bluuebunny/crossref_metadata_2025 huggingface dataset:
DOXAZOSIN IN ELDERLY PATIENTS WITH HYPERTENSION
Authors: Weinberger MH , Fawzy A
Published: April 2023

Hypertension constitutes a major cardiovascular risk factor of high prevalence in the elderly, and reducing elevated blood pressure has been shown to be of significant benefit in decreasing the incidence of cardiovascular and cerebrovascular disease in this patient population. Elderly patients are more likely to have comorbid disorders, such as dyslipidaemia, diabetes, renal disease, atherosclerosis and, for males, benign prostatic hyperplasia (BPH). Therefore, when choosing an antihypertensive agent for elderly patients, it is particularly important to ensure that treatment does not exacerbate comorbid conditions and does not interact deleteriously with any concurrent medication that the patient is taking. The α1‐adrenoceptor antagonist, doxazosin, has been shown to be an effective, well‐tolerated antihypertensive therapy in elderly male patients and does not exacerbate – and in some cases improves – some other common disorders. Doxazosin has been shown to be effective in reducing the symptoms of BPH in elderly patients whose blood pressure is well controlled by concomitant antihypertensive medication. In addition, improvements in the symptoms of BPH as well as reductions in blood pressure have been observed in elderly men with mild‐to‐moderate hypertension. Doxazosin has been shown to have positive effects on lipid profiles and glycaemic control, which make it an attractive choice of therapy for elderly patients with hypertension and diabetes or dyslipidaemia. In addition, doxazosin is administered once daily, either in the morning or the evening, which may aid compliance, an important consideration in the elderly. (Int J Clin Pract 2000; 54(3): 181‐189)
ARE WOMEN DISCRIMINATED AGAINST FOR LIPID LOWERING THERAPY? RESULTS FROM A PROSPECTIVE COHORT OF WOMEN WITH CORONARY ARTERY DISEASE
Authors: Lloyd G , Cooper A , Mcging E , Chia H , Jackson G
Published: April 2023

The objective of the study was to compare the lipid management of men and women with documented coronary artery disease in 587 patients (433 men and 154 women) undergoing coronary angiography between 1991 and 1995. A fasting total cholesterol (TC) was measured in all patients on the morning of angiography. A postal/telephone follow‐up was carried out one year after angiography in a subpopulation of 278 patients (194 men and 84 women) who were not taking lipid‐lowering therapy (LLT) or whose TC was >5.2 mmol/l at the time of angiography. At baseline, mean TC was 5.89 mmol/l (SE 0.06) in the men and 6.47 mmol/l (SE 0.09) in the women (p=<0.0001). Action or recommendation to institute LLT was taken in 141 (32.7%) men and 62 (40.3%) women (p=0.09). In the follow‐up population, comparing men with women, 74 (38.3%) vs 39 (46.4%) were taking LLT (p=0.21); 56 (28.9%) vs 26 (31.0%) had not undergone repeat TC testing (p=0.73); when performed, repeat TC was 5.75 (0.09) mmol/l vs 5.64 (0.16) mmol/l (p=0.53); mean decrease in TC between baseline and follow‐up was 0.86 (0.10) mmol/l vs 1.01 (0.21) mmol/l (p=0.51). There was no significant gender difference in lipid management either at the time of coronary angiography or subsequent follow‐up, although the level of lipid‐lowering drug use remained inadequate in both sexes. (Int J Clin Pract 2000; 54(4): 217‐219)
BEHAVIOURAL AND CLINICAL FINDINGS IN COUPLES WHERE THE MAN PRESENTS WITH ERECTILE DISORDER: A RETROSPECTIVE STUDY
Authors: Riley A , Riley E
Published: April 2023

Relevant data were extracted from the case records of a consecutive series of 128 men (median age 57 years) who presented with erectile disorder and whose partners (median age 54 years) attended on the first or second consultation. The case records included responses to questionnaires addressing issues relating to sexual behaviour, used routinely in the clinic. Of these partners, 123 agreed to be clinically examined, including pelvic examination. The duration of erectile disorder ranged from less than one year to 40 years. Only about 10% of couples had experienced sexual kissing and/or caressing in the four weeks before presentation. Almost half the couples had not experienced any sexual activity for about 2.5 years. While 83.7% of men considered intercourse to be important to themselves, only 20.2% of the women rated intercourse somewhat or very important. Clinical evidence of urogenital atrophy was present in 33.3% of women over the age of 46 years. Three women had a vaginismic response to examination in the clinic and one of these women reported long term vaginismus pre‐dating the onset of her partner's erectile disorder. One case of malignant ovarian tumour was identified. The observations from this study demonstrate the need to involve the partner in the assessment process of men presenting with erectile disorder. (Int J Clin Pract 2000; 54(4): 220‐224)
STALKING: EVIL, ILLNESS, OR BOTH?
Authors: Parrott HJ
Published: April 2023

This article considers the definition and impact of stalking behaviours, and describes recent examples, as well as the characteristics and behaviours of stalkers. Current legal frameworks and their application are reviewed, including recent changes in the law. Management and treatment issues as well as attention to minimising a violent outcome and general ethical matters are discussed. (Int J Clin Pract 2000; 54(4): 239‐242)
DMARDS IN THE TREATMENT OF RHEUMATOID ARTHRITIS: CURRENT AGENTS AND FUTURE DEVELOPMENTS
Authors: Simon LS
Published: April 2023

