bluuebunny/crossref_metadata_2025 huggingface dataset:
PRAVASTATIN IN ACUTE ISCHAEMIC SYNDROMES: RESULTS OF A RANDOMISED PLACEBO‐CONTROLLED TRIAL
Authors: Den Hartog FR , Van Kalmthout PM , Van Loenhout TT , Schaafsma HJ , Rila H , Verheugt FWA
Published: April 2023

Therapy with individual 3‐hydroxy‐3‐methylglutaryl coenzyme A reductase inhibitors (statins) has been shown conclusively to diminish coronary event rates and mortality in both primary and secondary prevention. To date, scant attention has been paid to whether initiation of such regimens in the hospital phase of acute coronary syndromes might confer cardioprotective benefits. The purpose of this study was to determine the safety and tolerability of early initiation of statin therapy in patients with acute coronary syndromes. In this randomised, double‐blind, three‐month, pilot study, 100 patients with acute myocardial infarction or unstable angina and low‐density lipoprotein cholesterol >3.5 mmol/l were randomly assigned to pravastatin 40 mg daily or placebo initiated within 48 hours of hospital admission. Pravastatin proved safe and well tolerated in these patients, who were well matched at baseline. No statistically significant differences in death, MI and drug‐related adverse events were observed in the pravastatin group compared with control subjects. This pilot study shows that therapy with pravastatin early after an acute coronary event is safe and well tolerated. Larger, long‐term studies are needed to confirm these findings.
SELF‐MUTILATION: REVIEW AND CASE STUDY
Authors: Parrott HJ , Murray BJ
Published: April 2023

This article reviews in a systematic way the literature on severe self‐mutilation, emphasising possible aetiological factors and warning signs of impending self‐mutilation. It provides practical advice on the prevention and management of such events, including legal issues of capacity and consent. An illustrative case history is provided of an artist who cut off his ear.
THE NIACIN SKIN FLUSH TEST IN SCHIZOPHRENIA: A REPLICATION STUDY
Authors: Puri BK , Easton T , Das I , Kidane L , Richardson AJ
Published: April 2023

The aim of this study was to confirm a recent report that the non‐invasive niacin skin flush test can be used to demonstrate impaired arachidonic acid‐related signal transduction in schizophrenia. The response to topical aqueous methyl nicotinate solution was recorded at five‐minute intervals over 20 minutes in 21 patients with schizophrenia, and in 20 age‐ and sex‐matched normal individuals with no personal or family psychiatric history. The response was significantly lower in the patients with schizophrenia. At a concentration of 0.001 M, at the 15‐minute timepoint, only two out of the 21 patients with schizophrenia showed a response, compared with 15 out of 20 of the controls (p<0.00002), giving a sensitivity of the niacin skin test of 90% and a specificity of 75%. Our results are therefore consistent with the previous published report and suggest that this test may be useful clinically in the diagnosis of schizophrenia.
MEALTIME GLUCOSE REGULATION IN TYPE 2 DIABETES
Authors: Tuomilehto J , Del Prato S
Published: April 2023

Glucose control remains the cornerstone of therapeutic strategies designed to reduce the risk of long‐term complications in patients with type 2 diabetes. This article reviews a growing body of evidence suggesting that post‐mealtime glucose spikes may exert an independent effect on diabetic complications, and discusses how a more effective strategy requires better focus on the regulation of mealtime glucose. New treatment options, specifically designed to restore a more physiological post‐mealtime insulin profile, may provide better tools to ensure more comprehensive glycaemic control, which will allow for better prevention of micro‐ and macrovascular complications in type 2 diabetic patients.
SMOKING CESSATION: A CONSENSUS STATEMENT WITH SPECIAL REFERENCE TO PRIMARY CARE
Authors: Jackson G , Bobak A , Chorlton I , Fowler G , Hall R , Khimji H , Matthews H , Stapleton J , Steele C , Stillman P , Sutherland G , Swanton RH
Published: April 2023

EXECUTIVE SUMMARY

Nicotine addiction is a serious medical condition that needs to be treated like any other chronic disease.1

Primary care must play a key role in smoking cessation2 and offering help should be a routine part of primary care practice.

As the most frequent opportunity for intervention lies within primary care, GPs should ensure that they raise the issue of stopping smoking at least annually with their smoking patients. When the smoker is ready to stop, the initial personal involvement of the GP is likely to increase the chance of a successful quit attempt. Follow‐up may be with another healthcare professional.

The support of healthcare professionals for the smoker who is motivated to quit, combined with appropriate pharmacotherapy, can substantially increase the chances of a successful quit attempt.3

Secondary care staff should also make every effort to help people to stop smoking and should communicate effectively with primary care – opportunities during hospitalisation are frequently missed.

Specialist smoking cessation clinics have an essential role in providing more intensive specialist treatment and the expertise to partner and support the primary care effort.

