bluuebunny/crossref_metadata_2025 huggingface dataset:
A STUDY OF AUTONOMIC CARDIOVASCULAR REFLEXES IN ELDERLY PATIENTS WITH PNEUMONIA
Authors: Vassallo M , Allen SC
Published: April 2023

People recovering from pneumonia are often weak for no apparent reason. Clinical features such as postural hypotension, arrhythmia and syndrome of inappropriate ADH have, in other circumstances, been attributed to impaired autonomic function. The aim of this study was to see whether elderly patients with pneumonia had impaired autonomic cardiovascular reflexes and, if so, how long this persisted. We compared healthy elderly controls, elderly controls with trauma (fractured femoral neck) and elderly patients with pneumonia. Thirty‐eight subjects were studied in a series of cardiovascular autonomic function tests. Results suggest that elderly people have a high prevalence of impaired cardiovascular autonomic reflexes in the immediate post‐pneumonic phase, and that this improves significantly after six weeks, with a further improvement by six months. Elderly patients recovering from pneumonia are predisposed to the adverse effects of drugs and other factors which can further impair autonomic cardiovascular reflexes.
REM SLEEP BEHAVIOUR DISORDER: AN OVERVIEW
Authors: Chiu HFK , Wing YK
Published: April 2023

REM sleep behaviour disorder (RSBD) is a recently described parasomnia characterised by a history of excessive nocturnal motor activity and absence of muscle atonia during REM sleep. Only limited literature is available on this condition. The exact prevalence is unclear, but recent studies suggest it might not be an uncommon condition. The elderly are more often affected and there is a male preponderance. While transient RSBD can be seen after taking certain drugs or during drug withdrawal, the chronic type is usually idiopathic or associated with an underlying degenerative neurological condition. It can result in considerable distress and/or serious injury to the patients or their bed partners. Differential diagnoses include sleep‐walking, night terrors, nightmares, nocturnal seizures, obstructive sleep apnoea, post‐traumatic stress disorder, dissociative states and nocturnal confusional states. The dramatic response to clonazepam highlights the importance of recognition and appropriate treatment of this sleep disorder.
CHRONOBIOLOGY AND CHRONOPATHOPHYSIOLOGY OF NOCTURNAL ASTHMA
Authors: Syabbalo N
Published: April 2023

Asthma is increasing in prevalence and severity worldwide despite effective treatment and innovative research developments. Chronobiology is the study of biological rhythms and their mechanisms. Asthma is one of many diseases that exemplifies a circadian pattern in intensity, frequency of attacks and mortality. As many as 90% of asthmatics experience nocturnal symptoms severe enough to awaken them from sleep. Increased airway narrowing at night is thought to occur as a result of circadian variation in neurohormones and intensification of airway inflammation. Furthermore, vagal tone, neurogenic inflammation and airway hyperresponsiveness are increased at night. Many cells contribute to the nocturnal inflammatory process in the asthmatic airways, including mast cells, eosinophils, neutrophils and lymphocytes. These cells are capable of secreting innumerable inflammatory mediators, such as histamine, cytokines, leukotrienes, prostaglandins, neutral endopeptidase and superoxides, which are potent bronchoconstrictors and secretogogues. They also cause increased vascular permeability and airway oedema. All these chronobiological events promote nocturnal worsening of asthma and increased nocturnal deaths. Understanding the mechanisms of nocturnal asthma will help us learn more about asthma, and how to implement appropriate chronotherapeutic interventions.
COARCTATION OF THE AORTA: AN UNUSUAL CAUSE OF HYPERTENSION IN A 73‐YEAR‐OLD WOMAN
Authors: O'Byrne E , Mather J , Hargreaves
Published: April 2023

CLINICAL MESSAGE Secondary causes of hypertension should be considered when blood pressure control is difficult in elderly patients.
EMPHYSEMATOUS PYELONEPHRITIS RESPONDING TO MEDICAL THERAPY
Authors: Punnose J , Yahya TM , Premchandran JS , Ahmed HF
Published: April 2023

We describe two type 2 diabetic patients with unilateral emphysematous pyelonephritis who responded to medical treatment alone. Escherichia coli was isolated in both patients. The presence of gas was confirmed early by ultrasound and CT scan of abdomen. Following treatment, good functional recovery was demonstrable in the affected kidneys by isotope renogram. We stress the need for early diagnosis of this condition and aggressive treatment with broad spectrum antibiotics.
ACROMEGALY IN A WOMAN PRESENTING WITH DIABETIC KETOACIDOSIS AND INSULIN RESISTANCE
Authors: Szeto C‐C , Li K‐Y , Ko GTC , Chow C‐C , Yeung VTF , Chan JCN , Cockram CS
Published: April 2023

A 22‐year‐old Chinese woman presented with typical features of diabetic ketoacidosis. There was a family history of diabetes but she was not obese. Plasma glucose and bicarbonate levels were 27.0 mmol/l and 5 mmol/l, respectively. Significant insulin resistance was noticed: she needed up to 15 units of insulin per hour. She required up to 120 units daily for her diabetic control even after her acidosis had subsided. She was then noticed to have the clinical features of acromegaly. The diagnosis was confirmed, and a cranial CT scan confirmed the presence of a pituitary macroadenoma. She underwent uneventful trans‐sphenoidal resection of the tumour and her insulin requirement gradually lessened. Acromegaly should be considered in the differential diagnosis of unexplained insulin resistance.
EMERGENCY TRACHEOSTOMY IN GENERAL PRACTICE
Authors: Frosh A , Joyce R , Hern J , Almeyda J
Published: April 2023

