bluuebunny/crossref_metadata_2025 huggingface dataset:
AUTOIMMUNE ENCEPHALOPATHY AFTER TREATMENT OF THYMOMA‐ASSOCIATED MYASTHENIA GRAVIS
Authors: Maher D , Fritz V
Published: April 2023

SUMMARY A case of autoimmune encephalopathy associated with myasthenia gravis is presented.
GASTROENTERITIS CAUSING CRITICAL LIMB ISCHAEMIA
Authors: Mamode N , Mercer K , Gilmour DG
Published: April 2023

SUMMARY Six days after admission to hospital with Salmonella gastroenteritis, this patient presented with a critically ischaemic leg, having developed an iliac occlusion, and a subcutaneous Salmonella abscess in the anterior compartment of the leg. Critical limb ischaemia and abscess formation can be added to infective aortic aneurysm as vascular complications of Salmonella gastroenteritis.
SEVENTY‐TWO HOUR COMPARISON OF METHYLPREDNISOLONE SULEPTANATE AND METHYLPREDNISOLONE SODIUM SUCCINATE IN PATIENTS WITH ACUTE ASTHMA
Authors: Muir JF , Godard PH , Verhaert  , Leophonte P , Racineux JL , Harry JD
Published: April 2023

SUMMARY The efficacy and safety of the methylprednisolone prodrugs methylprednisolone suleptanate and methylprednisolone sodium succinate were evaluated in a multicentre, randomised, double‐blind, double‐dummy parallel study of 88 patients hospitalised with acute asthma. Each study drug was administered as a bolus intravenous injection of 40mg methylprednisolone equivalents every 6 hours for 48 hours. Methylprednisolone 32mg was administered orally 6 hours after the last dose. Pulmonary function, medical events, and clinical laboratory values were assessed at predefined intervals before and during the 72‐hour study. The primary response measure of pulmonary function was per cent predicted forced expiratory volume in one second (FEV1) at 48 hours. Secondary response measures were peak expiratory flow rate (PEFR) and FEV1/forced vital capacity (FVC) ratio. Although both drugs demonstrated within‐group mean changes from baseline (starting at 6 hours) that were statistically significant for each response, there were no statistically significant differences between the two groups. The mean percent predicted FEV1 at 48 hours and mean per cent change from baseline were 64% and 13% (p<0.0001) for the methylprednisolone suleptanate group and 67% and 17% (p<0.0001) for the methylprednisolone sodium succinate group, respectively. The mean PEFR and FEV1/FVC ratio at 48 hours were 5.77 l/s and 73% for the methylprednisolone suleptanate group and 5.78 l/s and 76% for the methylprednisolone sodium succinate group, respectively. There were no clinically or statistically significant between‐group differences in any of the safety parameters. In this study, methylprednisolone suleptanate and methylprednisolone sodium succinate have been shown to be therapeutically equivalent in the treatment of patients hospitalized with acute asthma.
ARE INTRAVENOUS CANNULAE STILL BEING MISUSED?
Authors: Smith T , Pritchard‐Howarth M , King D
Published: April 2023

SUMMARY We have surveyed the use of intravenous cannulae (IVC) in a district general hospital. Of 354 patients interviewed on various wards, 125 (35.3%) had IVC in situ. The wrist was the commonest location for the cannulae (41.6%). An indication for cannula insertion was present in the majority (93.7%) of patients. Cannulae were left in situ even after their use had ceased, most commonly on wards for the elderly, and on these wards complications were more common. Other wards had specific IVC documentation, which resulted in fewer complications. Cannulae should be used for specific indications and should be reviewed daily for the development of complications and the need for their continued presence.
ANEURYSMAL BONE CYST OF THE CLAVICLE IN A CHILD
Authors: Vedantam R , Crawford AH , Kuwajima SS
Published: April 2023

SUMMARY We report a case of an aneurysmal bone cyst (ABC) of the clavicle in a 9‐year‐old boy, which initially presented as a pathological fracture of a benign cystic lesion. ABC of the clavicle is rare in children less than 10 years old and radiological diagnosis may prove difficult in the early stages of presentation.
A SURVEY OF PERIPHERAL OEDEMA IN ELDERLY PATIENTS ADMITTED TO A GERIATRIC WARD
Authors: Smith E
Published: April 2023

SUMMARY Peripheral oedema is common in elderly people. This two‐month survey of an acute geriatric ward found that 48% of the 63 admissions over that period had oedema either on, or during the course of their admission. In many cases this was mild and asymptomatic, but complications of oedema were the cause of admission for four patients. The oedema was often multifactorial, but gravitational forces in dependent limbs seemed to be an important factor for many cases. Few patients were receiving any specific treatment for their oedema. It is concluded that oedema may be underrecognised, and that if greater attention is paid to this problem at an earlier stage, some of the associated morbidity could be avoided.
CHANGES IN THE USE OF EEG FOLLOWING CLINICAL AUDIT
Authors: Puri BK , Obaydi H , Singh I
Published: April 2023

SUMMARY An audit of the clinical use of EEG in mentally handicapped patients was performed over a three‐year period. EEG requests seemed inappropriate in more than one‐quarter of cases. Changes in clinical practice during the 10 months following presentation of these audit results were examined. There was a marked reduction in EEG requests, which were subsequently used in a more cost‐effective and clinically appropriate way. There was also a reduction in the time taken to process requests.
LEGIONNAIRES' DISEASE — A POTENTIAL HAZARD OF RATIONALISATION
Authors: Jack CIA , Smith T , Jones R , Ibreck R , Malster MG , Lye M
Published: April 2023