Smoking cessation is one of the most cost‐effective healthcare interventions that can be made.4
CLINICAL RATIONALE FOR ROSUVASTATIN, A POTENT NEW HMG‐COA REDUCTASE INHIBITOR
Authors: Hanefeld M
Published: April 2023

Coronary heart disease (CHD) is the leading cause of death worldwide, and effective treatment of hyperlipidaemia can prevent development of CHD and significantly reduce the risk for cardiovascular events and mortality in this disease. The advent of 3‐hydroxy‐3‐methylglutaryl coenzyme A (HMG‐CoA) reductase inhibitors (statins) has revolutionised the treatment of hyperlipidaemia, but many patients receiving these drugs still do not achieve their therapeutic goals. Rosuvastatin (Crestor™; formerly ZD4522) is a new, potent and long‐lasting inhibitor of HMG‐CoA reductase that is highly selective for hepatocytes. Its pharmacokinetics permit once‐daily dosing, and a lack of oxidative hepatic metabolism results in a reduced potential for drug‐drug interactions. Preliminary clinical results indicate that it produces rapid dose‐related reductions in total cholesterol, low‐density lipoprotein cholesterol, triglycerides, and apolipoprotein B that may exceed those achieved with other currently available statins. Increases in high‐density lipoprotein cholesterol have also been observed. Rosuvastatin is also well tolerated, with no evidence of either hepato‐ or myotoxicity. It is hoped that new agents such as rosuvastatin may help to reduce the high global morbidity, mortality and associated costs of CHD and related vascular disorders.
MAJOR ARTERIAL OCCLUSION BY EMBOLISATION OF AN OCCULT THROMBUS FOLLOWING THROMBOLYTIC THERAPY FOR MYOCARDIAL INFARCTION
Authors: Kathula SK , Bhargava A
Published: April 2023

We describe a case in which thrombolytic therapy for acute myocardial infarction resulted in a major arterial embolism from an existing aortic mural thrombus. Clinicians should be alert to this rare complication of thrombolytics, because timely diagnosis and treatment may prevent serious morbidity and mortality.
DOES BALANCE CONTROL DEFICIT ACCOUNT FOR WALKING DIFFICULTY IN PARKINSON'S DISEASE?
Authors: Chong RKY , Barbas J , Garrison K , Herolz A , Teheng R , Sethi K
Published: April 2023

Patients with Parkinson's disease (PD) walk slowly, in part to compensate for their balance control deficit. We tested the effect of balance support to determine if walking performance in PD patients would improve. The sample consisted of unmedicated older adults with idiopathic Parkinson's disease who had poor balance control but no stooped posture, arthritis or muscle weakness. There was no difference in walking speed between unsupported and supported walking. The speeds were between those reported for disease‐free older adults and older adults with muscle weakness and a history of falling. PD patients' walking difficulties, even while using a balance aid, may be partly explained by their set‐changing problems. They frequently hold the cane off the ground when walking, suggesting their set‐changing difficulty may be severe enough that using it aggravates their walking difficulty. Treatment of walking difficulty in PD patients should consider interventions other than those dealing only with balance control.
FACIAL PARALYSIS WITH AN INFLAMMATORY PAROTID MASS
Authors: Halfpenny W , Bhandari R , Dunkley S
Published: April 2023

Facial paralysis in association with a parotid mass is usually associated with a diagnosis of malignancy. Benign parotid neoplasms and inflammatory processes resulting in facial paralysis are extremely rare. This report describes such a case and highlights some of the difficulties surrounding the diagnosis and management of these cases.
COLLECTING DUCT CARCINOMA OF THE KIDNEY ASSOCIATED WITH THE SICKLE CELL TRAIT
Authors: Yip D , Steer C , Al‐Nawab M , Van Der Walt J , Harper P
Published: April 2023

Collecting duct carcinoma of the kidney is a rare neoplasm that arises from the medullary collecting ducts. It has an aggressive clinical course and patients usually present with metastatic disease. Treatment approaches apart from surgery have been unrewarding. Renal medullary carcinoma is also an aggressive tumour which occurs predominantly in young, black, male patients with sickle cell trait. We describe a case of collecting duct carcinoma in a 61‐year‐old black female who exhibited the sickle cell trait. Histopathology revealed a high‐grade tubular carcinoma with marked desmoplasia, adjacent dysplastic collecting ducts and positive immunohistochemical staining for high and low molecular weight cytokeratins and epithelial membrane antigen. The association of collecting duct carcinoma with sickle cell trait has not been previously reported. This case supports the postulate that collecting duct carcinoma and renal medullary carcinoma may be part of the same spectrum of renal malignancies.
CONGENITAL ANOSMIA
Authors: Ho TP , Carrie S
Published: April 2023

We present two cases demonstrating congenital anosmia. In both cases, magnetic resonance imaging (MRI) has served to highlight an interesting clinical oddity. To date, there has only been one study of the use of MRI in the assessment of patients with congenital anosmia who do not have Kallmann's syndrome.
WORD DEAFNESS PRESENTING AS A SUDDEN HEARING LOSS
Authors: Murray A , Fields MJ
Published: April 2023

Sudden hearing loss is a condition frequently seen in ENT departments and is usually due to otological pathology. We present a patient who described symptoms of a sudden inability to hear but who, on further questioning and investigations, had 'word deafness' due to bilateral temporoparietal infarcts. We discuss the clinical syndromes associated with these infarcts and the specific management of word deafness.
FOLLOW‐UP OF BREAST CANCER: TIME FOR A NEW APPROACH?
Authors: Donnelly J , Mack P , Donaldson LA
Published: April 2023

