bluuebunny/crossref_metadata_2025 huggingface dataset:
Lactulose in the treatment of symptomatic diverticular disease: a comparative study with high‐fibre diet
Authors: Smits B J , Whitehead A M , Prescott P
Published: April 2023

Objective

To compare the efficacy and tolerance of lactulose (Duphalac) and high‐fibre diet in the treatment of symptomatic diverticular disease.

Design

Prospectively randomised, parallel groups study over 12 weeks. Patients were seen by their clinician for an initial assessment and then at weeks 4, 8 and 12.

Setting

Hospital out‐patients in the United Kingdom.

Patients

Forty‐three patients with a confirmed diagnosis of diverticular disease were entered into the study.

Intervention

Patients were prospectively randomised to receive lactulose (15 ml bd) or high‐fibre diet (30‐40 g daily) for 12 weeks.

Measurements and results

Data were collected using diary cards and physicians' assessments. Bowel frequency and stool consistency improved similarly with both treatments. Pain on bowel movement improved with both treatments in respect of frequency (lactulose: P = 0.017, fibre: P = 0.084) and severity (lactulose: P = 0.028, fibre: P = 0.043). Abdominal pain also improved with both treatments in respect of frequency (lactulose: P = 0.0015, fibre: P = 0.022) and severity (lactulose: P = 0.009, fibre: P = 0.028). Nine patients on lactulose and 12 on fibre reported treatment‐emergent symptoms, of which none was serious.

Conclusions

Lactulose and high‐fibre diet were both shown to be effective in the treatment of diverticular disease, with some differences in favour of lactulose.
UNRECOGNISED CUSHING'S SYNDROME AND ADRENAL SUPPRESSION DUE TO TOPICAL CLOBETASOL PROPIONATE
Authors: Young C A , Williams I R , Macfarlane I A
Published: April 2023

SUMMARY A 53‐year‐old man with cushingoid appearance ‐ obesity, osteoporosis causing lumbar and thoracic vertebral collapse and a past history of hypertension and depression presented with symptoms and signs of adrenocortical insufficiency. He denied the use of corticosteroid medication. However, it was eventually discovered that he had used clobetasol propionate (Dermovate), a potent topical steroid cream, for five years. The development of adrenal insufficiency symptoms coincided with the withdrawal of the cream.
TREATMENT OF ADULT PYLORIC STENOSIS: A PHARMACOLOGICAL ALTERNATIVE?
Authors: Talbot D
Published: April 2023

SUMMARY Patients presenting with gastric outlet obstruction require investigation and treatment by surgery or balloon dilatation. This paper presents three cases of classic pyloric stenosis due to long‐standing scarring from peptic ulceration. All cases were planned for active intervention but all settled, while investigations were in progress, with omeprazole. This would suggest that there are increasing numbers of such patients who are temporised with this treatment but may present again with refractile pyloric stenosis.
CLINICAL AUDIT: IS DAY‐CASE ADENOTONSILLECTOMY SAFE?
Authors: Lannigan FJ , Martin‐Hirsch DP , Basey E
Published: April 2023

SUMMARY The trend towards day‐case procedures is growing, as a consequence not only of improved medical care but the increasing importance of economic considerations in today's healthcare environment. In the largest worldwide study to date to assess the safety of day‐case adenotonsillectomy, we reviewed the records of 4386 patients at the otolaryngology department of the Bradford Royal Infirmary. We found a reactionary haemorrhage rate of 0.57%. All patients who underwent surgery in the morning session had presented with haemorrhage and returned to the operating theatre before the end of the afternoon session. We discuss the implications of these findings, and consider that with careful monitoring day‐case tonsillectomy and/or adenoidectomy may safely be introduced.
COVERT HYPOTHYROIDISM WITH WEIGHT LOSS AND ATRIAL FIBRILLATION
Authors: Siddiqui AS , D'Costa DF , Moore‐Smith B
Published: April 2023

SUMMARY Hypothyroidism may present with weight gain and/or cardiovascular manifestations such as bradycardia or cardiac failure, but has not previously been documented as presenting with atrial fibrillation and weight loss. Our case highlights the importance of thyroid function tests in heart failure and emphasises the importance of regular follow‐up after irradiation to the thyroid.
CARDIAC AMYLOIDOSIS IN THE PRESENCE OF BENCE‐JONES PROTEINURIA AND NORMAL SERUM IMMUNOGLOBULINS
Authors: King D , Sheard JDH , Silas JH
Published: April 2023

SUMMARY We describe a case of cardiac amyloidosis, which is an uncommon cause of heart failure. This case is unusual, as the patient presented with symptoms of angina in the presence of normal coronary arteries and subsequently developed heart failure. Amyloidosis was secondary to myeloma with Bence‐Jones proteinuria alone, which is rare.
SUBCUTANEOUS ALVEOLAR SOFT‐PART SARCOMA MIMICKING METASTATIC HYPERNEPHROMA
Authors: Banerjee AK , Simon J , Simpson A
Published: April 2023

SUMMARY Alveolar soft‐part sarcoma represents a rare tumour of the subcutaneous and soft tissues that may present to the dermatologist. It may mimic both other primary tumours and other metastatic tumours. This mimickry has not been emphasised in the previous literature.
PRIMARY MENINGOCOCCAL CONJUNCTIVITIS IN CHILDREN
Authors: Neoh C , Agius‐Fernandez A , Kaye SB , Molyneux EM , Hart CA
Published: April 2023