SUMMARY The cases of two elderly patients who complained of general malaise after they had undergone ward transfer (due to rationalisation of the rehabilitation service) are discussed. Both were pyrexial and had signs of pneumonic consolidation. Subsequent investigation revealed that their symptoms were due to infection with Legionella pneumophila. Their cases highlight the problems sssociated with ward closures and the hazards of stagnant water.
CAUSTIC SODA BURNS TO THE EXTREMITIES: DIFFICULTIES IN MANAGEMENT
Authors: O'Donoghue JM , Al‐Ghazal SK , McCann JJ
Published: April 2023

SUMMARY Alkali burns to the extremities are unusual, but they are also a cause of significant morbidity, often because of their late presentation. Their management centres around water lavage, burn debridement and split‐skin grafting; there is controversy over the timing of surgery. Three unusual cases of caustic soda burn in adults, and the difficulties encountered in their management, are described, and the literature is reviewed.
JUVENILE DERMATOMYOSITIS ASSOCIATED WITH PARTIAL LIPODYSTROPHY
Authors: Huang J‐L
Published: April 2023

SUMMARY The case of a child who developed partial lipodystrophy and metabolic abnormalities during treatment of juvenile dermatomyositis is described and discussed.
EFFECT OF SUBCLINICAL LEAD INTOXICATION ON LARYNGEAL CANCER
Authors: Kandiloros DC , Goletsos GA , Nikolopoulos TP , Ferekidis EA , Tsomis AS , Adamopoulos GK
Published: April 2023

SUMMARY In this study we investigated the possible relationship of laryngeal cancer and subclinical lead intoxication, using the depression of aminolevulinic acid dehydratase (ALAD) activity in blood as indicator. Twenty‐six patients with laryngeal cancer and 53 normal controls met the criteria to enter the study. Blood ALAD activity values in the patients with laryngeal cancer ranged from 27.1 to 75.3 U/l with a mean of 50.79 U/l. The respective values in the control group ranged from 36.2 to 98 U/l with a mean of 59.76 U/l. There was a statistically significant difference between the two means (0.001 <p<0.01), whereas blood lead concentrations in all patients were within normal limits. These findings support the hypothesis that low level lead intoxication (subclinical blood lead levels), from cars, industries and products, may contribute to the risk of laryngeal cancer. Further investigation is needed to clarify the exact relationship between lead and cancer of the larynx.
CURRENT SURGICAL TREATMENT OF DUPUYTREN'S DISEASE
Authors: Wilson GR
Published: April 2023

SUMMARY The practice of surgery for Dupuytren's contracture is changing. Most surgery can be carried out under regional or local anaesthesia on a day case basis. Although the commonest surgery performed is partial fasciectomy, there is more of a polarisation developing with minimal surgery (e.g. segmental fasciectomy) for early disease and more aggressive surgery (dermofasciectomy) for advanced and recurrent disease.
OPTIMISING THE MEDICAL MANAGEMENT OF BENIGN PROSTATIC HYPERPLASIA
Authors: McDermott TED
Published: April 2023

SUMMARY The ageing population is presenting an increasing demand on future healthcare services. In males, prostatic disease is one of the commonest disorders contributing to this. Alternatives to surgical intervention have to be considered as the preferred option for individuals and whether this be a therapeutic or a financial option to be taken. Two major medical alternatives are alpha‐blockers and 5‐alpha reductase inhibitors. The results of such treatment can be very beneficial in selected groups of patients. Side‐effects with improved drugs electivity are reducing. Overall, while surgery still holds the gold standard, medical therapy has a significant role in the treatment of benign prostatic hypertrophy. Cost analysis may be a factor in deciding which treatment to have.
LOGISTICS OF PERFORMING AN OPHTHALMIC ASSESSMENT IN ELDERLY INPATIENTS
Authors: Whittaker KW , Shah P , O'Neill D
Published: April 2023

SUMMARY To assess the feasibility of performing an ophthalmic assessment on elderly inpatients, we examined 48 patients over 75 years of age who were consecutively admitted to an acute elderly‐care ward. Difficulties were encountered in 35 patients (73%). By employing simple methods to overcome these problems, useful information was obtained in all cases and the time taken to complete the examination ranged from six to 20 minutes (mean 7.5 minutes). Doctors looking after elderly patients should be encouraged to assess visual function and must not be deterred by anticipated logistical difficulties.
AN INCIDENTAL FINDING OF GITELMAN'S SYNDROME
Authors: Leonard MB , Neithercut D
Published: April 2023

SUMMARY Gitelman's syndrome is characterised by hypokalaemia, hypomagnesaemia and tetany. This rare disorder is not well described in the literature, probably due to its similarity with Bartter's syndrome. We describe the symptoms and treatment of a young patient whom we consider to have Gitelman's syndrome.
ROSIGLITAZONE: POTENTIAL BENEFICIAL IMPACT ON CARDIOVASCULAR DISEASE
Authors: Viberti GC
Published: April 2023

Rosiglitazone, a potent member of the thiazolidinedione class of oral antidiabetic agents, reduces hyperglycaemia by improving insulin sensitivity – an important underlying factor in the development of both type 2 diabetes and its related cardiovascular complications. Rosiglitazone has now been available in clinical practice for more than three years, so there is a large body of evidence supporting its efficacy and safety as an antihyperglycaemic agent in patients with type 2 diabetes. Given the significant burden imposed on patients and healthcare resources by diabetes‐related cardiovascular disease (CVD), there is growing interest in the thiazolidinediones in terms of their potential to ameliorate CVD risk factors as a result of their insulin‐sensitising action and thus improve cardiovascular outcomes in individuals with type 2 diabetes. As reviewed below, rosiglitazone has a beneficial impact on a number of factors associated with insulin resistance and CVD, including microalbuminuria, hypertension, dyslipidaemia, visceral fat, elevated plasminogen activator inhibitor‐1 levels and increased concentrations of C‐reactive protein. These thiazolidinedione compounds are not problem‐free and the long‐term implications of some of rosiglitazone side‐effects such as weight gain, changes in LDL‐cholesterol concentration and fluid retention remain to be resolved. Large‐scale clinical outcome studies should give a clearer picture for rosiglitazone and related thiazolidinediones in relation to the extent of their impact on diabetes disease progression and incident cardiovascular events.
OBSTRUCTIVE SLEEP APNOEA SYNDROME PRESENTING IN A NEUROLOGY OUTPATIENT CLINIC
Authors: Larner AJ
Published: April 2023