After treatment for breast cancer women are monitored for recurrent disease by means of routine hospital‐based follow‐up appointments. The aim of this study is to determine the efficiency of this system, by establishing how recurrence presents to our hospital. The study comes at a time of increasing pressure on breast clinics from new patient referrals and the need, since April 1999, to see all cases classified as urgent within two weeks of referral. A consecutive series of 643 patients who presented with operable breast cancer between 1992 and 1998 were reviewed. Details about the 108 patients who had locoregional or metatstatic relapse were obtained from our breast cancer database and their clinical records. Full data were available on 104 patients: 77 (74%) were seen at expedited (interval) appointments and a further 18 (17.3%) drew attention to symptoms at a routine visit. Two cases of locoregional recurrence were revealed by surveillance imaging. Unsuspected disease, locoregional in all cases, was detected on examination in 7 (6.7%) patients. The median time to presentation of recurrence was 19 months for metastatic and 18 months for locoregional disease. Breast cancer recurrence usually presents to an interval clinic. Most cases that are confirmed following a routine review are already symptomatic. Long‐term routine hospital follow‐up after treatment for breast cancer appears inefficient and unnecessary. Following liaison with local general practitioners we propose to discharge patients from routine review after two years. Thereafter they will have scheduled appointments with their GPs with immediate access to specialist review in the breast care unit if required.
SIMILAR FREQUENCY OF TT VIRUS INFECTION IN PATIENTS WITH LIVER ENZYME ELEVATIONS AND HEALTHY SUBJECTS
Authors: Kadayifci A , Guney C , Uygun A , Kubar A , Bagci S , Dagalp K
Published: April 2023

TT virus (TTV) is a novel DNA virus that has been identified in patients with post‐transfusional hepatitis of unknown aetiology. However, its pathogenic role in liver injury remains unclear. To determine its frequency and clinical impact in cryptogenic liver diseases, we investigated the TTV prevalence in patients with liver enzyme elevations of unknown aetiology and in healthy subjects. Fifty‐four patients (33 male, 21 female) who have been followed up for elevated ALT/AST levels of unknown aetiology and 118 healthy subjects (99 male and 19 female) were included in the study. TTV DNA was investigated by the polymerase chain reaction. Other possible causes of transaminase elevation were excluded in detailed biochemical and serological tests. A liver biopsy was performed in 45 patients. TTV DNA was detected in 46 patients with liver enzyme elevations (85.1%) and in 94 healthy subjects (79.6%). There was no statistical difference between the groups (p=0.51). Histological examination of the liver revealed no specific change in TTV DNA positive patients that could be attributed to this virus infection. These results showed that TTV is a common virus in patients with liver enzyme elevation of unknown aetiology and even among healthy subjects in our geographical area. TTV infection is therefore widespread in the general population and does not seem to be associated with liver damage.
2. BENIGN BREAST DISEASE
Authors: Hamed H , Eentiman IS
Published: April 2023

Benign breast disorders (BBD), classified by the ANDI system (aberrations of normal development and involution), constitute the major workload in breast clinics. Breast pain (mastalgia) is classified as cyclical, and non‐cyclical extramammary causes such as ribcage pain have to be identified. Most patients need reassurance alone but those with moderate/severe pain present for >6 months may need treatment: randomised trials have shown danazol, bromocriptine and tamoxifen to be effective. Fibroadenoma is the commonest benign solid lump in women aged 15–30 years. The diagnosis must be confirmed by triple assessment. Cysts occur usually in women of middle to late reproductive life. After ultrasound has confirmed the lump as cystic, it can be aspriated. Nipple discharge should be tested for the presence of haemoglobin (Hb). Those with HB+ discharge may require microdochectomy for treatment and diagnosis, common causes being duct papilloma and duct ectasia. Breast abscesses may occur during lactation or in women with duct ectasia and are treated by incision or aspiration together with antibiotics.
CLINICAL EFFICACY WITH FORMOTEROL IN THE ABSENCE OF A RESPONSE TO SALMETEROL: A REVIEW
Authors: Kottakis J , Wood R , Gros V Le , Cioppa G Bella
Published: April 2023

Salmeterol and formoterol are both β2‐agonist bronchodilators with a long duration of action and are often classified together, yet they are distinctly different in their pharmacology. Recent evidence suggests there is a subpopulation of asthmatic patients who do not respond to salmeterol, yet can attain clinical benefit with formoterol. Following a literature search, three published case reports are reviewed as well as results from two published clinical trials designed specifically to document response to formoterol in ‘non‐responders to salmeterol’ asthmatics. Possible mechanisms underlying this observation are discussed, including pharmacological differences of the two drugs relating to agonism at the β2‐receptor and to effect on nuclear transcription factors.
OMALIZUMAB, A MONOCLONAL ANTIBODY AGAINST IgE FOR THE TREATMENT OF ALLERGIC DISEASES
Authors: Solèr M
Published: April 2023

Omalizumab, a recombinant, humanised monoclonal antibody against human IgE, will be introduced soon for the treatment of allergic asthma. This antibody binds circulating IgE molecules and inhibits the type I immune response in the lung and other target organs. In the phase II and III studies performed, it demonstrated a significant and important effect in controlling and stabilising asthma by reducing exacerbations and the need for inhaled corticosteroids. The safety and tolerability up to one year of treatment were very good. This new treatment may have a role in patients with difficult‐to‐control asthma, with recurrent exacerbations, and those with concurrent asthma, nose and eye symptoms.
SEVERE HYPERKALAEMIA WITH NORMAL ELECTROCARDIOGRAM
Authors: Bandyopadhyay S , Banerjee S
Published: April 2023

Elevated serum potassium without associated electrocardiograph and biochemical changes makes the diagnosis of pseudohyperkalaemia likely. One of the common causes of this is thrombocytosis with in vitro leak of cellular potassium due to increased fragility of the platelets. We report a case where the diagnosis of essential thrombocytosis was made during investigation of persistent hyperkalaemia in an apparently healthy female.
THE EFFICACY OF ACETAZOLAMIDE ON VISUAL FUNCTIONS IN A PATIENT WITH CHOROID METASTASIS OF BREAST CARCINOMA
Authors: Sari R , Camci C , Kutlu R , Totan Y , Sevinc A , Buyukberber S
Published: April 2023