We set out to review the need for general practitioners (GPs) to be skilled at forming an emergency alternative airway by assessing mortality figures for acute airways obstruction. We also solicited the views of 100 GPs on the theory and practice of emergency tracheostomy and assessed whether they considered they were equipped to carry out such a procedure in the community. The results suggest a significant number of deaths of otherwise young and healthy individuals could be avoided by training community practitioners in emergency alternative airway formation. The results showed a marked lack of confidence in the practice of emergency airway formation and few GPs felt able to carry out the procedure. They indicated an overwhelming interest in receiving further education on the subject. We recommend that formal training programmes in the techniques of emergency airway formation should be available for community GPs.
COLORECTAL ADENOMA IN PATIENTS WITH A HISTORY OF BREAST CANCER: A PROSPECTIVE STUDY IN TAIWAN
Authors: Wu C‐S , Tung S‐Y , Chen P‐C , Kuo Y‐C , Wang C‐Y
Published: April 2023

The increased incidence of colorectal cancer in women with a history of breast cancer is well established. However, the relationship between the prevalence of adenomatous polyps and breast cancer is still controversial. We conducted a prospective study of the incidence of colorectal polyps in patients with a history of breast cancer in Taiwan. Eighty‐nine patients (86 women and 3 men) received colonoscopy to test for precancerous lesions. Mean age was 49.4 ± 10.4 years. Twelve polyps (9 adenomatous, 2 hyperplastic, 1 inflammatory) (13.5%) and one cancer (1.1%) were found. The mean age of patients with and without colorectal neoplasia was 56.3 ± 9.4 and 48.2 ± 10.2 years respectively. (p<0.005); 10 out of 13 patients (77%) with colorectal neoplasia were over 50 (p<0.1). Compared with a study of Chinese people in Hong Kong, our population had a lower incidence of colorectal adenomatous polyps, but breast cancer patients have a greater risk of developing colorectal cancer than the general population in Taiwan.
DOES SMOKING INFLUENCE THE ERADICATION OF HELICOBACTER PYLORI AND DUODENAL ULCER HEALING WITH DIFFERENT REGIMENS?
Authors: Kadayifçi A , Simsek H
Published: April 2023

To determine the effect of smoking on Helicobacter pylori eradication and ulcer healing, we investigated 232 patients with H. pylori‐positive duodenal ulcer. Patients were given one of seven different treatment protocols and divided into three groups according to smoking habits. Group 1 (n=128) consisted of non‐smokers, group 2 (n=65) of mild smokers (5‐20 cigarettes/day) and group 3 (n=39) of heavy smokers (>20/day). The eradication of H. pylori and ulcer healing rate was controlled eight weeks later after ceasing the therapy. The overall eradication rate was 66% in all patients and 68%, 66%, 59% in each group, respectively. The eradication rates showed no statistical difference between groups. Complete ulcer healing was achieved in 84% of all patients and ulcer healing rate between groups did not show any significance (85%, 83% and 82% respectively). These results suggest that smoking status does not influence the eradication of H. pylori and duodenal ulcer healing rates at eight weeks in patients on different treatment schedules.
GASTROINTESTINAL AUTONOMIC NERVE TUMOUR PRESENTING AS SMALL BOWEL VOLVULUS: A RARE DISEASE WITH A RARE PRESENTATION
Authors: Chung CC , To KF , Lau WY , Li AKC
Published: April 2023

A 78‐year‐old Chinese woman presented with recurrent postprandial abdominal pain. Computerised tomography revealed a small bowel tumour causing volvulus of a segment of the small bowel. Laparotomy confirmed an extraluminal ileal tumour with partial volvulus of the involved small bowel segment. Small bowel resection was done. Histological and ultrastructural studies confirmed a gastrointestinal autonomic nerve tumour. We review the medical literature on this rare tumour.
SUBACUTE CEREBELLITIS IN LYME DISEASE
Authors: Neophytides A , Khan S , Louie E
Published: April 2023

Cerebellitis is not a recognised manifestation of Lyme disease. We describe a patient with clinical features of subacute cerebellitis, cerebrospinal fluid (CSF) monocytic pleocytosis, positive CSF Borrelia burgdorferi antibodies, negative brain magnetic resonance imaging and a benign course after treatment with ceftriaxone. Possible earlier cases are discussed. Lyme disease should be considered in all cases of subacute cerebellitis.
BLUNT LARYNGEAL TRAUMA: AN UNUSUAL CASE
Authors: Saab M , Birkinshaw R
Published: April 2023

Local external evidence of neck trauma – bruising, subcutaneous emphysema, cuts, abrasions and so on – signs of upper airway obstruction, dysphonia and dysphagia are the hallmarks of laryngotracheal lesions. Such lesions tend to occur after motor vehicle accidents and usually require surgery. We describe a case of blunt laryngeal trauma, resulting from an unusual mechanism, which healed spontaneously.
GASTROSTOMY‐RELATED PANCREATITIS IN A CHILD: A FATAL CASE
Authors: Rashid A‐MH
Published: April 2023

A case of acute pancreatitis following gastrostomy feeding tube insertion is presented. This is a rare and fatal complication, which has not been described before. The role of the gastrostomy catheter and total enteral nutrition in the causation of acute pancreatitis is discussed. Pathologists and clinicians should be aware of this disastrous and potentially avoidable condition.
DRUG ALLERGY: FACT OR FICTION?
Authors: Bowrey DJ , Morris‐Stiff GJ
Published: April 2023