The various neurological guises in which obstructive sleep apnoea syndrome (OSAS) may present are illustrated by reporting four previously undiagnosed patients seen by one consultant neurologist in general neurological outpatient clinics. Presenting features were episodes of loss of consciousness (2), stroke, and excessive daytime somnolence; morning headache and cognitive decline were also observed. Two patients had been involved in road traffic accidents. Diagnoses suggested by the referring doctors included epilepsy, stroke and narcolepsy. Since OSAS is associated with increased morbidity and mortality, yet is frequently amenable to treatment, neurologists should be familiar with the heterogeneous presentations of this condition.
INCONTINENCE IN ADULT FEMALES WITH CYSTIC FIBROSIS: A NORTHERN IRELAND SURVEY
Authors: Moran F , Bradley JM , Boyle L , Elborn JS
Published: April 2023

The objectives of this survey were to establish the prevalence, onset, severity and impact of incontinence and attitudes towards the availability of advice and treatment in female adults with cystic fibrosis (CF) in Northern Ireland. All female patients (n=59) at the Northern Ireland Regional Adult CF Centre were posted a questionnaire on incontinence. Leakage of urine occurred in 14/46 respondents. Leakage of urine occurred when chest was bad in 8/14 patients and when chest was good or bad in 3/14 patients. Patients reported that their bladder problem affected their ability to perform airway clearance or cough (13/14), and exercise (4/14). The main reason given for the patients who did not seek help for their incontinence (10/14) was that they were too embarrassed. This study highlights that patients with CF are reluctant to seek treatment for incontinence despite the impact this condition can have.
MANAGEMENT OF LOCALLY ADVANCED PROSTATE CANCER: A EUROPEAN CONSENSUS
Authors: Boccon‐Gibod L , Bertaccini A , Bono AV , Dev Sarmah B , Höltl W , Mottet N , Tunn U , Zamboglou N
Published: April 2023

This report summarises the findings of a European Consensus Group review of current standards of care in locally advanced prostate cancer defined as (a) untreated cancer extending clinically beyond the prostatic capsule in patients with no evidence of lymph node invasion or distant metastases, and (b) residual disease remaining after local treatment with positive surgical margins, seminal vesicle invasion, persistent prostate‐specific antigen (PSA) and/or secondary PSA relapse. There was no overall consensus as to the standard of care in clinically apparent locally advanced prostate cancer. It was agreed, however, that hormonal therapy (e.g. with a gonadotrophin releasing hormone analogue [GnRHa]) represents a valid treatment in these patients. Treatment practices and regimens vary considerably between European countries, but GnRHa is widely used, either alone or in combination with antiandrogens. Hormonal therapy alone is a valid option, though the optimal modality, timing and duration of treatment remain to be defined. Adjuvant therapy with a GnRHa has been shown to improve survival in patients undergoing external beam radiotherapy. It is a viable option after prostatectomy in patients with persistent or secondary relapsing PSA. It was determined that optimal treatment will be different according to PSA, clinical staging and Gleason score, and the treatment of locally advanced disease should be individually tailored after discussion between physician and patient. In many instances, patients prefer and expect some form of treatment in preference to watchful waiting. Treatment nomograms such as the Kattan nomograms provide precise, comprehensive and invaluable tools for everyday use and may be used to predict outcomes and guide treatment decisions.
AUSCULTATORY PERCUSSION: AN ADDED DIMENSION IN PHYSICAL DIAGNOSIS
Authors: Brunk SF
Published: April 2023

The combination of both auscultation and percussion in the diagnostic examination improves both auscultation and percussion and, in so doing, increases the skill of palpation. Auscultatory percussion (AP) is easy to learn, easy to use and requires little time to perform. The size of normal organs and the size of abnormal masses as determined by AP are usually similar to measurements determined by X‐rays and CT scans. Abnormalities found by AP need to be evaluated and confirmed by other diagnostic procedures. AP brings increased precision to physical diagnosis and is felt to be a valuable addition to medical practice.
EFFICACY AND SAFETY OF BUPROPION SR FOR SMOKING CESSATION: DATA FROM CLINICAL TRIALS AND FIVE YEARS OF POSTMARKETING EXPERIENCE
Authors: Ferry L , Johnston JA
Published: April 2023

Bupropion SR was introduced for smoking cessation in the US in 1997. This review assesses the efficacy and safety of bupropion SR for treatment of tobacco dependence based on data from clinical trials and five years of postmarketing experience. Through June 2001, there were approximately 32 million patient exposures to bupropion (9 million for smoking cessation) in clinical practice, and more than 8000 patients have been studied in clinical trials for tobacco dependence. In clinical trials, bupropion SR was more effective than placebo at improving initial and long‐term abstinence rates and preventing relapse. Bupropion SR is generally well tolerated. The most common adverse event in clinical trials or clinical practice is insomnia, which can also be a symptom of nicotine withdrawal. The two main risks of treatment with bupropion SR are major motor seizure and hypersensitivity reaction. Clinical trials data suggest that the incidence of seizure is approximately 0.1%, and that of serious cases of hypersensitivity approximately 0.12%. Benefit‐risk assessment, assuming a 30% one‐year quit rate demonstrates that for every 10,000 smokers treated with bupropion SR, 19 lives are saved and 86 cases of smoking‐attributed morbidity are averted in a five‐year period while the risk of experiencing one of the two potentially serious adverse events during treatment is 0.22%. These data further establish both the efficacy and safety of bupropion SR and its use in preventing the adverse health effects of chronic tobacco use.
BILATERAL RENAL ARTERY STENOSIS AFTER ABDOMINAL RADIOTHERAPY FOR HODGKIN'S DISEASE
Authors: Saka B , Bilge AK , Umman B , Yilmaz E , Nisanci Y , Erten N , Karan MA , Tascioglu C
Published: April 2023