Breast carcinoma is the most frequent cancer in women and is the second leading cause of death. Choroid metastasis of breast carcinoma can be found either at presentation or in remission. It is frequently encountered in disseminated breast cancer with multiple organ metastasis. It has been proposed that the oedema‐reducing effect of acetazolamide is due to stimulated ion and fluid removal from the retina to the choroid. A 40‐year‐old female patient on adjuvant chemotherapy for breast cancer was found to have an isolated choroid metastasis. Clinical and radiological remission was achieved after orbital radiotherapy, chemotherapy and acetazolamide treatment. In this case report, we emphasise the possible beneficial effect of acetazolamide in patients with choroid metastasis.
COMPARISON OF ALENDRONATE, CALCITONIN AND CALCIUM TREATMENTS IN POSTMENOPAUSAL OSTEOPOROSIS
Authors: Dursun N , Dursun E , Yalçin S
Published: April 2023

The present study was planned to assess the safety, tolerability and efficacy on bone mineral density (BMD), pain, quality of life and fracture risk of alendronate, calcitonin and calcium treatments. A total of 151 postmenopausal women with lumbar spine BMD 2 SD or more below the young adult mean were randomly assigned to one of three groups: 51 patients received oral alendronate 10 mg and calcium 1000 mg (alendronate group), 50 patients intranasal salmon calcitonin 100 IU and oral calcium 1000 mg (calcitonin group), and 50 patients oral calcium 1000 mg (calcium group) daily for one year. BMD was assessed by dual energy X‐ray absorbtiometry, pain by a visual analogue scale, and quality of life by the Nottingham health profile. Significant increases in BMD at all sites were obtained in the calcitonin and alendronate groups, but not in the calcium group. Pain and quality of life improved significantly in both the calcitonin and alendronate groups, but not in the calcium group. New vertebral fractures were seen in 31.58% of the alendronate, 37.5% of the calcitonin, and 40% of the calcium groups, representing no statistical difference. No serious side‐effects were seen in any of the patients during follow‐up.
VALSARTAN ALONE AND AS PART OF COMBINATION THERAPY IN GENERAL PRACTICE IN BRAZIL
Authors: Madi JC , Oigman W , Franco R , Armaganijan D ,   Group of Investigators from the Brazilian Multicentre Evaluation
Published: April 2023

The objective of this study was to assess the efficacy and tolerability of valsartan (Diovan®) when given alone or as part of a combination regimen in normal clinical practice, in general practice patients in Brazil. In an open, multicentre post‐marketing surveillance (PMS) study, 7256 hypertensive patients were evaluated. Therapy with valsartan either as monotherapy or in combination with 12.5 mg chlorthalidone was observed for up to six months. Assessments at baseline and study endpoints included analysis of adverse events and measurement of systolic and diastolic blood pressure (BP). A total of 3855 patients (53%) received valsartan as monotherapy (mostly as 80 mg once daily), 1162 (16%) received 80 mg valsartan + 12.5 mg chlorthalidone, and 347 (4.8%) received valsartan together with other antihypertensive agents; 858 patients were not evaluable because of inadequate records. A control group of 1034 patients received other antihypertensives. Overall tolerability was high, with 98.5% of patients receiving valsartan alone, 97.7% of those receiving valsartan + chlorthalidone and 92.4% of those receiving other antihypertensives giving tolerability ratings of ‘excellent’ or ‘good’. In this large PMS study, valsartan alone and in combination with chlorthalidone was associated with excellent safety and tolerability in general practice patients in Brazil with primary hypertension, irrespective of age, sex or concomitant diseases.
THE INCIDENCE OF CHLAMYDIA TRACHOMATIS IN WOMEN WITH URETHRAL SYNDROME
Authors: Mutlu B , Mutlu N , Yücesoy G
Published: April 2023

The objective of this study was to discover the incidence of Chlamydia trachomatis in women with urethral syndrome. A total of 102 patients included in this study were divided into two groups: group 1 comprised 63 women suffering from painful urination and frequency, with no organisms seen on Gram stain or isolated in routine urine culture; group 2 consisted of 39 women with no complaints. Chlamydia antigen was found to be positive in 24 patient samples (38%) in group 1 and in four patient samples (11%) in group 2. The difference between the two groups was statistically significant (p=0.0435). There was also a weak correlation between Chlamydia antigens and finding more than 10 polymorphonuclear leucocytes in the Gram stains (r=0.02364).
3. FIXED AND MODIFIABLE RISK FACTORS FOR BREAST CANCER
Authors: Fentiman IS
Published: April 2023

Likely pathogenesis of breast cancer is in two phases, initiation and promotion. Initiating factors include ionising irradiation, dietary factors and possibly alcohol consumption causing DNA mutations uncorrected by repair mechanisms. Subsequent promotional factors include exposure to oestrogens, reduced by late menarche, early pregnancy and lactation and increased by nulliparity, oral contraceptive use and hormone replacement therapy. Only 5% of breast cancers result from inherited genetic mutations of BRCA1 and BRCA2, but individuals with such mutations have a high risk (66–80%) of developing the disease. Most patients with benign breast problems are not at increased risk of breast cancer, but those with atypical epithelial hyperplasia have an increased risk and should be kept under surveillance or asked to participate in trials of prevention.
PERCUTANEOUS ENDOSCOPIC GASTROSCOPY TUBE MIGRATION: A RARE CAUSE OF A COMMON SURGICAL PROBLEM
Authors: Hussien M , Eawzy M , Carey D
Published: April 2023