From our clinical practice, it was apparent that patients often reported drug allergies without a substantiating history. A prospective study over six months was undertaken to examine the reporting of drug allergies by hospital patients. Based on the history, allergic reactions were triaged into one of three categories: high probability of an allergic reaction, low probability of an allergic reaction, and uncertain, where the history was incomplete or unclear. Of 1519 patients interviewed, 133 (9%) reported prior drug allergies. The most commonly implicated agents were penicillin (74%), septrin (6%), aspirin (6%), cefuroxime (2%) and trimethoprim (2%); 61% of reactions were deemed to be high probability, with the. remainder either low (29%) or uncertain (10%) probability. It was apparent that patients often considered drug allergy to be synonymous with adverse reaction. Preventing patients from being labelled as drug allergic, thus being denied therapy with first‐line agents, requires patient education and vigilance by doctors in their history‐taking.
PROMOTING EFFECTIVE COMMUNICATION IN NEONATAL INTENSIVE CARE UNITS BY AUDIOTAPING DOCTOR‐PARENT CONVERSATIONS
Authors: Koh THHG , Jarvis C
Published: April 2023

Parents of newborn babies receiving intensive care may find it difficult to understand, remember and accept information. We evaluated how practical and useful it is to give parents a tape‐recording of their initial conversation with the neonatologist. They seem to benefit from being able to listen repeatedly to such recordings. Parents and nurses have similar scores of usefulness of the method but their score is significantly higher than that of the neonatologists. This method could be useful in other clinical situations.
SUMATRIPTAN SUPPOSITORIES FOR THE ACUTE TREATMENT OF MIGRAINE
Authors: Tepper SJ , Cochran A , Hobbs S , Woessner M ,   S2B351 Study Group
Published: April 2023

A randomised, double‐blind, parallel‐group, placebo‐controlled trial was undertaken to assess the efficacy and tolerability of the sumatriptan suppository in 184 patients with acute migraine. Patients used a sumatriptan suppository (12.5 mg or 25 mg) or placebo at home for the treatment of a moderate or severe migraine attack and those who experienced headache recurrence within 24 hours of dosing had the option to repeat the dose. By 2 hours post‐dose, 68% of patients in the sumatriptan 25 mg group and 47% of patients in the sumatriptan 12.5 mg group compared with 25% of placebo patients achieved headache relief. Relief rates 2 hours post‐dose for nausea, vomiting, photophobia and phonophobia were similar to those reported 2 hours post‐dose for headache. Post hoc review of the recurrence data showed that administration of a second suppository was effective in alleviating recurrent headache in over 80% of the sumatriptan‐treated patients experiencing recurrence. No serious or unusual adverse events were reported, and the pattern and incidence of adverse events did not vary as a function of dose. These data demonstrate that the sumatriptan suppository is a well‐tolerated, effective treatment for the acute treatment of migraine pain and its associated symptoms.
MANAGEMENT OF THYROTOXICOSIS IN PREGNANCY
Authors: Ghaneim A , Atkins P
Published: April 2023

Between April 1985 and June 1995, 20 patients being treated for thyrotoxicosis became pregnant. These patients are reviewed. Control of thyrotoxicosis early in pregnancy using minimal doses of propylthiouracil or carbimazole, followed by subtotal thyroidectomy in the middle trimester, is safe for both mother and fetus.
TUBERCULOUS TENOSYNOVITIS: A RARE MANIFESTATION OF A COMMON DISEASE
Authors: Soub H Al
Published: April 2023

Two cases of tuberculous tenosynovitis of the hand are presented. The clinical features were those of a gradually enlarging swelling and mild pain over several months. Diagnosis was not initially suspected in either patient, reflecting decreased awareness of this uncommon condition. Both patients had concomitant active pulmonary tuberculosis which was quiescent in the second patient! Combined surgical debridement and antituberculous drugs led to a successful outcome. The condition is discussed and pertinent literature is reviewed.
RETROPERITONEAL PERFORATION OF DUODENAL ULCER PRESENTING AS SCROTAL SEPSIS
Authors: Rajasekar A , Macintyre IMC
Published: April 2023

Retroperitoneal extravasation is an extremely uncommon complication of duodenal ulcer perforation. The preoperative diagnosis is difficult and may even be missed at operation. There were, 25 cases reported in the literature. Only one patient was correctly diagnosed preoperatively and only seven patients survived. We describe the first case of retroperitoneal extravasation from perforated duodenal ulcer presenting as scrotal sepsis.
A MULTICENTRE, DOUBLE‐BLIND, RANDOMISED STUDY COMPARING THE EFFICACY AND SAFETY OF ORAL LEVOFLOXACIN VERSUS CIPROFLOXACIN IN THE TREATMENT OF UNCOMPLICATED SKIN AND SKIN STRUCTURE INFECTIONS
Authors: Nicodemo AC , Robledo JA , Jasovich A , Neto W
Published: April 2023

A multicentre, randomised, double‐blind trial in Latin America compared oral levofloxacin 500 mg once daily for 7 days with oral ciprofloxacin 500 mg twice daily for 10 days in 272 patients with uncomplicated skin and skin structure infections. Among 253 subjects evaluable for clinical efficacy (129 levofloxacin, 124 ciprofloxacin), clinical success (cure and improvement) was observed in 96.1% of levofloxacin‐treated patients and in 93.5% of ciprofloxacin‐treated patients. Overall, bacteriological eradication rates by pathogen were 93.2% and 91.7%, respectively. Levofloxacin eradicated 94% (66/70) of Staphylococcus aureus and 94% (17/18) of Streptococcus pyogenes isolates, compared with 93% (70/75) and 92% (12/13) for ciprofloxacin. Microbiological eradication rates by subject were approximately 93% and 90% for the levofloxacin and ciprofloxacin groups, respectively. Drug‐related adverse events were reported by 8.9% of those receiving levofloxacin and 8.2% of those administered ciprofloxacin. Findings support the efficacy of oral levofloxacin for uncomplicated skin and skin structure infections due to S. aureus and S. pyogenes.
MORNING VERSUS EVENING DOSING WITH DOXAZOSIN IN BENIGN PROSTATIC HYPERPLASIA: PHARMACOKINETICS, EFFICACY AND SAFETY
Authors: Kirby RS
Published: April 2023