A 49‐year‐old woman was admitted with fatigue, dyspnoea, pretibial oedema and decreased daily urination. Seven years ago she was treated with doxorubicin, bleomycin, vinblastine and dacarbazine, alternating with mechlorethamine, vincristine, procarbazine and prednisone and 80 Gy abdominal radiotherapy for Hodgkin's disease. Two years later, malignant hypertension was diagnosed. Angiotensin‐2 antagonist and p‐blocker treatment was given. After increased serum creatinine levels were determined, renal angiography was performed and total obstruction in the left renal artery and near total obstruction in the right side was observed. She was admitted to our clinic with oliguria, and acute renal failure was diagnosed. Balloon angioplasty and stent implantation was performed to the right renal artery. After a polyuric period, serum creatinine reduced to near normal levels. Angiotensin‐2 antagonist treatment worsened the course in this patient. Patients with resistant hypertension occurring years after abdominal radiotherapy should be evaluated for renal artery stenosis.
THE EFFECT OF VITAMIN D3 ON INSULIN SECRETION AND PERIPHERAL INSULIN SENSITIVITY IN TYPE 2 DIABETIC PATIENTS
Authors: Borissova A‐M , Tankova T , Kirilov G , Dakovska L , Kovacheva R
Published: April 2023

The aim of this study was to evaluate the effect of vitamin D3 supplementation on insulin secretion and insulin resistance. Ten females with type 2 diabetes being treated with oral hypoglycaemic agents and with normal serum and urine calcium levels were enrolled in the study. The study was conducted in March, when levels of vitamin D are lowest in our region. The level of plasma 25(OH)D was measured (normal range in winter 25–120 nmol/l). The first (FPIS) and second (SPIS) phases of insulin secretion were studied during IVGTT Peripheral insulin resistance was measured. A group of 17 age‐ and BMI‐matched females with normal glucose tolerance served as a control group. The diabetic patients were treated with cholecalciferol 1332 IU daily for one month. The mean plasma 25(OH)D level was 35.3±15.1 nmol/l at baseline, 70% of patients being vitamin D deficient. After one month of treatment with vitamin D3, the plasma 25(OH)D level increased by a mean of 75.8%; 70% of the patients achieved normal vitamin D levels. FPIS increased significantly by 34.3%, while the change in SPIS of 20.4% was not significant (p>0.8). We found a significant correlation between the change in FPIS and the change in 25(OH)D level after vitamin D3 supplementation (p<0.018). The results showed a decrease of 21.4% in insulin resistance after one month, but the change was not significant. Bearing in mind that the main defects in type 2 diabetes mellitus are reduced FPIS and insulin resistance, and the favourable effect vitamin D3 had on them, we suggest vitamin D3 deficiency may at least partly contribute to the impairment of insulin secretion and probably of insulin action. Our results suggest that vitamin D3 supplementation could be an element in the complex treatment of type 2 diabetes mellitus during the winter.
MANAGEMENT OF PSYCHOSIS IN PARKINSON'S DISEASE
Authors: D'Souza C , Gupta A , Alldrick MD , Sastry BSD
Published: April 2023

Psychosis is one of the most disabling complications associated with Parkinson's disease (PD) and occurs in up to 30% of PD patients treated chronically with antiparkinsonian drugs. Visual hallucinations, with or without delirium and paranoid delusions, are the most frequent symptoms. Psychosis complicating PD can be more disabling than the motor symptoms of PD; it frequently poses a serious threat to the patient's ability to maintain independence and is the single greatest risk factor for nursing home placement. Choosing an antipsychotic drug for a PD patient is a common clinical dilemma. The conventional antipsychotic drugs are poorly tolerated in PD because of their predictable and at times profound worsening in parkinsonian motor symptoms. The recent availability of atypical antipsychotic drugs that can control psychotic symptoms without compromising motor function has led to significant advances in therapeutic strategies in the management of PD psychosis in the community. This article reviews data on the use of atypical antipsychotics in patients with PD and the current recommendations on their use in the management of PD psychosis.
ETORICOXIB IN THE TREATMENT OF CHRONIC PAIN
Authors: Duncan MR , Capell HA
Published: April 2023

For the many patients who suffer chronic pain, we seek the most effective anti‐inflammatory drug with the least side‐effect profile and the greatest long‐term safety. Etoricoxib, a selective COX2 inhibitor, has been shown to be as effective as non‐selective non‐steroidal anti‐inflammatory drugs in the management of chronic pain in rheumatoid arthritis and osteoarthritis, for periods of up to one year. Data on etoricoxib efficacy in chronic low back pain is beginning to emerge. The side‐effect profile of etoricoxib suggests it is well tolerated with similar adverse effects to non‐selective NSAIDs. Larger studies are awaited, to see whether superior gastrointestinal tolerability can be proven. Further work will be required to show that etoricoxib is safe in patients with pre‐existing cardiovascular or gastrointestinal comorbidity, and the potentially confounding role of aspirin still needs to be elucidated. However, etoricoxib shows promise as a new and effective COX2 inhibitor in clinical practice.
SMALL INTESTINAL METASTASIS FROM RENAL CELL CARCINOMA EXHIBITING RARE FINDINGS
Authors: Nozawa H , Tsuchiya M , Kobayash T , Morita H , Kobayashi I , Sakaguch M , Mizutani T , Tajima A , Kishida Y , Yakumaru K , Kagami H , Sekikawa T
Published: April 2023

