bluuebunny/crossref_metadata_2025 huggingface dataset:
CONGENITAL VALLECULAR CYST: A CAUSE OF FAILURE TO THRIVE
Authors: Oluwole M
Published: April 2023

SUMMARY Congenital vallecular cysts are fairly uncommon, but can lead to death. They may present as failure to thrive. This case emphasises the value of plain radiographs of the neck. Direct laryngoscopy is mandatory to confirm diagnosis and ablate the lesion satisfactorily. Laryngomalacia should be a diagnosis of exclusion. Adequate marsupialisation is necessary to prevent recurrence.
LIGATION OF THE SUPERIOR MESENTERIC VEIN: A CAUTIONARY TALE
Authors: Nydahl S
Published: April 2023

SUMMARY Acute interruption of flow in the superior mesenteric vein can, in most instances, be tolerated. In the event of compromised venous collateral circulation, however, continuity of the main venous flow must be restored.
ACUTE EOSINOPHILIC PNEUMONIA ACCOMPANIED BY GUILLAIN‐BARRÉ SYNDROME
Authors: Ishiura Y , Tsuji H , Takeda S , Takazakura K , Fujimura M , Matsuda T , Kitagawa M
Published: April 2023

SUMMARY A 74‐year‐old man presented with chest pain, dry cough, progressive respiratory distress and infiltrative lung shadow. Diagnosis of acute eosinophilic pneumonia was confirmed by histological examination as well as clinical features. On the 8th day post‐admission, he developed progressive generalised muscle weakness that required mechanical ventilation. Clinical investigations revealed features concurring with the accepted diagnostic criteria for Guillain‐Barré syndrome. Although precise aetiologies for the disorders suffered by this case were unknown, a common cause of allergic nature was speculated. This is the first report of acute eosinophilic pneumonia accompanied by Guillain‐Barré syndrome.
COMPARATIVE EFFICACY AND TOLERABILITY OF TWO DICLOFENAC FORMULATIONS IN THE TREATMENT OF PAINFUL OSTEOARTHRITIS
Authors: Bakshi R
Published: April 2023

SUMMARY The efficacy and tolerability of a new resinate formulation of diclofenac 75mg taken once or twice daily were compared with that of conventional enteric‐coated diclofenac sodium 50mg tablets given two or three times daily in a double‐blind, randomised, between‐patient, 12‐week trial in 216 adult patients suffering from painful osteoarthritis of the hip and/or knee. Similar and clinically significant reductions in the mean intensity scores of pain at rest or on activity were observed after treatment with either formulation. Global evaluations showed the overall response rate to range between 60% and 75%. A significant analgesic effect was obtained within two weeks of treatment with 150mg diclofenac daily; this improvement was maintained on reduction of the dosage to 75‐100mg over the next ten weeks. One or more drug‐related adverse events, predominantly gastrointestinal adverse events, were reported by 40% and 38% of patients in the diclofenac resinate and diclofenac sodium groups, respectively.
CLINICAL CHALLENGE — AN EXPERIENCE OF SPONTANEOUS TRANSMURAL RUPTURE OF THE OESOPHAGUS IN TAIWAN
Authors: Wu C‐S , Chang K‐Y , Kuo Y‐C , Chiu C‐T , Liaw S‐J , Liu H‐P
Published: April 2023

SUMMARY In Taiwan, spontaneous oesophageal rupture is uncommon but the outcome is often lethal because of failure to make an early diagnosis. We have analysed clinical data, management and the risk factors that affect mortality for a consecutive series of 11 patients who had spontaneous oesophageal perforation between 1983 and 1994. The primary symptom was chest or abdominal pain, which was present in 100% of patients; 91% of patients had abnormal chest x‐ray (63% pleural effusion, 46% pneumomediastinum, 37% subcutaneous emphysema). In our series of patients the lower thoracic area was the most common location of the perforation (80% of patients. There were no statistically significant differences in mortality due to age, underlying disease, perforation size, location or surgical methods. A poor prognosis seems to be correlated with the time elapsed between the perforation and treatment (especially if >72 hours) (p<0.05), respiratory failure (p<0.05), and heavy contamination of the mediastinum (p<0.05). The clinical findings depend on the location and time of perforation. History, chest x‐ray and oesophagogram are the most useful diagnostic tools. Early diagnosis and treatment are mandatory for these patients.
EFFICACY OF RAMIPRIL VERSUS ENALAPRIL IN PATIENTS WITH MILD TO MODERATE ESSENTIAL HYPERTENSION
Authors: Yasky J , Verho M , Erasmus TP , Luus HG , Angela M , Grandin L , Akbary MA , Rangoonwala B
Published: April 2023

SUMMARY This double‐blind, randomised, cross‐over study investigated the antihypertensive efficacy of ramipril and enalapril was completed by 30 patients with mild‐to‐moderate essential hypertension. After a four‐week placebo run‐in phase, the patients received either 2.5mg ramipril or 10mg enalapril once daily for four weeks. The dosages were increased to 5mg ramipril and 20mg enalapril for a further four weeks. After a placebo washout phase of four weeks, the patients were crossed over to the alternative treatment. The decrease in average 24‐hour ambulatory diastolic blood pressure from week 0 to week 8 was 1.6mmHg greater with ramipril than enalapril (90% confidence interval 0.6‐2.7mmHg). The corresponding reduction in for systolic blood pressure was also greater with ramipril than enalapril by 2.4mmHg (90% confidence interval: 0.5‐4.2mmHg). For the difference in the drop of 24‐hour ambulatory diastolic blood pressure between ramipril and enalapril the lower level of the 90% confidence interval (CI) is above the clinically relevant difference of ‐3mmHg. This is an indication that ramipril (2.5 and 5mg dose) is at least as effective as enalapril (10 and 20mg dose) in decreasing blood pressure in patients with mild‐to‐moderate essential hypertension. The duration of adequate antihypertensive effect was relatively long for both ramipril and enalapril; however, ramipril tended to have a more prolonged antihypertensive effect. Ramipril had a higher diastolic and systolic trough/peak ratio than enalapril, resulting in a more uniform antihypertensive effect over the 24‐hour treatment period. Both ramipril and enalapril were well tolerated and the two treatment groups had similar safety profiles.
AUTOIMMUNE POLYGLANDULAR SYNDROME AND PRIMARY BILIARY CIRRHOSIS
Authors: Ko GTC , Szeto CC , Yeung VTF , Chow CC , Chan H , Cockram CS
Published: April 2023