Percutaneous endoscopic gastroscopy (PEG) is now the preferred method for long‐term enteral nutrition for patients with inadequate oral intake. It is usually replaced by a Foley catheter when it becomes non‐functional because of blockage or wear and tear. PEG tube migration is an unusual complication which may not be noticed by the patient or the medical staff and may present as delayed small bowel obstruction. We report on a patient who developed such a complication and the missing PEG tube was replaced by a Foley catheter when it was thought the original tube had fallen out. The use of catheters with an external stop device is recommended to prevent this rare complication.
ABNORMALITIES OF THYROID HORMONAL FUNCTION TESTS IN HOSPITALISED ELDERLY PATIENTS: A PROSPECTIVE STUDY
Authors: Gupta A , Habubi N , Thomas P
Published: April 2023

We measured thyroidal hormonal function tests in unselected sick and hospitalised elderly patients with a new immunoassay technique. Our results show a significant percentage of subjects with thyroid hormonal dysfunction.
PATENT FORAMEN OVALE IN ELDERLY STROKE PATIENTS
Authors: Lewis RR , Hussain A , Rashed KA , Cooke RA , McNabb WR , Chambers J
Published: April 2023

The aim of this study was to determine the incidence of echocardiographically detectable patent foramen ovale (PFO) in elderly patients who have strokes from cerebral infarction, as well as to assess the association between PFOs and other risk factors for stroke disease. Forty‐three patients aged ≥65 years admitted consecutively with cerebral infarction shown on computerised tomography of the brain were assessed using transoesophageal echocardiography. A PFO was present in 8 (19%) of the 43 patients. Four patients (50%) in this PFO group had stroke risk factors. Two were in atrial fibrillation and, of the six patients in sinus rhythm, a risk factor was present in two, both of whom had diabetes mellitus. A PFO was not detected in 35 patients. Twenty‐nine (83%) of the patients in this group had risk factors, with 18 having two or more. Seven patients were in atrial fibrillation. Of the 28 patients in sinus rhythm, risk factors were present in 22 (78%).
METHANOL‐INDUCED OPTIC NEUROPATHY: TREATMENT WITH INTRAVENOUS HIGH DOSE STEROIDS
Authors: Sodhi PK , Goyal JL , Mehta DK
Published: April 2023

The aim of this study was to find the potential benefit of intravenous high dose steroids in the treatment of patients with methanol optic neuropathy. Four patients complaining of diminution of vision after taking methylated spirit presented to us within a variable period of its consumption. The systemic features of methanol poisoning were absent in these patients. Raised blood levels of methanol confirmed the diagnosis of methanol optic neuropathy. All these patients received high doses of intravenous steroids for three days, followed by oral steroids, 1 mg/kg body weight, for 11 days. The administration of high doses of intravenous steroids led to an improvement of visual status in all four patients. Intravenous high dose steroids benefit the visual status of patients with methanol‐induced optic neuropathy, provided the interval between the consumption of methanol and starting treatment is short. Further studies should be undertaken to document the role of intravenous steroids in this context.
NON‐NEUROLOGICAL VARIABLES AND MORTALITY OF ACUTE STROKE
Authors: Sharma JC
Published: April 2023

Acute stroke is associated with high mortality. While this is the direct consequence of the neurological injury, stroke patients develop a number of physiological abnormalities and complications in the acute phase. Extensive research has produced a plethora of information about these non‐neurological variables. Different patients have different abnormalities. Some of these variables have severe adverse effects on mortality, both acute and long term. Some of the variables are pre‐existing, while others are non‐modifiable. The body responds to cerebral tissue injury in a way that seems to lead to further damage to the brain and other vital systems, and patients usually have more than one variable needing attention. Acute stroke presents as a multisystem disease on the verge of multisystem failure. Although there is lack of evidence of the benefits of correcting the deranged variables, it makes clinical sense that non‐neurological variables should be identified, monitored and managed, with the aim of improving the outcome of acute stroke patients.
THE ECHINOCANDINS, FIRST NOVEL CLASS OF ANTIFUNGALS IN TWO DECADES: WILL THEY LIVE UP TO THEIR PROMISE?
Authors: Graybill JR
Published: April 2023

The echinocandins comprise a major development in systemic antifungal therapy. They rapidly and irreversibly inhibit glucan synthesis in the fungal cell wall, a distinct target from azole antifungals, flucytosine and polyenes. As such, the echinocandins appear effective against triazole and amphotericin B resistant fungi. The spectrum is still not fully understood because of problems with susceptibility testing, and because of limited studies in animal models. The primary target species for clinical studies include Candida and Aspergillus, but the class is likely to have broader use. Lack of nephrotoxicity and few drug interactions make this class attractive. The major limitations at present appear to be the lack of oral formulation and uncertainty regarding the extent of the spectrum. These drugs have the potential of being significant additions to the management of mycoses in the critically ill patient.
REPAIR OF CONCOMITANT INGUINAL AND FEMORAL HERNIAS UNDER LOCAL ANAESTHESIA
Authors: Elton C , Stoodley BJ
Published: April 2023

We describe the case of a 91‐year‐old patient with small bowel obstruction due to an obstructed groin hernia. It was decided to repair the hernia under local anaesthesia and sedation because of the patient's age and medical condition. At surgery, concomitant inguinal and femoral hernias were found and repaired. We discuss the technique of repairing groin hernias under local anaesthesia, especially in the elderly, and the previously reported incidence of concomitant hernias.
AN UNUSUAL CASE OF LEFT PARADUODENAL HERNIA
Authors: Patterson JA , Tadros EG , Wilkinson AJ
Published: April 2023

