bluuebunny/crossref_metadata_2025 huggingface dataset:
PROFOUND HYPONATRAEMIA FOLLOWING AN IDIOSYNCRATIC REACTION TO DIURETICS
Authors: WierzbiCki AS , Ball SG , Singh NKP
Published: April 2023

A case report of a 79‐year‐old woman with a breast adenocarcinoma who presented with clouding of consciousness and anorexia with a hyponatraemia of 97 mmol/l is described. An initial diagnosis of secretion of inappropriate antidiuretic hormone (SIADH) was made on the clinical history and a urine:plasma osmolality ratio of 2.25. Further investigation revealed the correct diagnosis of a sodium‐losing state with dehydration, and that her ADH level was normal. The actual cause of her hyponatraemia was the recent prescription of a thiazide diuretic. This case illustrates the unreliability of urine:plasma osmolality ratios for the diagnosis of SIADH.
THE PREDICTIVE VALUE OF DIAGONAL EAR‐LOBE CREASE SIGN
Authors: Motamed M , Pelekoudas N
Published: April 2023

Studies on selected cardiac patients have supported the association between diagonal ear‐lobe crease (ELC) sign and coronary artery disease (CAD). The aim of this study was to assess the value of this sign as a predictor of the presence of CAD in the non‐cardiac patient population, to see if any association exists between the two and to compare any association with other established risk factors. A significant association exists between ELC and a history of CAD, which is not solely attributable to the increased prevalence of the sign with increasing age. A higher correlation was found between CAD and ELC than between CAD and other risk factors. The sensitivity of the sign was 48%, the specificity 88%, and the positive predictive value 16%. In this population the finding of an ELC is of little clinical value.
NEW LONG STAY PATIENTS: FROM ACUTE WARDS TO WHERE?
Authors: Rowlands P , Milner E , Wing S , Inch H
Published: April 2023

Inadequate alternatives to the old mental hospitals have placed many inner city acute psychiatric units under great pressure as bed numbers have contracted and disturbed patients have accumulated. This study set out to assess the outcome at two‐year follow‐up of a cohort of 26 patients resident on an acute psychiatric ward for more than six months. Results showed that a substantial minority of ‘new long stay’ patients made a successful return to independent living, but that at two‐year follow‐up half the cohort remained in a highly supported setting. Two deaths had occurred, neither by suicide. Psychiatric services remained involved with 90% of the patients in the cohort.
ANDROGENETIC ALOPECIA IN MEN: THE SCALE OF THE PROBLEM AND PROSPECTS FOR TREATMENT
Authors: Rushton DH
Published: April 2023

While the precise incidence of androgenetic alopecia is unknown, it is universally acknowledged to be the most common hair problem in men. Balding is generally associated with ageing; consequently, the desire to prolong a youthful appearance inevitably leads to demands for effective treatments. Further, changing attitudes in modern society have resulted in people becoming concerned about their appearance and less tolerant about conditions that might be alleviated by medical intervention. The importance of hair loss upon quality of life has been underestimated by the medical profession. Clinicians failing to accept hair loss as an important medical problem ignore the real distress suffered by a significant proportion of those affected. New options for treatment that selectively target the metabolic pathways involved in the balding process are showing promise. The first generation of such drugs, Propecia, is now available in some countries and other molecules are currently under development.
THE ROLE OF LIPID LOWERING IN TRANSPLANTATION
Authors: Wierzbicki AS
Published: April 2023

Transplantation is an increasingly common procedure. Yet the contribution of accelerated atherosclerosis to the reduction of graft life is often underestimated. This review examines the evidence for the involvement of hyperlipidaemia and other cardiovascular disease risk factors in the aetiology of chronic graft failure in renal, cardiac, liver and pancreatic transplantation. The evidence for the role of lipid lowering therapy in the prevention of accelerated atheroma in these patients is reviewed.
THE EFFECT OF PREVIOUS ANTIBIOTIC THERAPY ON THE BACTERIOLOGY OF THE TONSILS IN CHILDREN
Authors: Woolford TJ , Hanif J , Washband S , Hari CK , Gangulp LA
Published: April 2023

The bacteriology of the tonsillar surface and core in 30 children undergoing tonsillectomy was studied. Antibiotics taken in the six months before surgery were recorded. Haemophilus influenzae and Staphylococcus aureus were the commonest isolates; Streptococcus pyogenes was relatively rare. Eight children had received no antibiotics, the others had been prescribed 65 different courses of 13 different types. No relationship between the various antibiotic regimens prescribed and tonsillar bacteriology could be demonstrated, and it would appear that the tonsillar bacteriology at the time of tonsillectomy is not altered by antibiotics prescribed in the previous six months.
TRANSFUSION IN THE MANAGEMENT OF PATIENTS WITH MEGALOBLASTIC ANAEMIA
Authors: McMullin MF , Cuthbert RIG
Published: April 2023

Transfusion has been associated with significant morbidity and mortality in megaloblastic anaemia (MA). This retrospective study was undertaken to examine the usefulness of transfusion in the management of MA. Fifty‐two patients with MA were identified. Of the 20 transfused patients 13 were treated with diuretics and six with potassium supplements. The mean haemoglobin (Hb) of the transfused group was 6.5 g/dl (range 4.8‐10.4 g/dl), and of the 32 non‐transfused patients 10.5 g/dl (range 5.6‐17.0 g/dl). The Hb and packed cell volume (PCV) were significantly lower in the transfused group. Only two of 32 non‐transfused group were given potassium supplements. In this small group of patients with MA, transfusion appeared to be safe and no complications of transfusion were identified. However, advice was not being followed. We would suggest that, although transfusion has a minor role in the management of MA, consideration must be given to the general hazards of transfusion.
IS A MAN'S FACIAL APPEARANCE PREDICTIVE OF HOW HE WILL DIE?
Authors: Cummins D , Hoskin P , Young J , Goodman IL , Coupe MO , Halil O , Foy CJ
Published: April 2023

