Variability in clinicians' opinions regarding fitness to drive in patients with obstructive sleep apnoea syndrome (OSAS).

We evaluated clinicians' current practice for giving advice to patients with obstructive sleep apnoea syndrome. Clinicians were invited to complete a web-based survey and indicate the advice they would give to patients in a number of scenarios about driving; they were also asked what they considered to be residual drowsiness and adequate compliance following CPAP treatment. In the least contentious scenario, 94% of clinicians would allow driving; in the most contentious a patient had a 50% chance of being allowed to drive. Following treatment with CPAP, clinicians' interpretation of what constituted residual drowsiness was inconsistent. In each vignette the same clinician was more likely to say 'yes' to 'excessive' than to 'irresistible' (71%±12% vs 42%±10%, p=0.0045). There was also a lack of consensus regarding 'adequate CPAP compliance'; 'yes' responses ranged from 13% to 64%. There is a need for clearer guidance; a recent update to the Driver and Vehicle Licensing Agency guidance, and a statement from the British Thoracic Society, making it clear that sleepiness while driving is the key issue, may help.

UK national survey of thoracic ultrasound in respiratory registrars.

Thoracic ultrasound training has become part of the respiratory medicine curriculum. Data on training, access to teaching and achievement of competency in thoracic ultrasound by respiratory specialty trainees are scarce. Using the web-based kwiksurveys, we surveyed current respiratory specialty trainees (STs) in the UK. 177 responses were recorded. Nearly three-quarters of trainees had access to bedside ultrasound but only 15.3% had regular ultrasound training. Overall, 28.8% had achieved level 1 competency but only 44.4% of trainees at ST6 and above were level 1 competent. The majority of respiratory trainees have access to thoracic ultrasound but structured training is limited, with only a small proportion of trainees attaining level 1. More structured training and mentoring is needed to enable trainees to achieve the required competencies.

Postoperative urinary retention after inguinal hernia repair: a single institution experience.

PURPOSE: Inguinal hernia repair is a common general surgery procedure with low morbidity. However, postoperative urinary retention (PUR) occurs in up to 22% of patients, resulting in further extraneous treatments.This single institution series investigates whether patient comorbidities, surgical approaches, and anesthesia methods are associated with developing PUR after inguinal hernia repairs. METHODS: This is a single institution retrospective review of inguinal hernia from 2012 to 2015. PUR was defined as patients without a postoperative urinary catheter who subsequently required bladder decompression due to an inability to void. Univariate and multivariate logistic regressions were performed to quantify the associations between patient, surgical, and anesthetic factors with PUR. Stratification analysis was conducted at age of 50 years. RESULTS: 445 patients were included (42.9% laparoscopic and 57.1% open). Overall rate of PUR was 11.2% (12% laparoscopic, 10.6% open, and p = 0.64). In univariate analysis, PUR was significantly associated with patient age >50 and history of benign prostatic hyperplasia (BPH). Risk stratification for age >50 revealed in this cohort a 2.49 times increased PUR risk with lack of intraoperative bladder decompression (p = 0.013). CONCLUSIONS: At our institution, we found that patient age, history of BPH, and bilateral repair were associated with PUR after inguinal hernia repair. No association was found with PUR and laparoscopic vs open approach. Older males may be at higher risk without intraoperative bladder decompression, and therefore, catheter placement should be considered in this population, regardless of surgical approach.

Long-term aminosalicylate therapy is under-used in patients with ulcerative colitis: a cross-sectional survey.

BACKGROUND: There is evidence from case-control studies that aminosalicylate drugs can reduce colorectal cancer risk by 75-81% in patients with ulcerative colitis. Patients may fail to comply with long-term therapies, however, or may have been advised to discontinue treatment once in remission. AIM: To describe the usage of long-term aminosalicylate therapy in patients with ulcerative colitis. METHODS: A cross-sectional study was performed using data extracted from general practitioner clinical records on demographic features, extent and duration of disease, use of aminosalicylate therapy and specialist care. RESULTS: Three hundred and sixty-three people had ulcerative colitis and no history of colorectal surgery. Ninety-five of 175 (54%) patients with proctitis, 78 of 123 (63%) patients with left-sided colitis and 28 of 45 (62%) patients with extensive colitis were currently taking an aminosalicylate drug. Those doing so were more likely to be under specialist care than to be definitely or possibly discharged (odds ratio, 4.9; 95% confidence interval, 2.9-8.4). The likelihood of current aminosalicylate therapy was not related to gender or the extent of disease, but was negatively related to the duration of disease. CONCLUSIONS: A substantial minority of patients with ulcerative colitis does not take long-term aminosalicylate therapy. Those who do are more likely to be under specialist care, to be older or to have disease of shorter duration.