SUMMARY Liver involvement in autoimmune polyglandular syndrome (APS) in the form of chronic active hepatitis has been well described. However, to our knowledge, primary biliary cirrhosis in APS has not been reported. Here we report the case of a 27‐year‐old man who presented with classical insulin‐dependent diabetes mellitus and subsequently developed Hashimoto's thyroiditis, hypogonadism, and primary biliary cirrhosis. The latter diagnosis was confirmed by a cholestatic pattern of liver enzymes, positive anti‐mitochondrial antibody, normal cholangiogram, and characteristic liver biopsy findings. Primary biliary cirrhosis should probably be regarded as a possible, though uncommon, component of APS.
A CLINICAL COMPARISON OF INTRANASAL BUDESONIDE WITH BECLOMETHASONE DIPROPIONATE FOR PERENNIAL NON‐ALLERGIC RHINITIS: A 12 MONTH STUDY
Authors: Synnerstad B , Lindqvist N
Published: April 2023

SUMMARY To evaluate possible differences in efficacy and safety between budesonide and beclomethasone dipropionate when used intranasally in the treatment of perennial non‐allergic rhinitis, a 12‐month open study was undertaken in 24 patients suffering from perennial non‐allergic rhinitis. Both drugs were applied intranasally from pressurised aerosols at a daily dosage of 400 μg. On entry and at visits after 1, 2, 4, 6, 9 and 12 months, rhinoscopy was performed and the severity of nasal symptoms graded according to a four‐point rating scale. All nasal symptoms were reduced from baseline during the treatment period in both groups. Tachyphylaxis was not observed. No clinically significant changes in haematology or blood chemistry parameters were observed in either group, and analysis of plasma cortisol levels revealed no influence of either drug on the hypothalamic‐pituitary‐adrenal axis. Local adverse reactions were uncommon and mild. Budesonide and beclomethasone dipropionate used intranasally at 400 μg per day were found to be safe, and budesonide was found to have a significantly higher (p<0.05) efficacy than beclomethasone dipropionate in alleviating symptoms of perennial non‐allergic rhinitis.
A STUDY TO INVESTIGATE THE COMPARATIVE EFFICACY AND TOLERABILITY OF NISOLDIPINE COAT‐CORE AND ATENOLOL IN THE TREATMENT OF MILD TO MODERATE HYPERTENSION
Authors: Murray TS
Published: April 2023

SUMMARY The efficacy and tolerability of nisoldipine coat‐core (nisoldipine CC 10, 20, 40 mg) and atenolol (50, 100 mg) were compared in 230 patients with mild to moderate essential hypertension. Treatment was titrated at two‐weekly intervals as necessary to control blood pressure. After eight weeks of active therapy, the two treatments proved to be equally effective in reducing sitting diastolic blood pressure (13.7 ± 8.3 mmHg and 14.2 ± 9.1 mmHg for nisoldipine CC and atenolol, respectively), and provided equivalent reduction in systolic blood pressure and identical response rates (69%). Heart rate was reduced from baseline in the atenolol group but remained unchanged in the nisoldipine CC group (p < 0.001 difference between the two groups). Both nisoldipine CC and atenolol were well tolerated and had no detectable metabolic effects. Adverse events were minor and of the type commonly associated with drugs of these classes.
MODERN LINES OF MANAGEMENT OF ECTOPIC PREGNANCY
Authors: Dimitry ES , Atalla RK
Published: April 2023

The recent increase in the incidence of ectopic pregnancies was associated with rapid improvement in the diagnostic and therapeutic techniques. Quantitative serum B‐HCG radioimmunoassay and high resolution vaginal ultrasonography have facilitated early diagnosis of ectopic pregnancy allowing a more conservative approach to patient management. Different conservative surgical and medical lines of management recently developed were associated with and increased chance of subsequent intrauterine pregnancy with no increase in the incidence of repeat ectopic pregnancy. Outpatient systemic medical treatment seems to be a preferred alternative to conservative surgery. In selected cases, it is associated with a lower complication rate and promising result for fertility. (Br J Clin Pract 1996; 50(7): 376‐380.)
LIMITATIONS OF TYPHOID VACCINATION FOR TRAVELLERS
Authors: Stephen J , Mara N , Nathwani D
Published: April 2023

SUMMARY Around one‐third of travellers to endemic areas receive pre‐travel typhoid vaccination, increasingly with the new parenteral vaccination Typhim Vi (Mérieux). More than 200 cases of Salmonella typhi and S. paratyphi infection are imported into the UK each year. Despite the widespread use of immunisation, non‐specialist clinicians and the travelling public do not appear to fully appreciate the limitations of currently available vaccination. These limitations are not adequately highlighted in either the Green Book of Immunisation against Infectious Diseases (HMSO, 1992) or the new handbook Health Information for Overseas Travel (HMSO, 1995) which are important sources of reference for clinicians and practice nurses. This may delay consideration of diagnosis and presentation for treatment in immunised travellers.
NOCTURNAL 8mg DEXAMETHASONE SUPPRESSION TEST: A PRACTICAL AND ACCURATE TEST FOR IDENTIFICATION OF THE CAUSE OF ENDOGENOUS CUSHING'S SYNDROME
Authors: Sriussadaporn S , Ploybutr S , Peerapatdit T , Plengvidhya N , Nitiyanant W , Vannasaeng S , Vichayanrat A
Published: April 2023