The ability of a range of health professionals including an oncologist, a haematologist, a cardiologist, a general practitioner and a counsellor to predict the cause of death from facial appearance has been evaluated. Each participant was asked to predict the cause of death from facial photographs of 200 Caucasian male doctors whose cause of death was known to be due to either arterial disease or neoplasia. Statistically significant concordance was found between the oncologist and both the GP and the counsellor in their predictions of cause of death, although the individual accuracy was no greater than would be expected by chance. This suggests that common judgements based on facial appearances may be shared among certain health professionals.
BECLOMETHASONE DIPROPRIONATE INHALATION AS A TREATMENT FOR POST‐INTUBATION TRACHEAL STENOSIS
Authors: Abo M , Fujimura M , Kibe Y , Kida H , Matsuda T
Published: April 2023

A 67‐year‐old man was intubated for one week and suffered from wheeze and dyspnoea three months after the extubation. Bronchoscopy revealed tracheal stenosis by a web, which subsequent biopsy showed to be granulation tissue. The stenosis was removed by laser therapy but the stenosis soon returned. As cardiac function was poor, beclomethasone diproprionate (BDP) inhalation therapy (1200 μg daily) was started and proved successful. Discontinuation of inhalation therapy resulted in restenosis. Steroid inhalation therapy may be able to control post‐intubation tracheal stenosis caused by granulation tissue.
SUPRACONDYLAR NAIL FAILURE: TWO CASE REPORTS
Authors: Thompson NS , Cooke EA , Craig BF
Published: April 2023

We describe two case reports of supracondylar nail failure in young patients who had sustained high energy, closed, comminuted supracondylar femoral fractures. These injuries had been successfully treated using retrograde intramedullary nails which failed several months later because of excessive activity on the part of the patient without the presence of full flexion at the knee. The failed implants were removed and dynamic condylar screws were inserted with bone graft to the fracture site. This revision procedure produced solid bony union. We recommend that these patients should not fully weight bear, or engage in strenuous physiotherapy after nailing, until the fracture has consolidated and a functional range of knee motion has been obtained. Failed implants should be managed by nail removal, bone grafting and insertion of a dynamic condylar screw.
AN UNUSUAL CAUSE OF UNILATERAL FACIAL PAIN
Authors: Chukwuemeka AO , John LCH
Published: April 2023

Cardiac pain that is referred to the face is a common symptom in patients with angina pectoris, but unilateral facial pain referred from a non‐ischaemic cardiac source is rare. We report a case of unilateral facial pain that occurred in relation to a large pericardial effusion and which resolved on drainage of the effusion.
ANAESTHETIC ASSESSMENT AND MANAGEMENT OF CARDIAC PATIENTS FOR NON‐CARDIAC SURGERY PART 2: MANAGEMENT
Authors: Shaw A , Boscoe MJ
Published: April 2023

In an earlier article in this journal (June 1999) we discussed the risk that the presence of cardiac disease poses to patients undergoing non‐cardiac surgery. We outlined factors in the patient's medical history, examination findings and the value of various tests in arriving at an overall assessment of risk for any given patient. In this article we concentrate on the management of these patients as they undergo surgery itself. We shall consider what measures may usefully be employed in order to minimise the risk of an adverse cardiac event occurring in the perioperative period.
POLYCYSTIC OVARIAN SYNDROME: IS COMMUNITY CARE APPROPRIATE?
Authors: Gupta S
Published: April 2023

In recent years the complexities and heterogeneity of polycystic ovarian syndrome (PCOS) have been recognised. Most PCOS sufferers with amenorrhoea, menstrual dysfunction, hirsutism, acne and infertility can be evaluated and safely managed in primary care. It is prudent to remember that all women with PCOS are at risk of insulin resistance and the associated abnormalities of the insulin resistance syndrome – dyslipidaemia, hypertension, coronary artery disease and diabetes mellitus.
DELAYED DIAGNOSIS OF AN ENTERIC DUPLICATION CYST
Authors: Parks RW , Casey J , Paterson‐Brown S
Published: April 2023

Enteric duplication cysts are rare and often prove extremely difficult to diagnose. We report a case in which the definitive diagnosis was made 40 years after first presentation and following five exploratory laparotomies. A review of the literature is presented, with discussion regarding the presenting features, potential complications, radiological investigations and surgical treatment of this uncommon clinical entity.
A SYSTEMATIC APPROACH TO ERECTILE DYSFUNCTION IN THE CARDIOVASCULAR PATIENT: A CONSENSUS STATEMENT
Authors: Jackson G , Betteridge J , Dean J , Hall R , Holdright D , Holmes S , Kirby M , Riley A , Sever P
Published: April 2023

EXECUTIVE SUMMARY

• Sexual activity is no more stressful to the heart when compared with a number of other natural daily activities, e.g. walking one mile on the level in 20 minutes.

• The cardiac risk of sexual activity in patients diagnosed with cardiovascular disease is minimal in properly assessed and advised patients.

• Erectile dysfunction (ED) is common, affecting 10% of men aged 40‐70 years and increases in frequency with age.

• ED and cardiovascular disease share many of the same risk factors and often coexist.

• ED in the diagnosed cardiovascular patient should be identified by routine questioning in general practice. Modern therapies can restore a sexual relationship in the majority of patients with ED and can lead to a substantial improvement in quality of life.