The purpose of this paper is to review the benefits and limitations of current disease‐modifying antirheumatic drugs (DMARDs) used for the treatment of rheumatoid arthritis (RA). Literature about DMARD use in RA, both as monotherapy and in combination therapy, is reviewed. The efficacy and safety of methotrexate, antimalarials, gold‐containing compounds, sulphasalazine, D‐penicillamine, azathioprine and cyclosporin, as well as several new antirheumatic agents are considered. Controlled short‐term clinical studies demonstrate that DMARDs are superior to placebo. Early and continuous use of DMARDs is necessary to slow joint damage and improve long‐term outcomes. Unfortunately, long‐term treatment with these drugs is frequently limited by loss of response and/or onset of serious adverse events. The efficacy of combination DMARD therapy has also been tested, but with mixed success, and the goals of combination DMARD therapy have yet to be fully realised. New DMARDs that have recently been introduced offer promise for future RA management. (Int J Clin Pract 2000; 54(4): 243‐249)
WHEN IS AN AORTIC VALVE PROSTHESIS TOO SMALL? THE NEED FOR DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Authors: Das P , Chambers J , Jackson G
Published: April 2023

We describe a patient who had undergone aortic valve replacement with a small prosthesis 10 years previously and who presented with exertional breathlessness. The resting transaortic pressure gradient was only 30 mmHg but increased to 165 mmHg on dobutamine stress. Conventional resting echocardiography may fail to demonstrate abnormal prosthetic aortic valve function; in the presence of symptoms, dobutamine stress echocardiography should be considered. (Int J Clin Pract 2000; 54(4): 261‐262)
TRAINING IN SIGMOIDOSCOPY: THE EXPERIENCE OF TRAINEES IN ELDERLY MEDICINE IN EAST ANGLIA
Authors: Mallinson RH
Published: April 2023

To assess the standard of training in postgraduate sigmoidoscopy in East Anglia, a questionnaire was prepared and distributed to pre‐registration house officers (JHOs), senior house officers (SHOs) and specialist registrars (SpRs) in eight hospitals. The results suggest that practical instruction in technique is inadequate, and that most trainees perform too few sigmoidoscopies to become competent at either examining or recognising lesions. Many JHOs have not performed sigmoidoscopies or even witnessed important lesions in their early training. The training improved little during the SHO grade, with few trainees feeling happy with their training. The SpRs felt they were competent, although their training was thought inadequate. The current training programme needs detailed reassessment and improvement. (Int J Clin Pract 2000; 54(4): 265‐266)
A CASE OF NOONAN SYNDROME WITH PULMONARY AND ABDOMINAL LYMPHANGIECTASIA
Authors: Öztürk S , Çefle K , Palanduz S , Erten NB , Karan MA , Tasçioglu C , Umman S , Falay O , Vatansever S , Güler K , Cantez S
Published: April 2023

Noonan syndrome is characterised by a Turner‐like phenotype and a normal karyotype. Although it is reported to be associated with abnormalities of the lymphatic system, involvement of the pulmonary lymphatics is rare. We present a case of Noonan syndrome where a whole body scintigraphy revealed lymphangiectasia of the lower extremities, abdomen and lungs. (Int J Clin Pract 2000; 54(4): 274‐276)
COST‐EFFECTIVE PRESCRIBING OF PROTON PUMP INHIBITOR THERAPY: AN AUDIT IN GENERAL PRACTICE
Authors: Cooper AL , Langworthy H , Porter S
Published: April 2023

General practitioners must prescribe cost effectively to control drug expenditure and provide optimal treatment for patients requiring long‐term management. An audit was implemented in general practices to review the management of dyspepsia, improve care, rationalise therapy and reduce costs. Policy included identifying patients receiving proton pump inhibitor (PPI) therapy and changing to low‐dose cost‐effective therapy. If PPI therapy was not required, patients were changed to antacids, H2 receptor antagonists or no treatment. This was an audit in general practice, not a clinical trial, therefore findings reflect outcomes in normal clinical practice. This paper describes the implementation and findings of the audit between January 1997 and July 1999 in 91 general practices involving 7121 patients. Extrapolation of the results concluded that savings of up to £50,000 could be made in a practice of 10,000 patients, allowing reinvestment in health improvement plans and optimal care. (Int J Clin Pract 2000; 54(5): 287‐292)
A COMPARISON OF A FIVE‐DAY REGIMEN OF CEFDINIR WITH A SEVEN‐DAY REGIMEN OF LORACARBEF FOR THE TREATMENT OF ACUTE EXACERBATIONS OF CHRONIC BRONCHITIS
Authors: Paster RZ , Mcadoo MA , Keyserling CH , Nemeth MA , Tack KJ , Griffin TJ
Published: April 2023

To compare the efficacy and safety of five‐day cefdinir treatment with seven‐day loracarbef treatment in patients with acute exacerbations of chronic bronchitis, 586 patients were enrolled in a multicentre, randomised, double‐blind trial. Patients received either five days of treatment with cefdinir (n=291) at 300 mg twice daily or seven days of treatment with loracarbef (n=295) at 400 mg twice daily. Microbiological assessments were done on sputum specimens obtained at admission and at the two post‐therapy visits, if available. The clinical cure rates were 86% (138/160) and 85% (141/166) for the evaluable patients treated with cefdinir and loracarbef, respectively. Respiratory tract pathogens were isolated from 457 (78%) of 586 admission sputum specimens, with the predominant pathogens being Haemophilus parainfluenzae, H. influenzae, Moraxella catarrhalis and Staphylococcus aureus. The microbiological eradication rates at the test‐of‐cure visit were 88% (193/219 pathogens) and 90% (227/251 pathogens) for the evaluable patients treated with cefdinir and loracarbef, respectively. Adverse event rates while on treatment were 30% and 21% for cefdinir‐ and loracarbef‐treated patients, respectively. These results indicate that a five‐day regimen of cefdinir is effective and safe for the treatment of patients with acute exacerbations of chronic bronchitis. (Int J Clin Pract 2000; 54(5): 293‐299)
EVIDENCE‐BASED COUNSELLING FOR VASECTOMY
Authors: Kenogbon JI
Published: April 2023