SUMMARY The efficacy of a nocturnal 8mg dexamethasone suppression test (nocturnal DST) was compared with that of the standard high‐dose dexamethasone suppression test (standard DST) in identifying the cause of endogenous Cushing's syndrome in 10 proven cases with Cushing's disease, 20 with adrenal tumours, and one with ectopic ACTH syndrome. The nocturnal test compared serum cortisol concentration at 8am before and after administration of a single dose of 8mg dexamethasone at 11pm. Suppression of serum cortisol level to <50% of the baseline value indicated a diagnosis of Cushing's disease, while a lack of suppression below that limit indicated one of the other two causes of Cushing's syndrome: glucocorticoid‐secreting adrenal tumour or ectopic ACTH syndrome. The nocturnal DST had a sensitivity of 90%, a specificity of 100%, an accuracy of 96.8%, a positive predictive value of 100%, and a negative predictive value of 95.5%. These values are comparable to the efficacy of the standard DST in distinguishing Cushing's disease from glucocorticoid‐secreting adrenocortical tumour or ectopic ACTH syndrome. Furthermore, this rapid test does not require hospitalisation or urine collection like the standard DST. The nocturnal 8mg dexamethasone suppression test is practical, fairly reliable, and an effective alternative with which to identify the cause of endogenous Cushing's syndrome.
PATIENT PERCEPTION OF THE DISKUS INHALER: A COMPARISON WITH THE TURBUHALER INHALER
Authors: Schlaeppi M , Edwards K , Fuller RW , Sharma R
Published: April 2023

SUMMARYAsthmatic patients who were regular and experienced users of the metered‐dose inhaler (MDI) but with no history of powder inhaler use were interviewed by questionnaire. Most (71%) of the 159 adults recruited had suffered from asthma for more than five years; 89% had used an MDI for more than one year. In all, 153 (97%) found their current MDI easy or very easy to handle. Effectiveness in delivering the drug and ease of operation were the two features of the device they were most satisfied with. The two features ‘of an ideal inhaler’ rated most highly were the presence of a dose counter and ease of use during an attack (58% and 72% of respondents, respectively). Other important features included hygiene, sensation that a dose had been taken, and small size. When attitudes towards the Diskus inhaler and the Turbuhaler inhaler were compared, 108 (68 %) would have been quite or very happy to have a Diskus inhaler prescribed for them, and 79 (50%) a Turbuhaler inhaler. The Diskus inhaler scored significantly better than the Turbuhaler inhaler for knowing how many doses were left, the presence of an attached cover, attractiveness (p<0.001), hygiene, shape, weight (p=0.001), and perceived ease of use (p=0.002). The Turbuhaler inhaler scored significantly better in terms of size (p<0.001). Overall, the Diskus inhaler was preferred by 104 of 159 patients (p<0.001), with perceived ease of use, the dose counter, and shape cited as the main reasons for preference.
DYSPAREUNIA IN UNDIAGNOSED SJOGREN'S SYNDROME
Authors: Tayal SC , Watson PG
Published: April 2023

SUMMARY A case of superficial dyspareunia in a 46‐year‐old women is described. Clinical suspicion, examination and investigations supported a diagnosis of Sjogren's syndrome.
BOUVERET'S SYNDROME (GALLSTONE ILEUS) — A MINEFIELD
Authors: Kosorok P
Published: April 2023

SUMMARY Gallstone ileus is an uncommon cause of intestinal obstruction. Diagnosis may be delayed or even missed. This case history illustrates some characteristics of gallstone ileus that can complicate its subsequent management.
INCORRECT DIAGNOSIS OF THYROID DISEASE BY JUNIOR DOCTORS
Authors: Shotliff K , Blight A , Mukherjee D
Published: April 2023

SUMMARY Thyroid function tests (TFTs) are commonly performed on elderly patients admitted to hospital. Several diseases and commonly used drugs may alter thyroid function test results. We assessed the knowledge of such interactions among 50 junior doctors in our departments: 60% were unaware that (in our laboratory) the normal range for TFTs is the same in those above 65 years as in those below; 72% correctly noted the effect of an acute illness, while only 48% correctly noted the effect of a chronic illness on test results; 72% were well aware of common drug effects such as those of the oral contraceptive pill, but only 22% and 42% knew of the potentially more important interactions in the elderly with the salicylates and phenytoin respectively. Thyroid screening in elderly people is important. The knowledge of interactions between drugs, disease states and the normal range of biochemical assays used in routine thyroid screening needs to be improved if thyroid function tests are to be interpreted appropriately.
INFLUENCE OF TEACHING ON THE TRIAGE OF MULTIPLE INJURY PATIENTS
Authors: O'Sullivan ST , Stuart RC , O'Connor M , Hehir DJ , Brady MP
Published: April 2023

SUMMARY Attempts to improve the standard of early trauma management through the training and instruction of medical personnel have had variable results. Knowledge of trauma care is inadequate among all grades of medical and paramedical staff, and not much improvement has been made by the availability of instruction courses in trauma management. Staff most likely to attend such courses are seemingly already more proficient than staff who choose not to. To achieve maximum benefit from future courses, therefore, we believe attendance should be compulsory for all personnel involved in acute trauma care.
BENIGN GASTROCOLIC FISTULA ASSOCIATED WITH PERITONITIS
Authors: Parks RW
Published: April 2023

