerable morbidity and mortality. The case of a 5½‐month‐old infant with aspiration of a piece of apple is presented, together with a review of the literature.
TOPICAL IMMUNOTHERAPY IN DERMATOLOGY
Authors: Buckley DA , Vivier AWP Du
Published: April 2023

Topical immunotherapy of skin diseases has been used since the 1970s to treat conditions thought to result from an altered immunological state, mainly extensive alopecia areata and resistant viral warts. Despite its effectiveness, only a handful of dermatology departments in the UK currently provide such treatment. Any of three universal contact sensitisers may be used for topical immunotherapy; but diphencyprone (DCP) has advantages over dinitrochlorobenzene (DNCB) and squaric acid dibutyl ester (SADBE). Sensitisation of medical, nursing and pharmacy staff may be avoided by careful handling of the solutions. Local blistering and eczematous eruptions are the most common risks in patients undergoing treatment; vitiligo and erythema multiforme‐like reactions are rare complications. Topical immunotherapy using DCP with close supervision is a useful option for severe alopecia areata and resistant viral warts.
PRIAPISM INDUCED BY CHLORPROMAZINE
Authors: Mutlu N , Ozkurkcugil C , Çulha M , Turran S , Gökalp A
Published: April 2023

Priapism is a pathologically prolonged and painful penile erection, usually unassociated with sexual desire or intercourse. Causes include certain oral medications, although the mechanism for drug‐induced priapism is unknown. We describe two cases of priapism attributed to chlorpromazine who have presented within the past two years.
MIVACURIUM APNOEA: A TRAP FOR THE UNWARY
Authors: Ogunbiyi OA , Branch KG
Published: April 2023

We present a case of unanticipated postoperative apnoea in a patient with associated medical illness to illustrate the diagnostic difficulty that can arise in the detection and subsequent management of mivacurium apnoea. A high index of suspicion is essential in the presence of concomitant medical conditions that may cause prolonged apnoea. To our knowledge, no report exists documenting the unanticipated occurrence of mivacurium apnoea in a patient with previously undiagnosed pseudoCholinesterase deficiency and concomitant medical illness who has previously undergone ‘balanced’ general anaesthesia.
TREATMENT OF COMPLICATED INTRA‐ABDOMINAL INFECTIONS: COMPARISON OF THE TOLERABILITY AND SAFETY OF INTRAVENOUS/ORAL TROVAFLOXACIN VERSUS INTRAVENOUS IMIPENEM/CILASTATIN SWITCHING TO ORAL AMOXYCILLIN/CLAVULANIC ACID
Authors: Luke  , Peterson J
Published: April 2023

Three‐ to four‐times‐daily intravenous (IV) imipenem/cilastatin switching to oral amoxycillin/clavulanic acid is often used to manage complicated intra‐abdominal infections. Trovafloxacin, a clinically and bacteriologically proven new‐generation fluoroquinolone antibiotic, given as single‐agent, once‐daily IV/oral therapy, can provide equivalent clinical and bacteriological efficacy. Tolerability and safety of up to 14 days treatment with 300 mg IV alatrofloxacin (the prodrug of trovafloxacin) switching to 200 mg oral trovafloxacin were compared with those of 1 g IV imipenem/cilastatin switching to 625 mg oral amoxycillin/clavulanic acid. Comparable incidences of adverse events, mainly mild or moderate in intensity, were experienced in each treatment group. For both therapies, gastrointestinal events were most common, but diarrhoea was reported by proportionately more comparator group patients. In conclusion, once‐daily IV‐to‐oral trovafloxacin has a comparable safety profile to IV imipenem/cilastatin followed by oral amoxycillin/clavulanic acid. Cost saving may be achieved with trovafloxacin due to the lack of any need to monitor creatinine levels and the once‐daily dosing regimen that allows a switch to the same orally administered drug.
BRONCHODILATORY RESPONSES TO FORMOTEROL, IPRATROPIUM, AND THEIR COMBINATION IN PATIENTS WITH STABLE COPD
Authors: Sichletidis L , Kottakis J , Marcou S , Constantinidis TC , Antoniades A
Published: April 2023