• The majority of patients assessed to be at low or intermediate cardiac risk, as defined later in this paper (Table 4), can be effectively managed in primary care. Primary care treatment for ED in patients defined as high risk can be initiated following a specialist opinion and/or confirmation that the patient's cardiovascular condition is stabilised.

• There is no evidence that currently licensed treatments for ED add to the overall cardiovascular risk in patients with or without diagnosed cardiovascular disease.
NEW THERAPEUTIC APPROACHES FOR RHEUMATOID ARTHRITIS
Authors: Abdelaty EM , Schumacher HR
Published: April 2023

Better understanding of the immunopathogenesis of rheumatoid arthritis over the past few decades has promoted the innovation of new therapeutic approaches targeting the disease more specifically. In addition, refinements in the non‐steroidal anti‐inflammatory drugs (NSAID) may offer advantages for patients with RA. This brief review reports and analyses some of the important aspects of these new therapies available for treatment of RA and in which situations you might consider each. Before using any of these agents, physicians should become thoroughly familiar with the package inserts.
III. ALCOHOL, DRUGS AND STIGMA
Authors: Ritson EB
Published: April 2023

Alcohol and drug‐related problems are common in clinical populations but are often stigmatised by the public and the professions. These attitudes may interfere with patients obtaining effective help. The reasons for these barriers are explored, including the views that these problems are self‐inflicted – and therefore less worthy of help – and the stereotypes and resistances that abound in working with those who have become addicted. Training and public education may go some way to improve this situation.
CYSTIC LYMPHOCYTIC HYPOPHYSITIS, VISUAL FIELD DEFECTS AND HYPOPITUITARISM
Authors: Farah JO , Rossi M , Foy PM , MacFarlane IA
Published: April 2023

A 45‐year‐old man presented with anterior pituitary failure, requiring thyroxine, hydrocortisone and androgen replacement. An MRI scan revealed a large cystic pituitary mass and thickening of the pituitary stalk. Over three years, diabetes insipidus and bitemporal hemianopia developed and the cystic mass had enlarged on MR scanning. Transphenoidal resection was performed with normalisation of the visual fields. Histology revealed lymphocytic hypophysitis, which is rare in men. The presentation with cystic enlargement is unique.
THE ROLE OF STATINS IN ACUTE CORONARY SYNDROMES: MANAGING THE UNMET NEED
Authors: Jackson G
Published: April 2023

Coronary heart disease is the major cause of death in the industrialised world. As the prevalence increases with advancing age, coronary heart disease will be a growing problem as the average age of the population increases. The cost of treatment following an acute coronary syndrome is considerable and there is a substantial risk of further episodes. However, there is much evidence that the disease is a dynamic and reversible process and further episodes are preventable. Numerous trials have shown the efficacy of statins in coronary heart disease. The most recent studies have shown efficacy in secondary prevention when statin therapy was started early (hours/days) after an acute episode. Although guidelines recommend that statin therapy should be initiated following an acute coronary syndrome, prescription rates seem to be static at around 40%. A number of measures need to be taken to improve the situation. Firstly, each hospital and coronary care unit should implement a clearly defined protocol delineating patient management following hospital admission. Provision of comprehensive discharge information should be a key feature of this communication. Secondly, regular audit of prescribing habits is essential to assess the situation. Finally, patient adherence to their regimen should be improved by collaborative involvement of doctor and patient in planning and implementing the treatment regimen.
DIAGNOSES IN DISCHARGE COMMUNICATIONS: HOW FAR ARE THEY RELIABLE?
Authors: Adhiyaman V , Oke A , White AD , Shah IU
Published: April 2023

To discover whether general practitioners are correctly notified of a patient's final diagnosis following hospital discharge, an observational study was undertaken in a district general hospital. The final diagnosis was compared with the diagnosis documented in the discharge summary and the take‐home prescription. Two hundred discharges were studied. Only 163 (81%) discharge summaries and 138 (69%) take‐home prescriptions had the correct diagnosis; 24 (12%) take‐home prescriptions did not have any diagnosis at all. In some cases the diagnosis differed between the discharge summaries and the take‐home prescriptions. Only in 122 (61%) cases was the final diagnosis correctly documented in both instances. Communication regarding diagnosis in discharge letters is less than adequate. Every effort should be made to improve this.
CATECHOLAMINE SECRETION AND PLOIDY IN PHAEOCHROMOCYTOMA
Authors: Tormey WP , Fitzgerald RJ , Thomas G , Kay EW , Leader MB
Published: April 2023

The aim was to evaluate 24 hr urine catecholamine, HMMA and HVA excretion in relation to ploidy in phaeochromocytoma. Data from five diploid and nine tetraploid tumours showed a significant reduction in urine noradrenaline (p=0.02) and HMMA (p=0.03) in diploid tumours but no difference in adrenaline, dopamine and HVA excretion using the Mann‐Whitney U test. None of the patients showed recurrence after a mean of 5.7 years of follow up. A review of published ploidy studies in phaeochromocytoma shows that malignancy is more than six times more common in non‐diploid tumours but diploidy does not equate with benignity. No biochemical marker is a reliable index of malignancy. All patients should undergo lifetime review for recurrence.
SILDENAFIL CITRATE (VIAGRA®) IS EFFECTIVE AND WELL TOLERATED FOR TREATING ERECTILE DYSFUNCTION OF PSYCHOGENIC OR MIXED AETIOLOGY
Authors: Olsson AM , Speakman MJ , Dinsmore WW , Giuliano F , Gingell C , Maytom M , Smith MD , Osterloh I ,   Sildenafil Multicentre Study Group
Published: April 2023