Pharmacokinetic and clinical data from two studies provided evidence that the pharmacokinetics of doxazosin indicate its clinical behaviour: the long half‐life of doxazosin allows once‐daily dosing, with no differences, in terms of clinical efficacy or tolerability, between morning and evening dosing.
HORMONE REPLACEMENT THERAPY AND BREAST CANCER
Authors: Faiz O , Fentiman IS
Published: April 2023

Hormone replacement therapy (HRT) leads to a similar annual increase in risk of breast cancer as does each extra year of remaining premenopausal. Taken for more than 10 years HRT leads to a 35% increase in risk of developing breast cancer. It does not increase a woman's risk of dying of breast cancer, and may improve the prognosis. Some breast cancer patients can safely take HRT and some formulations might reduce the subsequent risk of relapse.
GROWTH HORMONE THERAPY FOR ADULT GROWTH HORMONE DEFICIENCY
Authors: Shalet SM
Published: April 2023

Growth hormone deficiency in adult life is associated with a number of adverse biological changes which include osteopenia, reduced exercise capacity, altered body composition, deleterious alterations in the lipid profile and insulin status, and reduced quality of life. Most of these changes can be reversed by growth hormone replacement therapy, but in an era of health rationing, such therapy is unlikely to be offered to every growth hormone deficient adult. Therefore we have proposed a strategy aimed at delineating which adults with growth hormone deficiency might benefit most from growth hormone therapy.
BIOCHEMICAL INVESTIGATION OF DIABETES MELLITUS
Authors: Rosalki SB
Published: April 2023

Simple biochemical investigations serve to identify diabetes, can assist in its management, and facilitate the early recognition of complications. This review outlines some of the applications of various relevant test procedures.
A COMPARISON OF RISK FACTORS FOR MALIGNANT MELANOMA, SQUAMOUS CELL CARCINOMA AND BASAL CELL CARCINOMA IN THE UK
Authors: Lear JT , Tan BB , Smith AG , Jones PW , Heagerty AH , Strange RC , Fryer AA
Published: April 2023

Cutaneous malignant melanoma (MM), squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) exhibit markedly different natural histories, but few studies have compared risk factors in individuals from a single population. Using logistic regression analysis in case and control groups, we assessed the association of individual characteristics with MM (n=240) and SCC (n=184). We also compared differences in risk factors (eye/hair colour, skin type, smoking history, occupation, social class, tumour site) between MM/BCC and SCC/BCC. MM patients were more likely to have red/blonde hair and blue/green eyes than controls, and those with SCC more likely to have red/blonde hair, blue/green eyes, outdoor occupation, skin type 1 and to have smoked more. There were few differences in individual characteristics between the skin cancer groups, illustrating their non‐specific nature. Tumour site, however, showed marked differences: MM patients were more likely to have a tumour on the trunk or limbs than BCC patients, while patients with SCC were more likely to have a tumour on the limbs. Reasons for this variation are unclear. The relatively weak effect of individual factors supports the view of a multifactorial disease and suggests that interactions between UV exposure and genetic predisposition may be more significant determinants of risk.
A SURVEY OF PATIENT RESPONSE TO PREOPERATIVE SURGICAL ASSESSMENT
Authors: Offiah CJ , Grimley RP
Published: April 2023

An anonymous questionnaire‐based study was devised to examine the role of preoperative assessment of patients by pre‐registration surgical house officers. One hundred and eight patients awaiting elective surgery were entered into the study. The main outcome measures were the proportion of patients who felt they had received a satisfactory explanation concerning the risks and benefits of their intended operation at a preoperative assessment clinic (PAC). Of the patients who believed that details of their operations had been explained to them, more than one‐quarter cited the PAC as the source. More than 25% of patients who stated that the benefits of their operation had been explained cited the PAC as the source; 45% of patients who believed the risks of their surgery had been provided felt the PAC had been the only source of this explanation. It was concluded that preoperative assessment clinics are an efficient and effective means of providing patients with valuable information about their operation.
A RETROSPECTIVE SURVEY OF DIAGNOSIS AND MANAGEMENT OF PATIENTS PRESENTING WITH CHRONIC COUGH TO A GENERAL CHEST CLINIC
Authors: McGarvey LPA , Heaney LG , MacMahon J
Published: April 2023

Respiratory physicians often encounter patients with chronic cough. The evaluation and outcome of such patients by centres with established diagnostic protocols has been well described. By contrast, little is known about patients referred to general respiratory clinics where no such protocol exists. We describe the findings of a retrospective survey of all new patient referrals with chronic cough to a general respiratory clinic over a 12‐month period. A diagnosis of asthma or chronic airflow obstruction was made in 43% of patients. Gastro‐oesophageal reflux and postnasal drip syndrome, together accounting for over 60% of diagnoses in specialist clinics, were infrequently identified in our study (4% and 2% respectively). At follow‐up, 43% of patients reported persistent symptoms, contrasting the excellent treatment response reported by specialist clinics. In general respiratory clinics where a specific diagnostic protocol is not in place, these differences in diagnosis and outcome may be due to inadequate investigation or may reflect a different patient population.
BLOOD PRESSURE MEASUREMENT AND ANTIHYPERTENSIVE THERAPY IN ACUTE STROKE
Authors: Panayiotou BN , Lloyd M , Fotherby MD , Crome P
Published: April 2023