Paraduodenal hernias are the commonest form of intra‐abdominal hernia. We report on a rare paraduodenal hernia involving the duodenojejunal recess.
REFERRAL PATTERNS TO A DISTRICT GENERAL HOSPITAL GASTROENTEROLOGY OUTPATIENT CLINIC: IMPLICATIONS FOR ‘THE TWO‐WEEK TARGET’
Authors: Martin JP , Gabe SM , Pitcher MCL , Jacyna
Published: April 2023

We defined the pattern and appropriateness of GPs' new‐patient referrals to a large district general hospital gastroenterology department, and assessed the implications for workload in the context of the recently introduced ‘two‐week target’. Prospective data were collected on all new referrals over a two‐month period and 426 new appointments were included, from which data were available on 390. Only six referrals were deemed inappropriate. Sixty‐nine patients had a functional disorder, and GPs were less likely to diagnose this group at referral than the gastroenterologist was after the initial consultation. Nineteen per cent of all GP referrals were classified as urgent and 6% of these had a malignancy. Fifty per cent of patients with malignancy were not perceived as meriting an urgent referral by the GP Gastroenterology outpatient facilities are already overstretched and the implementation of the two‐week target will add considerable strain to the current resources, with little gain in identifying malignancy.
THE CURRENT PHYSIOTHERAPY MANAGEMENT OF PATIENTS WITH BRONCHIECTASIS: A UK SURVEY
Authors: O'Neill B , Bradley JM , McArdle N , Macmahon J
Published: April 2023

The purpose of this survey was to ascertain which physiotherapy techniques are currently used, how interventions are assessed and to determine the views of physiotherapists in the UK on the need for further research. Senior physiotherapists in 100 randomly selected hospitals providing respiratory care in the UK were sent a previously piloted questionnaire on their bronchiectasis practice. The response rate was 82%. A variety of physiotherapy treatment techniques and outcome measures are used, and there are no national guidelines on the physiotherapy management of patients with bronchiectasis. There is a clear need for research into the effectiveness of physiotherapy techniques in bronchiectasis including a cost‐benefit analysis which would enable targeting of resources and the development of evidence‐based practice guidelines.
CURRENT CLINICAL PRACTICE OF INDUCTION AND MAINTENANCE IMMUNOTHERAPY FOR METASTATIC RENAL CELL CARCINOMA
Authors: Little B , Young M , Ho KJ
Published: April 2023

Current systemic treatment of metastatic renal cell carcinoma revolves around the use of interleukin‐2 and interferon‐α, often in combination with 5‐fluorouracil. This article looks at the currently reported response rates for these modalities. It also looks at current practice as regards maintenance treatment, i.e. the continued therapeutic regimen following the initial response to the induction immunotherapy cycles.
AMIODARONE‐INDUCED THYROTOXICOSIS: NOT A BENIGN CONDITION
Authors: Leung PM , Quinn ND , Belchetz PE
Published: April 2023

Amiodarone is a heavily iodinated drug effective in the control of various tachyarrhythmias. Despite its undoubted benefit, treatment with amiodarone is not without risk, because a number of potentially serious side‐effects may develop during therapy. Thyrotoxicosis is most commonly recognised but its potential consequences tend to be underestimated, and its treatment can be challenging and difficult. We report several cases of amiodarone‐induced thyrotoxicosis which serve to highlight the potential severity of the condition.
USE OF A CUSTOMISED ENDOTRACHEAL TUBE FOR TRACHEOSTOMY IN THE LARGE NECK
Authors: Coatesworth AP
Published: April 2023

Patients with huge necks who require a tracheostomy pose particular problems. This paper describes a technique to customise a standard endotracheal tube to make a long tracheostomy tube. This can be used as a short‐term emergency airway. It is recommended because it is cheap, simple, safe and potentially life saving.
RIEDEL'S THYROIDITIS: CLINICAL, PATHOLOGICAL AND IMAGING FEATURES
Authors: Papi G , Corrado S , Cesinaro AM , Novelli L , Smerieri A , Carapezzi C
Published: April 2023

Riedel's thyroiditis (RT) is an extremely rare form of chronic thyroiditis, characterised by a fibroinflammatory process which partially destroys the thyroid, often involving surrounding tissues. We describe an unusual case of RT in a 38‐year‐old woman, and discuss its typical clinical, pathological, ultrasound, radionuclide scanning and magnetic resonance findings. We conclude that the diagnosis of RT is highly suggestive in the presence of a hard gland (or nodule), fixed to adjacent structures; ‘cold’ on Tc99 scan; hypoechoic with absence of vascular flow, invading the adjacent neck structures on ultrasound; hypointense in T1‐ and T2‐weighted MR images; and showing fibrous tissue fragments with inflammatory cells at cytological examination. Thyroidectomy has to be performed to confirm the diagnosis and to relieve pressure symptoms.
A COST‐EFFECTIVENESS EVALUATION OF AMLODIPINE USAGE IN PATIENTS WITH CORONARY ARTERY DISEASE IN SWEDEN
Authors: Doyle JJ , McGuire A , Arocho R , Arikian S , Casciano J , Svangren P , Casciano R , Kim R , Kugel H
Published: April 2023