5-amino salicylic acid absorption and metabolism in ulcerative colitis patients receiving maintenance sulphasalazine, olsalazine or mesalazine.

BACKGROUND: All 5-aminosalicylic acid (5-ASA) preparations are potentially nephrotoxic, but there has been concern that newer delivery systems may increase this risk, either because of altered absorption or altered metabolism. Previous studies of 5-ASA absorption and excretion have usually either been performed in healthy controls or have only examined short-term therapy. 5-ASA and N-acetyl-5-ASA have therefore been measured in blood samples, and N-acetyl-5-ASA in urine samples, from patients with ulcerative colitis on long-term maintenance with different 5-ASA preparations and compared with sensitive markers of renal damage. METHODS: Patients receiving mesalazine (Asacol) (n = 13), sulphasalazine (n = 12) or olsalazine (Dipentum) (n = 8), all at doses within the recommended range were studied. Six-hour and trough serum concentrations of 5-ASA and N-acetyl-5-ASA and 24-h urinary excretion of N-acetyl-5-ASA were measured by high-performance liquid chromatography. RESULTS: Absorption of 5-ASA, assessed as 24-h excretion of N-acetyl-5-ASA expressed as molar % of ingested dose, was greater in patients receiving mesalazine, 23.25 +/- 10.65% (mean +/- s.d.; n = 13), than those receiving sulphasalazine (11.16 +/- 10.52%, n = 12; P = 0.003) or olsalazine (9.70 +/- 3.89%, n = 8; P < 0.002). The ratio of 5-ASA: N-acetyl-5-ASA in the serum 6 h after dose was also greater with mesalazine (1.02 +/- 0.44, mean +/- s.d.) than sulphasalazine (0.54 +/- 0.44, P < 0.02) or olsalazine (0.38 +/- 0.44, P < 0.005). Urinary markers of tubular damage were increased in four of 33 patients, but showed no correlation with concentration of 5-ASA or N-acetyl-5-ASA in serum and N-acetyl-5-ASA in urine, nor with lifetime dose or average daily dose of 5-ASA. CONCLUSIONS: In patients with ulcerative colitis receiving maintenance 5-ASA therapy there was greater absorption and less acetylation of 5-ASA from mesalazine (Asacol) compared with sulphasalazine or olsalazine, but no evidence from this study that this resulted in increased nephrotoxicity.

Fatal Pasteurella dagmatis peritonitis and septicaemia in a patient with cirrhosis: a case report and review of the literature.

Pasteurella species cause zoonotic infections in humans. Human pasteurella infections usually manifest as local skin or soft tissue infection following an animal bite or scratch. Systemic infections are less common and are limited to patients at the extremes of age or those who have serious underlying disorders, including cirrhosis. Most human pasteurella infections are caused by the multocida species. We report a case of Pasteurella dagmatis peritonitis and septicaemia in a patient with cirrhosis. The infection followed a scratch inflicted by a pet dog. Despite appropriate antibiotic treatment the infection proved fatal. Spontaneous bacterial peritonitis caused by P dagmatis has not been reported previously. Pasteurella dagmatis is a relatively recently described species, which is rarely reported as a human pathogen. This species may be misidentified unless commercial identification systems are supplemented by additional biochemical tests.

The production of neuraminidase and fucosidase by Helicobacter pylori: their possible relationship to pathogenicity.

The pathogenicity of enterobacteria often correlates with their production of neuraminidase (sialidase). Forty-nine Helicobacter pylori isolates have therefore been examined for their production of neuraminidase and other glycosidases. All 49 isolates produced considerable neuraminidase (median 228 IU/microg protein, interquartile range 121-370), pH optimum 7.5. Nine of the 49 also produced fucosidase (median 23 IU/microg protein, interquartile range 12-39), pH optimum 7.0. Production of these enzymes did not correlate with bacterial Cag A expression or duodenal ulceration. Neutrophils exposed to neuraminidase show increased adherence to endothelium so the neuraminidase production by H. pylori could partly explain the predominant neutrophil inflammatory infiltrate seen in H. pylori-associated gastritis. Inhibition of this enzyme by use of neuraminidase-inhibitors could be a useful therapeutic approach.

The potential impact of high-quality MRI of the biliary tree on ERCP workload.

