bluuebunny/crossref_metadata_2025 huggingface dataset:
SAFETY, EFFECTIVENESS AND COST EFFICACY OF DIAGNOSTIC ELECTROPHYSIOLOGY AND RADIOFREQUENCY ABLATION IN A DISTRICT GENERAL HOSPITAL
Authors: Mitchell ARJ , Patel NR , Kamalvand K , Topham A , Paul VE , Sulke AN
Published: April 2023

Electrophysiological studies (EPS) are now being performed in district general hospitals (DGH) in the UK. In order to audit our results, a prospective database was established for all patients undergoing EPS and radiofrequency (RF) ablation at Eastbourne District General Hospital, East Sussex. Between 1 January 1997 and 1 July 2000, 300 EPS procedures were performed, resulting in 155 RF ablations. The average RF ablation procedure time was 119.3 minutes with an average fluoroscopy time of 19.1 minutes. Cost per RF ablation procedure was £1166.79 excluding use of facilities, pacemaker devices, medical nursing and radiography staffing costs. The overall success rate for RF ablation was 93.6% with a major complication rate of 0.6%, a total complication rate of 3.9% and no associated mortality. We have shown that RF ablation can be performed safely, effectively and economically in a DGH setting with a high rate of success and a low complication rate.
MOTOR RESTLESSNESS
Authors: Tan EK , Ondo WG
Published: April 2023

Motor restlessness, characterised by an irresistible urge to move about, can be a manifestation of many underlying disorders. Unfortunately, it is often poorly recognised and underdiagnosed in clinical practice, possibly because patients do not seek medical attention, or their complaints were thought to be secondary to anxiety. While the two major conditions to consider are restless legs syndrome and neuroleptic‐induced akathisia, there are many other differential diagnoses. We provide a concise review of the clinical features and diagnostic pitfalls of these conditions. A proper detailed clinical history and examination can often help clinch the diagnosis, as most of these conditions have their unique clinical features.
MANAGEMENT OF UPPER RESPIRATORY TRACT INFECTION BY FAMILY DOCTORS
Authors: Lam TP , Lam KF
Published: April 2023

The prescribing behaviour of family doctors in Hong Kong towards upper respiratory tract infections (URTIs) and the factors that might affect such behaviour were studied. All 1016 members of the Hong Kong College of Family Physicians were sent a postal questionnaire. A total of 730 family doctors completed the questionnaire, with an overall response rate of 71.8%. Doctors who were older, more senior, or in private practice were more likely to think antibiotics were useful for URTIs and to prescribe them. These doctors were also more likely to think their patients would expect antibiotics from them. Postgraduate vocational training in general practice/family medicine helped make family doctors think fewer patients would expect antibiotics from them but did not affect their perception of the usefulness of antibiotics for URTIs. Our results showed that doctors with certain characteristics were more likely to prescribe antibiotics for URTIs and these doctors may be targeted for continued medical education.
THE EFFICACY OF MOXIFLOXACIN IN ACUTE EXACERBATIONS OF CHRONIC BRONCHITIS: A SPANISH PHYSICIAN AND PATIENT EXPERIENCE
Authors: Miravitlles M , Ros F , Cobos A , Kubin R , Tillotson G
Published: April 2023

Chronic bronchitis is a debilitating disease affecting many millions of patients globally. They suffer multiple acute exacerbations each year, often requiring many courses of antimicrobials to enable them to return to normal. The impact of the condition on both the individual patient and society as a whole is considerable and growing; thus antimicrobial therapy should induce rapid and effective outcomes as soon as possible. This open, community‐based study of 5737 patients enrolled by over 2000 primary care physicians from across Spain examined the clinical effect of oral moxifloxacin on patients' signs and symptoms of acute exacerbations of chronic bronchitis (AECB) over a 45‐day period. The symptoms were assessed using daily diary cards in addition to physician evaluations. Clinical assessment at day 7 showed 93.0% of patients were cured. The patient diary card showed that two‐thirds of patients felt better by day 3 or 4. Adverse events were reported in 3.5% of patients in this study, the most common being diarrhoea, nausea and dizziness, and epigastric pain. These reactions were mild to moderate in intensity. There were no patient deaths due to infection during the study. Physicians and patients reported that once‐daily moxifloxacin gave fast relief of symptoms of acute excerbations of chronic bronchitis.
WHAT IS THE RELEVANCE OF THE HOPE STUDY IN GENERAL PRACTICE?
Authors: Kennedy J , Mogensen CE , Ball SG , Castaigne AD , Commerford PJ , Distiller L , Fisher BM , Gonzalez‐Jaunatey J , Nosadini R , Novials A , Östergren J , Palma‐Gámiz J , Perrone‐Filardi P , Schipperheijn JJ , Senges J , Trevisan R
Published: April 2023

The unique findings from the HOPE (Heart Outcomes Prevention Evaluation) study strongly support extending the use of the angiotensin‐converting enzyme (ACE) inhibitor ramipril as a preventive agent for patients at high risk of cardiovascular events with normal left ventricular function. In addition, ramipril provides significant benefit in diabetic patients. These findings will impact on how ramipril is used in primary care, where ACE inhibitors are currently underprescribed. Patients reflecting the inclusion criteria of the HOPE study should be considered as suitable candidates for long‐term ramipril therapy as an addition to their existing drug regimen. Screening should include control of kidney function (by serum creatinine), particularly within the first two weeks of treatment, in addition to regular monitoring of serum potassium. However, the HOPE study shows that ramipril is well tolerated at high doses and over a long treatment period. The effectiveness of therapy should also be regularly reviewed and dose adjustments made where necessary. If concern remains, referral to a specialist – a cardiologist or a diabetologist – may ultimately be necessary.
1. ASSESSMENT OF BREAST PROBLEMS
Authors: Fentiman IS , Hamed H
Published: April 2023