We studied 27 patients with stable chronic obstuctive pulmonary disease (COPD) in a randomised, single‐blind, within‐patient, placebo‐controlled clinical study. Each patient was assigned on six separate days to receive one of the following drug regimens in random order: A. 40 μg ipratropium bromide (Atrovent MDI, 20 μg/puff) plus 2 puffs placebo; B. 12 μg formoterol fumarate (Foradil MDI,12 μg/puff) plus 3 puffs placebo; C. 80 μg ipratropium; D. 24 μg formoterol plus 2 puffs placebo; E. 12 μg formoterol plus 40 μg ipratropium plus 1 puff placebo; F. 4 puffs placebo. On each study day, Spirometric indices and vital signs were measured at 5, 10, 15 and 60 minutes, and hourly thereafter up to and including 12 hours after study drug administration. Mean peak FEV1 change (primary endpoint) was maximum with the administration of the combination of ipratropium and formoterol (335.2 ml, SE 24.6), and it differed significantly from the observed peak changes following single administration of the two tested doses of ipratropium (p<0.05 and p<0.05 respectively). Safety and tolerability were satisfactory throughout the study.
SCIATICA IN THE COMMUNITY – NOT ALWAYS DISC HERNIATION
Authors: Hopayian K
Published: April 2023

Three cases of sciatica seen in general practice are described. The clinical features were consistent with pyriformis syndrome, a condition of compression of the sciatic nerve at the pelvic outlet. The literature on causes and clinical features is briefly reviewed. The prevalence of the condition in the community and the accuracy of clinical diagnosis are unknown. It is suggested that pelvic outlet syndrome, comparable to carpal tunnel syndrome, is a more appropriate name for the condition.
EMERGENCY CONTRACEPTION
Authors: Sarkar NN
Published: April 2023

Emergency contraception means preventing pregnancy after unprotected sexual intercourse. This is also called postcoital contraception (PCC) or the ‘morning‐after pill’. High doses of oestrogen or progestogen or a combination of both may be used as PCC up to 72 hours after unprotected intercourse. The use of mifepristone as emergency contraception has also proved promising. Some women use emergency contraception, but there are many who do not know much about it. Users, providers and other health professionals need to be educated about this method. Emergency contraception does not fall within the ambit of abortion law, yet its acceptability depends on the legal, cultural and religious consideration of most countries. This method is safe and effective and could be used occasionally to prevent unwanted pregnancy.
‘NOT FOR RESUSCITATION’: GUIDELINES FOR DECISION MAKING AND DOCUMENTATION
Authors: Blackie KA , Davidson AC , Marsh MJ , Kinirons MT
Published: April 2023

In 1991, the government's Chief Medical Officer made it clear that the responsibility for resuscitation policy lay with consultants, and that they should ensure this policy was understood by all staff caring for a patient, in particular junior medical staff. Since then, many hospitals and trusts have provided members of the multidisciplinary team with guidance on how to ensure that adequate and satisfactory communication is in place to record a patient's resuscitation status. However, as is common in the NHS, poor documentation is still evident. Guy's & St Thomas' Hospital Trust has been using a document since April 1998 which is clearly written, user friendly and does not contain ambiguous statements. With ongoing audit of this policy document we hope to reduce the incidence of inappropriate resuscitation attempts which are costly, both emotionally and financially, for all concerned.
HYPERCALCAEMIA: A CLUE TO MYCOBACTERIUM AVIUM INTRACELLULARE INFECTION IN A PATIENT WITH AIDS
Authors: Aly E‐S , Baig M , Khanna D , Baumann MA
Published: April 2023

Hypercalcaemia is uncommon in HIV‐infected patients and should suggest a different priority for differential diagnosis than would be considered in other settings. Although hypercalcaemia has long been associated with granulomatous diseases including tuberculosis, it has only recently been recognised that patients with illness due to Mycobacterium avium intracellulars (MAI) may develop it. We report a patient with AIDS in whom unexplained hypercalcaemia was the harbinger of clinically significant MAI infection. Patients with AIDS who develop hypercalcaemia should be closely evaluated for underlying MAI infection.
INTERNATIONAL MULTICENTRE COMPARISON OF CERIVASTATIN WITH PLACEBO AND SIMVASTATIN FOR THE TREATMENT OF PATIENTS WITH PRIMARY HYPERCHOLESTEROLAEMIA
Authors: Betteridge DJ
Published: April 2023