The objective of this analysis was to calculate the cost‐effectiveness of amlodipine therapy in patients with coronary artery disease in Sweden. It is hypothesised that treatment with amlodipine will have an impact on overall cardiovascular disease treatment costs, resulting in a positive cost‐effectiveness profile. A Markov cohort simulation model was constructed to simulate event‐related and procedure‐related health economic outcomes of coronary artery disease populations on amlodipine versus those on placebo. Patient level data from the Prospective Evaluation of the Vascular Effects of Norvasc Trial was used to populate the model. The total number of adverse cardiovascular clinical outcomes experienced over a three‐year period was lower for patient on amlodipine than for those on placebo. The rate of hospitalisation per patient due to angina, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, congestive heart failure, and myocardial infarction in the placebo cohort was 64.7%, while the rate in the amlodipine cohort was 46.9%. The cost per patient was Swedish kroner (SEK)26,600 for amlodipine patients and SEK27,400 for placebo patients. The use of amlodipine resulted in improved clinical outcomes as well as a slight savings in cost over a three‐year period.
ACCEPTABLE AGREEMENT BETWEEN TYMPANIC AND RECTAL TEMPERATURE IN ACUTE STROKE PATIENTS
Authors: Christensen H , Boysen G
Published: April 2023

Major concerns remain about the reliability of tympanic thermometers. The aim of this study was to investigate the agreement between rectal and tympanic thermometry and compare this with the repeatability of each method in patients with acute stroke. Tympanic temperature readings were from 0.7°C below to 0.8°C above rectal readings. As to repeatability, we found second rectal readings to be between 0.3°C below and 0.4°C above first readings, and second tympanic readings to be between 0.4°C below and 0.5°C above first readings. The agreement between the two methods is acceptable in clinical practice. Tympanic thermometry is useful in serial measurements, whereas, for a single accurate measurement, rectal mercury thermometry remains the method of choice.
MULTIDOSE FLURBIPROFEN 8.75 MG LOZENGES IN THE TREATMENT OF SORE THROAT: A RANDOMISED, DOUBLE‐BLIND, PLACEBO‐CONTROLLED STUDY IN UK GENERAL PRACTICE CENTRES
Authors: Blagden M , Christian J , Miller K , Charlesworth A
Published: April 2023

The flurbiprofen 8.75 mg lozenge is a novel formulation that combines a demulcent effect with the analgesic activity of a non‐steroidal anti‐inflammatory drug. Previous controlled clinical studies have demonstrated the single‐ and multi‐dose efficacy of these lozenges over placebo. The current study reflected the treatment of sore throat in general practice, investigating multiple dose efficacy where patients also had access to concomitant antibiotics and rescue medication. The efficacy of flurbiprofen 8.75 mg lozenge over placebo was confirmed: there was a significant difference in pain relief obtained from flurbiprofen 8.75 mg versus placebo, along with a significant reduction of difficulty in swallowing from the time of first assessment and significantly greater reductions in throat soreness and difficulty in swallowing throughout the study period. Additionally, significant benefit over placebo was demonstrated where concomitant antibiotic use was introduced, indicating that flurbiprofen 8.75 mg lozenges can be co‐administered when antibiotic therapy is appropriate. No significant safety issues were identified.
EFFICACY OF A PROPRIETARY IBUPROFEN GEL IN SOFT TISSUE INJURIES: A RANDOMISED, DOUBLE‐BLIND, PLACEBO‐CONTROLLED STUDY
Authors: Machen J , Whitefield M
Published: April 2023

The efficacy of a novel, proprietary topical formulation of ibuprofen 5% gel (Ibugel™) was evaluated in a placebo‐controlled study in patients with soft tissue injuries. Patients received either active gel (n=40) or placebo gel (n=41) for a maximum of seven days. Pain and interference with physical activity were assessed daily using visual analogue scales. There was a significant difference (p<0.001) in favour of active treatment for the time to achieve clinically meaningful reduction in pain. By day 7, 75% of patients in the active gel group had a clinically meaningful reduction of pain compared with 39% of patients who received placebo. Despite differences between study centres, the data for interference with physical activity also showed an advantage for active treatment. By day 7, 79% of patients in the active gel group had a clinically meaningful reduction in interference with physical activity, compared with 44% of patients who received placebo.
10. SENTINEL NODE BIOPSY IN PRIMARY BREAST CANCER
Authors: Beechey‐Newman N
Published: April 2023

Sentinel node biopsy is a minimally invasive but accurate way of staging the axilla such that as many as 50% of women with primary breast cancer could avoid axillary clearance and the morbidity this carries with it. The methodology has yet to be perfected but identification of the sentinel node(s) with either dye or isotope, or with a combination of these, is a robust technique that is quick to learn and correctly predicts the status of the rest of the axilla in significantly more than 90% of patients. Improvements in the methodology and in patient selection will inevitably make sentinel node biopsy even more accurate. Studies to demonstrate the survival impact of replacing axillary clearance with sentinel node biopsy and selective axillary node treatment are required and are in their early stages.
DIPYRIDAMOLE MAY BE USED SAFELY IN PATIENTS WITH ISCHAEMIC HEART DISEASE
Authors: Humphreys DM , Street J , Schumacher H , Bertrand‐Hardy J‐M , Palluk R
Published: April 2023