Patients with discrete breast lumps, irrespective of age, should be referred for assessment. Premenopausal women with equivocal lumps can be re‐checked two weeks later and, if still present or dubious, sent to a breast clinic. Almost all women with breast pain do not need referral unless the symptoms are severe or prolonged. Careful examination will detect those individuals with underlying rib cage pain who can be reassured and given analgesics, if necessary, but not referred. Blood‐containing nipple discharge is an indication for referral but such cases can be reassured that, in the absence of a lump, it is unlikely they have breast cancer. Most women who suspect their family history of breast cancer places them at increased risk can be safely reassured and do not need to be kept under surveillance. All those women who are eligible for the NHS screening programme should be encouraged to attend when invited.
MANAGING GASTRO‐OESOPHAGEAL REFLUX DISEASE IN PRIMARY CARE
Authors: Nathoo V
Published: April 2023

The National Institute for Clinical Excellence recently issued guidance on the use of proton pump inhibitors (PPIs) in the management of dyspepsia, including gastro‐oesophageal reflux disease (GORD). GORD is a common disorder that reduces quality of life and can indicate serious disease such as reflux oesophagitis. The symptoms of GORD must be distinguished from those of other diseases, such as functional dyspepsia or cardiac problems. Furthermore, atypical alarm symptoms, such as bleeding or sudden weight loss, require urgent further investigation. Most GORD is uncomplicated and can be treated using management algorithms that make the best use of resources. Newer strategies such as ‘step‐down’ or ‘on‐demand’ therapy can cost‐effectively improve the long‐term management and quality of life of patients with recurrent GORD.
RHABDOMYOLYSIS ASSOCIATED WITH VARICELLA INFECTION
Authors: Al‐Langawi M , Al‐Marri MRHA , Al Soub H
Published: April 2023

Varicella infection is a common childhood disease that usually resolves without complications. However, children under 2 months of age, adolescents, some adults and immunocompromised individuals are at high risk of certain rare life‐threatening complications. We report a case of primary varicella infection in an immunocompetent adult complicated by rhabdomyolysis. Recognition of this complication and aggressive fluid therapy with an antiviral agent helped to improve the outcome.
TRILOBED PHARYNGEAL DIVERTICULUM
Authors: Coatesworth AP
Published: April 2023

A previously undescribed case of a trilobed pharyngeal diverticulum is reported. Its presentation, radiological features and treatment are discussed.
THE IMPACT OF CORONARY HEART DISEASE IN DETERMINING USE OF HORMONE REPLACEMENT THERAPY IN A GENERAL PRACTICE POPULATION
Authors: Chin BSP , Futaba K , Jethwa A , Lip GYH
Published: April 2023

The use of hormone replacement therapy (HRT) for cardiovascular risk reduction remains uncertain. Although previous epidemiological surveys have suggested a clear benefit and nearly 50% mortality risk reduction with HRT in postmenopausal women, recent randomised trials have largely failed to support this. The epidemiological surveys may have been biased in a number of ways including the possibility that HRT users in these studies may have been healthier and taken a greater interest in modifying cardiovascular risks. The aim of the present study was to determine to what extent the revelations from all these trials have influenced HRT prescribing in general practice, in relation to cardiovascular disease. We reviewed 140 women on HRT and 140 age‐matched controls from one city centre general practice in the west of Birmingham who were randomly selected by computer. The main indication for HRT use was presence of symptoms associated with oestrogen deficiency. The prevention of osteoporosis accounted for 7.1% of HRT indications, while the primary prevention of CHD was not an issue discussed by either the patient or the GP. Among non‐users, 86.4% did not have a known contraindication and many did not have serum lipid measurements or estimations of cardiovascular risk. There was no difference between HRT users and non‐users for smoking habits and presence of cardiovascular risk factors including diabetes, hypertension and coronary heart disease. HRT users were also less likely to undergo investigations, such as cervical smear tests and mammograms. In conclusion, this survey reflects the current uncertainty surrounding the use of HRT for cardiovascular risk prevention. Importantly, women on HRT may not be any healthier than non‐users, nor do they seek more preventive care than non‐users. This is contrary to previous presumptions that selection and prevention bias were the explanation for the apparent cardioprotective effects of HRT.
MANAGEMENT OPTIONS FOR HYPERTENSION SYNDROME
Authors: Abarquez RF
Published: April 2023

Hypertension is usually managed on a case‐finding basis, and yet continued blood pressure control can be inadequate. Furthermore, hypertension is often a ‘silent’ condition until comorbid events, target organ damage and subsequent heart failure become manifest, leading to a reactive rather than a proactive approach. Management of the hypertension syndrome becomes complex, because blood pressure control may not be just an isolated concern. This review considers the various options, in addition to existing guidelines, that can help to reduce hypertension‐related morbidity and mortality.
SPONTANEOUS INTRAMURAL DISSECTION OF THE OESOPHAGUS
Authors: Bandyopadhyay P , Patel CU
Published: April 2023