Couples requesting vasectomy need to be properly counselled. Vasectomy is generally safe but it can fail in up to 6% of cases. Reversal is possible but not always successful. Most men are azoospermic six weeks after vasectomy. They must be warned that the procedure may have to be repeated if there are persistent motile sperm in their post‐vasectomy semen analysis. (Int J Clin Pract 2000; 54(5): 317‐321)
ROSIGLITAZONE
Authors: Goldstein BJ
Published: April 2023

Rosiglitazone, a potent thiazolidinedione oral antidiabetic agent recently approved in the US, differs structurally from pioglitazone and troglitazone (other approved thiazolidinediones), with greater PPARγ binding affinity and antihyperglycaemic potency in preclinical models. Clinical data on more than 4500 patients with type 2 diabetes show that rosiglitazone is a safe, effective monotherapy or combination therapy, producing significant reductions in haemoglobin A1c and fasting plasma glucose under different dosing regimens. Unlike troglitazone, which has been associated with idiosyncratic hepatotoxicity and rare cases of liver failure and death, rosiglitazone has shown a low incidence of liver abnormalities in more than 3500 patient‐years of exposure. No significant food or drug interactions have been reported. Particularly effective as first‐line therapy, rosiglitazone is a useful addition to the roster of oral antidiabetic agents. (Int J Clin Pract 2000; 54(5): 333‐337)
COLONIC PERFORATION ASSOCIATED WITH SLOW‐RELEASE DICLOFENAC SODIUM
Authors: Adhiyaman V , Asghar M , White AD
Published: April 2023

Upper gastrointestinal tract complications due to non‐steroidal anti‐inflammatory drugs are well recognised. However, adverse effects on large intestinal mucosa are less common and less well recognised, even though they carry a significant morbidity and mortality. Here we report a case of colonic perforation in a healthy woman without any underlying colonic pathology associated with ingestion of slow release diclofenac sodium. (Int J Clin Pract 2000; 54(5): 338‐339)
ISCHAEMIC MYELOPATHY PRESENTING AS GUILLAIN‐BARRÉ SYNDROME
Authors: Hui AC‐F , Wong KS , Fu M , Kay R
Published: April 2023

Spinal cord stroke is uncommon. We report a woman presenting with paraesthesia followed by tetraparesis and respiratory failure who was initially diagnosed as having Guillain‐Barré syndrome. Subsequent clinical and imaging features supported the diagnosis of an anterior spinal cord infarction. We describe the main clinical and imaging features of this condition. (Int J Clin Pract 2000; 54(5): 340‐341)
FIRST BRANCHIAL GROOVE ANOMALY
Authors: Kumar M , Hickey S , Joseph G
Published: April 2023

First branchial groove anomalies are very rare. We report a case of a first branchial groove anomaly presented as an infected cyst in an 11‐month‐old child. Management of such lesions is complicated because of their close association with the facial nerve. Surgical management must include identification and protection of the facial nerve. Embryology and facial nerve disposition in relation to the anomaly are reviewed. (Int J Clin Pract 2000; 54(5): 342‐344)
RESEARCH: IS AN ‘IDEAL’ QUESTIONNAIRE POSSIBLE?
Authors: Charlton R
Published: April 2023

Writing a research protocol and designing a questionnaire are not as easy as might be thought. Producing the ‘ideal’ questionnaire can be fraught with difficulties, and the guidelines provided are intended to avoid potential pitfalls. Designing a questionnaire takes time and patience. The importance of a pre‐test and pilot study cannot be overemphasised and resultant modifications to the questions will increase the validity, reliability and responsiveness of a questionnaire and lend support to any findings following appropriate statistical interpretation of the data. The advantages of the questionnaire research method, together with the disadvantages and the problems associated with poor response rates, are discussed. (Int J Clin Pract 2000; 54(6): 356‐359)
CLINICAL AND ELECTROMYOGRAPHIC EXAMINATION OF TREMOR IN PATIENTS WITH THYROTOXICOSIS
Authors: Milanov I , Sheinkova G
Published: April 2023

Tremor is a well‐known symptom of thyrotoxicosis, yet no detailed clinical and electromyographic (EMG) examination of it has been published. The aim of this investigation was to establish the clinical and EMG pattern of tremor in patients with thyrotoxicosis and to compare it with the well‐known pattern of enhanced physiological tremor caused by anxiety. Twenty‐six patients with thyrotoxicosis and tremor and 30 patients with tremor and generalised anxiety disorder were investigated. Tremor was scored clinically in all possible limb positions. EMG examination of tremor activity from antagonist hand muscles was performed. A postural and kinetic tremor with characteristics of an enhanced physiological tremor was found in patients with thyrotoxicosis and generalised anxiety disorder. Tremor involved only the upper limbs in all patients. In conclusion, tremor in thyrotoxicosis and generalised anxiety disorder is an enhanced physiological tremor which cannot be separated clinically or by EMG measurement. Both types of tremor have similar mechanisms and can be distinguished only by the circumstances responsible for their occurrence. Despite only a moderate correlation between tremor intensity and thyroid hormone levels, successful treatment of thyrotoxicosis results in a dramatic improvement of tremor. (Int J Clin Pract 2000; 54(6): 364‐367)
BECLOMETHASONE DIPROPIONATE EASYHALER® IS AS EFFECTIVE AS BUDESONIDE TURBOHALER® IN THE CONTROL OF ASTHMA AND IS PREFERRED BY PATIENTS
Authors: Jäger L ,   German Study Group, Laurikainen K , Leinonen M , Silvasti M
Published: April 2023