Small intestinal metastasis from renal cell carcinoma (RCC) has only rarely been described. We report two patients who developed small bowel metastases from RCC showing different clinicopathological characteristics. Both patients underwent hemilateral nephrectomy for RCC and developed lung metastases metachronously or simultaneously. One patient developed occlusive ileus caused by multiple polypoid tumours composed of sarcomatoid tissue in the jejunum shortly after nephrectomy. The other patient presented melaena due to bleeding from a Borrmann 2‐like tumour in the jejunum six years after nephrectomy. Clinically, his disease was slow‐growing. Sarcomatoid histology and Borrmann 2‐like tumour in this report are rare findings in metastatic tumour of RCC in the small bowel.
EFFICACY AND TOLERABILITY OF ONCE‐DAILY ORAL THERAPY WITH TELITHROMYCIN COMPARED WITH TROVAFLOXACIN FOR THE TREATMENT OF COMMUNITY‐ACQUIRED PNEUMONIA IN ADULTS
Authors: Pullman J , Champlin J , Vrooman PS
Published: April 2023

A randomised, double‐blind study of adults with community‐acquired pneumonia (CAP) resulted in clinical cure rates of 90.0% for telithromycin and 94.2% for trovafloxacin. Bacteriological eradication rates were also comparable for both treatments. All high‐risk patients (i.e. ≥65 years old [n=25], Pneumonia Severity Index score; ≥lll [n=16], pneumococcal bacteraemia [n=4]) were clinically cured. In infections caused by Mycoplasma pneumoniae and Chlamydophila (Chlamydia) pneumoniae, clinical cure rates were 93.3% (14/15) for telithromycin and 100% (16/16) for trovafloxacin. Possibly drug‐related, treatment‐emergent adverse events (TEAEs) were considered mild and occurred in 47.2% of telithromycin and 33.0% of trovafloxacin patients. The most frequently reported, possibly drug‐related, TEAEs were diarrhoea and nausea for telithromycin and diarrhoea and headache for trovafloxacin. Serious TEAEs occurred in 1.9% of telithromycin and 1.8% of trovafloxacin subjects and were considered not drug related. No deaths occurred during the study. Telithromycin and trovafloxacin were safe and comparable in efficacy in these patients with CAR
STEROIDAL CONTRACEPTIVE VAGINAL RINGS
Authors: Sarkar AW
Published: April 2023

The development of steroid‐releasing vaginal rings over the past three decades is reviewed to illustrate the role of this device as an effective hormonal contraceptive for women. Vaginal rings are made of polysiloxane rubber or ethylene‐vinyl‐acetate copolymer with an outer diameter of 54–60 mm and a cross‐sectional diameter of 4–9.5 mm and contain progestogen only or a combination of progestogen and oestrogen. The soft flexible combined ring is inserted in the vagina for three weeks and removed for seven days to allow withdrawal bleeding. Progesterone/progestogen‐only rings are kept in for varying periods and replaced without a ring‐free period. Rings are in various stages of research and development but a few, such as NuvaRing, have reached the market in some countries. Women find this method easy to use, effective, well tolerated and acceptable with no serious side‐effects. Though the contraceptive efficacy of these vaginal rings is high, acceptability is yet to be established.
DELAYED REPAIR OF A FRACTURED PENIS: A NEW TECHNIQUE
Authors: Naraynsingh V , Ramdass MJ , Thomas D , Maharaj D
Published: April 2023

Fracture of the penis can be managed conservatively or surgically. Conservative management is associated with a high morbidity, and early surgical repair of the fracture is usually recommended in order to prevent complications. Because a fractured penis is swollen throughout its length, it is difficult to identify the fracture site accurately, so a degloving technique is usually used to locate and repair the torn corpus cavernosum; this can lead to further trauma and complications. In cases where extensive swelling makes accurate clinical localisation difficult, delaying the repair for 7–12 days facilitates easy identification and repair of the torn corpus cavernosum. We report three cases where treatment was delayed until the swelling had subsided, when a simple direct repair was successfully carried out.
RENOVASCULAR HYPERTENSION SECONDARY TO SPONTANEOUS RENAL ARTERY DISSECTION AND TREATMENT WITH STENTING
Authors: Bilge AK , Nisanci Y , Yilmaz E , Umman B , Hunerel D , Ozsaruhan O
Published: April 2023

Renovascular disease is the cause of less than 1% of patients with hypertension; within this group aneurysm and dissection in renal artery are even rarer causes. It may be not only iatrogenic or traumatic, but may also develop spontaneously from fibromuscular disease or atherosclerotic lesions. We present a 26‐year‐old male patient with recently developed and progressive hypertension in whom renal angiography showed aneurysmal dilatation and dissection of the right renal artery. With the implantation of two stents in the true lumen, normal renal blood flow and thrombosis of the aneurysmal sac was established. As a result, stent implantation to renal artery dissection is effective, reliable and easy and can be an alternative to surgical treatment.
CARDIAC METASTASIS FROM A RENAL CELL CARCINOMA
Authors: Cheng ASH
Published: April 2023

Renal cell carcinomas are known to extend into the renal vein and inferior vena cava, but cardiac metastases are rare and usually clinically silent. In the case described here, there was evidence of right ventricular outflow obstruction, associated with a metastatic renal tumour in the right ventricular wall protruding into the ventricular cavity. The patient had presented years earlier with an ulnar neuropathy, for which the tumour may have been responsible. This case highlights the need to consider an underlying paraneoplastic syndrome in a patient presenting with neuropathy, because appropriate investigation could have led to early detection and possible cure of the renal lesion. When renal cell carcinoma is confined to the renal parenchyma, five‐year survival is up to 70%, but this falls to 5% in the presence of distant metastases.
SPREAD OF MELANOMA AFTER LYMPHATIC DRAINAGE: RELAUNCHING THE DEBATE
Authors: Vereecken P , Mathieu A , Laporte M , Petein M , Heenen M
Published: April 2023