SUMMARY Four cases of primary meningococcal conjunctivitis in children are reported. This represents an incidence of 2% of patients presenting with conjunctivitis to a paediatric A&E department. All were initially treated with topical chloramphenicol, followed by systemic rifampicin once the diagnosis had been established. No ocular or systemic complications developed, nor recolonisation of the conjunctiva or colonisation of the nasopharynx at follow‐up (1–2 years).
CICATRICIAL PEMPHIGOID PRESENTING AS UPPER AIRWAYS OBSTRUCTION
Authors: Yong ASM , Elborn JS , Stanford CF
Published: April 2023

SUMMARY A 53‐year‐old woman presented with a history of increased shortness of breath, stridor and dryness of the eyes. Flow volume loops demonstrated evidence of upper airways obstruction. Conjunctival and laryngeal biopsies suggested a diagnosis of cicatricial pemphigoid. Immunosuppressive therapy improved symptoms and the flow volume loops returned to normal.
MESENTERIC FIBROMATOSIS
Authors: Tsamandas ACh , Tzanakakis GN , Karatzas Th , Repandi M , Karavias D
Published: April 2023

SUMMARY Mesenteric fibromatosis is commonly associated with Gardner's syndrome and familial polyposis. These lesions may have an insidious onset via compression of the small or large intestines, or may be noted for the first time during abdominal exploration for some other cause. Differential diagnosis may be difficult. We report a case of mesenteric fibromatosis with two recurrences, and two cases with no evidence of tumour recurrence.
CHOLINERGIC CRISIS FOLLOWING TREATMENT OF POSTOPERATIVE URINARY RETENTION WITH DISTIGMINE BROMIDE
Authors: Hameed A , Charles TJ
Published: April 2023

SUMMARY Distigmine bromide is a long‐acting anticholinesterase, available for the treatment of postoperative urinary retention. Its effectiveness is unproven and administration may be hazardous. We describe a case in which oral distigmine bromide was used for postoperative retention, resulting in a potentially life‐threatening ‘cholinergic crisis‘. We review the literature and conclude that the use of oral distigmine bromide in postoperative urinary retention is not justified.
CASES OF ACUTE MOUNTAIN SICKNESS ON MOUNT AGRI
Authors: Ergün Y
Published: April 2023

SUMMARY Between 1983 and 1990 a total of 74 freestyle mountaineers and 88 mountaineers with skis attempted to climb Mount Agri (Ararat). From the freestyle group two mountaineers were affected by acclimatisation disorder at 3200 m and seven at 4200 m above sea level. Acute mountain sickness (AMS) affected four mountaineers at 4200 m, eight at 4700 m, two at 5000 m and two at 5165 m, while 49 reached the summit. Only one of the mountaineers with skis was affected by AMS (at 4200 m), while all the others reached the summit. The symptoms of acclimatisation disorder and AMS, according to their degree of frequency, were headache, weakness, dyspnoea and palpitation, anorexia, nausea, vomiting, giddiness, ataxia and insomnia. Pulse rates varied between 115 and 124/min, and breathing between 30 and 38/min.
INTERMAMMARY PILONIDAL SINUS
Authors: Richardson HC
Published: April 2023

SUMMARY This is the first case of intermammary pilonidal sinus to be described in the literature.
THERAPY OPTIONS IN ALZHEIMER'S DISEASE
Authors: Gottfries CG
Published: April 2023

SUMMARYThe aetiology of Alzheimer's disease and senile dementia of the Alzheimer type (AD/SDAT) are unknown, and primary prevention is thus infeasible. As overactivity in the hypothalamicpituitary‐adrenal axis (possibly indicating maladaptation to stress) and vitamin B12deficiency are common, secondary prevention should focus on stress and dietary factors. Nerve growth factors and ganglioside GM1have been used to inhibit progression of the disorder, but this treatment is still at an experimental stage, as are efforts to prevent the formation of amyloid. Breakthroughs in AD/SDAT treatment have been seen in trials with supplementation of neurotransmitter deficits. Tacrine, a drug that inhibits acetylcholinesterase, has proved to have a cognitive‐enhancing effect, but this is limited in time and the drug has side‐effects. Selective serotonin reuptake inhibitors have a proven effect on the emotional disturbances seen in AD/SDAT.
PHARMACOTHERAPY OF OBSESSIVE‐COMPULSIVE DISORDER
Authors: Ko S‐M
Published: April 2023

SUMMARY Previously thought of as merely an interesting syndrome, obsessive‐compulsive disorder is now estimated to afflict 1%–2% of the world's population. Over the past decade extensive research into the epidemiology, aetiology, pathophysiology and pharmacological treatment of this condition has greatly improved its prognosis. This is largely due to the development of the serotonergic group of antidepressants, the selective serotonin reuptake inhibitors (SSRIs), which have consistently demonstrated antiobsessional properties. Monoamine oxidase inhibitors (MAOIs) and lithium have also contributed to the amelioration of symptoms in some patients. Other pharmacological treatment, often prescribed in combination with the SSRIs, include the antipsychotic drugs, benzodiazepines, and anticonvulsants.
OUTCOME OF BURCH COLPOSUSPENSION IN A DISTRICT GENERAL HOSPITAL
Authors: Chinegwundoh FI , Nayeem N
Published: April 2023

SUMMARY Genuine stress incontinence is a problem affecting women of all ages. There are several conservative means of alleviating the condition, but surgical intervention is an alternative when these fail. The Burch colposuspension has become a popular choice of procedure. In this report of 61 patients in a district general hospital, the success rate was high (84%, which compares favourably with the literature). There was a high rate of complications (55%), some of which have not commonly been reported. Burch colposuspension is a good operation for stress incontinence, although patients should be counselled about possible postoperative difficulties.
PENILE GRANULOMAS WITH URETHRAL STRICTURE: UNUSUAL PRESENTATION OF WEGENER'S GRANULOMATOSIS
Authors: Linehan JD , Bhakri HL
Published: April 2023