Sildenafil citrate (Viagra®) has been shown to be an effective treatment for erectile dysfunction (ED) of organic aetiology. This study assessed the efficacy and tolerability of sildenafil for treating ED of psychogenic and mixed psychogenic/organic aetiology. Men with ED of psychogenic and mixed aetiology were randomised in a double‐blind, fixed‐dose study to placebo (n=95) or sildenafil 10 mg (n=90), 25 mg (n=85), or 50 mg (n=81) once daily for 28 days. Efficacy was evaluated with two global efficacy questions, a patient log of erectile activity, a sexual function questionnaire and a partner questionnaire. Patients receiving sildenafil had significantly more grade 3 (hard enough for penetration) or grade 4 (fully hard) erections per week than patients receiving placebo, and a greater proportion of patients receiving sildenafil reported that treatment had improved their erections (p<0.001). Results of the sexual function questionnaire demonstrated significant improvement for patients with ED receiving sildenafil compared with patients receiving placebo for frequency, hardness and duration of erections (p<0.01), and for enjoyment of sexual intercourse and satisfaction with sex life (p<0.05). The results of the partner questionnaire were consistent with the results reported by patients and showed that treatment with sildenafil was associated with significant improvement in the partners' own sex lives (p<0.001). Adverse events were mostly mild to moderate in nature. The commonest adverse events were headache, dyspepsia, flushing, myalgia, arthralgia and flu syndrome. Discontinuations due to treatment‐related adverse events were few, ranging from 1.1% to 6.2% for patients receiving different doses of sildenafil and 4.2% for patients receiving placebo. Sildenafil is an effective and well‐tolerated treatment for ED of psychogenic or mixed aetiology with once‐daily dosing.
COMPLICATIONS OF A SIMPLE PROCEDURE: DE QUERVAIN'S DISEASE REVISITED
Authors: Mellor SJ , Ferris BD
Published: April 2023

We reviewed the results of 22 operations performed on 21 patients for the relief of de Quervain's disease over the last six years. At a mean follow‐up of 34 months (range 4‐78 months), 18 of 22 wrists had complete relief of their original symptoms. One patient required reoperation because of inadequate decompression, and two others await further surgery. Most operations (14 out of 22) were performed under local anaesthesia, and 17 out of 22 used a longitudinal incision. The use of a longitudinal incision was associated with a significant risk of complications: four patients had a poor cosmetic result, and six showed evidence of superficial radial nerve injury. Two patients had a wound infection, and one developed reflex sympathetic dystrophy. Although surgical decompression for de Quervain's disease is effective in curing the symptoms in most patients, using a longitudinal incision is associated with poor wound healing and damage to the terminal branches of the radial nerve. (Int J Clin Pract 2000; 54(2): 76‐77)
THE EFFECTS OF VALETTE® ON SKIN AND HAIR: A POST‐MARKETING SURVEILLANCE STUDY
Authors: Zimmermann T , Wisser K‐H , Dietrich H
Published: April 2023

The effects of Valette® ‐ an oral contraceptive containing ethinyloestradiol 0.03 mg and the antiandrogenic progestogen dienogest 2.0 mg ‐ on the skin and hair were surveyed over 63,474 cycles in 10,718 women in routine gynaecological practice. Improvements were greatest in women with severe or moderate androgen‐related symptoms. After six cycles, <1% of women had severely greasy hair and 6% had moderate greasiness, compared with 11 % and 27% at baseline; fewer hair washes were needed per week. The incidence of severe and moderately greasy skin disorders fell from 16% to <1%, and from 39% to 7.5%, respectively. Self‐assessments indicated less greasy hair and improved greasy skin disorders in 70% and 81% of women, respectively. The overall effect of Valette on the skin and hair was rated very good or good by 87.5% of women. These results confirm previous observations of a beneficial effect of Valette on androgen‐related skin and hair conditions. (Int J Clin Pract 2000; 54(2): 85‐91)
IS PAEDIATRIC DAY CASE TONSILLECTOMY DESIRABLE? THE PARENTS' PERSPECTIVE
Authors: Vowles R , Loney E , Williams H , Gormley‐Fleming E , Kulkarni P , Ryan R
Published: April 2023

Tonsillectomy is the most commonly performed otolaryngological procedure in most units. There is considerable financial pressure to perform paediatric tonsillectomy as a day case. Responding to concern that day case tonsillectomy might not be welcomed by parents or felt to be in the best interests of the patients, we carried out an audit of paediatric tonsillectomy, by means of a questionnaire for parents and nursing staff to complete while 32 consecutive patients underwent tonsillectomy as inpatients. Although eight parents (25%) felt that day surgery should be an option, none of those surveyed felt that on this occasion their child was well enough to be discharged home six hours postoperatively. Furthermore, no child in the audit fulfilled all the essential discharge criteria at six hours. In this area, at least, it appears parents do not uniformly welcome paediatric day case tonsillectomy. (Int J Clin Pract 2000; 54(4): 225‐227)
RAMIPRIL
Authors: Smith WHT , Ball SG
Published: April 2023

Ramipril is a long‐acting, lipophylic angiotensin converting enzyme inhibitor. its principle action is to inhibit the conversion of angiotensin I to the active angiotensin II. Ramipril is indicated in the treatment of hypertension, congestive cardiac failure (including that following acute myocardial infarction), nephropathy (with and without diabetes mellitus) and now, following the findings of the HOPE study, in the prevention of cardiovascular events (including myocardial infarction) in high risk individuals. This article concentrates on reviewing the evidence supporting ramipril's use in these indications. (Int J Clin Pract 2000; 54(4): 255‐260)
AN UNUSUAL CAUSE OF CUSHING'S SYNDROME: PRIMARY PIGMENTED NODULAR ADRENAL DYSPLASIA
Authors: Sofat N , Turner J , Khoo B , Sohail M , Krausz T , Evans P , Meeran K
Published: April 2023