SUMMARY Gastrocolic fistula is most often related to malignancy or previous gastric surgery. It is an uncommon complication of benign gastric ulceration in patients who have not had a previous operation. Benign gastrocolic fistula associated with peritonitis is extremely rare — this case is only the fourth ever reported. The patient presented with an acute abdomen, and subsequent investigations demonstrated a gastrocolic fistula of benign aetiology.
OPEN ACCESS FUNDHOLDING ENDOSCOPY IN THE PRIVATE SECTOR
Authors: Martin J , Arlett P , Holdstock G
Published: April 2023

SUMMARY We conducted a comparative study of 150 patients referred for endoscopy to an NHS hospital and 150 patients referred to an open access scheme in the private sector for fundholding GPs. The concept of consultoscopy, whereby a consultant gastroenterologist gives an opinion at the same visit as the endoscopy is performed, is introduced. Results showed a similar number of normal studies (about 40%) were performed in each group, although the number of examinations showing serious pathology was significantly higher in the fundholding group (p<0.01). Patients seen in the fundholding scheme had less sedation, required fewer outpatient appointments, and the GPs were given more advice on further management than those seen in the non‐fundholding group. We conclude that open access endoscopy in the private sector is a workable option and may result in work being transferred from NHS hospitals to the private sector unless NHS hospitals review their working practices. The concept of consultoscopy is a useful development on traditional open access systems.
VARIABILITY IN POST‐OPERATIVE FLUID AND ELECTROLYTE PRESCRIPTION
Authors: Stoneham MD , Hill EL
Published: April 2023

SUMMARY A four‐week retrospective survey of intravenous fluid and electrolyte prescriptions on postoperative surgical patients revealed wide variability in fluid and electrolyte prescription by medical staff. Median volume of intravenous fluid prescribed was 3000 ml (range 1667‐5000). Total sodium prescribed varied from 0 to 770, median 242 mmol/day), with potassium infrequently added (range 0‐81, median 0 mmol/day). Patients undergoing emergency surgery were prescribed more sodium than those undergoing routine procedures (p=0.0403); 0.9% saline was the most common fluid prescribed overall. There was poor correlation between serum electrolyte values and the amounts of electrolytes prescribed. Intravenous fluid prescription should take into account the post‐operative stress response which reduces sodium requirements (unless there are other concomitant losses) and increases urinary potassium losses. A suitable post‐operative ‘maintenance’ fluid is 4% dextrose/0.18% saline with 1‐2 g potassium chloride, particularly if serum electrolyte levels are not known. Other fluid losses should be replaced with equivalent fluids.
ACUTE ADMISSIONS WITH ATRIAL FIBRILLATION IN A BRITISH MULTIRACIAL HOSPITAL POPULATION
Authors: Zarifis J , Beevers G , Lip GYH
Published: April 2023

SUMMARY To assess the clinical characteristics and management of patients with atrial fibrillation (AF), we performed a prospective survey of all acute medical admissions over six months to our hospital. Of 7451 such admissions, 245 had AF (110 male, 135 female; mean age 74.4 years). Of these, 213 were Caucasian, 10 black/Afro‐Caribbean and 22 Asian. Complete data were available for 185 patients. Of these, 82 had newly diagnosed AF, 83 had previous chronic AF and 20 had paroxysmal AF. The main presenting features was dyspnoea, stroke and syncope. A history of ischaemic heart disease was present in 64, heart failure in 46, hypertension in 51 and rheumatic heart disease in 13, while 31 had a previous stroke. Chest X‐ray showed cardiomegaly and pulmonary oedema in 121 patients, but was normal in 28. Echocardiography showed poor cardiac function in eight patients and enlarged left atria in five. Only 28% of those with previously diagnosed AF were on anticoagulation. Of the newly diagnosed patients, only 18% were started on anticoagulants. Cardioversion was attempted or planned in only 6%. The primary diagnosis on discharge was heart failure in 45, stroke in 24 and myocardial infarction in 12. AF remains a common arrhythmia among acute medical admissions and is commonly associated with heart failure and a high mortality. There is still a reluctance to start anticoagulant therapy or to perform cardioversion in such patients.
INTERFERONS IN ONCOLOGY
Authors: Woll PJ , Pettengell R
Published: April 2023

SUMMARY The interferons are natural glycoproteins secreted in response to various stimuli, including viral infection. They have antiviral, antiproliferative and immunomodulatory effects on different target cell populations. Since recombinant human interferons have become available, they have been tested in a wide range of malignancies. They are well established in the treatment of hairy cell leukaemia, chronic myelogenous leukaemia and multiple myeloma. Although they have documented activity against lymphoma, melanoma, renal cell cancer and carcinoid tumours, their role in the treatment of these tumours is less clear. In the common solid tumours, such as lung cancer and colorectal cancer, the use of interferons remains experimental. Here we will summarise their practice applications in oncology, using randomised studies where available to establish their place in multi‐modality treatment. We will not discuss their use as antiviral or immunomodulating agents in viral and autoimmune diseases, multiple sclerosis or after organ transplantation.
INFLAMMATORY FIBROID POLYP OF PROXIMAL ILEUM CAUSING RECURRENT INTUSSUSCEPTION
Authors: Bandyopadhyay PK , Ishaq N , Malik AK , Mahroos S
Published: April 2023

SUMMARY A 64‐year‐old female presented with episodes of small bowel obstruction. Ultrasound and barium meal showed a polypoidal lesion in the proximal segment of small bowel. The patient underwent emergency surgery because of signs of impending acute intestinal obstruction. Pathology showed characteristic features of an inflammatory fibroid polyp (IFP) which is an important though rare benign cause of small bowel obstruction. We document clinical and pathological aspects of this case.
THE ASSOCIATION BETWEEN BLOOD COAGULATION MARKERS, ATHEROTHROMBOSIS AND DEMENTIA
Authors: Gupta A , Pansari K
Published: April 2023