Inappropriate management of high blood pressure in acute stroke can adversely affect outcome. We examined blood pressure evaluation and antihypertensive therapy during the first week post‐stroke in 40 patients at a district general hospital with no stroke unit. In the first 24 hours, median frequency of blood pressure recording was 3 (range 1‐12). After day 1, 11 (28%) had no blood pressure readings for one or two consecutive days. The side of measurement was not recorded in any patient. None of the 22 hypertensives (55%) had a bilateral measurement to exclude interarm inequality, and only 3 (7%) of all patients had postural readings to exclude orthostatic hypotension. Fourteen (35%) received antihypertensive therapy without meeting recommended indications; some even had low blood pressure. As most stroke patients are managed in general medical wards rather than stroke units, a greater awareness of these important aspects of blood pressure evaluation and therapy are needed among medical and nursing staff.
OSTEOPOROSIS IN MEN
Authors: Anderson FH
Published: April 2023

Osteoporosis in men is a common cause of morbidity, mortality and health care expenditure throughout the Western world. Most cases are secondary to disease or to drug therapy, but in 30‐45% of affected individuals no cause can be identified. Research into the factors underlying ‘idiopathic’ male osteoporosis is limited, but is gradually moving more patients into the ‘secondary’ category. Recently, attention has focused on interactions between sex hormones and bone: there is evidence that male bone requires both androgens and oestrogens for normal health. Many conditions predispose to osteoporosis in men: hypogonadism, alcohol abuse and the use of corticosteroids are the most frequently identified factors. Osteoporosis following organ transplantation attracts interest despite its relative rarity. Treatment for osteoporotic men is poorly researched and remains largely unsupported by experimental evidence, although clinical experience suggests a useful role for bisphosphonates, testosterone and perhaps fluorides. Symptom control and explanation remain the most important therapeutic interventions.
CENTRALLY ACTING ANTIHYPERTENSIVES: NOT OBSOLETE AFTER ALL
Authors: Schachter M
Published: April 2023

Centrally acting antihypertensive drugs, or sympatholytics, have a long history of efficacy, including some of the earliest major clinical trials, but they are now little used in the UK and elsewhere. This has been due to the introduction of new drugs with better tolerability than the centrally acting agents. In the case of clonidine there was also concern about rebound hypertension. However, at least some hypertensives may benefit from a centrally acting drug and a new class of agents, the imidazoline agonists, has recently been developed. One of these, moxonidine, is available in the UK. Clinical studies so far suggest that its efficacy is comparable to currently used drugs and that adverse effects are less severe than with earlier sympatholytics. Rebound hypertension has not been described, so this may lead to a revival in interest in these drugs as antihypertensive agents.
A DIFFICULT CASE OF PYREXIA
Authors: McIlmoyle J , Johnston GD
Published: April 2023

We present a case of non‐specific vasculitis presenting as a pyrexia of unknown origin to illustrate the diagnostic difficulty which can arise with this condition. The diagnostic event was central retinal artery occlusion and the disease was also associated with pyoderma gangrenosum. History, examination, investigations and management are discussed.
A CASE OF INTRAHEPATIC CHOLESTASIS DUE TO AMYLOIDOSIS
Authors: McDonald P , Usbourne C , Playfer JR
Published: April 2023

Amyloidosis commonly involves the liver but clinical features of liver disease are rare. We report a case of cholestasis and hepatic failure in an 85‐year‐old man due to primary amyloidosis. This has not been reported previously in anyone of this advanced age. We discuss the clinical features of hepatic amyloidosis and the importance of making a diagnosis.
SEPTIC SACROILIITIS: AN UNUSUAL CAUSATIVE ORGANISM IN A RARE CONDITION
Authors: O'Brien CM , Darley ESR , Kelly AJ , Nelson IW
Published: April 2023

Streptococcus pneumoniae is a relatively uncommon cause of septic arthritis,1 and Infection of the sacroiliac joint by this organism has been rarely described. We present such a case.
ONCE‐DAILY BUDESONIDE: 400 μg ONCE DAILY IS AS EFFECTIVE AS 200 μg TWICE DAILY IN CONTROLLING CHILDHOOD ASTHMA
Authors: Campbell LM , Bodalia B , Gogbashian CA , Gunn SD , Humphreys PJ , Powell JP ,   PETITE research group
Published: April 2023

One hundred and sixty seven children on 0‐200 μg/day of inhaled steroid with asthma symptoms and sub‐optimal peak flow values (less than 90% of that predicted for their height) were randomly allocated either 400 μg once daily (nocte with placebo o.m.) or 200 μg twice daily of budesonide Turbohaler® for 8 weeks. Bronchodilator usage and symptoms were reduced in both groups at 4 and 8 weeks compared with baseline. There was a significant increase within both groups in morning and evening PEF after 4 and 8 weeks. The increase in evening PEF after 8 weeks was greater in the once‐daily group than in the twice‐daily group but there were no other significant differences between the groups (morning: +24.6 l/min vs 15.2 l/min, p=0.059; evening: +19.7 l/min vs +8.3 l/min; p=0.013). Budesonide Turbohaler® 400 μg once daily is therefore as effective as 200 μg twice daily in achieving asthma control in children.
PULMONARY TUBERCULOSIS AND ITS THERAPY DO NOT SIGNIFICANTLY AFFECT THYROID FUNCTION TESTS
Authors: Ilias I , Tselebis A , Boufas A , Panoutsopoulos G , Filippou N , Christakopoulou J
Published: April 2023