SUMMARY A case of penile granuloma due to Wegener's granulomatosis is documented.
HORNER'S SYNDROME: AN UNUSUAL IATROGENIC COMPLICATION OF PNEUMOTHORAX
Authors: Pearce SHS , Rees CJ , Smith RH
Published: April 2023

SUMMARY A patient is reported with spontaneous pneumothorax in whom a Horner's syndrome occurred as a complication of drainage tube thoracostomy. Ascending sympathetic fibres lie in close contact with the parietal pleura at the apex of the hemithorax and may be damaged by an inappropriately positioned thoracostomy tube. It is suggested that drainage tubes found to be sited medially at the apex of the hemithorax should be immediately repositioned to avoid this complication.
EXTRAPONTINE MYELINOLYSIS AFTER CORRECTION OF CHRONIC HYPONATRAEMIA WITH ISOTONIC SALINE
Authors: Ellis SJ
Published: April 2023

SUMMARY Rapid correction of severe chronic hyponatraemia with hypertonic saline can cause central pontine myelinolysis. Less well appreciated are the dangers of rapid correction with isotonic saline. A case is reported in which correction of severe hyponatraemia by 11 mmol/l in 24 hours with isotonic saline produced extensive extrapontine myelinolysis, one of the manifestations of the osmotic demyelination syndrome.
COMPARISON OF CLOTRIMAZOLE, FLUCONAZOLE AND ITRACONAZOLE IN VAGINAL CANDIDIASIS
Authors: Woolley PD , Higgins SP
Published: April 2023

SUMMARY Women attending a genitourinary medicine clinic (n=229) with mycologically confirmed acute vulvovaginal candidiasis were randomised to receive either clotrimazole (500 mg pessary and 1% cream), fluconazole (150 mg single oral dose) or itraconazole (200 mg bd oral dose for 1 day). Mycological cure rates were 96% in the itraconazole group, 95% in the clotrimazole group, and 83% in the fluconazole group (P=0.008). The proportion of patients who were clinically cured showed a similar pattern (itraconazole 80%, clotrimazole 80%, fluconazole 62%). This suggests that itraconazole or clotrimazole are more effective than fluconazole in the treatment of acute vaginal candidiasis.
HYPERVENTILATION AND DIZZINESS: CASE REPORTS AND MANAGEMENT
Authors: Sama A , Meikle JCE , Jones NS
Published: April 2023

SUMMARY Dizziness is a common symptom in patients presenting to an otorhinolaryngologist. Hyperventilation accounts for up to 5% of cases with dizziness and is a contributory factor in a further 20% of cases. Six cases of dizziness due to hyperventilation are presented to illustrate the authors' simple management policy. A high index of suspicion in the absence of an organic cause of dizziness and a simple provocation test will identify these cases. Management is aimed at demonstrating resting hypocapnia, investigations to exclude organic causes of hyperventilation and rehabilitation in collaboration with a clinical psychologist ensures the appropriate treatment for the dizziness and can avoid the development of chronic somatisation behaviours.
SURGICAL PATIENTS WITH SUPRISING LABORATORY DATA
Authors: Leppänen E , Luisto M , Dugué B
Published: April 2023

SUMMARY Preoperative laboratory tests were performed on elective ambulant orthopaedic patients (n=26) on the afternoon after their arrival in hospital and on the next morning before the operation. Significantly lower concentrations of leukocytes, albumin, total protein, platelets, and total calcium were observed in samples taken in the morning. Posture and chronobiological rhythms may be responsible for these changes. An overnight change in laboratory values may lead to unnecessary further investigations and postponement of surgery. The clinician should be aware of the effects of preanalytical factors on laboratory data.
ATRIAL FIBRILLATION IN THE ELDERLY: PHYSICIANS' ATTITUDES TO ANTICOAGULATION
Authors: King D , Davies KN , Slee A , Silas JH
Published: April 2023

SUMMARY The use of warfarin and aspirin for the primary prevention of stroke in elderly patients with atrial fibrillation (AF) is controversial. To establish current practice we circulated a questionnaire to 300 geriatricians (G) and 300 cardiologists (C). The response rates were 47% G and 51% C. Most physicians prescribed warfarin in AF associated with mitral stenosis (G vs C, 86% vs 89%, NS). Cardiologists were more likely to prescribe warfarin in AF associated with dilated cardiomyopathy (G vs C, 52% vs 86%, P<0.01). A minority would prescribe warfarin in aortic valve disease and AF (G vs C, 37% vs 24%, P<0.05) and lone AF (G vs C, 10% vs 26%, P<0.01). Aspirin was favoured in aortic valve disease and lone AF. The cardiologists were less reluctant to use warfarin in the young and more likely to electrically cardiovert the young with chronic AF.
FLUTICASONE PROPIONATE IN THE TREATMENT OF INFLAMMATORY DERMATOSES
Authors: Chu AC , Munn S
Published: April 2023

SUMMARY Fluticasone propionate is a new, topically active glucocorticoid which shows high specificity for the glucocorticoid receptor. After topical application systemic absorption is low. The small amount that is absorbed is rapidly and completely inactivated by esterase‐catalysed hydrolysis in the liver. Even when applied in large doses under occlusion, there is no evidence of hypothalamic/pituitary/adrenal (HPA) axis suppression. Studies on skin thinning have shown no significant effect on skin thickness after once‐daily application of fluticasone propionate 0.05% cream for 8 weeks. This cream has been shown to be highly effective in the treatment of eczema, and once‐daily application shows no significant difference in efficacy compared with twice‐daily treatment. Limited studies using 0.005% ointment in moderate to severe psoriasis showed similar efficacy to 0.1% betamethasone‐17‐valerate ointment. Fluticasone propionate 0.05% thus represents a major advance in topical corticosteroids. It has a high safety profile and the cream formulation is effective in a single daily application.
DOES ENCOURAGING GOOD COMPLIANCE IMPROVE PATIENTS' CLINICAL CONDITION IN HEART FAILURE?
Authors: Goodyer LI , Miskelly F , Milligan P
Published: April 2023

