Clinical experience of methotrexate in Crohn's disease: response, safety and monitoring of treatment.

BACKGROUND: Methotrexate is an immunosuppressant used in the treatment of patients with Crohn's disease who are intolerant or refractory to azathioprine. AIM: To present clinical experience in terms of response, side effects and reason for cessation of methotrexate treatment as well as adherence to monitoring regimens. DESIGN: Retrospective review of case records of 37 patients taking methotrexate for Crohn's disease at the Bristol Royal Infirmary, a large UK teaching hospital. Thirty-five patients used oral methotrexate. RESULTS: Response rate to methotrexate was 78% at 3 months. Adverse events were uncommon and rarely dangerous. Monitoring of treatment did not adhere to British Society of Gastroenterology guidelines. CONCLUSION: Oral methotrexate is effective and safe in the treatment of Crohn's disease. This is in contrast to findings of previous series, which have mainly reported on intramuscular methotrexate use. Monitoring of treatment is currently inadequate and consensus should be sought for a pragmatic monitoring schedule to resolve this important governance issue.

Ultrasound-guided regional anaesthesia in foot and ankle surgery.

The use of regional anaesthesia in foot and ankle surgery is becoming well recognised, particularly in patients who prefer to stay awake during the procedure and for better post-operative analgesia. Its use is ideal for patients with multiple co-morbidities, in whom general anaesthesia (GA) otherwise would could be challenging. The procedures performed with landmark/anatomical guidance alone carry a relatively higher risk of complications, risk of inadvertant injection into the intarvascualr space leadinf to local anaesthetic toxicity, the majority of which complications are caused by incorrect placement of the needle. Hence, ultrasound guidance is frequently used to minimise those risks. Although various regional anaesthetic techniques for foot and ankle surgery have been described, their comprehensive review is lacking. This manuscript aims to fulfil this void. The focus will be on the peripheral methods of regional anaesthesia including the plexus and single nerve blocks. Various techniques with their benefits and potential complications will be discussed. In addition, the evidence on the efficacy of an ultrasound-guided approach as well as its cost implications will be explored. There are significant considerations in deciding whether to implement this technique in routine clinical practice and this review aims to summarise the available literature to establish the evidence base behind it.