We report a case of Cushing's syndrome due to primary pigmented nodular adrenal dysplasia (PPNAD) and discuss the diagnostic process and management of this rare case. The diagnosis of PPNAD is discussed in the context of other causes of Cushing's syndrome. Eighty‐five per cent of cases of Cushing's syndrome are due to a pituitary corticotrophic tumour (Cushing's disease). Rarer causes include cortisol secreting adrenal adenoma and ectopic ACTH secretion. In the routine investigation of Cushing's disease it is not unusual to find bilateral adrenal nodules on the CT scan. We present a case of Cushing's syndrome in which this radiographic finding was present and yet the biochemical diagnosis was one of ACTH independent disease. Histology revealed PPNAD. (Int J Clin Pract 2000; 54(4): 269‐271)
A COMPARISON OF PATIENTS ADMITTED TO TWO MEDIUM SECURE UNITS, ONE FOR THOSE OF NORMAL INTELLIGENCE AND ONE FOR THOSE WITH LEARNING DISABILITY
Authors: Puri BK , Lekh SK , Treasaden IH
Published: April 2023

Differences between patients being treated in two different medium secure units, one for those of normal intelligence and one for those with learning disability, were investigated.

Sociodemographic, psychiatric, medical and medicolegal data were recorded for all inpatients in both secure units. Patients in the medium secure unit for those of normal intelligence were older at the time of the study and at conviction for the index offence, more likely to have been admitted from the penal system, and more likely to suffer from a psychotic disorder, particularly schizophrenia or a mood disorder. Their index offence was more likely to be homicide, attempted murder, manslaughter or grievous bodily harm, while that of the patients with learning disability was more likely to be a sexual offence. A need for separate medium secure unit facilities for those of normal intelligence and those with learning disability is supported by differing psychiatric and behavioural requirements. (Int J Clin Pract 2000; 54(5): 300‐305)
CODEINE ANALGESIA IS DUE TO CODEINE‐6‐GLUCURONIDE, NOT MORPHINE
Authors: Vree TB , Van Dongen RTM , Koopman‐Kimenai PM
Published: April 2023

Eighty per cent of codeine is conjugated with glucuronic acid to codeine‐6‐glucuronide. Only 5% of the dose is O‐demethylated to morphine, which in turn is immediately glucuronidated at the 3‐ and 6‐ position and excreted renally. Based on the structural requirement of the opiate molecule for interaction with the μ‐receptor to result in analgesia, codeine‐6‐glucuronide in analogy to morphine‐6‐glucuronide must be the active constituent of codeine. Poor metabolisers of codeine, those who lack the CYP450 2D6 isoenzyme for the O‐demethylation to morphine, experience analgesia from codeine‐6‐glucuronide. Analgesia of codeine does not depend on the formation of morphine and the metaboliser phenotype. (Int J Clin Pract 2000; 54(6): 395‐398)
RUPTURED ECTOPIC PREGNANCY PRESENTING WITH HYPERGLYCAEMIA
Authors: Bhattacharyya A , Tymms DJ
Published: April 2023

A ruptured ectopic pregnancy is always an emergency. The key to successful treatment is early diagnosis, which is not always easy, mainly because typical presenting features may be absent. We report a case of a ruptured ectopic pregnancy that presented with a gastroenteritic illness together with hyperglycaemia, leading to an initial diagnosis of diabetes mellitus. The patient was treated successfully, however, once the correct diagnosis had been made. We conclude that a urine pregnancy test should be a routine procedure in all abdominal emergencies involving female patients of childbearing age, to avoid misdiagnosis or a delay in diagnosis. (Int J Clin Pract 2000; 54(6): 409‐410)
THE FOLEY CATHETER IN THE MANAGEMENT OF EPISTAXIS
Authors: Holland NJ , Sandhu GS , Ghufoor K , Frosh A
Published: April 2023

The Foley urinary catheter has been used in the management of epistaxis for many years, yet it has never been designed or licensed for this purpose. We performed a telephone questionnaire of senior house officers in 90 ENT departments in England and Wales. The aim was to determine how many departments used the Foley catheter for epistaxis management, whether licensed nasal balloon devices were available and if there had been any complications associated with their use. Eighty‐three (92%) ENT departments in the study used the Foley catheter for epistaxis management and 44 (49%) departments had licensed balloon devices available. Only 22% of ENT senior house officers questioned were aware that the Foley catheter was not licensed for use in the nose. Most complications associated with the use of nasal balloon devices appear to be due to Foley catheters.
CONSERVATIVE MANAGEMENT OF LOW BACK PAIN
Authors: Frank AO , De Souza LH
Published: April 2023

Back pain is prevalent worldwide, but back pain disability has reached epidemic proportions in many industrialised societies. Few patients have serious medical pathology or direct neurological involvement requiring surgery. Although the causes remain unclear, physical stress and its consequences on discs, facet joints and supporting soft tissues at work or leisure are important, sometimes aggravated by adverse psychosocial factors. Modern management emphasises the role of self‐care, beginning in primary care with the first episode. Without root compression, bed rest should not exceed 48 hours. Emphasis is on encouraging a rapid return to physical fitness and other activities, including employment, acknowledging that returning to a normal life may require working through pain. Medication facilitates this. No one should remain in pain beyond six weeks without being referred to a specialist service for a physical and psychosocial assessment by appropriately trained professionals and with consultant support for investigation, pain management and rehabilitation when needed.
RIFAMPICIN TEST IN THE DIAGNOSIS OF GILBERT'S SYNDROME
Authors: Erdil A , Kadayifci A , Ates Y , Bagci S , Uygun A , Dagalp K
Published: April 2023