It is thought that up to 50% of patients with cerebrovascular disease will have concurrent ischaemic heart disease. Dipyridamole co‐formulated with aspirin has been shown to increase the relative reduction in risk of second stroke in patients with prior stroke/transient ischaemic attack beyond that obtaining with aspirin alone. We have sought to resolve the question of whether dipyridamole treatment increases the risk of cardiac adverse events in patients with co‐existing ischaemic heart disease. The published literature, periodic safety update reports, the randomised controlled trials of antiplatelet agents in stroke prevention and those including dipyridamole in cardiovascular indications, have been reviewed and analysed. The early reports of serious adverse cardiac effect attributable to dipyridamole occurred in patients with severe coronary artery disease using dipyridamole as a stress test adjunct to cardiac imaging. The randomised controlled trials databases show no evidence of mortality and only isolated cases of significant cardiac morbidity attributable to dipyridamole at recommended oral doses in patients with ischaemic heart disease. We conclude that patients with cerebrovascular and mild to moderate concomitant ischaemic heart disease may be treated safely with dipyridamole for the secondary prevention of stroke.
NEPHROTIC SYNDROME: MORE THAN JUST OEDEMA
Authors: Jayawardene SA , Scoble JE , Goldsmith DJA
Published: April 2023

Oedema is the commonest presenting symptom and sign in nephrotic syndrome. Hypercholesterolaemia, thromboembolic events, and infectious complications may also be features. Three patients are described, each of whose nephrotic syndrome presented with a less common symptom or sign – recurrent pleural effusion, hypercholesterolaemia and oedema, pulmonary embolism – and, as a result, experienced some diagnostic delay. By forgetting to consider nephrotic syndrome, and its underlying causes, there may be inappropriate investigations and treatment for the patient.
THE POTENTIAL OF MIFEPRISTONE (RU486) AS A FEMALE CONTRACEPTIVE DRUG
Authors: Sarkar NN
Published: April 2023

This article reviews the development of mifepristone (RU486) as a female contraceptive drug. Mifepristone is an orally active compound with nearly 40% bioavailability after first pass effect. The steady plasma level of mifepristone ranges from 65 nmol/l with 1 mg/day to 1 μmol/l with 10 mg/day and reaches 2.5 μmol/l, 4.5 μmol/l and 5.4 μmol/l with mifepristone 50 mg, 100 mg and 200 mg daily, respectively, over the treatment period. Inhibition of ovulation may be achieved at serum mifepristone concentration of 232.7 nmol/l. Mifepristone appears to antagonise progesterone at the pituitary level to suppress gonadotropin and steroid hormone secretion rather than to act primarily on the hypothalamus to delay or inhibit ovulation. In fact, the endometrium is most sensitive to mifepristone. Low‐dose mifepristone impairs luteal phase endometrial development and receptivity by altering endometrial parakine, cytokine and enzyme activity. Thus, low‐dose mifepristone can significantly reduce the rate of conception without inhibiting ovulation. However, further research is needed to standardise the dose and dose‐schedule to achieve the desired efficacy of low‐dose mifepristone for routine clinical use with minimal or no side‐effects.
SUCCESSFUL PREGNANCY FOLLOWING GONADOTROPIN THERAPY IN A PATIENT WITH HYPOGONADOTROPIC HYPOGONADISM RESULTING FROM CRANIOPHARYNGIOMA
Authors: Hayashi M , Tomobe K , Hoshimoto K , Ohkura T
Published: April 2023

The authors report a rare case of a patient with panhypopituitarism who became pregnant by gonadotropin therapy and gave birth to a healthy baby. A brain tumour and/or the surgical resection of a brain tumour occasionally results in pituitary dysfunction. An 18‐year‐old Japanese patient developed hypogonadotropic secondary amenorrhoea because of a craniopharyngioma, which was surgically removed. The patient came to us, and peripheral blood was collected every 15 minutes for four hours. The levels of luteinising hormone (LH) and follicle‐stimulating hormone (FSH) were measured. Results showed that LH and FSH levels were very low and did not fluctuate. Several years later, the patient complained of infertility, and treatment with human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) was started. The therapy was repeated for several cycles, but she did not conceive, so hMG‐hCG therapy combined with conjugated oestrogen administration was started. The patient became pregnant at the seventh cycle of this combined therapy. She was not treated with supplementary growth hormone.
BLEEDING ANGIODYSPLASIA: SHOULD WE CONCENTRATE MORE ON THE AORTIC VALVE THAN ON THE BOWEL?
Authors: Soran H , Lewis M , Whorwell PJ
Published: April 2023

A case of bleeding from angiodysplasia in association with aortic stenosis is presented. The particular interest in this patient is that the bleeding ceased immediately after the insertion of a bioprosthetic valve and recurred when the valve restenosed. Furthermore, the bleeding again promptly resolved when the valve was exchanged for a metallic prosthesis despite long‐term anticoagulation. The implications of these observations are discussed.
SHOULD OXYGEN SATURATION BE INCLUDED IN THE VITAL SIGNS SHEET OF ALL MEDICAL ADMISSIONS?
Authors: Al‐Mobeireek AF , Abba AA , Kumo AM
Published: April 2023

Hypoxaemia is not uncommon in hospitalised patients and may be overlooked because cyanosis is a late sign. To estimate the incidence of undetected hypoxaemia we measured oxygen saturation (SpO2) by pulse oximetry randomly in medical patients who were not receiving supplemental oxygen in a teaching hospital and a community hospital. Of 580 patients studied, nine patients (1.55%) had SpO2 <92%. All nine patients had multiple morbidities, but all had cardiopulmonary disease in common. There was no significant difference between the teaching and the community hospitals. We conclude that undetected hypoxaemia is not common in patients on the medical wards, and that routine pulse oximetry is not necessary except for patients with known cardiopulmonary disease.