Spontaneous intramural dissection or intramural haematoma of the oesophagus is an unusual condition and has been recognised as a separate clinical entity. The commonest presenting symptoms are chest pain, dysphagia and haematemesis usually affecting women in their sixties and seventies. Conservative management is usually thought to be adequate. We present a case of spontaneous intramural dissection in an elderly male who did not respond to conservative management and died.
A PREVENTABLE CAUSE OF ACUTE ABDOMEN
Authors: Hadjianastassiou VG , Eddleston M , Toogood G , Britton BJ
Published: April 2023

Haemoperitoneum is an extremely rare presentation of hepatocellular carcinoma in the industrialised world. We present the first reported case in the UK. In contrast, up to 10% of hepatocellular carcinomas in Africa present in this way, the median time between presentation and death being just six weeks. Hepatitis B infection at birth and during childhood is the major cause of hepatocellular carcinoma in the developing world. The World Health Organisation, UNICEF and the World Bank have all advocated routine hepatitis B vaccination of children. This can reduce the burden of disease in these communities, among people in their productive years of life.
CAMPTODACTYLY IN A NEUROLOGY OUTPATIENT CLINIC
Authors: Larner AJ
Published: April 2023

Camptodactyly is a non‐neurogenic flexion deformity of the proximal interphalangeal joint, most commonly affecting the little finger. The frequency of camptodactyly in patients referred to three general neurology outpatient clinics, two in district general hospitals and one in a regional neuroscience centre, over the course of one year (2000) was measured. Five out of 978 consecutive new outpatients (0.5%) had camptodactyly (2M, 3F); four had bilateral deformity. In only one was camptodactyly the reason for referral. In two cases, camptodactyly was entirely incidental to the neurological symptoms; in two others it was incidental but might have been confused with the neurological features. In three cases other family members were affected, in a manner consistent with autosomal dominant inheritance with variable penetrance. Camptodactyly is not infrequently observed in the general neurology outpatient clinic. It merits attention in order to avoid confusion with other, neurogenic, causes of clawing, and so avoid unnecessary investigation.
6. RADIOTHERAPY FOR EARLY AND ADVANCED BREAST CANCER
Authors: Harris S
Published: April 2023

Postoperative radiotherapy (RT) forms an intrinsic part of breast conservation therapy, substantially reducing the risk of breast relapse. It is given 4–6 weeks postoperatively using medial and lateral beams to achieve a near homogeneous dose to the breast while minimising the dose to adjacent structures. Typically, a dose of 40 Gy in 15 daily fractions over three weeks or 50 Gy in 25 fractions over five weeks is given, with a boost of 10 Gy using low energy electrons or superficial X‐rays. RT is delivered to the chest wall after mastectomy in patients with large tumours (>5 cm), close surgical margins, or significant axillary node involvement and may result in an additional 10% survival benefit. Early complications of RT include tiredness, skin erythema and moist desquamation. Late reactions, breast fibrosis, telangiectases and peau d'orange are reduced if more treatment fractions are given. Lung irradiation is minimised by careful treatment planning and <1% of patients experience radiation pneumonitis or pulmonary fibrosis. Patients with locally advanced breast cancer may be offered a combination of systemic therapy, endocrine, chemotherapy and radical RT. Preoperative systemic and radiation therapy reduces the mastectomy rate but at present does not improve survival. Those who are unfit for radical treatment and have large ulcerating or fixed cancers are offered either endocrine or cytotoxic therapy, depending upon the oestrogen receptor status, followed by RT, which is unlikely to cure but may achieve local control for a variable duration. RT forms part of the multidisciplinary approach to palliative treatment for metastatic disease. Bone metastases occur in 75% of women with metastatic disease and RT provides effective pain relief and reducing risk of pathological fractures. Patients with brain metastases need high‐dose steroids followed by cranial RT
IS ERECTILE DYSFUNCTION A MARKER FOR CARDIOVASCULAR DISEASE?
Authors: Kirby M , Jackson G , Betteridge J , Friedli K
Published: April 2023

There is now significant evidence that erectile dysfunction (ED) can be a symptom of cardiovascular disease, and can act as a marker for disease progression. National Health Service (NHS) prescribing restrictions on treatments for ED have recently been reviewed by the Department of Health, and current arrangements will not change. Unrestricted availability of licensed treatments for ED on the NHS, irrespective of the cause of the ED, may encourage men to present for investigation, enabling early detection of cardiovascular disease. Sildenafil citrate (Viagra), an effective treatment for ED, can also have a direct beneficial effect on cardiovascular disease. Unrestricted NHS availability of ED treatments such as sildenafil could facilitate greater achievement of National Service Framework targets for coronary heart disease.
THALIDOMIDE: 40 YEARS ON
Authors: Diggle GE
Published: April 2023

Thalidomide was marketed in the late‐1950s as a sedative and tranquilliser of exceptionally low general toxicity, but in 1961 it was implicated separately by Lenz and MacBride as the cause of the epidemic of congenital malformations that had been puzzling the world for some years. It is a very potent teratogen in humans, but in few other mammalian species; damage to the embryo is produced at specific stages of gestation, but the mechanism of embryopathic action is still not understood. Following the withdrawal of the drug worldwide, it was consigned to the history of medical tragedies. In 1965, however, Sheskin discovered that it was effective in treating erythema nodosum leprosum, a distressing complication of leprosy. As the drug is neither an antibiotic nor an analgesic, its action was assumed to be immunosuppressive. In Brazil the drug was used widely with few regulatory controls, since when more than 100 cases of congenital malformation have appeared. Sheskin's discovery led to the experimental use of thalidomide in many other indications thought to possess some immunological component. In some cases, e.g. Behçet's syndrome, graft‐versus‐host disease and aphthous ulceration in HIV‐positive patients, the drug has been shown to possess some efficacy. And there is some evidence that it inhibits the replication of one of the immunodeficiency viruses. The AIDS community in the US has exerted much pressure on the FDA to allow the drug on to the market, although the use of a potent immunosuppressive drug of unknown mechanism in an immunodeficiency condition raises further questions. Thalidomide is not always beneficial; its use is associated with an increased mortality in epidermal necrolysis. In 1991, D'Amato confirmed it possessed antiangiogenic properties and this led to further trials in malignant conditions. Results were mixed, but those in multiple myeloma gave some grounds for optimism. In 1998, the FDA announced its extraordinary decision to grant marketing approval for thalidomide.
BILATERAL DUPUYTREN'S CONTRACTURE IN A BLACK PATIENT
Authors: Aladin A , Oni JA
Published: April 2023