Secondary lymphoedema of the leg can result in disruption of lymphatic vessels following lymph node surgery. Evidence supports the use of complex decongestive physiotherapy (CDP) in such cases, despite the possibility of tumour recurrence due to this therapy in cancer patients. We present the case of a 52‐year‐old woman who developed in‐transit metastases and systemic evaluable disease one month after starting CDP for secondary lymphoedema of the leg. (lnt J Clin Pract 2003; 57(5): 444–445)
A ONE‐YEAR, RANDOMISED, PLACEBO (SALINE) CONTROLLED CLINICAL TRIAL OF 500–730 KDA SODIUM HYALURONATE (HYALGAN®) ON THE RADIOLOGICAL CHANGE IN OSTEOARTHRITIS OF THE KNEE
Authors: Jubb RW , Piva S , Beinat L , Dacre J , Gishen P
Published: April 2023

The primary objective of this study was to investigate structural changes, as measured by joint space narrowing (JSN), within the knee joint during treatment with intra‐articular sodium hyaluronate (HA) of molecular weight 500–730 kDa in patients with osteoarthritis (OA) of the knee. Patients received a weekly intra‐articular injection of either 20 mg2/ml HA or a 2 ml vehicle placebo (saline) for three weeks. This course was repeated twice more at four‐monthly intervals. Concomitant treatment with analgesics or NSAIDs was allowed. The primary efficacy measure was the reduction in mean joint space width (JSW) of the medial compartment at 52 weeks. A total of 408 patients were randomised and 319 completed the one‐year study (HA: n=160, placebo: n=159); 273 of the 319 were included in the primary analysis. Analysis of variance on these 273 patients did not show a statistically significant difference between the two treatment groups. However, there was a significant difference in response to treatment in terms of the baseline JSW (p=0.01), indicating that outcome of treatment may depend on‐baseline JSW. Therefore, a subgroup analysis by baseline JSW was conducted. This compared patients with a JSW >4.6 mm with those with a JSW <4.6 mm. In those with radiologically milder disease at baseline and receiving HA, the JSN was significantly reduced compared with placebo (p=0.02). In patients with radiologically more severe disease there was no difference in JSN between the two treatments. Although, in this one‐year study, no overall treatment effect was seen, those with radiologically milder disease at baseline had less progression of joint space narrowing when treated with HA.
ANTIHYPERTENSIVE EFFICACY OF MOXONIDINE IN PRIMARY CARE: A ‘REAL‐LIFE’ STUDY
Authors: Schachter M , Mitchell G , Niziol C , Abhyankar BA
Published: April 2023

Both clinical trials and everyday experience indicate that most hypertensive patients will need two or more drugs to reach target blood pressures. The current framework for the selection of drugs for combination therapy is based mainly on their interaction with the renin‐angiotensin system. However, this approach would not fully exploit the range of drugs now available. This study, based on current primary care practice, confirms that the centrally acting drug moxonidine has efficacy as an add‐on agent comparable to that of other drugs such as beta‐blockers and ACE inhibitors and that it can effectively be combined with these agents. It also shows that moxonidine is as well tolerated as the other drugs and much better than older centrally acting agents such as clonidine and methyldopa. The study reinforces the view that moxonidine can be considered as an effective and well‐tolerated drug for use in combination with any other class of antihypertensives.
MALIGNANCY IN CHINESE ADULTS PRESENTING AS FEVER OF UNKNOWN ORIGIN
Authors: Wei W , Hesheng L
Published: April 2023

It is difficult to make a diagnosis when malignancy presents as fever of unknown origin (FUO). In order to update information on this disease entity, we performed a retrospective survey on adult cancer patients (n=48) presenting with FUO who were admitted to our university hospital between 1989 and 2002. All 48 patients had a median fever course of 56 days and a diagnostic phase of 13 days. Anaemia was found in 89.6% of the patients and elevated ESR in 77.1%. Of 35 patients (72.9%) with haematological malignancy, most were either lymphoma (n=18) or malignant histiocytosis (n=13). Solid tumours were found in 13 patients (27.1%), of which seven were hepatic carcinoma. Only five patients were correctly diagnosed, and 39 (90.7%) were mistaken for various infections. Inconclusive signs and symptoms, misinterpretation of test results and improper use of broad‐spectrum antibiotics and corticosteroids all contributed to the misdiagnoses.
XELODA® AND TAXOTERE®: A REVIEW OF THE DEVELOPMENT OF THE COMBINATION FOR USE IN METASTATIC BREAST CANCER
Authors: McDonald F , Miles D
Published: April 2023

Docetaxel (Taxotere®) and capecitabine (Xeloda®) demonstrate synergy in pre‐clinical studies and both show high single‐agent efficacy in metastatic breast cancer patients previously treated with an anthracycline. The two drugs used in combination in a similar group of patients have been evaluated in a randomised phase III trial comparing this combination with single‐agent docetaxel. The results of this study indicate the combination arm to be favourable with significantly superior median time to disease progression (6.1 vs 4.2 months, hazard ratio 0.652, p=0.0001), objective response rate and overall survival without a significant increase in the overall incidence of treatment related adverse effects. This combination of docetaxel and capecitabine provides improved survival prospects for patients with metastatic breast cancer. Ongoing studies will provide further data to optimise the scheduling and use of this combination in the future.
SYMPATHETIC BLOCKADE AND AMITRIPTYLINE IN THE TREATMENT OF REFLEX SYMPATHETIC DYSTROPHY
Authors: Karakurum G , Pirbudak L , Oner U , Gulec A , Karadasli H , Satana T
Published: April 2023