Gilbert's syndrome (GS) is characterised by the existence of chronic mild unconjugated hyperbilirubinaemia. The value of rifampicin as a provocative test for the diagnosis of GS was evaluated and compared with a fasting test. Twenty‐two patients with GS, 15 patients with chronic liver disease and 20 healthy controls were included. Both rifampicin and fasting tests were applied to all subjects. In the fasting test, the subjects were given a 400 calorie/day diet for 24 hours; in the rifampicin test, unconjugated bilirubin levels was measured before and four hours after taking 600 mg of rifampicin. Both tests achieved a significant increase in mean unconjugated bilirubin levels in patients with GS but not in the controls. The sensitivity and specificity of a rifampicin test in the diagnosis of GS were comparable with the fasting test. However, both tests caused a significant increase in unconjugated bilirubin levels in nearly half the patients with chronic liver disease. A rifampicin test may be used in the diagnosis of suspected GS instead of a fasting test, as it is simpler and more practical. However, its specificity for GS is not sufficient, because it also causes an increase in unconjugated bilirubin levels in some patients with chronic liver disease.
THE COST‐EFFECTIVENESS OF DOXAZOSIN FOR THE TREATMENT OF HYPERTENSION IN TYPE II DIABETIC PATIENTS IN THE UK AND ITALY
Authors: Casciano J , Doyle J , Casciano R , Kopp Z , Marchant N , Bustacchini S , Arikian S , Kim R
Published: April 2023

The objective of this analysis was to assess the cost‐effectiveness of achieving ‘tight control’ versus ‘less tight control’ of blood pressure, as defined in the UK Prospective Diabetics Study 38, in type II diabetic patients in the UK and Italy. The effect of including doxazosin in a ‘tight control’ combination therapy was analysed. Given doxazosin's positive impact on lipid levels in addition to its antihypertensive effect, it is hypothesised that treatment including doxazosin will reduce the incidence of macrovascular complications. For each country, a Markov model was constructed to simulate macrovascular outcomes of patients on various drug combinations. Transitional probabilities were based on the risk rates presented in UKPDS 38. Risk rates were adjusted for the ageing of the cohort and the lipid‐lowering properties of doxazosin using Framingham risk equations. Incremental cost‐effectiveness ratios ranged from £2224 to £4867 (US$3225–7057) per life‐year saved for the UK and from L1.8–9.3 million (US$818–4159) per life‐year saved for Italy. Doxazosin is a cost‐effective agent when included in a combination therapy in the treatment of hypertension in the diabetic populations of the UK and Italy.
NECROSIS OF THE NASAL ALA AFTER IMPROPER TAPING OF A NASOGASTRIC TUBE
Authors: Lai PBS , Pang PCW , Chan SKC , Lau WY
Published: April 2023

Inserting a nasogastric tube during various abdominal procedures is a common manoeuvre to decompress the upper gastrointestinal tract. Improper placement and taping of the nasogastric tube results in excessive pulling on the nasal ala and subsequent pressure necrosis. This complication not only carries serious cosmetic morbidity, it is also preventable if a proper taping technique is employed.
CARDIAC SAFETY IN THE EUROPEAN STROKE PREVENTION STUDY 2 (ESPS2)
Authors: Diener H‐C , Darius H , Bertrand‐Hardy JM , Humphreys M
Published: April 2023

The second European Stroke Prevention Study investigated the prevention of stroke and/or death in 6602 patients with transient ischaemic attack or stroke with aspirin (25 mg b.d.), dipyridamole (400 mg b.d.), the combination of aspirin and dipyridamole or placebo. This post hoc analysis investigated cardiac events in patients with coronary heart disease or myocardial infarction (MI) at entry. Dipyridamole did not result in a higher number of cardiac events, e.g. angina pectoris, MI, or death from all causes. The combination of aspirin plus dipyridamole was superior to either drug alone in the prevention of stroke.
AN UNUSUAL CAUSE OF RENAL IMPAIRMENT: A LATEX GLOVE
Authors: Shah J , Jayawardene S , Das G
Published: April 2023

Male genital self‐mutilation is thought to be increasing in incidence and is underreported in the literature. We therefore have no clear and uniform treatment programmes. We present a case of genital self‐mutilation involving a 16‐year‐old male. The case highlights an important complication and the multidisciplinary approach to its management.
LYMPHOCYTIC HYPOPHYSITIS: SPONTANEOUS RESOLUTION ON MRI WITH PROGRESSION OF ENDOCRINE DEFECT
Authors: Krimholtz MJ , Thomas S , Bingham J , Powrie JK
Published: April 2023

Lymphocytic hypophysitis is an uncommon condition that typically occurs during the last trimester of pregnancy or in the postpartum period. Presentation is of an anterior pituitary mass with varying degrees of pituitary dysfunction. We present a case in which there was dramatic resolution of the pituitary lesion on sequential MRI scanning. Despite this apparent resolution, however, the patient continues to have significant pituitary dysfunction.
HAIR AS A BIOLOGICAL SPECIMEN FOR THERAPEUTIC DRUG MONITORING
Authors: Beumer JH , Bosman IJ , Maes RAA
Published: April 2023