The first case of Dupuytren's contracture in a black patient with no obvious caucasian admixture was reported in 1979. This condition is rare in the purely black population and since 1979 only 23 cases have been reported. We present the case of a black man with no history of caucasian admixture with bilateral Dupuytren's contracture. We suggest that this condition may not be as rare as the literature suggests and, that canvassing other hand societies for their experience, particularly in the continent of Africa, may help to establish the true incidence of this condition.
COMPLETE RESOLUTION OF REFRACTORY IMMUNE THROMBOCYTOPENIC PURPURA AFTER COLECTOMY FOR ULCERATIVE COLITIS
Authors: Kathula SK , Polenakovik H , El‐Tarabily M , Polenakovik S
Published: April 2023

Immune thrombocytopenia (ITP) is a destructive thrombocytopenia caused by an autoantibody directed to platelet membrane antigens. Various immunological diseases have been associated with ITR but an association between inflammatory bowel disease (IBD) and ITP is not well recognised. We report a case of refractory immune thrombocytopenia associated with ulcerative colitis that resolved after colectomy. Although the medical treatment of inflammatory bowel disease or splenectomy are usually enough to treat ITP, it may be necessary to do a colectomy in refractory patients.
PATIENT PERSPECTIVE ON ZANAMIVIR IN THE TREATMENT OF INFLUENZA
Authors: Bricaire F , Cohen JM , Jacquet M , Boucot I , Nicolas M ,   JAG Committee
Published: April 2023

Placebo‐controlled clinical studies have shown zanamivir to be an effective treatment of influenza A and influenza B illness. This survey, conducted in France, was done to evaluate patients' perception of zanamivir in clinical practice. Between January and mid‐April 2000, 271 retail pharmacists gave questionnaires to patients with a prescription for zanamivir to be completed on a voluntary basis. A total of 514 patients returned completed questionnaires, of whom 97 (19%) were considered at high risk of developing influenza complications. Fifty‐one (10%) patients, mainly those over 65 years, were vaccinated against influenza. Fever or feverishness was reported by 93% of patients, and cough, myalgia and headache by 72%. Most (58%) patients consulted their doctor within 24 hours of the onset of symptoms, and 96% within 48 hours. Eighty‐five per cent of patients overall and 82% of high‐risk individuals (82/97) reported being satisfied with their zanamivir treatment. Treatment compliance was high with 75% of patients completing the whole course of treatment. Symptom relief was reported by 45% of patients within 24 hours and by 74% of patients within 48 hours; 66% of patients resumed normal activities within 72 hours. These results suggest that patient satisfaction is high and compliance with zanamivir is highly satisfactory. In addition, the use of zanamivir was reported to be associated with rapid symptom relief and return to normal activity.
NON‐INVASIVE IMAGING METHODS BEFORE FINE‐NEEDLE ASPIRATION IN THE DIAGNOSIS OF CERVICAL MASSES
Authors: Camci C , Sari R , Buyukberber S , Kutlu R , Sevinc A , Çokkeser Y
Published: April 2023

A carotid body tumour is a vascular tumour usually located at or around the bifurcation of the carotid artery and originating from the tunica adventitia. Carotid body tumours, which are generally non‐functional and asymptomatic, grow slowly, which is why diagnosis can be delayed. Because of the vascular structures, fine‐needle aspiration biopsy may be dangerous and impractical. Efficient and reliable methods of diagnosis, such as colour Doppler ultrasound, magnetic resonance imaging, computerised tomography and arteriography, can be useful. We report on a 58‐year‐old woman with diarrhoea, flushing and a cervical, hard, non‐tender, fixed mass. An unsuccessful diagnostic fine‐needle aspiration biopsy was performed after palpation of the cervical mass. A carotid body tumour was finally diagnosed. We concluded that non‐invasive imaging methods should be evaluated before fine‐needle aspiration in cervical masses. It should also be kept in mind that asymptomatic cervical masses may be related to non‐local symptoms.
SUDDEN PERMANENT HEARING LOSS FOLLOWING ANTERIOR INFERIOR CEREBELLAR ARTERY INFARCTION
Authors: Nagaratnam N , Mak J , Phan TA , Kalouche H
Published: April 2023

Anterior inferior cerebellar artery infarction with the only sequel being a permanent unilateral hearing loss is described. The damage was confirmed by magnetic resonance imaging. Hearing loss of vascular cause may be more common and permanent than realised, and missed if the other neurological deficits have resolved.
THE CLINICAL BENEFITS OF RIVASTIGMINE MAY REFLECT ITS DUAL INHIBITORY MODE OF ACTION: AN HYPOTHESIS
Authors: Bullock R
Published: April 2023