Abnormalities of coagulation and the fibrinolytic system leading to a hypercoagulable state could lead to accelerated atherogenesis. The abnormalities of haemostasis and resulting ischaemic cerebrovascular disease may contribute to cognitive decline in the elderly. There is increasing evidence in the literature of haemostatic abnormalities not only in vascular dementia but also in patients with Alzheimer's dementia. Among the serum markers of hypercoagulability leading to thrombosis and dementia, serum fibrinogen has been one of the factors most commonly studied. Modification and control of these serum markers of hypercoagulability offer an exciting approach to the control of dementia in the community. This article explores the association between serum markers of hypercoagulability, associated atherothrombosis and the risk of dementia.
CHRONIC LOBAR CONSOLIDATION
Authors: Jayakrishnan B , Abul AT , Behbehani NA
Published: April 2023

Lobar consolidation in a chest X‐ray is often thought to be due to infection. We present the problem of a 66‐year‐old female with low grade non‐Hodgkin's lymphoma of the mucosa associated lymphoid tissue (MALT) type who had features of lobar consolidation that persisted for years. The different causes, both infectious and non‐infectious, of this kind of presentation are discussed.
OPEN ACCESS ECHOCARDIOGRAPHY: A PROSPECTIVE AUDIT OF REFERRAL PATTERNS FROM PRIMARY CARE
Authors: Williams SG , Currie P , Silas JH
Published: April 2023

Following recently published recommendations and guidelines, a prospective audit of 222 consecutive patients referred for open access echocardiography was conducted over a period of three months in a large district general hospital in the UK. Our study demonstrated the waiting time for an open access echocardiogram to be shorter than the waiting time for the outpatient clinic, which allowed identification of clinically significant cardiac disease sooner, leading to early advice on patient management. Specialist referral was avoided by the inclusion of management comments by a cardiologist in the technical echocardiogram report. We showed that open access echocardiography for detection of left ventricular systolic function, should be performed only if the ECG is abnormal, confirming previous reports. ECG interpretation in primary care is unreliable. In view of limited resources, hospitals should vigorously screen referrals for open access echocardiography.
A SIMPLE QUESTIONNAIRE TO DETECT HYPERMOBILITY: AN ADJUNCT TO THE ASSESSMENT OF PATIENTS WITH DIFFUSE MUSCULOSKELETAL PAIN
Authors: Hakim AJ , Grahame R
Published: April 2023

The aim of the study was to develop a simple and reproducible self‐reporting questionnaire that identifies individuals with hypermobility. Two hundred and twelve consecutive hypermobile female new attendees to the hypermobility clinic at two London teaching hospitals and a random selection of 57 healthy volunteers completed a 10‐part questionnaire. Questions were selected from clinical experience (RG), and assessed musculoskeletal symptoms and past and present physical agility. Of the 212 cases, 30 were hypermobile with no other underlying disorder and 182 fulfilled the 1998 Brighton criteria for benign joint hypermobility syndrome (BJHS). Odds ratios for the presence of hypermobility were calculated for each question. Six questions were found to be significant and the model of ‘best fit’ for sensitivity and specificity contained five of these. To demonstrate the reproducibility of the five‐part questionnaire a second cohort of 170 hypermobile cases with BJHS and 50 controls was surveyed. Analysis demonstrated that a positive answer to any two questions in the five‐part questionnaire gave the highest combined sensitivity and specificity for detecting hypermobility. The sensitivity and specificity was 84% and 89% respectively in the first cohort and reproduced with values of 84% and 80% in the second cohort. Overall the questionnaire correctly identified 84% of all cases and controls. This simple and reproducible questionnaire for detecting hypermobility could be of particular use as an adjunct in the clinical assessment of chronic, diffuse pain syndromes where hypermobility is often missed yet is potentially treatable.
AN OPEN‐LABEL, MULTICENTRE STUDY TO ASSESS THE SAFETY AND EFFICACY OF A NOVEL REFLUX SUPPRESSANT (GAVISCON ADVANCE®) IN THE TREATMENT OF HEARTBURN DURING PREGNANCY
Authors: Lindow SW , Regnéll P , Sykes J , Little S
Published: April 2023

This study investigated the efficacy and safety of a novel reflux suppressant, Gaviscon Advance®, in the treatment of heartburn during pregnancy. The study was an open‐label, multicentre, phase IV study in general practice and antenatal clinics in the UK and Republic of South Africa. Pregnant women (≤38 weeks gestation; n=150) aged 18–40 years suffering from heartburn were instructed to take Gaviscon Advance 5–10 ml, as required, to relieve symptoms. The main outcome measures were the efficacy rating of the study medication by the investigator and women after four weeks using a five‐point efficacy scale. After four weeks the investigators' and women's rating of efficacy was ‘very good’ or ‘good’ in 88% and 90% of women, respectively. Most women (57%, n=83) reported symptom relief within 10 minutes. Thus Gaviscon Advance effectively and rapidly treats heartburn during pregnancy. Its use during pregnancy presents no known significant safety concerns for mother or child.
ACUTE RHABDOMYOLYSIS DUE TO PROLONGED EXPOSURE TO THE COLD
Authors: Korantzopoulos P , Papaioannides D , Sinapidis D , Kolios P
Published: April 2023

Rhabdomyolysis represents an acute skeletal muscle injury and may be accompanied by acute renal failure due to myoglobinuria. This disorder has many potential causes. We describe the case of a 75‐year‐old man who developed rhabdomyolysis after prolonged exposure to cold but without associated hypothermia. This unusual case highlights that an appropriate investigation for rhabdomyolysis such as serum CK measurement should be performed in patients presenting with a history of prolonged exposure to cold, even in the absence of an obvious precipitating factor.
COMBINATION FIB RATE‐STATIN THERAPY FOR THE TREATMENT OF SEVERE HYPERTRIGLYCERIDAEMIA IN RENAL DISEASE
Authors: Badawy O , Wierzbicki AS , Hilton R
Published: April 2023