An international multicentre double‐blind randomised trial compared the efficacy and safety of cerivastatin (0.025, 0.05, 0.1 and 0.2 mg once daily) with placebo and simvastatin (20 mg) over a period of 12 weeks, with study extensions to 52 and 100 weeks. The primary efficacy parameter was the percentage change in low density lipoprotein cholesterol (LDL‐C). This was reduced from the baseline by 12.5% (0.025 mg) to 30.6% (0.2 mg) compared with falls of 2.0% on placebo and 40.3% on simvastatin. All four cerivastatin doses and simvastatin (20 mg) produced significantly greater falls than placebo (p<0.0001) and the decrease in LDL‐C was dose‐dependent for cerivastatin. Simvastatin produced significantly greater falls than any cerivastatin dose or placebo (p<0.0001). The effect was maintained at 1 year but somewhat attenuated at 100 weeks. Significant falls were also seen in serum total cholesterol and triglycerides. High density lipoprotein cholesterol (HDL‐C) levels were significantly increased by cerivastatin (0.1 and 0.2 mg) and simvastatin (20 mg) at 12 weeks and increased further by 100 weeks. Mean fasting apolipoprotein A1 and lipoprotein A1 were increased and apolipoprotein B decreased by cerivastatin and simvastatin therapy. All doses of cerivastatin produced significant falls in the total cholesterol/HDL‐C ratio at 12 weeks (0.5‐1.6) compared with a fall of 2.1 for simvastatin (20 mg). Cerivastatin was well tolerated. Elevations in creatine Phosphokinase, aspartate aminotransferase and alanine aminotransferase were mostly minor and transitory. Vital signs, electrocardiogram determinations, urinalysis and ophthalmic assessment showed similar results for both drugs. Cerivastatin, at doses of 0.1 mg and 0.2 mg daily, is considered to be of therapeutic value in the treatment of patients with primary hypercholesterolaemia, with 0.2 mg cerivastatin achieving reductions of LDL‐C and total cholesterol similar to those achieved in the WOSCOP and CARE studies.
ANAESTHETIC ASSESSMENT AND MANAGEMENT OF CARDIAC PATIENTS FOR NON‐CARDIAC SURGERY PART I: ASSESSMENT
Authors: Shaw A , Boscoe MJ
Published: April 2023

Cardiac disease is known to increase the risk of non‐cardiac surgery to patients who suffer from it. Clinical and investigation data may be used to identify those at increased risk. Attempts have been made to integrate these risk factors into systems that can quantify risk in terms of increased morbidity and mortality. In this article we discuss the various aspects of cardiac illness that are known to increase risk for patients and then look at the different scoring systems that have been produced. We consider the type and urgency of surgery and finish by providing an approach to risk assessment for non‐cardiac surgery.
THERAPEUTIC ADVANCES IN ACUTE ISCHAEMIC STROKE
Authors: Bhalla A , Rudd AG
Published: April 2023

No drug has yet been shown to be unequivocally effective for acute stroke. Over the past decade, however, there has been an explosion in stroke research resulting in the development of novel therapeutic approaches. Therapies to improve arterial recanalisation and agents used to protect the brain from neurotoxic cellular damage are currently being evaluated. Tight control of physiological parameters may also limit neuronal damage. It is likely that within the next few years effective therapy will become available that will need a major change in the way that services are provided for stroke patients in the acute phase of their illness.
OBSTRUCTIVE SLEEP APNOEA CAUSES TRANSIENT AND SUSTAINED SYSTEMIC HYPERTENSION
Authors: Zwillich CW
Published: April 2023

Apnoea with associated fall in arterial oxygen tension results in increased blood pressure and a striking surge in sympathetic activity, which can be measured as high catecholamine levels or increase in muscle sympathetic nerve activity. Following the termination of apnoea with resumption of breathing, sympathetic nerve activity decreases and blood pressure returns to lower values. Sympathetic mediated alternations in peripheral vascular resistance best explain these findings. Hypertension during wakefulness in untreated patients with apnoea is also associated with high sympathetic nervous system activity. Nasal continuous positive airway pressure (CPAP) has been shown to lower blood pressure in some hypertensive obstructive sleep apnoea (OSA) patients. Recently, previously untreated OSA patients exhibiting awake sympathetic hyperexcitation demonstrated striking attentuation of the response following initiation of effective CRAP therapy. Accordingly, the common problem of systemic hypertension found in untreated OSA appears to be mediated by sympathetic excitation and responds to effective CRAP therapy.
STAPHYLOCOCCUS AUREUS ENDOCARDITIS PRESENTING AS MENINGITIS AND MIMICKING MENINGOCOCCAL SEPSIS
Authors: Kelly J , Barnass S
Published: April 2023

A case of Staphylococcus aureus meningitis (SAM) secondary to endocarditis is presented. The presence of a petechial rash affecting the lower limbs led to an initial presumptive diagnosis of meningococcal meningitis. There were no stigmata of endocarditis at presentation, though these subsequently developed. Underlying endocarditis should be diligently sought in any patient presenting with spontaneous SAM, even if typical stigmata are initially absent. In view of the association with skin lesions and neurological complications, S. aureus endocarditis may mimic the classical presentation of meningococcal sepsis.
PAPILLARY THYROID ADENOCARCINOMA ARISING IN A THYROGLOSSAL TRACT REMNANT FOLLOWING EXCISION OF A THYROGLOSSAL CYST: THE IMPORTANCE OF THE SISTRUNK PROCEDURE
Authors: Rampaul R , Maharaj D , Naraynsingh V , Ramcharan KS , Josa D
Published: April 2023