We prospectively investigated the outcome of a combination therapy of oral amitriptyline and sympathetic ganglion blockade on 10 patients suffering from reflex sympathetic dystrophy of the upper extremity for at least three months. The efficacy of the treatment was evaluated by clinical examination, pain ratings on the visual analogue scale (VAS) and grip strength measurements using the Jamar dynamometer. The results were statistically analysed with Wilcoxon signed‐ranks test for comparison of the before and after treatment grip strength measurements and with paired t‐test for comparison of the mean of initial and consecutive pain ratings on the VAS. Values of p<0.01 were considered to be statistically significant. Combination therapy proved beneficial in this particular patient population, which, as far as previously documented studies are concerned, would otherwise respond less favourably to a treatment consisting solely of sympathetic blockade.
FEVER OF UNKNOWN ORIGIN: A REPORT FROM CHINA OF 208 CASES
Authors: Zhiyong Z , Bingjun L , Xiaoju L , Xinjian F , Ping F , Wenya W
Published: April 2023

Fever of unknown origin (FUO) is a clinical dilemma in western countries and in China. To investigate the causes and prognosis of FUO, 208 patients with FUO admitted to a large university hospital in China were investigated. The final diagnoses established in 158 cases (75.96%) were: infectious disease in 66 cases (31.73%), collagen vascular disease in 46 patients (22.11%), neoplasm in 35 cases (16.83%), and other disease in 11 patients (5.29%). In 66 cases with infectious disease, tuberculosis, septicaemia and typhoid fever were the principal causes. SLE and adult Still's disease were the most important causes among collagen vascular disease. Lymphoma and malignant histiocytosis were mostly associated with FUO among neoplasms. In 50 cases (24.04%), the cause of fever was not found. On discharge from hospital, fever had subsided in 133 cases (63.94%), and had persisted in 63 cases (30.29%); 12 patients (5.87%) died. In China, infectious disease, collagen vascular disease and neoplasm are the main causes of FUO. While most patients recover, there are some differences in the distribution of causes between the West and China, and there are relatively more deaths than in previous reports.
CLINICAL TRIALS OF SILDENAFIL CITRATE (VIAGRA®) DEMONSTRATE NO INCREASE IN RISK OF MYOCARDIAL INFARCTION AND CARDIOVASCULAR DEATH COMPARED WITH PLACEBO
Authors: Mittleman MA , Glasser DB , Orazem J
Published: April 2023

We pooled data regarding myocardial infarction (Ml) and cardiovascular death from more than 120 clinical trials of sildenafil citrate (Viagra®) conducted from 1993 to 2001. During placebo‐controlled trials, the rate of Ml or cardiovascular death was 0.91 (95% CI: 0.52–1.48) per 100 Person‐years (PY) of follow‐up among sildenafil‐treated patients compared with 0.84 (95% CI: 0.39–1.60) per 100 PY of follow‐up among placebo‐treated patients. The relative risk of Ml or cardiovascular death was 1.08 (95% CI: 0.45–2.77) for sildenafil compared with placebo (p=0.88). During open‐label studies, the rate of Ml or cardiovascular death was 0.56 (95% CI: 0.44–0.72) per 100 PY of follow‐up. This analysis showed that the rates of Ml and cardiovascular death were low and comparable between men treated with sildenafil and those treated with placebo. The use of sildenafil was not associated with an increase in the risk of Ml or cardiovascular death.
LEVETIRACETAM: A NEW THERAPEUTIC OPTION FOR REFRACTORY EPILEPSY
Authors: Pinto A , Sander JW
Published: April 2023

Levetiracetam (LEV) is the most recently licensed antiepileptic drug (AED) for adjunctive therapy of partial seizures. Its mechanism of action is uncertain but it exhibits a unique profile of anticonvulsant activity in models of chronic epilepsy. Three randomised, double‐blind, placebo‐controlled trials enrolling 904 patients with refractory partial epilepsy have demonstrated the efficacy of LEV as adjunctive therapy, with a responder rate (≥50% reduction in seizure frequency) of 28–41%. Long‐term efficacy studies suggest retention rates of 60% after one year, with 13% of patients seizure‐free for six months of the study and 8% seizure‐free for one year. Adverse effects of LEV, including somnolence, lethargy and dizziness, were generally mild and the frequency of incidents was not significantly different between the active treatment and placebo groups in clinical trials. LEV has no clinically significant pharmacokinetic interactions (PKI) with other AEDs, or with commonly prescribed medications. Preliminary data suggest that LEV has efficacy in primary generalised epilepsy and further randomised trials are under way. The combination of potent antiepileptic properties with a relatively mild adverse effect profile makes LEV an attractive adjunctive therapy for partial seizures.
AN UNUSUAL CAUSE OF CARPAL TUNNEL SYNDROME
Authors: Hui ACF , Wong SM , Griffith JF
Published: April 2023

Tuberculosis is an uncommon cause of carpal tunnel syndrome. We report a patient with systemic lupus erythematosus who developed hand numbness. Ultrasonic, operative and microbiological findings supported the diagnosis of median nerve compression secondary to a tuberculous abscess. The symptoms resolved with surgical excision and antituberculous chemotherapy.
BUDESONIDE/FORMOTEROL IN A SINGLE INHALER (SYMBICORT®) REDUCES HEALTHCARE COSTS COMPARED WITH SEPARATE INHALERS IN THE TREATMENT OF ASTHMA OVER 12 MONTHS
Authors: Rosenhall L , Borg S , Andersson F , Ericsson K
Published: April 2023