This case report describes the treatment of a patient with end‐stage renal disease on peritoneal dialysis who presented with triglycerides of 35 mmol/l, cholesterol of 14 mmol/l and visible chylomicronaemia. She was only partially responsive to statin and fibrate monotherapy, so was treated with fibrate‐statin combination therapy. Daily fibrate therapy resulted in a myositis, but once‐weekly fibrate therapy with nocturnal daily statin therapy resulted in a reduction in total cholesterol of 49%, triglycerides of 82% and raised HDL by 52%, enabling her to achieve a target LDL of 3 mmol/l and HDL of 1 mmol/l. Combination therapy with low frequency (weekly) fibrate administration and daily statin treatment may provide a means to control the severe hypertriglyceridaemia of patients with renal disease.
EFFICACY AND TOLERABILITY OF FIXED‐DOSE COMBINATIONS OF TELMISARTAN PLUS HCTZ COMPARED WITH LOSARTAN PLUS HCTZ IN PATIENTS WITH ESSENTIAL HYPERTENSION
Authors: Lacourcière Y , Gil‐Extremera B , Mueller O , Byrne M , Williams L
Published: April 2023

Telmisartan, an angiotensin II receptor blocker, is an effective once‐daily antihypertensive agent available either alone or in fixed‐dose combination with hydrochlorothiazide (HCTZ). This multicentre, prospective, randomised, open‐label, blinded‐endpoint (PROBE) study assessed the efficacy and safety of six weeks' treatment with telmisartan 40 mg/HCTZ 12.5 mg (n=199) and telmisartan 80 mg/HCTZ 12.5 mg (n=200) versus losartan 50 mg/HCTZ 12.5 mg (n=198) in patients with mild to moderate essential hypertension. During the last six hours of the dosing interval, telmisartan 40 mg/HCTZ 12.5 mg and telmisartan 80 mg/HCTZ 12.5 mg reduced mean ambulatory diastolic blood pressure (DBP) to a greater extent than losartan 50 mg/HCTZ 12.5 mg (treatment differences 1.8 mmHg [p<0.05] and 2.5 mmHg [p<0.001], respectively). Telmisartan 80 mg/HCTZ 12.5 mg also lowered mean 24‐hour DBP by 2.3 mmHg more than losartan 50 mg/HCTZ 12.5 mg (p<0.001). Telmisartan 40 mg/HCTZ 12.5 mg and telmisartan 80 mg/HCTZ 12.5 mg produced greater reductions in ambulatory systolic blood pressure versus losartan 50 mg/HCTZ 12.5 mg of 2.5 mmHg and 3.4 mmHg, respectively, during the last six hours of the dosing interval (p<0.05), and of 2.1 mmHg and 3.4 mmHg, respectively, over the entire 24‐hour dosing interval (p<0.05). All treatments were well tolerated.
SEXUAL ACTIVITY CARDIOLOGICAL SURVEY ON MEMBERS OF THE ISRAEL HEART SOCIETY
Authors: Roth A , Malov N , Survey S
Published: April 2023

A nationwide telephone survey conducted under the auspices of the Israeli Heart Society examined cardiologists' knowledge of and attitudes towards sexual activity among cardiac patients with concomitant sexual dysfunction. The items covered demography, understanding of relevant mechanisms, drug effects and cardiovascular physiology during sexual activity, suitable interventions and sources of the cardiologists' knowledge. Compliance was excellent (364/379 [96%] responders). Attitudes and knowledge were similar among males and females: 74% underestimated the published frequency of erectile dysfunction in general and among cardiac patients specifically; 90% knew that beta‐blockers cause erectile dysfunction but few responded correctly about other non‐cardiac drugs; 77% try to cope with their patient's problematic sexual function, especially younger cardiologists who tended to be more up to date about it. Israeli cardiologists are motivated to assist these patients but demonstrate a general lack of adequate up to date knowledge on the epidemiological, physiological and pharmacological aspects of the problem.
THE DESIGN OF VENOUS THROMBOEMBOLISM PROPHYLAXIS TRIALS: IS ENOXAPARIN MORE EFFECTIVE THAN FONDAPARINUX?
Authors: Lalourcey L
Published: April 2023

The aim of thromboprophylaxis is to minimise the incidence of clinically relevant venous thromboembolism (VTE) but in many trials designed to determine the efficacy of thromboprophylactic agents, asymptomatic VTE is included in the primary endpoint. Since asymptomatic events occur much more frequently than symptomatic events, they dominate the results. Data from trials comparing the thromboprophylactic efficacy of enoxaparin and fondaparinux in orthopaedic surgical patients are used to demonstrate that asymptomatic and symptomatic endpoints may yield different conclusions. There was no difference between these agents in the incidence of symptomatic VTE. Efficacy and safety results of thromboprophylactic studies are affected by other aspects of trial design such as the dose of each agent and the timing of treatment initiation and endpoint assessment. Such factors should be considered when designing clinical trials and evaluating their results.
A YOGA TEACHER WITH PERSISTENT CHEILITIS
Authors: Biswas R , Dalal M
Published: April 2023

This is a depiction of an evolving case report right from its presentation to the physician and its documentation and further sharing of it through the net via e‐mails and evidence‐based‐health@jiscmail.ac.uk as well as other colleagues.
PALLIATIVE SURGERY FOR ACUTE BOWEL OBSTRUCTION CAUSED BY KAPOSI'S SARCOMA IN A PATIENT WITH AIDS
Authors: Wheeler DW , Baigrie RJ
Published: April 2023