SUMMARY The aim of this study was to determine whether improved compliance by intensive medication counselling, given by a pharmacist, to elderly patients with chronic stable heart failure can influence both objective and subjective measures of heart failure. Elderly patients were randomly allocated to receive a 3‐month counselling programme, or no counselling. Measures recorded at the beginning and end of the study included; submaximal 6‐minute exercise tests, visual analogue scores of breathlessness, the Nottingham Health Profile, and clinical signs of heart failure. Compliance was measured by a tablet count and medication knowledge assessed by means of a questionnaire. There was no significant difference between the groups in their initial level of compliance, medication knowledge or other assessments. Compliance improved for the counselled group by 32% (P<0.001) but remained unchanged for controls. Medication knowledge improved for the counselled group only. The 6‐minute exercise test improved by 20 metres from a baseline of 137 m for the counselled group (P<0.005) but worsened by 22 m for the control group (P<0.01). Distance to breathlessness improved for the counselled patients and worsened for controls. In contrast bodyweight, jugular venous pressure and Nottingham Health Profile scores did not change significantly for either group. Peripheral and pulmonary oedema scores improved for the counselled group (P<0.01) but remained unchanged for controls. A small improvement was seen in the visual analogue scores (P<0.05) for the counselled group only. Improved compliance due to intensive medication counselling had a small but measurable beneficial effect on objective measures of heart failure. However, the beneficial effect was small compared with the increase in compliance. It is doubtful whether improved compliance produces a clinically relevant benefit in elderly patients with heart failure.
HAEMOLYTIC ANAEMIA COMPLICATING EPSTEIN‐BARR VIRUS INFECTION
Authors: Whitelaw F , Brook MG , Kennedy N , Weir WRC
Published: April 2023

SUMMARY Hepatitis is a well‐recognised complication of Epstein‐Barr virus (EBV) infection that usually resolves spontaneously. Jaundice occasionally results from the unusual complication of autoimmune haemolytic anaemia rather than hepatitis. Two adult patients are described with infectious mononucleosis‐related hepatitis who also developed significant haemolysis, a situation that could have led to diagnostic delay and a deleterious outcome. Haemolysis should be considered in all patients who become jaundiced after infectious mononucleosis. The management of this potentially fatal complication is discussed.
SEVERE REVERSIBLE ARTERIAL SPASM WITH ERGOTAMINE
Authors: Paraskevopoulos JA , Teasdale DE , Cuschieri RJ
Published: April 2023

SUMMARY A patient is described with marked unilateral arterial spasm of the proximal vessels and severe ischaemia of the left foot as a result of excessive use of ergotamine tartrate. Treatment with intravenous heparin infusion followed by chemical sympathectomy was successful.
DIGOXIN IN CLINICAL PRACTICE: SORTING OUT THE FACTS
Authors: Doi SAR , Landless PN
Published: April 2023

SUMMARY The aim of this review is to sort out from the huge amount of facts related to digoxin in the literature those pertinent to current clinical practice. Seven aspects of digoxin are discussed: its mechanism of action, therapeutic controversy, clinical efficacy, avoidance of toxicity, manifestations of toxicity, indications, and its use in coronary artery disease
VIRAL HEPATITIS: AN OVERVIEW
Authors: Hadziyannis SJ
Published: April 2023

SUMMARY The types of hepatitis and their various modes of transmission are identified.
PERSISTENT MULLERIAN DUCT SYNDROME
Authors: Köksal S , Tokmak H , Tibet HB , Olgun E
Published: April 2023

SUMMARY Persistent müllerian duct syndrome is a rare form of male pseudohermaphroditism. It is usually diagnosed in the early years of life. A case is reported of normal male appearance with bilateral undescended testicles and a right inguinal hernia. On exploration a uterus, two fallopian tubes and a testis were found in the hernial sac. As these patients have an increased risk of gonadal tumours they should be kept under long‐term review.
UNDESCENDED TESTES: SCREENING AND EARLY OPERATION
Authors: Gordon N
Published: April 2023

SUMMARY The prevalence of undescended testes at birth, or cryptorchidism, is about 2‐3% — higher among premature babies. Associated complications include infertility and malignancy, and a number of studies have shown that UK screening programs to date — the examinations carried out by the community services, for example — have failed to identify cryptorchidism at an early age in many cases. If complications, particularly infertility, are to be avoided, operations on undescended testes should be done before the age of two; at this age, operation may also be less disturbing for the patient. The cause of maldescent of the testes is uncertain, but there are related conditions, including exposure to oestrogens in the first trimester, and low birth weight: these need to be considered as they influence management.
LOW‐DOSE MAINTENANCE CLOZAPINE TREATMENT IN THE PROPHYLAXIS OF BIPOLAR AFFECTIVE DISORDER
Authors: Puri BK , Taylor DG , Alcock MEC
Published: April 2023

SUMMARY A chronically relapsing middle‐aged man with bipolar affective disorder responded poorly to different forms of conventional pharmacotherapy, including depot antipsychotic medication and lithium. The addition of clozapine to lithium, even at doses as low as 25mg/day, led to a stabilisation of his mood. The withdrawal of low‐dose clozapine led to a relapse within a few days. It is concluded that maintenance low‐dose clozapine should be considered in bipolar disorders resistant to other treatments.
AN AUDIT OF THE USE OF SPHYGMOMANOMETERS
Authors: Hussain A , Cox JGC
Published: April 2023