Carcinoma of the thyroglossal tract is a rarity – over the past 85 years only 160 cases have been reported. We report the first case of carcinoma arising in a thyroglossal tract remnant 10 years after simple excision of a thyroglossal cyst. This case highlights the importance of the Sistrunk procedure, (the removal of the entire thyroglossal tract) for preventing not only cyst recurrence, sinus and fistula formation, but also the occurrence of carcinoma.
SPLENIC TUBERCULOSIS: AN UNUSUAL SONOGRAPHIC PRESENTATION
Authors: Chandra S , Srivastava DN , Gandhi D
Published: April 2023

Tuberculosis (TB) of the spleen is rare, especially in the immunocompetent. Recently there has been an increase in the incidence of splenic TB, primarily attributable to the raging HIV epidemic. Almost all cases of splenic TB present as multiple hypoechoic foci (<2 cm) on ultrasonography. We present a case of a large solitary splenic tuberculoma in a middle‐aged, non‐immunosuppressed female, an employee at the local TB hospital. To the best of our knowledge, only two such cases have been described on ultrasound before. We suggest that, regardless of immune status, splenic TB should be considered as a diagnostic possibility when dealing with the solitary nodules of the spleen, especially when there is a history of exposure to or evidence of tuberculous foci elsewhere in the body.
A COMPARISON OF THE EFFECTS OF TWO MODIFIED RELEASE PREPARATIONS OF NIFEDIPINE – NIFEDIPINE RETARD 10 MG TWICE DAILY AND NIFEDIPINE GITS 20 MG ONCE DAILY – IN THE TREATMENT OF MILD TO MODERATE HYPERTENSION
Authors: Kirby BJ , Kitchin NRE
Published: April 2023

A multicentre, randomised, double‐blind, cross‐over comparison of nifedipine GITS 20 mg once daily and nifedipine retard 10 mg twice daily in 49 patients with mild to moderate hypertension was conducted. Both treatments resulted in clinically significant trough blood pressure reductions (nifedipine GITS ‐10.1/‐8.9 mmHg, nifedipine retard ‐7.5/‐8.2 mmHg). The study demonstrated that nifedipine GITS was ‘at least equivalent’ to nifedipine retard in the reduction of trough diastolic blood pressure (one‐sided lower 95% confidence limit, ‐1.2 mmHg). The overall incidence of adverse events (nifedipine GITS 25.5%, nifedipine retard 34.0%), as well as the incidences of headache (nifedipine GITS 8.5%, nifedipine retard 12.8%) and peripheral oedema (nifedipine GITS 2.1%, nifedipine retard 8.5%), was higher with nifedipine retard compared to nifedipine GITS. Nifedipine GITS 20 mg once daily is ‘at least equivalent’ to nifedipine retard 10 mg twice daily in patients with mild to moderate hypertension, as well as being better tolerated.
A COMPARISON OF NIMESULIDE BETA CYCLODEXTRIN AND NIMESULIDE IN POSTOPERATIVE DENTAL PAIN
Authors: Scolari G , Lazzarin F , Fornaseri C , Carbone V , Rengo S , Amato M , Cicciù D , Braione D , Argentino S , Morgantini A , Bassetti C , Tramèr M , Monza GC
Published: April 2023

The aim of this study was to assess the efficacy and tolerability of single doses of nimesulide beta cyclodextrin compared with nimesulide in patients with dental pain following surgical procedures. This was a randomised, double‐blind, between‐patient, multicentre study involving 148 outpatients suffering from moderate to severe pain, who received single doses of either 400 mg nimesulide beta cyclodextrin or 100 mg nimesulide. The principal criterion for efficacy was pain intensity assessed on a visual analogue scale (VAS) 15 minutes after drug intake. Pain intensity was further evaluated 30, 45, 90, 120, 180, 240 and 360 minutes after dosing. Pain relief was evaluated at the same time points by means of a categorical scale. The time point of first pain relief, the use of rescue medication and the global evaluation of efficacy were also recorded. The reduction in pain intensity was significantly more pronounced in the nimesulide beta cyclodextrin group at 15, 30, 45 and 60 minutes (p<0.01). Pain relief was significantly greater (p<0.05) and more rapid with nimesulide beta cyclodextrin. In the patient overall assessment of efficacy, nimesulide beta cyclodextrin and nimesulide were rated excellent or good by 95% and 92% respectively; only one patient in the nimesulide beta cyclodextrin group needed rescue medication. Both study drugs were effective and well tolerated in the treatment of acute dental pain, with nimesulide beta cyclodextrin showing a faster onset of analgesic action.