Patients with human immunodeficiency virus (HIV) infection or acquired immune deficiency syndrome (AIDS) can present with acute abdominal surgical problems, either with intra‐abdominal opportunistic infection as a result of their immunosuppression, or with associated malignancies. We report a 39‐year‐old man who developed intermittent nausea and vomiting, which was originally thought to be a side‐effect of the chemotherapy he was receiving for facial Kaposi's sarcoma. However, he was found to have intraperitoneal Kaposi's sarcoma causing small bowel obstruction, which was successfully excised at laparotomy. There were no perioperative complications despite AIDS‐related respiratory disease. The patient remained free of abdominal symptoms until his death. HIV infections or AIDS alone should not be contraindications to surgery for such problems, as careful patient selection can yield good results and significantly improve quality of life.
THE IMPORTANCE OF REACHING LIPID TARGETS: STATINS AND THE PREVENTION OF ATHEROSCLEROSIS
Authors: Schwandt P
Published: April 2023

To help prevent the development of coronary heart disease (CHD), the European and NCEP guidelines have recommended target cholesterol levels for all individuals. Lifestyle changes are advocated for individuals not achieving these targets. Intervention with lipid‐modifying agents may be required for patients at high risk of a cardiovascular event and statins are generally recognised as first‐line therapy. Unfortunately, large numbers of patients at risk of cardiovascular events are not being treated to the guideline targets. Primary care physicians are in a good position to improve lipid management by assessing risk factors, implementing lipid management strategies, monitoring whether targets are being reached and amending treatment appropriately. Furthermore, by educating and motivating patients, primary care physicians may improve compliance with lifestyle changes and medication. These approaches may help more patients to achieve recommended lipid levels and prevent the development of cardiovascular disease.
DENSE MIDDLE CEREBRAL ARTERY SIGN: A PICTORIAL STUDY
Authors: Nagaratnam N , Nagaratnam K , Ng K
Published: April 2023

The hyperdense middle cerebral artery on computed tomography (CT), although a useful sign of middle cerebral artery occlusion, does not presage the events to follow. Because of the wide availability of CT it is useful to illustrate the radiological spectrum of findings following middle cerebral artery occlusion. This is pictorial study of four prototypic patients with hyperdense middle cerebral artery which was the common denominator. There was a marked heterogeniety among the patients in relation to the character of the vascular disturbances, location, extent of ischaemic changes and the final outcome. We emphasise that a single radiological sign should be seen in the context of the entire scan.
POOR UPTAKE OF INFLUENZA VACCINATIONS IN PATIENTS RECEIVING CYTOTOXIC CHEMOTHERAPY
Authors: Ring A , Marx G , Steer C , Prendiville J , Ellis P
Published: April 2023

This audit was designed to assess whether existing UK vaccination programmes mean that patients receiving chemotherapy are being vaccinated against influenza. One hundred and ten adult patients receiving chemotherapy at a south London tertiary referral centre were interviewed when they attended for their chemotherapy. Thirty‐six of the 110 (33%) patients had received their influenza vaccination at the time of the study. Vaccination rates were significantly higher in those patients older than 65 years (53% vs 17%, p<0.001), and in those with co‐morbidities (49% vs 25%, p<0.05). The vaccination rate in this at‐risk population is lower than the overall national uptake in those aged 65 and over. Those patients most likely not to receive their influenza vaccination are those who have no indication for vaccination other than the fact they are receiving chemotherapy. Increased awareness of the benefits of influenza vaccine and its safety is needed among general practitioners, patients and oncologists.
POSTPARTUM THYROIDITIS PRESENTING AS A COLD NODULE AND EVOLVING TO GRAVES' DISEASE
Authors: Papi G , Corrado S , Carapezzi C , Corsello SM
Published: April 2023

We describe the case of a 30‐year‐old woman who, five months after giving birth, was referred with a solitary nodule in her anterior neck. Laboratory analysis, ultrasonography, pertechnetate (Tc99m) thyroid scan and cytological examination of fine needle aspiration biopsy performed on the nodule led us to diagnose postpartum thyroiditis (PPT). Twenty‐eight months after parturition, overt hyperthyroidism developed, with raised thyroperoxidase and thyroid stimulating hormone receptor antibody titres, diffuse high uptake of Tc99m at thyroid scan, and high vascular flow throughout the gland at Color‐Power imaging. The diagnosis of Graves' disease (GD) was established. The differential diagnosis of thyrotoxicosis in the postpartum period, and the possible aetiological relationships between PPT and GD are discussed. To our knowledge, this is the first published report of a PPT presenting as a cold nodule, and evolving to GD.
CAROTID ARTERY INVASION BY SQUAMOUS CELL CARCINOMA OF THE UPPER AERODIGESTIVE TRACT: THE PREDICTIVE VALUE OF CT IMAGING
Authors: Nix PA , Coatesworth AP
Published: April 2023

Carotid artery invasion by squamous cell carcinoma of the upper aerodigestive tract is a poor prognostic indicator and a relative indicator of tumour inoperability. A number of imaging modalities are available for detecting such invasion, but, because of its availability, computerised tomography (CT) is the usual modality We have analysed the CT scans of 196 patients referred to the department with an upper aerodigestive tract squamous cell carcinoma. Comparing the scans with the operative findings indicates that CT scans significantly overestimate carotid artery invasion.
INTRATHYROIDAL THYROGLOSSAL DUCT CYST PRESENTING AS A THYROID NODULE
Authors: Roy D , Roy PG , Malik VK , Seenu V
Published: April 2023

A 50‐year‐old woman presented with a lateral neck swelling, clinically indistinguishable from solitary thyroid nodule. A right hemithyroidectomy was performed and microscopy revealed an intrathyroidal thyroglossal cyst. Intrathyroidal thyroglossal cyst should be considered in the differential diagnosis of a thyroid nodule.
AUTOIMMUNE HEPATITIS TRIGGERED BY BRUCELLA INFECTION OR DOXYCYCLINE OR BOTH
Authors: Selimoglu MA , Ertekin V
Published: April 2023