Recent health technology assessments have given us the go‐ahead to use Cholinesterase inhibitors, which, in combination with community services, are currently the most appropriate treatment for patients with Alzheimer's disease (AD). Initial research focused upon acetylcholinesterase (AChE)‐selective agents, but it is now thought that dual inhibitors of AChE and butyrylcholinesterase (BuChE) may provide more sustained efficacy over the course of AD and may help to slow disease progression. Rivastigmine is a potent inhibitor of AChE and BuChE and has demonstrated broad benefits across the severity of AD and across the cognitive, functional and behavioural domains of AD. In addition, rivastigmine has shown cognitive and behavioural benefits in patients with dementia with the Lewy body variant of AD. These benefits may reflect the inhibition of both AChE and BuChE, as demonstrated by significant correlations between cognitive improvements and Cholinesterase inhibition in rivastigmine‐treated patients with AD. Rivastigmine shows a clear dose‐response relationship, and physicians should aim to maintain patients on doses of 6 mg/day or higher, to a maximum of 12 mg/day. As with all Cholinesterase inhibitors, rapid forced dose escalation may increase the incidence of typical cholinergic side‐effects, resulting in lower maintenance doses. In a chronic disease such as AD, there is time to implement slow dose escalation and higher final maintenance doses. If used appropriately, the benefits of rivastigmine seen in clinical practice may prove to be even greater than those reported in clinical trials.
CERVICAL SURGICAL EMPHYSEMA: A RARE PRESENTATION OF A SIGMOID COLON RETROPERITONEAL DIVERTICULAR PERFORATION
Authors: Basu S , Corless D
Published: April 2023

Spontaneous retroperitoneal sigmoid diverticular perforation presenting as subcutaneous cervical emphysema is rare. We describe a case successfully treated by surgery. Patients presenting with subcutaneous emphysema with negative thoracic findings should be scrutinised for signs of retroperitoneal hollow viscus perforation to improve their outcome.
USE OF OPIOID ANALGESICS IN A PATIENT WITH CHRONIC ABDOMINAL PAIN
Authors: Iles S , Catterall JR , Hanks G
Published: April 2023

Pethidine is the most commonly used opioid in hospitals in the UK, but it lacks potency, has a short duration of action and a narrow therapeutic index. These points are illustrated by a case history of a patient prescribed pethidine for chronic abdominal pain. Misplaced fears of the side‐effects of morphine result in its underuse in the management of chronic pain with consequential restriction of patients' functional ability.
EFFECTIVENESS OF QUININE IN TREATING MUSCLE CRAMPS: A DOUBLE‐BLIND, PLACEBO‐CONTROLLED, PARALLEL‐GROUP, MULTICENTRE TRIAL
Authors: Diener HC , Dethlefsen U , Dethlefsen‐Gruber S , Verbeek P
Published: April 2023

To determine the efficacy and safety of quinine in treating nocturnal muscle cramps we performed a double‐blind, placebo‐controlled, parallel‐group, multicentre trial in 17 general practice centres in Germany. Ninety‐eight patients aged 18–70 years with more than six muscle cramps in two weeks were enrolled. A two‐week run‐in period without treatment was followed by two weeks of treatment with 400 mg quinine or placebo per day and a wash‐out period of two weeks without treatment. The primary outcome measure was the reduction in the number of muscle cramps between the run‐in and treatment periods. The intensity of cramps, number of nights with cramps, sleep disturbance and intensity of pain were recorded as secondary outcome measures. At baseline the median number of cramps was 12 in two weeks in both groups. The median reduction between the run‐in and therapy phases was eight (95% CI 7–10) versus six (95% CI 3–7) muscle cramps during quinine and placebo treatment; 36 (80%) participants in the quinine group and 26 (53%) in the placebo group had a reduction of at least 50% in the number of muscle cramps. Frequency, intensity and pain at night showed a statistically significant difference in favour of quinine. The improvement was more evident according to physician assessment than patient assessment; this is corroborated by the high placebo response rate. No significant differences were found between the two groups with respect to side‐effects. Short term treatment with 400 mg quinine per day can effectively prevent nocturnal leg cramps in adults without relevant side‐effects.
ANTIMICROBIAL DRUG USE IN DERMATOLOGY IN A TEACHING HOSPITAL IN WESTERN NEPAL
Authors: Sarkar C , Das B , Sripathi H
Published: April 2023

Medical audit is supposed to oversee, monitor and analyse standards of medical treatment at all levels of the healthcare delivery system. This study was undertaken to monitor the prescribing of antimicrobial drugs for patients seeking treatment in the dermatology outpatient department of the Manipal Teaching Hospital in Nepal. A total of 292 dermatology prescriptions of patients attending the dermatology OPD were collected between July 2000 and June 2001. Prescriptions for antimicrobial agents were separated from the total prescriptions collected, and evaluated. There were more female patients (58.2%) than male (41.8%) in our study; most were in the 21–40 year age group. The commonest cutaneous infections were acne (15.8%) followed by fungal infections (14.8%). Of the 292 prescriptions audited, 149 contained antimicrobial agents, constituting 36% of the total number of drugs prescribed. Of 256 antimicrobials prescribed, 63% were topical and 37% systemic; 5% were generic, 29% were from the essential drug list of Nepal, and 15% were fixed‐dose combinations. Most of the patients received one or two antimicrobials, 50% of which were antibacterials and 40% antifungals. Though the selection of antimicrobial drugs used in dermatology was largely rational, anomalies were observed, and these issues were discussed with clinicians in relation to various aspects of drug use. The results indicate there is scope for improving prescribing habits. A periodic audit of drug prescribing is desirable in rationalising prescribing practice.
IMMUNISATION WITH A PNEUMOCOCCAL 7‐VALENT CONJUGATE VACCINE
Authors: Dagan R
Published: April 2023