To study the potential of hair as a biological specimen in therapeutic drug monitoring (TDM), a review of the correlation between hair concentration, blood levels, dose and therapeutic effects of various drugs is presented. The results indicate there is a fair correlation between plasma and hair for several medicines. Moreover, hair samples have the advantage of providing information of more prolonged drug intake, thus allowing a better evaluation of patient compliance. Using segmental hair analysis, only a single sample is necessary. We conclude that hair has potential as a biological specimen in TDM – at least as far as compliance is concerned and possibly as a longer term record of drug concentrations – and that correlation between hair concentration, blood levels and clinical efficacy should be investigated for all drugs where TDM is indicated.
GLATIRAMER ACETATE (COPAXONE)
Authors: Francis DA
Published: April 2023

Glatiramer acetate (Copaxone) is a novel preparation of synthetic peptides composed of four amino acids. Laboratory studies have shown that it prevents, or modifies, experimental allergic encephalomyelitis, the animal model for multiple sclerosis (MS), in several mammalian species. Its mode of action has not been fully elucidated but it is known to induce suppresser T‐cells, known to be deficient in MS, and competitively inhibits the effect of CNS myelin antigens, thought to be important in the pathogenesis of MS, through MHC blockade. Controlled clinical trials have shown it to improve the natural history of MS by reducing both the relapse rate and the resultant disability. GA shows similar efficacy to interferon‐beta (IFN‐β) but with fewer systemic side‐effects and appears to be better tolerated by patients. It has thus justified its place in the new era of disease‐modifying treatments for MS. While the evidence suggests GA should be considered as first‐line therapy in selected patients, its differing mechanism of action also gives patients and doctors the option of an alternative agent when the efficacy of IFN‐β is waning or side‐effects predominate.
DOES LOW TRI‐IODOTHYRONINE INDEPENDENTLY PREDICT MORTALITY IN ELDERLY HOSPITALISED PATIENTS?
Authors: Gupta A , Haboubi N , Thomas P
Published: April 2023

A fall in serum tri‐iodothyronine (T3) is the earliest abnormality in thyroid hormonal function tests in non‐thyroidal illnesses. Our study shows an association of low serum T3 with patient mortality in elderly hospitalised patients.
AXILLARY ARTERY PSEUDOANEURYSM
Authors: Nugud OO , Hedges AR
Published: April 2023

Axillary artery aneurysms are extremely rare. We report a case of an axillary artery aneurysm in a keen rugby player who had previous internal fixation of the shoulder for recurrent dislocation.
4. BREAST CANCER SCREENING
Authors: Michell MJ
Published: April 2023

Mammographic screening reduces breast cancer mortality by 24% in women aged ≥50 years. Women aged 50–53 are invited for their first screen in the National Health Service Breast Screening Programme (NHSBSP), thereafter at three‐year intervals until the age of 64. Two‐view mammography is offered at the first (prevalent) screening examination and one‐view for subsequent (incident) screens. The screening films are sorted into either ‘normal’ or ‘abnormal requiring further assessment’. Assessment is carried out by a specialist multidisciplinary team using the triple approach: clinical examination, imaging and, where appropriate, needle biopsy. Imaging is planned according to the mammographic abnormality – paddle compression view to assess parenchymal distortion, magnification view to assess microcalcification. After confirmation of a suspicious abnormality, needle biopsy is performed. Results of triple assessment are considered together by the multidisciplinary team and further management is planned. There are four likely outcomes: benign/normal, confirmed breast cancer, suspicious but needing diagnostic surgical excision, and diagnostic uncertainty needing early recall for screening.
SENSORINEURAL HEARING LOSS IN LINEAR IgA DISEASE
Authors: Hari CK , Hanif J , Frosh A
Published: April 2023

A 23‐year‐old female with progressive sensorineural hearing loss developed widespread blistering eruptions while under evaluation for the hearing loss. The lesions showed findings characteristic of linear IgA disease (LAD) on histochemical studies. Linear IgA disease is a dapsone responsive autoimmune subepidermal blistering disease characterised by linear IgA deposits in the basement membrane zone. The complete spectrum of this systemic disease is still not clear and this is the first report of association between LAD and sensorineural deafness.
THE NATURAL HISTORY AND ASSOCIATIONS OF SLEEP DISORDERED BREATHING IN FIRST EVER STROKE
Authors: Lawrence E , Dundas R , Higgens S , Howard R , Rudd A , Wolfe C , Williams A
Published: April 2023

Although the prevalence of sleep‐disordered breathing (SDB) in patients following stroke has been found to be high, there are few data about whether these changes persist in the months that follow stroke. The present study aims to confirm the prevalence of SDB following first ever stroke, to investigate an association between SDB and subtype of stroke and to determine the change in SDB three months following a first ever stroke.
5. THE SURGICAL MANAGEMENT OF EARLY BREAST CANCER
Authors: Young AE
Published: April 2023

Definitive surgical treatment should never be undertaken without a histological confirmation of the diagnosis. For operable disease primary treatment is normally breast‐conserving surgery or mastectomy, in association with axillary surgery. Patients with larger technically operable tumours may be treated with primary chemotherapy to try to shrink the tumour so that less radical surgery can be undertaken. The objective of surgery is clearance of local and regional disease with a margin of clear tissue, and to achieve an acceptable cosmetic outcome. Clinical assessment of the axilla is unreliable and because of the prognostic significance of the axillary nodal status this has to be determined histologically. Patients with single tumours ≤4 cm are suitable for conservation therapy but this will depend on breast size. After excision with clear margins and subsequent radiotherapy the breast recurrence rate should not exceed 5–10% at 10 years. Patients wiill require mastectomy because of disease extent, breast size, or for personal reasons. The usual operation is a total mastectomy with axillary clearance but small islands of breast tissue may persist subcutaneously as potential sites for future disease. Good breast‐conserving surgery is invariably better than reconstruction but, in the event of a mastectomy, reconstruction is offered either as an immediate or a delayed procedure. Complications of any form of surgery include haematoma, wound sepsis and wound flap necrosis. Specific complications are collections of serous fluid in the axilla or in the wound itself (seroma), shoulder stiffness and cording caused by distal thrombosis of lymphatics or veins after axillary dissection. The intercostobrachial nerve is often divided during surgery, causing numbness of the inner upper arm. Some degree of lymphoedema of the arm occurs in 10–15% of patients treated with axillary surgery. It is usually mild and may become rare as more patients have sentinel node biopsies.
DEVELOPMENT OF A NURSE‐LED CHRONIC PAIN CLINIC IN UK PRIMARY CARE
Authors: Glasgow ACA , Glasgow JA
Published: April 2023