SUMMARY This survey assessed the measurement of blood pressure and use of sphygmomanometers by general practitioners in Humberside and Yorkshire in 1988. All registered practitioners were sent a questionnaire — 1223 (58%) returned it completed. Their responses showed that 269 (22%) had an aneroid sphygmomanometer only, and that 120 (10%) had a random zero sphygmomanometer; 700 (57%) had special cuffs for obese patients, and 558 (46%) had special cuffs for children; 228 (23.5%) had never had their sphygmomanometers serviced (‘never’ corresponding to a mean time of 5.75 years), while 23% had patients who measured their own blood pressure. These findings suggest that the British Hypertension Society's recommendations on servicing and cuff use are not always applied. A formal audit of the use of different types of sphygmomanometer in general practice may encourage and improve accuracy and uniformity in blood pressure recording.
MARKEDLY ELEVATED ERYTHROCYTE SEDIMENTATION RATES: CONSIDERATION OF CLINICAL IMPLICATIONS IN A HOSPITAL POPULATION
Authors: Lluberas‐Acosta G , Schumacher HR
Published: April 2023

SUMMARY In order to evaluate the clinical significance of very high erythrocyte sedimentation rates (ESRs) we studied 100 consecutive men in a VA Medical Center whose Westergren ESR was more than 100mm/hr. All were followed for up to six months and the ESR‐requesting physicians were interviewed. A total of 162 diagnoses known to be associated with an elevated ESR were present in the 90 patients available for follow up. As in most previous series on very high ESRs, infections (seen in 43 patients) were the most common diagnoses. Other diagnoses included: malignancy (16), rheumatologic disease (30), other inflammatory diseases (seven), renal disease (25), and miscellaneous problems (38). Evaluation of 16 patients led to a diagnosis that had not initially been apparent — the ESR‐requesting physician did not consider that a high ESR was instrumental in guiding him towards any of these delayed diagnoses. Most of the markedly elevated ESRs in this patient population, requested in the context of already evident serious multisystem disease, contributed little diagnostic information.
CHANGING INCIDENCE OF ATRIAL FIBRILLATION FOLLOWING CORONARY ARTERY BYPASS GRAFTING: A RETROSPECTIVE ANALYSIS
Authors: Gaylard E
Published: April 2023

SUMMARY The cases of 455 consecutive patients undergoing coronary artery bypass grafting (CABG) in one unit between 1990 and 1993 were retrospectively analysed with particular reference to the incidence of atrial fibrillation (AF), and with reference to any postoperative management that might have influenced this incidence. The recorded incidence of AF fell from 21% in 1990 to 11% in 1993. During this same period: the use of potassium chloride (KCl 20‐40mmol/l) supplements in the intravenous fluid replacement during the Immediate postoperative period increased from 0‐96%; the use of intravenous frusemide decreased from 12‐3%; and the practice of prescribing up to four Frumil (frusemide/amiloride hydrochloride) tablets daily was replaced by a more usual one tablet daily. Although the aetiology of AF post cardiac surgery is multifactorial, these three factors are implicated in the decreasing incidence of this complication in one unit.
HEARTBURN, OESOPHAGITIS AND BARRETT'S OESOPHAGUS IN SELF‐MEDICATING PATIENTS IN GENERAL PRACTICE
Authors: Corder AP , Jones RH , Sadler GH Millward , Daniels P , Johnson CD
Published: April 2023

SUMMARY A postal questionnaire on heartburn sent to 6760 randomly selected subjects yielded 3971 replies suitable for analysis. Heartburn had never been experienced by 1665 (42%) respondents. Significant symptoms of more than three months' duration that had occurred at least once a month in the preceding 12 months were reported by 1337 (34%) respondents. Of these, 875 had not consulted their general practitioner and were invited to attend for a structured interview with questionnaire and upper gastrointestinal endoscopy. A total of 177 were interviewed, and 143 underwent upper gastrointestinal endoscopy. Of those endoscoped, 106 (74%) experienced symptoms at least once a week. These were relieved by alginate consumption in 97 (68% of) cases. Just nine (6%) patients had been taking H2‐receptor antagonists. Macroscopic appearances of oesophagitis were seen in 46 cases [13 (6%) grade 1, 24 (11%) grade 2, five (2%) grade 3, two (1%) grade 4, and two (1%) grade 5]. Three patients had mild strictures and six patients had Barrett's oesophagus. There were no appearances suggestive of malignancy. Biopsies were taken in 122 cases, including all those in which abnormalities had been seen. Histological evidence of oesophagitis was seen in 47 cases. Gastric metaplasia was found in six cases and dysplasia seen in three. Patients who self‐medicate for reflux symptoms have a low prevalence of pre‐neoplastic and neoplastic pathology. A substantial proportion, however, have histological evidence of oesophagitis and a small number have metaplasia.
EFFICACY OF NIZATIDINE, CLARITHROMYCIN AND BISMUTH SUBCITRATE THERAPY FOR HELICOBACTER PYLORI ERADICATION IN DUODENAL ULCER PATIENTS — A PRELIMINARY REPORT
Authors: Papp J , Juhasz L , Lakatos L , Lonovits J , Szekely I , Tarnok F , Tulassay Z , Varkonyi T
Published: April 2023

SUMMARY The triple combination of nizatidine, clarithromycin, and bismuth subcitrate resulted in an ulcer healing rate of 98% and an H. pylori eradication rate of 90%. Corresponding ‘intention‐to‐treat’ figures were 92% and 84%, respectively. These results suggest that further studies, shorter in duration, using lower dosages, and possibly testing other combinations with a double‐blind methodology, are required.
DRUG‐INDUCED AKATHISIA REVISITED
Authors: Chung WSD , Chiu HFK
Published: April 2023