Pneumococcal disease causes approximately 1 million deaths a year worldwide in children aged younger than 5 years. Increasing antibiotic‐resistant strains have made management of pneumococcal disease difficult. A pneumococcal 7‐valent conjugate vaccine (PNCRM7) has been shown to prevent invasive disease in young children; it has also demonstrated a modest impact on the prevention of otitis media. This conjugated vaccine provides a consistent immune response in infants and young children and can be administered simultaneously with other childhood vaccines. It is generally well tolerated, with local reactions similar to those observed with other licensed childhood vaccines. The objective of this review is to discuss the clinical efficacy, immunogenicity and safety of PNCRM7.
CLINICAL AND BIOCHEMICAL OUTCOME OF RENAL AMYLOIDOSIS
Authors: Odabas AR , Cetinkaya R , Selcuk Y , Erman Z , Bilen H
Published: April 2023

AA amyloidosis is a relatively rare disease which complicates chronic inflammatory diseases, chronic infections, familial Mediterranean fever (FMF) and malignant diseases. Although amyloid deposition may be found in many organs, renal involvement dominates the clinical picture. We reviewed 63 patients with AA amyloidosis who presented to our nephrology department between 1995 and 2000. Prognostic markers, detailed history, physical examination and laboratory tests were evaluated. The causes of AA amyloidosis were as follows: FMF 42 (66.6%), pulmonary tuberculosis 9 (14.2%), chronic osteomyelitis 4 (6.3%), bronchiectasia 4 (6.3%), rheumatoid arthritis 1 (1.5%), juvenile idiopathic arthritis 1 (1.5%), inflammatory abdominal aortic aneurysm 1 (1.5 %), unknown aetiology 1 (1.5%). The diagnosis was made on renal biopsies in 63.4% of the patients, while the remaining 36.6% were diagnosed as a result of rectal biopsies. Sixteen patients died. A low serum albumin, high creatinine and high 24‐hour urine albumin excretion were associated with high mortality.
ATRIAL FIBRILLATION CURRENT AND FUTURE TREATMENTS: RADIOFREQUENCY ABLATION AND NOVEL PACING TECHNIQUES
Authors: Baszko A , Rinaldi CA , Simon RDB , Gill JS
Published: April 2023

Atrial fibrillation (AF) is a common clinical arrhythmia with significant symptomatology and is associated with an increased risk of systemic embolic events. Until recently, the treatment options for AF were essentially pharmacological. Recent developments in the understanding of the mechanisms of AF have resulted in a series of non‐pharmacological treatments becoming available. Such treatments include surgical ‘maze’ procedures and, more recently, the introduction of radiofrequency ablation techniques within the atria to prevent fibrillation. Complex pacing procedures, including multisite and biatrial pacing, have been used to treat AF. Tailoring treatment for individual patients is a complex task and this review will attempt to rationalise the non‐pharmacological treatment paths for individual patients with AF.
GIANT GASTRIC TRICHOBEZOAR
Authors: Baskonus I , Gökalp A , Maralcan G , Sanal I
Published: April 2023

Bezoars are relatively common foreign body lesions of the stomach and intestine. Small bezoars can be treated using non‐surgical methods, but large bezoars usually require open surgery. Occasionally they are giant‐sized and may mimic an intra‐abdominal mass clinically. We present the case of a 24‐year‐old woman with a giant gastric trichobezoar treated by open surgery; treatment methods are discussed.
INSULIN GLARGINE (LANTUS®)
Authors: Owens  , Griffiths S
Published: April 2023

Insulin glargine (Lantus®) is a long‐acting, human insulin analogue that has been specifically designed to overcome the deficiencies of traditionally available ‘intermediate‐acting’ insulins that are currently used for basal insulin supplementation. In contrast to NPH insulin, subcutaneous insulin glargine injected once daily provides a relatively constant basal level of circulating insulin with no pronounced peak. In patients with type 1 and type 2 diabetes, once‐daily insulin glargine achieves equivalent glycaemic control to NPH insulin given once or twice daily. In patients with type 1 diabetes, it is associated with significantly lower fasting blood glucose (FBG) levels, especially in those patients previously on twice‐daily NPH insulin. Insulin glargine is well tolerated and elicits less hypoglycaemia, especially nocturnal episodes, than NPH insulin, with similar levels of glycaemic control. This benefit is seen in patients with both type 1 and type 2 diabetes, in particular those previously on a once‐daily NPH insulin regimen. Patients with type 1 and type 2 diabetes have also reported higher levels of treatment satisfaction when treated with insulin glargine. Insulin glargine provides the opportunity to achieve target blood glucose levels more effectively and safely compared with NPH insulin, due to the reduced risk of hypoglycaemia, especially nocturnal hypoglycaemia. Insulin treatment needs to be individualised, with the dose of insulin glargine adjusted according to the blood glucose level as part of an aggressive regimen in an attempt to achieve near normoglycaemia without incurring episodes of hypoglycaemia. Insulin glargine should be used in combination with short‐acting insulin analogues in patients with type 1 diabetes. In patients where oral hypoglycaemic agents are failing, insulin glargine can be added. The early introduction of insulin in patients with type 2 diabetes is to be encouraged.
ONE‐AND‐A‐HALF SYNDROME RESULTING FROM SPONTANEOUS VERTEBRAL ARTERY DISSECTION
Authors: Larner AJ , Rudge P
Published: April 2023