This randomised, crossover study compared the efficacy, safety, acceptability and patient preference of two multidose powder inhalers (MDPIs) – beclomethasone dipropionate Easyhaler® (BDP‐EH) and budesonide Turbohaler® (BUD‐TH) – in 79 stable asthmatics who used inhaled steroids but had no experience of MDPIs. After eight weeks' treatment a mean increase in morning PEF of 16 l/min from a baseline of 356 ±112 l/min was observed for each treatment. Similar improvements occurred in evening PEF, FEV1, FVC and asthma symptoms. Both treatments had only minimal effect on morning serum Cortisol levels. Compliance with both treatments was high (>97%) but almost twice as many patients favoured the EH (59%) compared with the TH (33%); 7% rated the devices equally. Scores of device acceptability were significantly in favour of the EH (p=0.001). BDP‐EH and BUD‐TH showed comparable efficacy and safety in the treatment of asthma. Each MDPI had a high rate of compliance, but patients registered greater preference for the EH than the TH. (Int J Clin Pract 2000; 54(6): 368‐372)
UNSTABLE ANGINA – A DEFINITIVE ROLE FOR STATINS IN SECONDARY PREVENTION
Authors: Colquhoun D
Published: April 2023

Unstable angina is a life‐threatening disease. The overall incidence is estimated to be between 0.1 and 0.2% and, of those admitted to hospital, up to 5% die within the first six weeks. With such a high prevalence and poor prognosis, there is still a clear need for improved secondary preventive treatment. Several landmark statin trials (CARE, LIPID and 4‐S) have now shown the benefits of lowering cholesterol, starting months after an acute coronary event, and several smaller studies (such as L‐CAD, PTT and RECIFE) have demonstrated the clinical benefits of very early statin treatment. Recent research suggests the underlying cause of the disease, atherosclerosis, is a dynamic and potentially reversible process. Statins may tip this balance in favour of resolution by cholesterol lowering and through pleiotropic effects independent of lipid lowering. Pravastatin, when given very early in the clinical course, has already been shown to improve both plaque stability and endothelial function, as well as clinical outcome, suggesting it as the drug of choice in early secondary prevention. (Int J Clin Pract 2000; 54(6): 383‐389)
ANOMALOUS CORONARY ARTERIES OF AORTIC ORIGIN
Authors: Felmeden D , Singh SP , Lip GYH
Published: April 2023

Anomalous coronary arteries cause only uncharacteristic symptoms and are therefore often an incidental finding during conventional coronary angiography, with an incidence of 0.3‐0.8%. The commonest anomaly is an aberrant origin of the main left or right coronary artery from the wrong sinus of Valsalva. Rarely there is a fistula draining into one of the cardiac cavities (right ventricle, right atrium, left ventricle or, rarely, superior vena cava) or displaced connection, as seen in anomalous origin of coronary artery from the pulmonary artery, resulting in a left‐to‐right shunt. In congenital heart disease, especially Fallot's tetralogy, the incidence of abnormal coronary arteries may be 2% or more. The proximal course in the former category may be misdiagnosed in up to 50% of cases. Aortic root injection with subtraction angiography, further detailed investigation with transoesophageal echocardiography or magnetic resonance angiography are therefore required as these have potential implications on subsequent surgery. Because of the abnormal course between aorta and pulmonary artery/outflow tract of the right ventricle and acute angulation there is a risk of angina, acute myocardial infarction or sudden death during or after exercise. It is therefore important to identify the exact cardiac anatomy, particularly in patients undergoing angioplasty, stenting or cardiac surgery. (Int J Clin Pract 2000; 54(6): 390‐394)
FATAL CHOLESTATIC JAUNDICE ASSOCIATED WITH AMITRIPTYLIN
Authors: Randeva HS , Bangar V , Sailesh S , Hillhouse EW
Published: April 2023

A 75‐year‐old woman was admitted with a two‐week history of anorexia and vague abdominal pain. She had been taking amitriptyline 75 mg at night for depression for four months before her admission. On presentation she was jaundiced, but with no stigmata of chronic liver disease. Initial liver function tests showed a slightly raised bilirubin, but were otherwise normal. Over the next three weeks her bilirubin concentration continued to rise without evidence of biliary obstruction on ultrasound examination. Her condition continued to deteriorate, and she later developed renal failure consistent with hepatorenal syndrome. Seven weeks after admission she died following a large gastrointestinal bleed. At autopsy, liver histology confirmed pure cholestasis consistent with amitriptyline ingestion. (Int J Clin Pract 2000; 54(6): 405‐406)
WHAT INFLUENCES OUTCOME OF STROKE – PYREXIA OR DYSPHAGIA?
Authors: Sharma JC , Fletcher S , Vassallo M , Ross I
Published: April 2023

To investigate the significance of pyrexia and dysphagia as risk factors for mortality at 90 days in patients admitted with an acute stroke when controlled with other confounding factors, 202 stroke patients admitted to acute medical wards were prospectively studied for demographic and neurological details, stroke syndromes and pathology. A number of other factors were recorded within three days of admission, including pyrexia and dysphagia. Cox's proportional hazards model was used to identify the effect of 10 factors on mortality at 90 days; 59 (29%) patients had died by 90 days. Univariate analysis revealed pyrexia and dysphagia to be independently and significantly associated with indices of stroke severity and 90 day mortality (p<0.001 for both). Cox's proportional hazards model, however, revealed that stroke mortality was associated with dysphagia (relative risk 2.6, 95% CI 1.2–5.4; p=0.009), pre‐existing diabetes mellitus (2.4, CI 1.2–4.5; p=0.006), higher age >75 years (1.8, CI 1.0–3.1), ischaemic heart disease (2.1, CI 1.1–4.2, p=0.025), total anterior circulation syndromes (2.8, CI 1.5–5.2) and previous stroke (1.8, CI 1.0–3.2, p=0.028). Pyrexia was not a significant factor (p=0.50). Although both pyrexia and dysphagia are associated with higher mortality in acute stroke patients, dysphagia was a significant variable predicting death at 90 days when controlled for other factors known to influence stroke mortality. Pyrexia is not significant when other variables are considered.
THE PHARMACOLOGY UNDERLYING PHARMACOTHERAPY FOR TOBACCO DEPENDENCE: A FOCUS ON BUPROPION
Authors: Balfour DJK
Published: April 2023