We describe the development of an innovative, nurse‐led chronic pain clinic in primary care. Benefit of the structured intervention was seen in terms of overall patient pain (as measured by the short form McGill‐Melzack pain scale) with no overall impact on drug costs. A significant proportion (54%) of patients taking non‐steroidal anti‐inflammatory drugs were deemed to be at risk of gastropathy and in need of gastroprotection as defined by the clinic protocol. Areas worthy of further study are discussed.
A SYSTEMATIC REVIEW OF THE EVIDENCE FOR RAPID ACCESS CHEST PAIN CLINICS
Authors: McManus RJ , Mant J , Davies MK , Davis RC , Deeks JJ , Oakes RAL , Hobbs FDR
Published: April 2023

To determine the impact of rapid access chest pain clinics (RACPC) on patient management, a systematic search (1966–2000) was performed of electronic databases, recent conference abstracts, citations of all identified studies, and by contact with other researchers. Studies of any design were included. Assessment of eligibility, methodological quality of studies and data abstraction was conducted independently by two reviewers. Outcome measures were sought in terms of admission rate of patients without acute coronary syndrome detection rate of acute coronary syndrome unrecognised by the GR timing of specialist assessment of patients with stable angina and speed and accuracy of detection of those with non‐cardiac chest pain. Nine relevant studies were found, but all had methodological flaws when considered as evaluative studies. All clinics described reviewed patients within 24 hours of referral. Only three studies made comparisons with control groups, none of which were randomised, and a further three provided follow‐up data only. Limited data were found for all four outcome measures, indicating possible benefits of RACPCs. However, all findings could be explained by potential biases in the original studies. In conclusion, the evidence base for the introduction of rapid access chest pain clinics is poor. The introduction of these clinics should include a randomised prospective evaluation of their worth.
ALZHEIMER'S DISEASE AND VASCULAR FACTORS: FACTS AND THEORIES
Authors: Pansari K , Gupta A , Thomas P
Published: April 2023

Although Alzheimer s disease is classified as a neurodegenerative dementia, in Alzheimer s dementia there is increasing evidence of an association with vascular risk factors and vascular pathology. These observations are supported by epidemiological and pathological studies. Vascular factors may play a significant role in the pathogenesis of Alzheimer s dementia. Further research is needed to explore this relationship. Modification of vascular risk factors could make a significant impact towards prevention and treatment of Alzheimer s disease, which is a distressing and prevalent condition in the community. This article considers the relationship of these vascular risk factors and potential mechanisms associated with the aetiopathogenesis of Alzheimer s dementia.
USE OF INTERNET MEDICAL WEBSITES AND NHS DIRECT BY NEUROLOGY OUTPATIENTS BEFORE CONSULTATION
Authors: Larner AJ
Published: April 2023

With increasing personal access to the internet, and the mass of medical information available in cyberspace, many patients may access information before an outpatient consultation. Since this information may shape individual health beliefs and expectations, yet is acknowledged to be of very variable quality, it may be important for practitioners to know about their patients' self‐directed findings. Medical information may also be gained from the NHS Direct telephone helpline. This study measured the frequency of use of the internet and of NHS Direct by questioning consecutive new referrals attending general neurology outpatient clinics over a three‐month period. A comparison was made between patients' searches and their final diagnosis. Patients' views on the use of the information received were sought.
INTRACARDIAC THROMBUS TRAVERSING A PATENT FORAMEN OVALE: IMPENDING PARADOXICAL EMBOLISM DEMONSTRATED BY TRANSOESOPHAGEAL ECHOCARDIOGRAPHY
Authors: Rinaldi CA , Stewart AJ , Blauth CI
Published: April 2023

Paradoxical embolism is a rare but potentially catastrophic complication of deep venous thromboses and pulmonary embolism. We describe a patient in whom transoesophageal echocardiography demonstrated a large clot traversing the atrial septum which was successfully removed by surgery.
INCORRECTLY ALIGNED FLY LEADS INSIDE THE ECG MACHINE CAUSING ‘ISCHAEMIC’ CHANGES
Authors: Butler J , Pooviah PK , Joglekar M , Hasan M
Published: April 2023

We describe a case in which a young woman was inappropriately diagnosed as having ischaemic heart disease after presenting with exertional neck pain and an abnormal ECG. Diffuse Q‐wave and T‐wave inversion changes were later attributed to erroneous placement of fly leads inside the ECG machine at a recent service. Clinicians should be aware of this uncommon cause of incorrect lead connections, which can result in unnecessary investigations and treatment.
INFILTRATING FIBROMATOSIS OF THE BREAST: A POTENTIAL PITFALL
Authors: Kouriefs C , Leris ACA , Mokbel K , Wells C , Carpenter R
Published: April 2023

Mammary fibromatosis is a rare condition. It presents a big dilemma for the clinician, because it mimics breast cancer clinically, radiologically and sometimes cytologically. We report a case of fibromatosis of the breast and highlight the diagnostic difficulties and management.