A patient with one‐and‐a‐half syndrome due to brainstem ischaemia is presented. The case emphasises the importance of attempting to establish the aetiology of this syndrome – in this case infarction secondary to spontaneous vertebral artery dissection – when making therapeutic decisions.
ROSIGLITAZONE IN THE MANAGEMENT OF OLDER PATIENTS WITH TYPE 2 DIABETES MELLITUS
Authors: Kreider M , Heise M
Published: April 2023

The prevalence of type 2 diabetes increases dramatically with age in all populations. This report describes a post‐hoc analysis of eight rosiglitazone monotherapy studies to characterise the efficacy and safety of rosiglitazone in older patients with type 2 diabetes, using a designation of ≥70 years for elderly. A total of 3127 patients were randomised to rosiglitazone (<70 years: n=2099; ≥70 years: n=427) or placebo (<70 years: n=497; ≥70 years: n=104). In both age groups, rosiglitazone 4 mg/day and 8 mg/day reduced HbA1c and fasting plasma glucose compared with baseline and placebo at week 26 with no difference between age groups. There was no difference between the nature, severity or type of adverse events experienced by older or younger patients. Rosiglitazone improves glycaemic control and is well tolerated in older as well as younger patients with type 2 diabetes.
DERMAL OBJECTIVE PHARMACODYNAMIC PROFILE OF CETIRIZINE AND EPINASTINE: TWO CONTROLLED, RANDOMISED, DOUBLE‐BLIND, CROSSOVER STUDIES
Authors: Leroy T , Van Neste D
Published: April 2023

Two double‐blind clinical pharmacology studies were performed in healthy volunteers to compare the dermal pharmacodynamic profile of epinastine with cetirizine, a well‐documented anti‐H1 antagonist, after oral administration at the usual recommended dosage, i.e. 10 mg cetirizine and 20 mg epinastine (versus placebo). Histamine skin challenges (prick test) were evaluated before and at 1, 2, 4, 8 and 24 hr after drug intake by measuring the wheal and flare area (studies 1 and 2) along with laser Doppler monitoring of the microvascular responses (study 2). A decrease in wheal and flare areas was observed following intake of both drugs compared with placebo controls. With the notable exception of 1 hr post dose wheal values, which were consistently smaller after epinastine, cetirizine was superior to epinastine for both wheal and flare at all other times. At the prick test site, treatment with epinastine and cetirizine accentuated the increase in blood flow induced by histamine. This reflects the decrease of the whealing but there was no significant difference between the two active test compounds. At 1 cm from the prick test site, the administration of both active treatments inhibited the increase of blood flow, and cetirizine showed a more potent inhibitory effect from 8 hr post dose. This reflects the reduction of the flare induced after histamine‐receptor activation of the axon reflex. In conclusion, epinastine shows a rapidly greater (within 1 hr post dose on the wheal only) but vanishing effect than cetirizine. At all other time points, cetirizine was generally more effective than epinastine.
16. BREAST CANCER IN OLDER WOMEN
Authors: Bultitude MF , Fentiman IS
Published: April 2023

Elderly women are more likely to have less aggressive tumours, which are oestrogen receptor positive. They are less likely to be offered screening and often given inadequate treatment leading to a higher mortality rate. They should be assessed in the same way as their younger counterparts. Age should not be a consideration, rather life expectancy. Patients' wishes are important but the mainstay of treatment is surgical, including axillary node clearance, with adjuvant tamoxifen as appropriate. Radiotherapy should not be withheld unless there are good reasons to contradict this. In unfit patients, tamoxifen alone is a suitable treatment but tumorectomy under local anaesthetic is preferable. If the tumour is oestrogen receptor negative, surgery and/or radiotherapy will be required.
ETHNICITY AND PERIPHERAL VASCULAR DISEASE
Authors: Makin AJ , Silverman SH , Lip GYH
Published: April 2023

There are well‐documented differences in the prevalence of coronary artery disease and carotid disease between Caucasians, Afro‐Caribbeans and Indo‐Asians. Very little data are available on ethnic differences in peripheral vascular disease (PVD). To investigate this further, we surveyed 200 consecutive patients attending the vascular surgery service at a city centre hospital serving a multiethnic patient catchment population. All patients had proven PVD, with an ankle brachial pressure index of less than 0.8. Within this cohort, Afro‐Caribbeans presented more frequently with PVD compared with the proportion of this ethnic group in the local population (p=0.013), with a greater proportion with diabetes mellitus than in the other two ethnic groups. There did not appear to be a significant difference between the ethnic groups in any of the other established risk factors or associations (i.e. treated hypertension, smoking, previous history of ischaemic heart disease, atrial fibrillation, previous history of cerebrovascular accident or transient ischaemic attack) with PVD. As with coronary artery disease and carotid disease, there are ethnic differences in the prevalence of PVD, and the underlying risk factors, between Caucasians, Afro‐Caribbeans and Indo‐Asians. Furthermore, patients of Afro‐Caribbean origin present more frequently with symptomatic PVD than do either Caucasians or Indo‐Asians.
THE NEW ROLE OF PHARMACOTHERAPY FOR WEIGHT REDUCTION IN OBESITY
Authors: Fernstrom MH , Fernstrom JD
Published: April 2023