Tobacco dependence remains the major preventable cause of early mortality and morbidity in the developed world. The primary reinforcer of the dependence is the nicotine present in tobacco smoke and, for many smokers, successful treatment depends upon breaking this dependence. Until recently, the only specific pharmacotherapy available for tobacco dependence was nicotine replacement therapy (NRT). Although this approach does significantly increase long‐term cessation rates, it is by no means a panacea for the many smokers who require help to quit. Recently, a new drug, bupropion (Zyban®), has been licensed as an additional pharmacological aid for smoking cessation. This commentary discusses the mechanisms that may account for its efficacy in this indication and considers the impact its introduction may have on the approach of healthcare systems to the treatment of tobacco dependence.
EFFICACY AND SAFETY OF ‘HOT’ TONSILLECTOMY
Authors: Maheshwar A A , Jones MB , Evans RA
Published: April 2023

Recurrent acute tonsillitis, peritonsillar infections and quinsy (peritonsillar abscess) are common clinical conditions that present to a general practitioner. Management in general practice and in hospital is confounded by apparently conflicting treatment options in the medical literature. We have developed clear guidelines as part of an ongoing audit cycle which include performing quinsy or ‘hot’ tonsillectomy in selected cases, alongside conservative treatments to ensure the speedy recovery and minimal hospitalisation of all patients, with resultant cost benefits.
LESSER EVALUATED DETERMINANTS OF FISTULA FORMATION IN CHILDREN WITH HYPOSPADIAS
Authors: Ratan SK , Sen A , Pandey RM , Hans C , Roychaudhary S , Ratan J
Published: April 2023

Determinants of fistula formation, some of them not previously evaluated, were studied in 30 consecutive children admitted for hypospadias repair to our centre. All children were screened for any urinary or local infections. Vicryl and catgut were used alternately for reconstruction of the neo‐urethra. Per urethral drainage was employed in all patients. The presence of unfavourable local anatomical factors, the surgeon's satisfaction at the end of the procedure and duration of surgery were noted. The patients were followed up for any urethrocutaneous fistula. Unsatisfactory surgery (chi‐square=6.53, p=0.01), unfavourable anatomical factors (chi‐square=10.80, p=0.001) and local infection (chi‐square=5.66, p=0.017) had a strong association with fistula formation, whereas urine leakage and a history of previous surgery had only a marginal association. On application of stepwise binary logistic regression, unfavourable local anatomical factors (OR [95% Cl]: 13.19 [1.20–143.50]) and urine leakage (OR [95% Cl]: 14.35 [1.20–171.45]) emerge as strong risk factors for urethrocutaneous fistula, and local infection (OR [95% Cl]: 8.70 (0.93–81.01]) as a moderate risk factor.
INSIGHT INTO SCHIZOPHRENIA: PLANNING MENTAL HEALTH SERVICE PROVISION FOR SCHIZOPHRENIA USING A BRIEF PSYCHOLOGICAL INTERVENTION
Authors: Pelton J ,   Insight into Schizophrenia Research Group
Published: April 2023

Six nurses were trained to deliver an Insight programme to patients with schizophrenia and their main carers. One outcome of the intervention was the highlighting of recommendations for future treatment. These were fed back on an individual basis through an exit letter to the patient's consultant psychiatrist and key worker. The individual treatment recommendations were then collated into a report for each site and presented to clinical co‐ordinators and business managers. It is envisaged that the recommendations could be used by managers in developing a business case for future mental health provision in schizophrenia. The complete results of the study are due to be published in the near future.
ACUTE ADRENOCORTICAL CRISIS: THREE DIFFERENT PRESENTATIONS
Authors: Bhattacharyya A , Macdonald J , Lakhdar AA
Published: April 2023

The adrenal cortex normally produces three principal steroid hormones: the glucocorticoid cortisol, the mineralocorticoid aldosterone, and a small quantity of sex steroids. In primary adrenocortical insufficiency, there is a deficiency of both cortisol and aldosterone with characteristic clinical and laboratory findings. In contrast, with a pituitary disorder there is isolated hypocortisolism, because its production is dependent on pituitary adrenocorticotropic hormone (ACTH), whereas aldosterone production is controlled by extracellular fluid volume, renin and serum potassium. Acute adrenocortical crisis is an absolute medical emergency and its presentation is not always typical. We describe three recent cases of acute adrenocortical crisis in our hospital who presented in three different ways in three different wards.
PELVIC LIPOMATOSIS PRESENTING AS URAEMIC ENCEPHALOPATHY
Authors: Sharma S , Nabi G , Seth A , Thulkar S , Ghai S
Published: April 2023

Pelvic lipomatosis is a benign disorder of unknown aetiology, characterised by deposition of mature fat in the pelvis. It has a variable natural history, manifesting either with symptoms attributable to the lower urinary tract or varying degrees of renal failure. Owing to the mild, non‐specific initial symptoms and slow progression, presentation is delayed and patients are often lost to follow‐up, only to present with advanced renal failure later on. We report a case of a young patient with pelvic lipomatosis who, after an initial diagnosis, was lost to follow‐up for several years and then presented with uraemic encephalopathy. The case highlights the importance of regular follow‐up and an early intervention before irreversible changes occur.
HIGHER ANTI‐HEPATITIS B RESPONSE WITH COMBINED DTPw‐HBV VACCINE COMPARED WITH SEPARATE ADMINISTRATION IN HEALTHY INFANTS AT 3, 4 AND 5 MONTHS OF AGE IN SLOVAKIA
Authors: Prikazsky V , Bock HL
Published: April 2023