Basal thyrotropin, total thyroxine, total tri‐iodothyronine and free tri‐iodothyronine were measured in 30 HIV‐negative patients with focal pulmonary tuberculosis upon starting and after one and two weeks of isoniazid, rifampicin and pyrazinamide therapy. Rapid and statistically significant elevations in free tri‐iodothyronine and total tri‐iodothyronine were noted after the first and second week of treatment respectively. For most patients, however, hormone levels remained within normal limits throughout the study. Overall, the effects of pulmonary tuberculosis and of its therapy on the thyroid function parameters examined, in otherwise healthy individuals, appear to be minimal.
INCIDENCE AND PROGNOSTIC IMPLICATIONS OF FALLS ASSOCIATED WITH ACUTE MEDICAL ILLNESS: A MEDICAL INPATIENT STUDY
Authors: Vassallo M , Sharma JC
Published: April 2023

Falls are associated with a wide range of acute medical illness across all ages. They have prognostic implications, and screening for falls on admission can help identify those patients who are likely to have an adverse hospital outcome and may benefit from more intense levels of care.
GROWTH AND METABOLIC RESPONSES IN PRETERM INFANTS FED FORTIFIED HUMAN MILK OR A PRETERM FORMULA
Authors: Warner JT , Linton HR , Dunstan FDJ , Cartlidge PET
Published: April 2023

Preterm infants fed human milk have been shown to grow poorly and develop mineral deficiencies that may lead to osteopenia. This study has investigated the efficacy of a human milk fortifier made up of glucose polymers, a mixture of bovine milk protein fractions and free amino acids, minerals and vitamins designed to improve these nutritional deficiencies. Growth and bone mineral deficiencies were compared in 38 preterm infants fed fortified mother's milk and 21 preterm infants fed a preterm formula until they reached 1800 g; all had a birthweight below 1600 g. Weight gain was similar in each group with a mean (SD) increase of 19.6 (3.5) g/kg/day in the fortified group and 19.9 (4.1) g/kg/day in the preterm formula group. There were also no significant differences in linear growth, head circumference, skin fold thickness or mid‐arm circumference. Serum phosphate, alkaline phosphatase and plasma urea concentrations were similar and there was no clinical evidence of osteopenia. These results indicate that the growth and metabolic disadvantages associated with feeding human milk to preterm infants are ameliorated by the addition of a milk fortifier that increases the calorific, protein and mineral content of breast milk.
THE EFFICACY AND SAFETY OF MIBEFRADIL IN SUBGROUPS OF PATIENTS WITH CHRONIC STABLE ANGINA PECTORIS
Authors: Charlon V , Kobrin I
Published: April 2023

The pool of controlled clinical studies on mibefradil, a new selective T‐type calcium channel blocker, for the treatment of chronic stable angina pectoris was analysed to determine the effects in subgroups of patients defined by age, gender, body weight and common co‐existing conditions. Total exercise tolerance test duration increased similarly in all subgroups, both at 50 mg (range 8.9‐17.3%; n=383) and 100 mg mibefradil (range 23.6‐30.8%; n=235). The increases in time to onset of angina and 1 mm ST‐segment depression were similarly comparable. Safety and tolerability was similar to placebo for subgroups at 50 mg, but the incidence of adverse events was slightly higher in females, older, and lower weight patients at the 100 mg dose, particularly in reported leg oedema (7.9% in femalesvs1.0% in males and 5.1% in oldervs0% in younger patients). Mibefradil proved a safe, well tolerated, and effective antianginal agent that can be used regardless of demographic factors or of frequent coexisting clinical conditions.
HYPOMAGNESAEMIA IN POSTOPERATIVE PATIENTS: AN IMPORTANT CONTRIBUTING FACTOR IN POSTOPERATIVE MORTALITY
Authors: Siddiqui MN , Zafar H , Alvi R , Ahmed M
Published: April 2023

Magnesium is the second most abundant intracellular cation and the fourth most abundant cation in the body. Clinical manifestations of hypomagnesaemia include neuromuscular, neurological, psychiatric and cardiac arrhythmias including torsade de pointes resulting in sudden death. Incidence of hypomagnesaemia in hospitalised patients is common and there is a lack of clinical awareness. Clinicians should become familiar with the common conditions and therapeutics that are risk factors for underlying hypomagnesaemia and become familiar with magnesium replacement regimens. Two patients who suffered fatal complications in whom hypomagnesaemia was an important contributing factor are presented. Hypokalaemia and hypocalcaemia are common in severe magnesium deficiency and require concurrent monitoring and correcting.
VOLVULUS OF THE RIGHT COLON IN PREGNANCY
Authors: Lopez Carral JM , Esen UI , Chandrashekar MV , Rogers IM , Olajide F
Published: April 2023

Intestinal obstruction in pregnancy is rare, volvulus being the commonest precipitating factor. It is a difficult diagnosis to make, because its symptoms mimic various pregnancy symptoms, but it commonly occurs in the third trimester or puerperium. A high index of suspicion is needed, and investigations for intestinal obstruction should be performed, especially when abdominal pain and vomiting persist. Careful evaluation of the abdominal cavity is also essential where a caesarean section is performed, particularly if there are unusual findings.
CEREBELLAR ENCEPHALITIS FOLLOWING EPSTEIN‐BARR VIRUS INFECTION
Authors: Pitts J , Norms ADC
Published: April 2023

A case is described of acute cerebellar symptoms as the presenting features of Epstein‐Barr virus (EBV) infection. Cerebellar encephalitis is discussed with particular reference to EBV infection.
SHORT‐COURSE CEFUROXIME AXETIL THERAPY IN THE TREATMENT OF ACUTE EXACERBATIONS OF CHRONIC BRONCHITIS
Authors: Langan C , Clecner B , Cazzola CM , Brambilla C , Holmes CY , Staley H
Published: April 2023