Obesity is associated with an increased risk for a wide variety of chronic health conditions. Despite this fact, less than half of obese patients are advised by healthcare professionals to lose weight. Creating a viable plan for losing weight and maintaining weight loss is difficult. Lifestyle change is always the cornerstone of treatment, but two new therapeutic agents approved for long‐term use, sibutramine and orlistat, can help maximise success. Increased weight loss can lead to reductions in the risk of obesity‐related co‐morbidities. Sibutramine and orlistat offer new weight reduction opportunities for obese patients.
TOLERABILITY OF IBUPROFEN, ASPIRIN AND PARACETAMOL FOR THE TREATMENT OF COLD AND FLU SYMPTOMS AND SORE THROAT PAIN
Authors: Moore N , Parc J‐M Le , Van Ganse E , Wall R , Schneid H , Cairns R
Published: April 2023

This double‐blind randomised study compared the tolerability of ibuprofen (up to 1.2 g daily), aspirin and paracetamol (both up to 3 g daily) for up to seven days, in patients with mild to moderate pain resulting from cold/flu symptoms or sore throat (CF/ST) (n=2815). The main outcome was the rate of significant adverse events (SGAE). Rates of SGAE for ibuprofen, aspirin and paracetamol were respectively 12.0%, 15.7% and 12.3%. Ibuprofen was significantly better tolerated than aspirin (p=0.02) and had comparable tolerability with paracetamol. The latter was also true for total digestive system events and for abdominal pain and dyspepsia. In conclusion, in patients with CF/ST, ibuprofen used at over‐the‐counter doses is as well tolerated as paracetamol and much better tolerated than aspirin.
MATCHING THE STANDARDS OF CLINICAL TRIAL EVIDENCE WITH APPLICATION IN PRACTICE
Authors: Sharpe N
Published: April 2023

A high standard of proof of efficacy and safety is required in clinical trials. This standard requires careful translation into practice, combining an evidence‐based approach with clinical experience and judgment to maximise patient benefits and minimise harms. The tendency to extend application of new treatments to patient groups other than those for whom reliable data exist should be avoided. Equally, extrapolation of the data to agents of the same class untested for particular indications should not occur. If the considerable potential benefits of modern cardiovascular therapeutics are to be maximised and harms avoided, clinicians should observe these principles carefully as new treatments become accessible and are applied.
SYMBICORT® TURBUHALER®: A NEW CONCEPT IN ASTHMA MANAGEMENT
Authors: Kuna P , Kuprys I
Published: April 2023

Symbicort® is a novel asthma product containing both budesonide and formoterol in a single inhaler, Turbuhaler®. Budesonide is a corticosteroid that treats underlying airway inflammation in asthma; formoterol is a rapid‐ and long‐acting β2‐agonist that prevents and reverses airway obstruction. Budesonide and formoterol therefore have complementary effects, treating two different components of asthma. Clinical studies have shown that Symbicort is more effective in the treatment of asthma than double‐dose corticosteroid, and clinical experience to date indicates that Symbicort is at least as effective and well tolerated as budesonide and formoterol given in separate inhalers. Symbicort has a fast onset of effect, which may help patients feel more in control of their condition and improve adherence to their medication, and a long duration of effect that allows twice‐daily or even once‐daily dosing during periods of good control. More convenient treatment represents another important benefit for patients with asthma, as ease of use can also result in improved adherence, leading to better disease control.
THROMBOCYTOPENIA IN PATIENTS WITH HCV‐POSITIVE CHRONIC HEPATITIS: EFFICACY OF LEUCOCYTE INTERFERON‐α TREATMENT
Authors: Benci A , Caremani M , Tacconi D
Published: April 2023

Treating patients with HCV‐associated thrombocytopenia is a problem, because the pathogenesis of thrombocytopenia is still unclear. We evaluated the clinical and haematological response to leucocyte interferon‐α in 20 naive patients with chronic hepatitis C and thrombocytopenia (platelet count <140 × 109/l for at least six months) without portal hypertension and/or hypersplenism. They were treated with leucocyte interferon‐α (3 MU three times per week) for 12 months and followed up for 12 months. Biochemical (ALT) and virological (HCV‐RNA) responses were determined. Two patients discontinued treatment because of hyperthyroidism. Of the 18 patients who completed treatment, 12 (66%) showed a biochemical response, 10 of whom (55.5%) also showed a virological response. At the end of follow‐up, four patients (22%) showed a complete (biochemical and virological) response. During treatment, platelet counts decreased to less than 10–20% of pretreatment values in most patients. Three of the four patients with a complete response showed a platelet increase during treatment and throughout the follow‐up period. In HCV‐associated thrombocytopenia leucocyte interferon‐α is well tolerated and in cases of sustained virological inhibition is able to ameliorate the disease by increasing the platelet count.
AMPHETAMINE‐RELATED ACUTE MYOCARDIAL INFARCTION DUE TO CORONARY ARTERY SPASM
Authors: Hung M‐J , Kuo L‐T , Cherng W‐J
Published: April 2023

A 27‐year‐old man developed acute myocardial infarction after intravenous amphetamine use. A coronary angiogram showed plaques in the mid‐portion of the left anterior descending artery which developed coronary artery spasm after administration of intracoronary ergonovine. The findings in this case suggest that these coronary artery plaques played a role in the endothelial dysfunction resulting from amphetamine use, and that induction of coronary arterial spasm was the likely mechanism of amphetamine‐related acute myocardial infarction.