BACKGROUND: Magnetic resonance cholangiography (MRC) is a non-invasive method of imaging the biliary tree with virtually no morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) has a significant morbidity, mortality and failed imaging rate. Unlike MRC, ERCP is highly dependent on the clinical team for high-quality results and minimal morbidity. MRC requires high-quality image acquisition and appropriate reconstructions, with skilled reading of the images. OBJECTIVES: To assess the impact on ERCP workload of using MRC as the initial imaging modality for the biliary tree in selected patient groups, and to assess procedure-related morbidity and mortality. METHODS: An analysis of 1078 consecutive ERCP examinations performed at our institution over the six years to 1996 has been undertaken. Complications, imaging failure rates and ERCP findings have been analysed in the different referral categories to assess the potential impact of MRC on future ERCP workload and patient outcomes. RESULTS: At our institution, if MRC had been used as the first imaging investigation in patients with abdominal pain (n = 336, with or without abnormal liver function tests but without clinical jaundice) and those with present or past acute pancreatitis (n = 101), we estimate that 83 (19%) would have needed to go on to ERCP, but 354 (81%) would not have required further invasive investigation. In these categories, this would have resulted in five patients with stones missed at MRC, but 14 extra patients with stones would have been identified whose stones would have been missed at ERCP (failed examinations). There would be an overall 33% reduction in ERCP workload and 20 serious complications related to ERCP would have been avoided. Overall 7% of patients would be subjected to both investigations. CONCLUSIONS: In the interests of efficient use of resources, minimization of patient complications and accurate identification of those requiring therapeutic ERCP, MRC should be the preferred initial investigation in selected groups of patients presently being subjected to ERCP.

Inspecting the colon from inside and out to solve pyrexia of unknown origin.

A man with longstanding intermittent symptoms of abdominal pain, diarrhoea and pyrexia of unknown origin was diagnosed with the novel technique of laparoscopic-assisted colonoscopy. At subsequent laparotomy, a longstanding perforation of sigmoid diverticular disease was resected, with resolution of his symptoms.

Biodegradable stent or balloon dilatation for benign oesophageal stricture: pilot randomised controlled trial.

AIM: To undertake a randomised pilot study comparing biodegradable stents and endoscopic dilatation in patients with strictures. METHODS: This British multi-site study recruited seventeen symptomatic adult patients with refractory strictures. Patients were randomised using a multicentre, blinded assessor design, comparing a biodegradable stent (BS) with endoscopic dilatation (ED). The primary endpoint was the average dysphagia score during the first 6 mo. Secondary endpoints included repeat endoscopic procedures, quality of life, and adverse events. Secondary analysis included follow-up to 12 mo. Sensitivity analyses explored alternative estimation methods for dysphagia and multiple imputation of missing values. Nonparametric tests were used. RESULTS: Although both groups improved, the average dysphagia scores for patients receiving stents were higher after 6 mo: BS-ED 1.17 (95%CI: 0.63-1.78) P = 0.029. The finding was robust under different estimation methods. Use of additional endoscopic procedures and quality of life (QALY) estimates were similar for BS and ED patients at 6 and 12 mo. Concomitant use of gastrointestinal prescribed medication was greater in the stent group (BS 5.1, ED 2.0 prescriptions; P < 0.001), as were related adverse events (BS 1.4, ED 0.0 events; P = 0.024). Groups were comparable at baseline and findings were statistically significant but numbers were small due to under-recruitment. The oesophageal tract has somatic sensitivity and the process of the stent dissolving, possibly unevenly, might promote discomfort or reflux. CONCLUSION: Stenting was associated with greater dysphagia, co-medication and adverse events. Rigorously conducted and adequately powered trials are needed before widespread adoption of this technology.

Endoscopic retrograde cholangio-pancreatography practice in district general hospitals in North East England: a Northern Regional Endoscopy Group (NREG) study.

AIM: Endoscopic retrograde cholangio-pancreatography (ERCP) is an important tool for the management of pancreato-biliary disease. The aim of this study was to compare the current practice of ERCP in North East England against the key 2004 National Confidential Enquiry Report into Patient Outcome and Death (NCEPOD) recommendations and the standards set by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG). METHODS: This was a prospective multicentre study involving all hospitals in North East England, coordinated through the Northern Regional Endoscopy Group (NREG). RESULTS: Fourteen endoscopy units submitted data for 481 ERCPs. Mean dose of midazolam was 3.24 mg (standard deviation 1.35; range 1-8 mg). Coagulation profile results were available on 469 patients (97%). Radiological investigations were documented in 96% of the procedures (463 of 481) prior to ERCP. The most common indication for ERCP was related to choledocholithiasis and its complications. All procedures were performed with a therapeutic intent. A total of 84% of all patients were either American Society of Anesthesiologists grade I or II. The selective biliary cannulation rate was 87.3%. The total completion rate of all procedures was 80.2% (381 of 475) and completion of therapy was 89.5% (425 of 475). The 30-day mortality rate was 2% (ten patients) and procedure-related complications occurred in 5% of patients. There were no deaths directly as a result of ERCP; all deaths were related to underlying medical conditions. CONCLUSIONS: The practice of ERCP in North East England adheres to the key recommendations of the NCEPOD and the standards set by JAG. The rates of complications compare favourably with those reported internationally.

Is anaemia relevant in the referral and diagnosis of colorectal cancer?