The efficacy and safety of a five‐day course of cefuroxime axetil (250 mg b.d.) and a seven‐day course of clarithromycin (250 mg b.d.) were compared in a large double‐blind, randomised, multinational study involving 684 patients with acute exacerbations of chronic bronchitis. In an intent‐to‐treat analysis, the post‐treatment clinical responses to each treatment were comparable (82%) and rates at follow‐up were similar: 64% on cefuroxime axetil and 61% on clarithromycin. Pre‐treatment pathogens were isolated from a total of 192 patients, Haemophilus influenzae being the most common. Overall pathogen eradication rates were similar for both treatments. Both treatments were well tolerated. In conclusion, a five‐day course of cefuroxime axetil is clinically equivalent to a seven‐day course of clarithromycin in the treatment of acute exacerbations of chronic bronchitis, and may have potential socioeconomic benefits.
TUBERCULOUS MENINGITIS: A CLINICAL AND LABORATORY STUDY OF 20 PATIENTS IN QATAR
Authors: Alsoub H
Published: April 2023

Twenty cases of tuberculous meningitis were diagnosed at the Hamad Medical Corporation between 1990 and 1995. Most of the patients (90%) were expatriates. The most common presenting features were fever, headache, neck stiffness and altered mental status. Five patients were in stage 1 disease at the time of presentation, 11 in stage 2, and four in stage 3. Examination of cerebrospinal fluid showed at least one abnormal finding in all patients, and culture grew Mycobacterium tuberculosis in 50%. A positive tuberculin skin test in 50% of patients, abnormal chest X‐ray in 35%, abnormal CT scan or MRI showing tuberculoma or hydrocephalus in 55%, and positive sputum culture for M. tuberculosis in 15% helped establish the diagnosis. All the patients were treated with antituberculous drugs and steroids. Seventeen (85%) survived, three with severe neurological sequelae; three (15%) died. Poor outcome was associated with advanced stage of disease at presentation and high CSF protein. Tuberculous meningitis continues to be an important disease in Qatar, especially in expatriates, and should be considered in the differential diagnosis in any patient presenting with fever and change in sensorium.
AN INFORMAL ASSESSMENT OF NUTRITIONAL STATUS IN ACUTE STROKE FOR USE IN AN INTERNATIONAL MULTICENTRE TRIAL OF FEEDING REGIMENS
Authors: Mead GE , Donaldson L , North P , Dennis
Published: April 2023

Patients with acute stroke may become malnourished because of feeding difficulties, so dietary supplementation may improve outcome. We investigated the validity and reliability of an ‘eyeball’ assessment of nutritional status for use in an international trial of different feeding following acute stroke. One hundred and one inpatients (mean age 75 years), of whom 40 had suffered an acute stroke, were independently observed by two medical students, a doctor and a nurse, and categorised as underweight, normal weight or overweight. Body mass index (BMI) was calculated using height and weight. Sensitivity of the informal assessment for correctly classifying the patient as underweight (BMI <20 kg/m2), normal (20‐30 kg/m2) and overweight (BMI >30 kg/m2) ranged from 64% to 100% and specificity from 71% to 100%. Interobserver agreement between different pairs of observers was moderate to good. An ‘eyeball’ assessment of nutritional status is valid and reliable enough for use in a multicentre trial of feeding regimens following acute stroke.
DEVELOPING A STRATEGY FOR THE PREVENTION OF HIP FRACTURES IN THE ELDERLY DUE TO OSTEOPOROSIS: THE APPLICATION OF ECONOMICS TO THE FINDINGS FROM A CLINICAL TRIAL
Authors: Phillips CJ , Moore RA
Published: April 2023

The occurrence of a fracture is the most obvious manifestation of osteoporosis. Preventive measures can reduce the risk of such events. The cost of preventing fractures depends on the cost and effectiveness of the intervention and the cost associated with treating the fractures. This paper aims to develop a framework for commissioners to evaluate new technologies by integrating the evidence on effectiveness with the costs likely to be incurred in providing interventions and the probable benefits generated. The explicit aim is to show how the effectiveness of an intervention designed to prevent hip fractures in the elderly, combined with an analysis of its potential economic impact, can provide an indication of how quality improvements in health‐care provision and cost savings may be generated.
PORPHYRIA AND ITS INVESTIGATION
Authors: Rosalki SB
Published: April 2023

The porphyrias are inherited disorders of haem synthesis and must be considered in the differential diagnosis of numerous disorders.
ISOLATED NASOPHARYNGEAL HODGKIN'S DISEASE PRESENTING AS NASAL OBSTRUCTION
Authors: Malis D‐D , Moffat D , McGarry GW
Published: April 2023

Lymphomas are the second most frequent malignancy affecting the head and neck. Within head and neck lymphomas, Hodgkin's disease accounts for only 10‐35% of all cases; 70‐80% of Hodgkin's disease of the head and neck involves nodal tissue, with extranodal Hodgkin's disease being most often found in the tissues of Waldeyer's ring. Extranodal Hodgkin's disease of the head and neck that does not involve Waldeyer's ring is extremely rare. We report a case of isolated extranodal Hodgkin's disease of the nasopharynx who presented to the rhinology clinic with symptoms of nasal obstruction. This unusual site, the possible reasons for its rarity and the investigations and management are discussed with reference to the literature.
LATENT TETANY ASSOCIATED WITH THE HYPOKALAEMIA OF CONN'S SYNDROME
Authors: Davies JS , Aguirre G , Cassidy DM , Griffiths BE
Published: April 2023

We describe the case of an asymptomatic patient with primary hyperaldosteronism, who was diagnosed fortuitously following the demonstration of a positive Trousseau's sign during routine blood pressure assessment. Further investigations revealed that the carpal spasm was due solely to the associated profound hypokalaemia.
A SURVEY OF HOSPITAL MORBIDITY, MORTALITY AND QUALITY OF LIFE FOLLOWING CORONARY ARTERY BYPASS SURGERY IN A UK INDO‐ASIAN POPULATION
Authors: Goldsmith IRA , Lip GYH , Kumar PP , Patel RL
Published: April 2023