To help achieve universal infant immunisation against hepatitis B, the World Health Organisation has recommended the development of a combined diphtheria, tetanus and pertussis (DTP) and hepatitis B vaccine (HBV). The advantages come from the fact that DTP coverage is estimated to be over 80% worldwide and a combined DTP‐HB vaccine would increase the coverage of HBV. This study was conducted to compare the immunogenicity and reactogenicity of a combined DTP‐HB vaccine with separate, concomitant administration of DTP and HBV vaccines. One hundred and twenty infants were randomised in a 1:1 ratio to one of the two vaccination regimens, given as three injections at approximately 3, 4 and 5 months of age. The only difference in immunogenicity between the two regimens was a higher antibody response to hepatitis B in the group given the combined vaccine, possibly as a result of the adjuvant effect of the whole cell pertussis component of the DTP vaccine. Both vaccine regimens were well tolerated.
IMPROVED GLYCAEMIC CONTROL WITH THE USE OF SELF‐PREPARED MIXTURES OF INSULIN LISPRO AND INSULIN LISPRO PROTAMINE SUSPENSION IN PATIENTS WITH TYPES 1 AND 2 DIABETES
Authors: Roach P , Strack T , Arora V , Zhao Z
Published: April 2023

A total of 166 patients (102 type 1, 64 type 2) were randomised to insulin lispro (LP) combined with insulin lispro protamine suspension (NPL), an intermediate‐acting formulation of LP, or to regular human insulin (HR) combined with human NPH insulin (NPH) in this open‐label, parallel study. Insulin doses were similar at endpoint. Blood glucose (BG) measurements (before and two hours after meals, bedtime, 3 a.m.)(mmol/l) were lower with LP/NPL two hours after breakfast (8.84 ± 0.32 vs 10.29 ± 0.41, p<0.001), before lunch (6.21 ± 0.20 vs 7.10 ± 0.31, p=0.016), two hours after the evening meal (10.18 ± 0.36 vs 7.86 ± 0.28, p<0.0.001), and at bedtime (7.85 ± 0.28 vs 9.43 ± 0.40, p=001). HbA1c was lower for LP/NPL at endpoint (7.54 ± 0.11% vs 7.92 ± 0.10%, p=0.019). There was no difference in hypoglycaemia or insulin antibody levels. LP/NPL resulted in better glycaemic control than HR/NPH without increasing the risk of hypoglycaemia.
MANAGING INFLUENZA: AMANTADINE, RIMANTADINE AND BEYOND
Authors: Fleming DM
Published: April 2023

Amantadine and rimantadine are effective in the treatment and prophylaxis of influenza A. Neither drug, however, has achieved widespread acceptance because of the rapid development of viral resistance, their lack of activity against influenza B and, in the case of amantadine, adverse events. Complete cross‐resistance occurs with these compounds and is associated with a single nucleotide change in the M2 protein. Resistant variants are transmissible and fully pathogenic. Zanamivir is the first widely approved neuraminidase inhibitor for the treatment of influenza. It is delivered directly to the primary site of viral replication, the respiratory tract, and is well tolerated and effective in the treatment of both influenza A and B. Data in prophylaxis are also encouraging. During the extensive clinical programme no evidence for the emergence of drug‐resistant strains with acute therapy was found. Zanamivir represents a significant advance over older agents in the management of influenza A and B.
TUMOUR NECROSIS FACTOR AS A THERAPEUTIC TARGET IN RHEUMATOID ARTHRITIS AND OTHER CHRONIC INFLAMMATORY DISEASES: THE CLINICAL EXPERIENCE WITH INFLIXIMAB (REMICADE™)
Authors: Bondeson J , Maini RN
Published: April 2023

Therapeutic strategies that aim to neutralise the important pro‐inflammatory cytokine tumour necrosis factor α (TNFα) have gained considerable prominence in the therapy of chronic inflammatory diseases, notably rheumatoid arthritis and Crohn's disease. This drug focus review will concentrate on the antitumour necrosis factor antibody infliximab (Remicade™), which has been approved for the treatment of rheumatoid arthritis and Crohn's disease in both the US and Europe. In addition, infliximab is under investigation for several other indications, mainly inflammatory rheumatic diseases. Clinical trials have been persuasive that infliximab is both safe and effective, and it has been proven to be far superior to the conventional drug therapy in both rheumatoid arthritis and Crohn's disease. Remarkably, infliximab in combination with methotrexate controls both the inflammatory joint symptoms and the progression of joint damage, which renders it a very attractive therapeutic option in moderate to severe, therapy‐resistant rheumatoid arthritis.
CROHN'S DISEASE PRESENTING AS LEFT GLUTEAL ABSCESS
Authors: Hussien M , Mudd DG
Published: April 2023

Although abscesses and fistulae are common complications of Crohn's disease, the gluteal area is a rare site for abscess formation. The abscess results from extension of pus through the fascial plains of the pelvis and through the greater sciatic foramen into the gluteal area. This is the first reported left gluteal abscess due to Crohn's disease as pus extends across the midline to the left side. The clinical picture can be misleading and diagnosing the source of infection may be difficult. Incision of this abscess without identifying the source of infection will result in enterocutaneous fistula. Ultrasound guided aspiration of the abscess as well as treatment of metabolic deficiencies and septicaemia before definitive surgical treatment of the bowel disease will reduce the morbidity and mortality of this rare complication. The clinical picture, management of this complication and review of the literature are discussed.
ERECTILE DYSFUNCTION: IS THERE SILENT OBSTRUCTIVE CORONARY ARTERY DISEASE?
Authors: O'Kane PD , Jackson G
Published: April 2023