OBJECTIVE: Current efforts to improve the outcome from colorectal cancer aim to shorten the delay between referral and diagnosis. Investigation of iron-deficiency anaemia has a high yield for the diagnosis of gastrointestinal malignancy and its presence is included in current referral guidelines. We explored the relationship between anaemia and colorectal cancer. METHOD: We reviewed hospital and laboratory database records of patients diagnosed with colorectal cancer between January 2003 and June 2004. The site of colorectal cancer was correlated with the presence of anaemia at the time of referral. Anaemia was defined according to local practice (Hb < 12.0 g/dl in females and <13.0 g/dl in males), compared with the threshold recommended in current national referral guidelines (Hb < 10 g/dl in females and <11 g/dl in males). RESULTS: Over 18 months, 143 patients were diagnosed with colorectal cancer. Anaemia was present in 48% of males and 50% of females using local practice and 24% of males and 16% of females using national referral guidelines. Those with right-sided and non-rectal cancers were significantly more likely to be anaemic than those with left-sided and rectal cancers, respectively. CONCLUSION: In approximately half of cases the diagnosis of colorectal cancer is not associated with anaemia. Anaemia is more common with proximal lesions but this is not a consistent finding. The current threshold for anaemia at which national guidelines suggest referral also appears to be insensitive.

Sulphasalazine induced renal failure.

Two men with longstanding ulcerative colitis who were treated with sulphasalazine for several years and who developed chronic renal failure are reported. Renal biopsy specimens showed histological changes consistent with drug induced chronic intestinal nephritis. Extensive investigation made other causes of chronic renal failure unlikely. One of these patients underwent renal transplantation, the other has impaired but stable renal function.

'Conversion' from ulcerative colitis to Crohn's disease associated with corticosteroid treatment.

A man who was a non-smoker presented with clinical, histological, and radiological features typical of distal ulcerative colitis. Prolonged treatment with corticosteroids was associated with the development of numerous granulomata, stricturing, and perianal disease. It is speculated that the immunosuppression associated with the corticosteroid treatment may have induced a change from ulcerative colitis to Crohn's disease of the colon. This case report lends support to the hypothesis that these conditions may just represent different forms of a continuum of inflammatory bowel disease.

'Sticky' neutrophils, pathergic arthritis, and response to heparin in pyoderma gangrenosum complicating ulcerative colitis.

Pyoderma gangrenosum is strongly associated with inflammatory bowel disease and exhibits pathergy, occurring at sites of previous minor trauma. A patient is presented with a 21 year history of extensive ulcerative colitis, who developed pyoderma gangrenosum and arthralgia while receiving high dose corticosteroids for active ulcerative colitis. The arthralgia exhibited pathergy affecting particularly the left temporomandibular joint, which was stressed by an asymmetric bite, and the left elbow, which had been fractured many years previously. This prompted the hypothesis that neutrophils in this condition may be marginated, as a result of increased stickiness of either the neutrophil or the vascular endothelium. The introduction of heparin therapy was associated with rapid resolution of the arthralgia, pyoderma gangrenosum, and ulcerative colitis.

Colonic mucin synthesis is increased by sodium butyrate.

The effects of sodium butyrate and sodium bromo-octanoate (an inhibitor of beta oxidation) on colonic mucus glycoprotein (mucin) synthesis have been assessed using tissue from colonic resection samples. Epithelial biopsy specimens were incubated for 16 hours in RPMI 1640 with glutamine, supplemented with 10% fetal calf serum and N-acetyl-[3H]-glucosamine ([3H]-Glc NAc), and differing concentrations of sodium butyrate. Incorporation of [3H] Glc NAc into mucin by normal epithelium at least 10 cm distant from colonic cancer was increased in the presence of sodium butyrate in a dose dependent manner, with maximum effect (476%) at a concentration of 0.1 mM (number of specimens = 24 from six patients, p < 0.001). The increase in response to butyrate was not seen when specimens were incubated in the presence of the beta oxidation inhibitor sodium bromo-octanoate 0.05 M. The striking increase in mucin synthesis that results when butyrate is added to standard nutrient medium suggests that this may be an important mechanism affecting the rate of mucin synthesis in vivo and may also explain the therapeutic effect of butyrate in colitis.

Interrelation of strongyloidiasis and tuberculosis.

A 31 year old man from Gambia, resident in the United Kingdom for two years, presented with a two month history of unproductive cough, malaise, weight loss, non-specific abdominal pain, and episodic diarrhoea. Acid alcohol fast bacilli were identified in his sputum, together with Strongyloides stercoralis larvae and Giardia lamblia cysts in his stools. This case illustrates that latent strongyloidiasis can become overt in the presence of tuberculosis, and the diagnosis of strongyloidiasis must be borne in mind in patients who have previously resided in endemic regions.