This open, multinational, randomised, parallel‐group, six‐month extension conducted in the Swedish centres of a previous six‐month study compared the costs of a total of 12 months of treatment with budesonide/formoterol in a single inhaler with budesonide plus formoterol separate inhalers in 320 adults with asthma. Patients received budesonide/formoterol (Symbicort® Turbuhaler®) 160/4.5 mg delivered doses, two inhalations b.i.d., or corresponding doses of budesonide (Pulmicort® Turbuhaler) plus formoterol (Oxis® Turbuhaler). Direct costs and indirect costs were estimated. Budesonide/formoterol treatment was associated with reduced healthcare service utilisation and statistically significant reductions in direct (SEK1595, p=0.0004) and total costs (SEK1884, p=0.043) per person per year compared with budesonide plus formoterol. Budesonide/formoterol reduced the average annual emergency room admission cost per person by SEK489.7 (31% of direct cost reduction) and physician costs by SEK235.4 (15%). The direct cost of study, relief and other medication was reduced by SEK893.8 (47% of total reduction). There were no statistically significant differences in efficacy and safety parameters following treatment with budesonide/formoterol from single or separate inhalers, other than a significantly lower proportion of withdrawals with the single inhaler (9.2% vs 19.4%, p=0.008). In summary, budesonide/formoterol treatment from a single inhaler reduced 12‐month treatment costs compared with separate inhalers, while maintaining at least as good control of asthma.
POTENTIAL LONG‐TERM EFFECTS OF RIVASTIGMINE ON DISEASE PROGRESSION MAY BE LINKED TO DRUG EFFECTS ON VASCULAR CHANGES IN ALZHEIMER BRAINS
Authors: Erkinjuntti T , Skoog I , Lane R , Andrews C
Published: April 2023

Alzheimer's disease patients with hypertension or other vascular risk factors have been shown to receive greater symptomatic benefits than patients with strictly Alzheimer's disease following short‐term treatment with rivastigmine, an inhibitor of acetylcholinesterase and butyrylcholinesterase. We evaluated the long‐term efficacy of rivastigmine in Alzheimer's disease patients with or without hypertension. Subjects in a 26‐week placebo‐controlled trial of rivastigmine entered an open‐label extension study for 104 weeks. Efficacy measures included the Alzheimer's Disease Assessment Scale–cognitive subscale (ADAS‐cog), Progressive Deterioration Scale (PDS) and Global Deterioration Scale (GDS). Subjects were stratified by the presence or absence of hypertension at baseline. At 104 weeks, there was a trend for hypertensive patients from the original rivastigmine 6–12 mg/day group (early starters), who received rivastigmine for the full 104 weeks) to have better ADAS‐cog scores than the original placebo group (late starters), who received open‐label rivastigmine for the last 78 weeks only). Significant treatment differences were observed in the hypertensive subgroup on the PDS and GDS. In non‐hypertensive patients, changes from baseline at week 104 were similar in ‘early’ and ‘late’ starters of rivastigmine treatment. The additional apparent benefits on disease progression detected in patients with hypertension and Alzheimer's disease may be linked to drug effects on cerebrovascular factors. These findings may have an important influence on the way cholinesterase inhibitors are prescribed.
PATIENT‐REPORTED BENEFITS OF RIZATRIPTAN COMPARED WITH USUAL NON‐TRIPTAN THERAPY FOR MIGRAINE IN A PRIMARY CARE SETTING
Authors: Baos V , Serrano A , Torrecilla M , Bertral C , Caloto MT , Nocea G , Gerth WC
Published: April 2023

The purpose of this open‐label study was to compare rizatriptan with usual non‐triptan therapy for migraine in patients who had never received a triptan. Patient‐reported outcomes were examined for a prestudy migraine attack and after three consecutive study attacks, the first and third treated with rizatriptan 10 mg wafer and the second with usual non‐triptan therapy. A total of 97 patients (83% women; mean age 39 years) completed the study Two‐thirds of patients reported severe or total disability during migraine attacks. All comparisons between rizatriptan therapy and usual non‐triptan therapy significantly favoured rizatriptan (p≤0.01). Headache relief by 2 hours was reported by 78–83% of patients after rizatriptan and by 46–48% of patients after usual therapy; 41–47% and 12–18%, respectively, were pain free at 2 hours. Patient satisfaction and migraine‐specific quality‐of‐life scores were also significantly better for attacks treated with rizatriptan. At study end, 62% and 17% of patients were very or completely satisfied with rizatriptan and usual non‐triptan therapy, respectively. Among those patients who worked for pay, therapy with rizatriptan significantly reduced absenteeism and improved the amount and quality of time at work compared with usual non‐triptan therapy. Allowing patients to have experience with rizatriptan may improve the level of medical care for migraine attacks.
A NATIONAL SURVEY OF TRANSRECTAL ULTRASOUND‐GUIDED PROSTATIC BIOPSIES: TIME FOR A NATIONAL GUIDELINE
Authors: Patel HRH , Lee F , Arya M , Masood S , Palmer JH , Sheriff MKM
Published: April 2023

The aim of this study was to elicit similarities and differences in transrectal ultrasound guided prostatic biopsy regimens in the UK and the Republic of Ireland. A telephone survey of 60 centres was conducted and information collected on the operator, the anaesthesia used, antibiotic prophylaxis and number of biopsies taken. Most prostatic biopsies were performed by urologists and most procedures involved six cores. There was a marked variation in the use of antibiotic prophylaxis, and anaesthesia was used sparingly. Our survey has shown a diversity in protocols used in transrectal ultrasound guided biopsies in the UK and Ireland. It seems sensible to standardise the technique for optimal patient satisfaction, as well as clinical efficiency. A national co‐ordinated, prospective trial is needed.