SUMMARY Despite the fact that the neuroleptic drugs have been widely used for more than 40 years, one of their most common side‐effects, akathisia, has been relatively neglected. There are still no universally agreed diagnostic criteria for akathisia, particularly chronic akathisia, and in this review article, we discuss the controversies surrounding the voluntary nature of its motor features and the importance of the dysphoric component. We also review the published epidemiological studies to show the great variation in frequency of occurrence. Finally, we discuss the possible neurotransmitters involved in the pathophysiology and treatment of this condition.
LANSOPRAZOLE PLUS CLARITHROMYCIN: EVALUATION OF A NEW DUAL THERAPY FOR Helicobacter pylori ERADICATION
Authors: Phull PS , Price AB , Halliday D , Jacyna
Published: April 2023

SUMMARY The aim of this pilot study was to evaluate the efficacy and safety of lansoprazole plus clarithromycin for eradication of Helicobacter pylori. A total of 26 patients with H. pylori infection were randomised to receive clarithromycin, 500 mg t.i.d. for 14 days, plus either lansoprazole, 30 mg o.m., (group L30, n=13) or lansoprazole, 30 mg b.i.d., (group L60, n=13). H. pylori status was determined pre‐treatment and four to six weeks after completion of the study medication by histology and 13C‐urea breath test. Two patients were unable to complete the course of medication. Of the remaining 24 patients, 14 (58%) successfully eradicated H. pylori — 8/12 (67%) patients in group L30 and 6/12 (50%) in group L60. Side‐effects were experienced by 17/26 (65%) of patients, most commonly a taste disturbance. The results from this pilot study suggest that dual therapy with lansoprazole plus clarithromycin is only a moderately effective regimen for eradicating H. pylori.
COUGH MIXTURE INDUCED PSYCHOSIS
Authors: Lee DTS , Lam LCW , Chan KPM , Leung HCM
Published: April 2023

SUMMARY Cough mixture is the third most commonly abused substance in Hong Kong. Over the last two years, ten cases of cough mixture‐induced psychosis were admitted to a University hospital. All of them were clinically indistinguishable from paranoid schizophrenia, but the psychotic symptoms often resolved promptly with the cessation of cough mixture use or a small dose of haloperidol. A representative case is described. The possible underlying aetiological mechanism and the treatment principle are discussed.
AN UNUSUAL CAUSE OF DYSPHAGIA
Authors: Ghiacy S , Khan A
Published: April 2023

SUMMARY We report a rare case of a bronchogenic cyst in an adult presenting with dysphagia. The benign nature of the lesion was established preoperatively by a series of radiological investigations. This enabled surgical planning and prediction of prognosis. The presentation, radiological findings and its differential diagnosis are discussed.
HEPARIN INDUCED THROMBOCYTOPENIA CAUSING LIFE‐THREATENING POSTOPERATIVE HAEMORRHAGE
Authors: Rice P , Dace S , Mcmullin MF , Clements WDB
Published: April 2023

SUMMARY Heparin is ubiquitously employed in surgery in the prevention and treatment of thromboembolic disorders. A small but significant number of patients receiving heparin develop thrombocytopenia and are at risk of both serious thromboembolic disease and haemorrhage. A case is reported where a young woman developed life‐threatening postoperative haemorrhage associated with heparin induced thrombocytopenia (HIT).
CRITICAL DRUG APPRAISAL: ETIDRONATE INTERMITTENT CYCLIC THERAPY FOR POSTMENOPAUSAL OSTEOPOROSIS
Authors: Miller PD
Published: April 2023

SUMMARY An overview of intermittent cyclical therapy with oral etidronate disodium in the treatment of postmenopausal osteoporosis is given. Etidronate has been used successfully in the treatment of Paget's disease and for the prevention and treatment of heterotopic ossification after hip replacement and spinal cord injury. It is approved for the treatment of postmenopausal osteoporosis in many European countries, Canada and Australia. Studies of such therapy indicate that etidronate significantly increases bone mass, reduces the risk of future vertebral fracture, and is safe and generally well tolerated.
HRT, A GENERAL PRACTICE APPROACH: HOW TO REACH THE MOST VULNERABLE
Authors: Coope JKM , Coope JR
Published: April 2023

SUMMARY Hormone replacement therapy has been shown to be effective in the preservation of bone density and its use should lead to a substantial reduction in the fracture rate of older women. Observational studies have also suggested that it may lead to a reduction in the incidence of coronary heart disease. Both effects are relevant to preventive care in general practice and have been applied within the framework of health promotion clinics. However, the tendencies for patients who are already healthy to select themselves for attendance at these clinics, and for long‐term hormone therapy, mean that efforts to improve the health of the population do not reach those most in need. Groups most at risk should be defined by individual practices and identification of high‐risk patients be followed by appropriate investigation and treatment. It is possible to identify the following high‐risk groups: long‐term users of corticosteroid therapy or thyroxine; women who have had an early hysterectomy or oophorectomy; women with known coronary artery disease, diabetes or familial hyperlipidaemia. Methods of ascertainment and investigation are described, as are the various modes of therapy and lifestyle modifications considered appropriate. Health promotion clinics are not currently reaching those most in need, and preventive therapy should be extended to target the most vulnerable.
DIAPHRAGMATIC HERNIATION OF THE LARGE BOWEL ASSOCIATED WITH UNUSUAL CLINICAL AND ELECTROCARDIOGRAPHIC PRESENTATION
Authors: Kounis NG , Zavras GM , Papadaki PJ , Artinopoulos CJ , Hadjuoannou AN , Goudevenos JA , Feretis AB , Frangides C
Published: April 2023