Autoimmune hepatitis is a disorder of unknown aetiology in which progressive destruction of the hepatic parenchyma occurs, often progressing to cirrhosis. Hepatitis A, Ebstein‐Barr virus and measles virus have been identified as triggers for autoimmune hepatitis in susceptible individuals. There are also reports about herbal medicine and minocycline. A case with autoimmune hepatitis triggered by Brucella infection or doxycycline, or both, is presented. An 11‐year‐old female patient treated with six weeks of doxycycline and three weeks of streptomycine for brucellosis presented with histologically proven autoimmune hepatitis (AH) and responded to corticosteroid treatment. Since neither brucellosis nor doxcycyline as triggering factors for AH have been described so far, these two entities are discussed and the literature reviewed.
ADENOID CYSTIC CARCINOMA OF THE BREAST
Authors: Kontos M , Fentiman IS
Published: April 2023

This study presents a series of eight patients with adenoid cystic carcinoma of the breast, a rare variant of breast cancer with special clinical and radiological characteristics that may lead to clinical misdiagnosis. Diagnosis may be made by core biopsy or fine needle aspiration cytology. Treatment by wide local excision followed by radiotherapy or mastectomy is necessary but axillary dissection can be avoided. Most of these patients have an excellent prognosis. (Int J Clin Pmct 2003; 57(8): 669–672)
PARATHYROID ADENOMA‐RELATED HYPERCALCAEMIA IN BREAST CANCER: A CRITICAL DIAGNOSIS IN CLINICAL ONCOLOGY
Authors: Barutca S , Yurekli Y , Erdogan S , Kadikoylu G , Kacar F
Published: April 2023

Hypercalcaemia in patients with breast cancer is generally due to osteolytic metastases or to the activity of circulating tumour‐derived products. Hyperparathyroidism is one of the most frequent aetiological factors in benign hypercalcaemia, but it is usually not considered in oncology patients. We present a high‐risk early breast cancer case with hypercalcaemia in the 19th postoperative month of follow‐up. The patient had high serum parathyroid hormone (PTH) levels, but ultrasonography was not diagnostic, and the existence of parathyroid adenoma was established by scintigraphy. Histopathological examination revealed chief cell parathyroid adenoma. The patient is still free of cancer recurrence in the 48th month of follow‐up. Hyperparathyroidism should be considered as a possible cause of hypercalcaemia in breast cancer patients, and parathyroid scintigraphy is essential in the initial evaluation of the cases with increased serum calcium and PTH concentrations.
PULMONARY ARTERIOVENOUS MALFORMATION: A RARE, TREATABLE CAUSE OF STROKE IN YOUNG ADULTS
Authors: Retnakaran RR , Faughnan ME , Chan RP , Pugash RA , O'Connor PW , Chow C‐M
Published: April 2023

Pulmonary arteriovenous malformation (PAVM) predisposes affected patients to a significantly increased risk of stroke. Most commonly, PAVM is seen in patients with hereditary haemorrhagic telangiectasia (HHT), an inherited disorder that can be difficult to diagnose in young people because of variable age‐related penetrance. As such, stroke in the young adult may be the presenting feature of underlying PAVM in a previously undiagnosed patient. The importance of considering this diagnosis in the evaluation of young adults with cryptogenic stroke is underscored by the availability of both sensitive screening and effective treatment for PAVM, from which this at‐risk population can greatly benefit.
EXPLOSION DURING DIATHERMY GASTROTOMY IN A PATIENT WITH CARCINOMA OF THE ANTRUM
Authors: Inan A , Dener C , Demirci S
Published: April 2023

Gas explosion during diathermy gastrotomy is a very rare occurrence. We report on an unusual case of gas explosion during diathermy gastrotomy in a patient with carcinoma of the gastric antrum.
EFFICACY OF POVIDONE‐IODINE IN PREPUTIAL ANTISEPSIS
Authors: Çakmak M , Çaglayan F , Kiliç D , Kaygusuz S , Çakmak A , Ulusoy S , Özlü N , Özlük O
Published: April 2023

Wound infection after a surgical procedure is one of the main problems affecting the success of an operation. The prepuce is used in hypospadias surgery and in tissue defects in reconstructive surgery. The objective of this study is to determine the efficacy of povidone‐iodine and surgical soap in preputial skin preparation. Ninety‐four healthy children were divided into three groups. After obtaining preputial skin swabs, an application of povidone‐iodine 10% was made and skin swabs were obtained after two and five minutes in group 1. An additional application of povidone‐iodine after two minutes was made in group 2 and swabs taken. Group 3 received a local scrub with surgical soap and an application of povidone‐iodine. Results showed that, despite painting with povidone‐iodine and/or local cleaning with surgical soap, it is not possible totally to eradicate the micro‐organisms in the prepuce. Surgical soap decreases the colony count, which can lead to increased effectiveness of povidone‐iodine after painting. We recommend preoperative local cleaning with surgical soap before surgical painting.
SNORING, NOT JUST A SOCIAL NUISANCE
Authors: Jarvis S , Rees PJ
Published: April 2023

Snoring is a very common source of complaints from partners and neighbours. Snorers themselves are less likely to be affected, unless they have associated daytime sleepiness caused by the sleep disruption from obstructive sleep apnoea. There is increasingly firm evidence that obstructive sleep apnoea is associated with hypertension, cardiovascular, cerebrovascular and metabolic problems such as insulin resistance, even at mild levels which may not cause much daytime somnolence. In addition, the central and obstructive apnoeas found in cardiac failure affect heart muscle function. Treatment of the apnoea improves blood pressure and cardiac function and is likely to have a beneficial effect on mortality. Since obstructive sleep apnoea is common it should be sought by appropriate questioning in these patient groups. The treatments for obstructive sleep apnoea are effective but cumbersome and this remains a challenge if patients do not achieve obvious early benefits such as reduction in sleepiness or breathlessness.