Erectile dysfunction (ED) has long been ascribed to the ageing process. Patients presenting with ED often have their symptoms ignored in terms of both underlying aetiology and treatment. It is now clear that, in many cases, the pathological processes in ED are common to those involved in vascular disease. Men with proven coronary artery disease (CAD) have a high incidence of ED when directly questioned. In some, the onset of ED pre‐dates the symptoms and diagnosis of CAD as exemplified in our two cases. Patient 1 developed ED two months before an acute anterior myocardial infarction. Patient 2 had several cardiovascular risk factors but only the presence of ED prompted investigations which eventually led to an angiographic diagnosis of three‐vessel disease. The presence of silent co‐existing myocardial ischaemia should be considered in men who present with ED, particularly when they have other cardiovascular risk factors.
BUPROPION OVERDOSE: A POTENTIAL PROBLEM WITH THE NEW ‘MIRACLE’ ANTI‐SMOKING DRUG
Authors: Bhattacharjee C , Smith M , Todd F , Gillespie M
Published: April 2023

Bupropion (Zyban) has recently been launched in the UK as an aid to smoking cessation. As a result of the considerable publicity, there has been unprecedented demand for this new drug in primary care. Within a few weeks of its launch, four patients presented to our A&E department having taken bupropion as an intentional overdose. Three recovered with simple supportive measures; one one was critically ill and required admission to the intensive care unit. There are several case reports on bupropion overdose in the US but none so far in the UK.
POST‐TRAUMATIC COMBINED TRANSDIAPHRAGMATIC INTERCOSTAL AND LUMBAR HERNIA
Authors: Çubukçu A , Gönüllü NN , Arslan SA , Alponat A
Published: April 2023

Traumatic rupture of the diaphragm following blunt trauma is rare. Lumbar hernia in association with blunt trauma is even rarer. To our knowledge, the combination of these two entities has not previously been reported. We describe such a case and review the literature.
ANTIHYPERTENSIVE EFFICACY AND TOLERABILITY OF LOW‐DOSE PERINDOPRIL/INDAPAMIDE COMBINATION COMPARED WITH LOSARTAN IN THE TREATMENT OF ESSENTIAL HYPERTENSION
Authors: Chanudet X , De Champvallins M
Published: April 2023

The aim of the study was to evaluate the antihypertensive efficacy and tolerability of the low‐dose combination of the angiotensin‐converting enzyme inhibitor perindopril 2 mg plus the diuretic indapamide 0.625 mg (P/I) compared with the angiotensin II antagonist losartan 50 mg (L50) in the treatment of essential hypertension. Patients (n=277) were randomised, double‐blind and allocated to receive either P/I or L50 once daily for a period of 12 weeks. Responder and normalisation rates in the two groups were compared by a chi2 test. Ambulatory blood pressure monitoring results were compared using the one‐tailed Student's t‐test. Normalisation rates were significantly greater in the P/I group (76.0%) than in the L50 group (60.0%) (p=0.009). Responder rates were significantly higher in the P/I group (91.7%) than in the L50 group (81.8%) (p=0.025). The average blood pressure reductions were: in sSBP (P/I‐L50 = ‐2.4 mmHg; CI: 6.2; 1.3) and sDBP (P/I‐L50 = ‐2.0 mmHg; CI: ‐4.2; 0.2). The average night‐time SBP decrease (ABPM) was significantly greater in the P/I group (p=0.041). The tolerability was comparable between the two groups in terms of emergent adverse events related to treatment (12.4% for P/I patients and 8.4% for L50 patients). Laboratory evaluations did not show any significant variations. It was concluded the low‐dose P/I combination had significantly higher responder and normalisation rates than L50. This study also confirmed the good tolerability of both treatments.
A COST‐EFFECTIVENESS MODEL OF ALTERNATIVE STATINS TO ACHIEVE TARGET LDL‐CHOLESTEROL LEVELS
Authors: Maclaine GDH , Patel H
Published: April 2023

An economic model was developed to estimate the relative cost‐effectiveness of alternative HMG‐CoA reductase inhibitors (statins) – atorvastatin, cerivastatin, fluvastatin, pravastatin and simvastatin – to achieve target low‐density lipoprotein cholesterol (LDL‐C) levels in a population of secondary CHD prevention patients. By using a cholesterol target as the endpoint of interest and a dose titration approach, the model assumes that the statins demonstrate a class effect through cholesterol lowering. The model was used to estimate the proportion of patients achieving target LDL‐C levels (<3 mmol/l) under each scenario tested. Total costs and incremental cost‐effectiveness relative to no treatment and to the lowest cost option were estimated for each scenario. Total costs were highest for pravastatin and lowest for cerivastatin. Compared with no treatment, the incremental cost per patient treated to target LDL‐C varied between £383 (atorvastatin) and £1213 (pravastatin). Incremental cost‐effectiveness ratios in comparison with the lowest cost treatment (cerivastatin) were £141 per additional patient achieving target LDL‐C with atorvastatin, and £275 with simvastatin. Fluvastatin and pravastatin were both less effective and more expensive than the lowest cost therapy. Although cerivastatin was associated with lowest expected costs, therapy with atorvastatin achieved the lowest cost‐effectiveness ratios. Hence atorvastatin would allow the largest number of patients to be treated to target LDL‐C within a fixed drug budget. Choosing between drug therapies on the basis of price alone may be misleading if the effectiveness of therapies varies.
COMBINATION THERAPY IN ANGINA: A REVIEW OF COMBINED HAEMODYNAMIC TREATMENT AND THE ROLE FOR COMBINED HAEMODYNAMIC AND CARDIAC METABOLIC AGENTS
Authors: Jackson G
Published: April 2023