SUMMARY This is the first case reported of combined hiatus hernia of the stomach and herniation of the splenic flexure of the colon through the oesophageal hiatus. It was associated with unusual clinical and electrocardiographic findings. We postulate that these were the result of an increase in intrathoracic pressure induced by the herniating structures.
AN AUDIT OF 319 DEATHS ACROSS FOUR GENERAL PRACTICES
Authors: Holden J , Brindley J , O'Donnell S , Miles L
Published: April 2023

SUMMARY Death is a major outcome measure, and the value of an audit of the preventable factors leading to individual deaths is accepted in secondary care. Although approximately 20 of a typical general practitioner's patients will die every year, audits of deaths in general practice are seldom published. This is probably partly due to the difficulties posed by comparability, partly due to the wide range of causes of such deaths and possible contributory factors, and partly due to confidentiality considerations. We describe an audit of all death occurring in our practices over a 12‐month period. Although cigarette smoking was considered to exceed all other contributory causes of death, preventable factors occurred in both primary and secondary care sufficiently often for important conclusions to be drawn. Comparison of causes of death between general practices is possible, and such enquiry can demonstrate important quality issues for both primary and secondary care.
RECENT ADVANCES IN THE MEDICAL MANAGEMENT OF PROSTATE CANCER
Authors: Kirby RS
Published: April 2023

SUMMARY Prostate cancer is a 20th century seedling which, because of its attendant morbidity and mortality and the increased longevity of the population, is set to germinate into a substantial economic burden in the next millennium. Most patients with prostatic cancer present with either locally advanced or metastatic disease, for which palliative endocrine therapies are the first‐line treatment. The increasingly sophisticated and selective hormonal methods available today, such as the longer‐acting formulations of luteinizing hormone‐releasing hormone (LH‐RH) analogues and newer, better‐tolerated, once‐daily, non‐steroidal anti‐androgens, have increased the therapeutic options and improved patient quality of life. Maximum androgen blockade, combining medical or surgical castration with an anti‐androgen, is an increasingly accepted therapy, and offers the greatest efficacy, particularly for patients with a lesser disease burden. The development of hormone‐refractory tumours is still a problem in advanced prostate cancer, although elucidation of the mechanisms involved should offer many potentially fruitful avenues for new therapies.
MELIOIDOSIS: A RARE BUT NOT FORGOTTEN CAUSE OF FEVER OF UNKNOWN ORIGIN
Authors: Handa R , Bhatia S , Wali JP
Published: April 2023

SUMMARY Melioidosis is widely prevalent in Southeast Asia and northern Australia. Although it is believed to pose no current threat to the populations of developed countries, the increased mobility of people around the world and of Southeast Asian refugees to Western countries may change this. Its long incubation period may put a relatively large number of currently asymptomatic people at risk. It should be considered in the differential diagnosis of any febrile illness in a person who has visited an endemic area, especially if the presenting features are those of fulminant respiratory failure, if multiple pustular or necrotic skin or subcutaneous lesions develop, or if there is a radiologic pattern of tuberculosis from which tubercle bacilli cannot be demonstrated.
IRON DEFICIENCY ANAEMIA IN GENERAL PRACTICE: PRESENTATIONS AND INVESTIGATIONS
Authors: Stellon AJ , Kenwright SE
Published: April 2023

Twenty‐six patients over the age of 50 years with proven iron deficiency anaemia were identified, investigated and followed up in general practice over a five‐year period. The anaemia was symptomatic in 50% of patients but only 20% had symptoms related to the gut. Faecal occult blood testing was positive in five patients only and negative tests occurred in three patients with significant disease, including one caecal carcinoma. All patients agreed to oesophagogastroduodenoscopy (OGD) and fibreoptic sigmoidoscopy carried out on the same occasion. In eight patients, significant abnormalities were found on OGD and in two patients on sigmoidoscopy. Four patients declined barium enema examinations, two of whom had significant OGD abnormalities. Barium enema examination of the other 22 patients showed polyposis of the colon and a caecal carcinoma and initially missed one carcinoma of the caecum which was found subsequently. The likelihood of finding significant disease in iron‐deficient patients over 50 years of age is high and should be assumed to be due to blood loss into the gut. Investigation by OGD, sigmoidoscopy and barium enema in the first instance seems warranted and is a condition that can be safely managed by the GP. (Br J Clin Pract 1997; 51(2): 78‐80)
PARATHYROID HORMONE‐RELATED PROTEIN IN PANCREATIC EXOCRINE CANCER ASSOCIATED WITH HYPERCALCAEMIA
Authors: Bandyopadhyay P , Baksi S , Bandyopadhyay D , Patel CU
Published: April 2023

Hypercalcaemia is a common complication of malignancy seen in about 10% of cases of advanced cancer. Although hypercalcaemia is not uncommon with endocrine tumour of the pancreas, hypercalcaemia with cancer of the exocrine pancreas unrelated to bone metastasis has been rarely reported. We report a case of undifferentiated pancreatic cancer with severe hypercalcaemia due to parathyroid hormone‐related protein produced by the tumour cells that did not respond to medical management.
SUCCESSFUL THERAPY OF TARDIVE DYSKINESIA IN A 71‐YEAR‐OLD WOMAN WITH A COMBINATION OF TETRABENAZINE, OLANZAPINE AND TIAPRIDE
Authors: Koch HJ , Szecsey A , Vogel M , Fischer‐Barnicol D
Published: April 2023

There is no generally accepted treatment for tardive dyskinesia following intake of neuroleptics. Many compounds with effects on serotonine, GABA, cholinergic or dopamine receptors have been clinically useful. We report on a 71‐year‐old female patient suffering from orofacial tardive dyskinesia after treatment with haloperidol, which did not respond to monotherapy with antidyskinetic drugs. The syndrome disappeared almost completely within two weeks after a multidrug approach consisting of tetrabenazine, olanzapine and tiapride. A combination of antidyskinetic drugs should be considered in patients with severe tardive dyskinesia.
WHY DO FAMILY DOCTORS PRESCRIBE ANTIBIOTICS FOR UPPER RESPIRATORY TRACT INFECTION?
Authors: Lam TP , Lam KF
Published: April 2023

