Mycophenolate mofetil-induced liver injury in a patient with aquaporin-4 antibody positive transverse myelitis.

We present a case of a 49-year-old woman diagnosed with aquaporin-4 antibody-positive transverse myelitis, who developed a significant transaminitis 2 months after commencing mycophenolate mofetil (MMF) as a steroid-sparing agent. No other risk factors were identified, a blood liver panel was negative and liver biopsy showed features compatible with drug-induced liver injury (DILI). MMF was stopped with a corresponding normalisation of serum alanine aminotransferase over the next 2 months. This case highlights MMF as a rare cause of DILI and provides justification for monitoring of liver biochemistry on therapy.

Hepatic artery aneurysm: an unusual cause of upper gastrointestinal bleed.

An 86-year-old woman presented to hospital with melaena. This was her third presentation with the same symptom. There was no obvious source of bleeding on her oesophagogastroduodenoscopy; however, it did show a previously clipped Dieulafoy lesion. CT angiography showed an aneurysm arising from the hepatic artery. Selective coeliac artery angiogram showed aneurysmal dilatation of the distal part of the coeliac trunk and confirmed the presence of the common hepatic artery aneurysm. The aneurysm was coiled by the interventional radiologist. Final angiogram showed good flow through the hepatic artery with obliteration of the inferior patch. The procedure was uncomplicated and the patient was discharged shortly afterwards.

Nutritional assessment in elderly care: a MUST!

Malnutrition affects over three million people in the UK with associated health costs exceeding £13 billion annually.[1] In hospital, malnutrition has been shown to increase complication rates, morbidity, mortality, hospital readmissions, and length of hospital stay.[2] To screen for malnutrition, a reliable and validated screening tool such as the malnutrition universal screening tool (MUST) should be used.[3] We believe that improved patient outcomes and significant savings to the trust can be achieved, not only by ensuring that every patient has a MUST score documented, but that it is calculated correctly and the appropriate interventions are implemented. We have carried out the audit three times (May, July, and November 2013). The study included the patients on the elderly care ward of Watford General Hospital (n=64, 62, and 63 respectively). MUST scores documented in nursing notes for each patient were noted. We re-calculated each MUST score ourselves for comparison. We went through patient notes and nursing information and noted which recommended nutritional interventions were being implemented. Our results highlighted several issues: 1) Patients did not consistently have a MUST score documented 2) MUST scores were calculated incorrectly. This was generally due to BMIs calculated incorrectly, and patients' weights from six months ago not being known 3) High MUST scores not being acted on appropriately. Our interventions have involved liaising with various teams within the hospital to maximise the efficacy of the MUST score. This has included encouraging the trust to provide regular training to nurses because of high nursing staff turnover. Following our audit, the dietitian department agreed to undertake weekly ward rounds to screen for patients at risk of malnutrition. Our interventions so far have resulted in increased proportion of MUST scores being calculated (73 to 97%), and increased rates of patients being referred to dietitians (62 to 86% in the second audit cycle).

Behavioural treatments for Tourette syndrome: an evidence-based review.

Tourette syndrome (TS) is a disorder characterised by multiple motor and vocal tics and is frequently associated with behavioural problems. Tics are known to be affected by internal factors such as inner tension and external factors such as the surrounding environment. A number of behavioural treatments have been suggested to treat the symptoms of TS, in addition to pharmacotherapy and surgery for the most severe cases. This review compiled all the studies investigating behavioural therapies for TS, briefly describing each technique and assessing the evidence in order to determine which of these appear to be effective. Different behavioural therapies that were used included habit reversal training (HRT), massed negative practice, supportive psychotherapy, exposure with response prevention, self-monitoring, cognitive-behavioural therapy, relaxation therapy, assertiveness training, contingency management, a tension-reduction technique and biofeedback training. Overall, HRT is the best-studied and most widely-used technique and there is sufficient experimental evidence to suggest that it is an effective treatment. Most of the other treatments, however, require further investigation to evaluate their efficacy. Specifically, evidence suggests that exposure with response prevention and self-monitoring are effective, and more research is needed to determine the therapeutic value of the other treatments. As most of the studies investigating behavioural treatments for TS are small-sample or single-case studies, larger randomised controlled trials are advocated.

The role of impulse control disorders in Tourette syndrome: an exploratory study.

INTRODUCTION: Tourette syndrome (TS) is a neurodevelopmental condition characterised by the presence of multiple motor tics and one or more phonic tics, often associated with co-morbid behavioural problems. Impulse control disorders (ICDs) are a set of disorders where patients have significant difficulties in controlling their urges to perform rewarding behaviours. ICDs are expected to be common in patients with TS, as many problems reported in TS are related to difficulties in controlling impulsivity. AIMS: This exploratory study aimed to determine the clinical characteristics of ICDs in adult patients with TS, and to investigate the relationship between the presence of ICDs and health-related quality of life (HR-QOL). METHODS: Thirty-one patients with a diagnosis of TS were screened for ICDs using the Minnesota Impulsive Disorders Interview (MIDI). HR-QOL was assessed using a generic instrument, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and a disease-specific scale, the Gilles de la Tourette Syndrome-Quality of Life Scale (GTS-QOL). RESULTS: Twenty-three out of 31 participants (74.2%) had at least one ICD. The most common ICDs were intermittent explosive disorder (51.6%) and compulsive buying disorder (41.9%). The number of ICDs significantly correlated with reduced HR-QOL (p=0.011) as measured by the GTS-QOL, but not by the SF-36. CONCLUSIONS: ICDs are common in patients with TS. HR-QOL measures specific to this patient population show that the presence of co-morbid ICDs results in poorer HR-QOL.