The 1997 European Society of Cardiology guidelines emphasised medical therapy as the mainstay of treatment of stable angina. Until recently, the antianginal drugs available to control symptoms (nitrates, beta‐blockers and calcium antagonists) have all been haemodynamic agents that eliminate or reduce angina attacks principally by decreasing myocardial oxygen demand. They may also improve myocardial perfusion. The haemodynamic agents are often used in combination. However, there is conflicting evidence for the efficacy of combination treatment. Two recently published large clinical studies, the Total Ischaemic Burden European Trial (TIBET) study and the International Multicenter Angina Exercise (IMAGE) study, suggest that combined haemodynamic treatment is no more effective than optimal monotherapy. The results from IMAGE suggest that most of the additional effect observed with combined therapy was attributable to recruitment by the second drug of patients who had not responded to monotherapy, and that most patients continued to have a disturbing frequency of anginal attacks after receiving combined therapy. Metabolic agents are a new class of drugs that directly modify the use of energy substrates in the heart, lessening ischaemic injury and improving cardiac performance during ischaemia. Due to their non‐haemodynamic mode of action, metabolic agents such as trimetazidine or L‐carnitine may provide independent benefit in ischaemia when used as monotherapy or additional benefit when used in combination with a conventional agent. Clinical trials have shown that combined haemodynamic and metabolic treatment is more effective than combined haemodynamic therapy and is well tolerated. It is suggested that combination haemodynamic and metabolic therapy is a logical new approach to patients whose angina is inadequately controlled despite optimal haemodynamic therapy.
RISEDRONATE: CLINICAL USAGE
Authors: Chapurlat RD , Delmas PD
Published: April 2023

Risedronate is a new bisphosphonate – a family of drugs that inhibit bone resorption – and thus can be used in various bone conditions involving increased levels of bone resorption, such as postmenopausal osteoporosis, glucocorticoid‐induced bone loss, and Paget's disease of bone. In placebo‐controlled clinical trials, risedronate has been shown to prevent bone loss in postmenopausal women, to decrease the incidence of vertebral and non vertebral (including hip) fractures in postmenopausal women with osteoporosis, and to prevent bone loss in men and women treated with moderate to high doses of glucocorticoids. Risedronate has also been shown substantially to decrease the severity of bone pain and the level of bone turnover in Paget's disease of bone, and to improve the radiographic lesions of this disease. Risedronate is safe and well tolerated. Thus, risedronate is a new option for the management of postmenopausal osteoporosis, Paget's disease of bone and corticosteroid‐induced bone loss.
IMAGES IN CARDIOLOGY: LEFT VENTRICULAR FREE WALL RUPTURE
Authors: Rinaldi CA , Coutts JF , Jackson G
Published: April 2023

Left ventricular free wall rupture is thought to account for approximately 15% of deaths following acute myocardial infarction (MI). We present a case of left ventricular free wall rupture in a 64‐year‐old man following a lateral MI. The diagnosis was made with 2D and colour flow Doppler echocardiography. Unfortunately the patient died before emergency surgery, could be performed.
POLYSEROSITIS AS A RARE COMPONENT OF POLYGLANDULAR AUTOIMMUNE SYNDROME TYPE II
Authors: Algün E , Erkoç R , Kotan Ç , Güler N , Sahin I , Ayakta H , Uygan I , Dilek I , Aksoy H
Published: April 2023

Polyglandular autoimmune (PGA) syndromes (types I and II) may affect various endocrine and non‐endocrine organs in the body. In the commoner PGA type II, primary adrenal insufficiency, autoimmune thyroid disease and type I diabetes mellitus are the most frequent manifestations. Serositis with pericardial or pleural involvement is not a well known component of the disease. Here, we report a 21‐year‐old man who first presented with a pleuropericardial effusion and Graves' disease, and who then developed type I diabetes mellitus.
SYNCHRONOUS COLONIC TUMOURS OF DUAL PATHOLOGY
Authors: Basu S , Selvachandran SN , Cade D
Published: April 2023

Synchronous colonic tumours of dual pathology are extremely rare. A review of the literature revealed that few cases have been reported to date. Because of their rarity and lack of specific symptoms, preoperative diagnosis is not easy and there is no protocol as yet for the ideal management of these cases. We present such a case which was treated by a combination of surgery and chemotherapy.
ENDOMETRIOMA OF THE LIVER
Authors: Bohra AK , Diamond T
Published: April 2023

Hepatic endometriosis is extremely rare. The diagnosis is often missed and treatment is delayed. A 37‐year‐old woman was referred to the gynaecology department with vague abdominal pains. She had a past history of pelvic endometriosis and hysterectomy with bilateral salpingo‐oophorectomy. Further investigations in due course confirmed it to be endometriosis of the liver. She was eventually referred to the hepatobiliary unit, almost three years after her first presentation, where she was operated on with good results.
THE HEALTH ECONOMIC IMPACT OF ANTIDEPRESSANT USAGE FROM A PAYER'S PERSPECTIVE: A MULTINATIONAL STUDY
Authors: Casciano J , Doyle J , Arikian S , Casciano R
Published: April 2023

A multinational decision analytic model was developed to examine the treatment of major depressive disorder (MDD) in 10 European and American countries. Input to the model was obtained from a meta‐analysis of current clinical trial data obtained from the published literature, and local clinical and health economic experts in each market. The patient‐ and policy‐level impact of MDD treatment was measured in each of the 10 markets. The total expected cost per patient for treating MDD with venlafaxine XR during the six‐month acute phase of MDD was the lowest expected cost in nine of the 10 countries studied, resulting in savings to the primary payer in almost all markets. As well as the cost savings, the higher efficacy and lower rate of dropout found for venlafaxine XR translate to a greater number of symptom‐free‐days (SFDs) per patient. The results of this investigation show that use of venlafaxine XR in most settings across Europe and the Americas will have a favourable impact on healthcare payer budgets and the overall mental health of MDD patients.