The prescribing behaviour of family doctors in Hong Kong towards upper respiratory tract infections (URTIs), and the major clinical factors that might affect such behaviour, were studied. Members of the Hong Kong College of Family Physicians were surveyed; 801 completed the questionnaire with an overall response rate of 65%. Purulent nasal discharge, purulent sputum, persistent fever over three days, patients looking unwell, exudates on throat, inflamed eardrums and cervical lymphadenopathy made more than half the respondents ‘likely’ or ‘very likely’ to prescribe antibiotics. Those in private practice and those who graduated in Hong Kong were more likely to prescribe antibiotics, while fellows of the College were less likely to do so. Vocational training and higher qualifications in family medicine/general practice, however, revealed minimal effect. Our results showed that many doctors are still prescribing antibiotics when they encounter URTI patients presenting with clinical factors that have been proven to have no or little benefit from antibiotics.
USE OF NEPHROSTOMY TUBES IN URETERIC OBSTRUCTION FROM INCURABLE MALIGNANCY
Authors: Little B , Ho KJ , Gawley S , Young M
Published: April 2023

Malignancy may produce ureteric obstruction. This obstruction may be relieved by inserting a nephrostomy tube. All 31 cases of malignant ureteric obstruction from a single institution were retrospectively analysed. The commonest indications for nephrostomy tube insertion were renal failure (87%) and flank pain with hydronephrosis (13%). The mean serum creatinine levels pre and post insertion were 481 and 170 umol/l, representing significant improvement (p<0.01). The complication rate was 13%, relating to tube blockage or dislodgement. Survival of patients was significantly worse if their malignancy was not resectable or suitable for chemotherapy (p=0.01). However, incurable patients still survived for a mean of 232 days, and although 46% of this time was spent as an inpatient, it did not differ significantly from the inpatient rate of curable patients (31%, p=0.1). Nephrostomy tube insertion should be considered for all palliative cases of malignant ureteric obstruction.
BONE METASTASIS AS THE FIRST MANIFESTATION OF LUNG CANCER
Authors: Kagohashi K , Satoh H , Ishikawa H , Ohtsuka M , Sekizawa K
Published: April 2023

Bone metastasis usually occurs late in the course of the disease, but in some patients it is the first manifestation of lung cancer. To evaluate the characteristics of patients with bone metastasis as a first manifestation of lung cancer, the medical records of 1063 patients with lung cancer between 1976 and 2001 were reviewed retrospectively. Twenty‐four (2.3%) lung cancer patients presented symptoms of bone metastasis as a first manifestation; 11 patients had bone metastasis as the only site of spread in lung cancer; 16 had adenocarcinoma; five had a primary lesion <30 mm, and nine had N0‐1 disease. Patients with sole bone metastasis did not have a more favourable survival rate than patients with bone and other systemic metastases (p=0.2938). Whether metastasis is the first manifestation of lung cancer or not, the occurrence of bone metastasis generally means a poor prognosis.
22. DIAGNOSTIC DELAYS IN BREAST CANCER AND IMPACT ON SURVIVAL
Authors: Kothari A , Fentiman IS
Published: April 2023

There is always an interval between the first symptoms, time to diagnosis and start of treatment in women with symptomatic breast cancer. Delay may be due to the patient, her general practitioner or a false negative diagnosis in hospital. A systematic overview showed that delays of 3–6 months were clearly associated with increased tumour size, advance in disease stage and poorer long‐term prognosis. Nevertheless, controversy persists regarding the impact of delay on survival. The conflicting results may be due to a difference in sample characteristics, differences in the delay interval studied or variations in the definition of delay. A major drawback of many studies was that the potential confounding effect of lead‐time bias was not taken into account. One of the largest single institution studies, designed to control for the lead‐time bias, confirmed that survival measured from both date of diagnosis and onset of patient's symptoms was worse in women with delays of >12 weeks. Within individual stages, longer delays had no adverse impact on survival. It is important to identify groups of patients at high risk of delay so that strategies can be developed and effectively targeted.
A PROSPECTIVE EVALUATION OF THE MANAGEMENT OF ACUTE PYELONEPHRITIS IN ADULTS REFERRED TO UROLOGISTS
Authors: Gujral S , Bell CR , Dare L , Smith PJB , Persad RA
Published: April 2023

In order to assess whether it is appropriate and clinically efficient to admit adults with ‘clinically diagnosed’ acute pyelonephritis (APN) under urologists, as is current practice in many NHS hospitals.a prospective study was undertaken over nine months in an NHS teaching hospital. Thirty‐nine patients with clinical APN were admitted to the urology unit; all were pyrexial and 30 (77%) had typical features of rigor, flank pain and irritative lower urinary tract symptoms. Twenty‐one (54%) had positive urine cultures, 31 (79%) had parenteral antibiotics, while another three (7%) had oral agents initially. The remaining five (14%) were continued on agents initiated by their GPs before admission. Thirty‐three (85%) had imaging procedures with eight significant anomalies being noted. Urgent invasive intervention was required in only four (10%) patients; length of stay varied from one to 25 days. Uncomplicated moderate to severe APN in adults may be treated safely without the need for admission to the urology unit, either in the outpatient setting or on an acute admissions observation ward. Complicated cases requiring intervention can be transferred to the urologist once recommended investigations have been undertaken. This care pathway may help to reduce cancellations of elective urological cases and is likely to be more cost‐effective for the NHS by reducing unnecessary admissions.