To survey the in‐hospital morbidity, mortality, length of stay in the intensive therapy unit (ITU) and hospital and quality of life in patients of Indo‐Asian origin following coronary artery bypass (CABG) surgery, 345 consecutive patients (mean age 58 years; SD 8.9; range 32‐88 years) undergoing primary, isolated CABG were studied. Non‐elective CABG was undertaken in 41% of patients. The left anterior descending artery (LAD) was grafted in 89%, although in 30% of these the internal mammary artery (IMA) was not used. Following CABG, the hospital morbidity and mortality was within the expected range, although there was a trend towards higher in‐hospital mortality in the Parsonnet low risk group of patients. The length of ITU and hospital stay was not prolonged. Using the SF‐36 questionnaire in postoperative patients, low quality of life scores were obtained for six of the eight modalities tested including physical functioning, bodily pain and general health perception. The low quality of life scores and IMA usage in Indo‐Asians needs to be addressed.
IDEAL PAIN RELIEF FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY
Authors: Johnson RC , Hedges AR , Morris R , Stamatakis JD
Published: April 2023

In a previous report the effectiveness of intraperitoneal bupivacaine in reducing pain following laparoscopic cholecystectomy was demonstrated. Other methods of pain relief are commonly used but none has been compared following laparoscopic cholecystectomy. In two further studies we have compared the analgesic effect of intraperitoneal bupivacaine against wound infiltration with bupivacaine, and against intraperitoneal bupivacaine with the addition of a non‐steroidal anti‐inflammatory drug (NSAID) in patients undergoing laparoscopic cholecystectomy. Two consecutive studies were performed. In the first, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine injected into the trocar wounds. In the second study, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity and a diclofenac suppository (100 mg) one hour before surgery. Postoperative pain was assessed with a visual analogue pain scale. There was no difference in pain scores in the two groups in either study. Intraperitoneal bupivacaine is as effective as wound infiltration. The addition of an NSAID makes no difference in the reduction of postoperative pain following laparoscopic cholecystectomy.
A COST MINIMISATION ANALYSIS OF CARDIAC FAILURE TREATMENT IN THE UK USING CIBIS TRIAL DATA
Authors: Malek M , Cunningham‐Davis J , Malek L , Paschen B , Tavakoli M , Zabihollah M , Davey P
Published: April 2023

The clinical benefits of beta‐blockers in heart failure are currently subject to intense debate and are being investigated. The economic impact of beta‐blockade, however, has largely remained unexplored. The Cardiac Insufficiency Bisoprolol Study (CIBIS), while failing to show statistically significant reduction in mortality over conventional therapy, demonstrates that the administration of bisoprolol adjuvant to standard therapy leads to a significant reduction in hospital admission. The present study is a cost minimisation analysis based on CIBIS data for the UK and is restricted to direct costs only. The costs of bisoprolol medication and inpatient treatment of heart failure are considered. The ‘base case’ analysis and the sensitivity analyses carried on all cosidriver parameters show that administering bisoprolol to heart failure patients adjuvantly to the standard therapy is at least cost neutral. Additional drug costs incurred by bisoprolol are compensated by the inpatient treatment costs of heart failure avoided. All other non‐quantifiable clinical benefits such as improvement of New York Heart Association functional class are positive extras to patients and the National Health Service.
HANDLING AND ACCEPTABILITY OF THE EASI‐BREATHE DEVICE COMPARED WITH A CONVENTIONAL METERED DOSE INHALER BY PATIENTS AND PRACTICE NURSES
Authors: Price DB , Pearce L , Powell SR , Shirley J , Sayers MK
Published: April 2023

This study compared the handling and acceptability of the Easi‐BreatheTM, a breath‐actuated metered dose inhaler (MDI), with that of a conventional MDI. A total of 104 patients and 14 practice nurses took part in interviews at a central location. An additional 100 practice nurses were interviewed in a telephone study. Significantly more patients (86%) found Easi‐Breathe easier than a conventional MDI to use correctly (p<0.001). Overall, more patients preferred Easi‐Breathe (82% vs 18%; p<0.001), ease of use and confidence in successful dose delivery being the main reasons for their preference. Nurses thought that Easi‐Breathe was easier for the vast majority of patients (97%) to use correctly, as well as being easier to teach and to use correctly in a crisis (p<0.001). Overall, 79% of nurses preferred the Easi‐Breathe to the conventional MDI (p<0.001), ease of use and ease of teaching being the main reasons for their preference.
RECENT ADVANCES IN THE NON‐SURGICAL MANAGEMENT OF ATRIAL FIBRILLATION
Authors: Kamalvand K , Sulke N
Published: April 2023

Atrial fibrillation is the commonest clinical arrhythmia, and is associated with significant morbidity and mortality. The treatment of choice is to restore and maintain sinus rhythm. Although certain antiarrhythmic drugs are more effective than placebo in maintaining sinus rhythm, recurrence of atrial fibrillation post cardioversion remains common. The use of antiarrhythmic drugs can be associated with serious adverse effects due to their negative inotropic and proarrhythmic effects. Radiofrequency ablation of the AV junction is a safe and effective palliative treatment option in patients who have failed drug therapy. Ventricular rate control without the need for permanent pacing can be achieved by AV nodal modification using radiofrequency energy. There is also interest in the role of catheter ablation as a possible curative procedure for atrial fibrillation. Atrial pacing can reduce the incidence of atrial fibrillation in certain subgroups of patients. Finally, low energy intracardiac atrial defibrillation has been shown to be feasible in humans.