The British journal of clinical practice最新文献

Increasing age, certain medications such as diuretics, disease processes such as malignant neoplasm and schizophrenia, and a history of hyponatraemia or polydipsia may predispose patients to the development of hyponatraemia. In addition, certain psychotropic medications, including TCAs, MAOIs, carbamazepine, trazodone and neuroleptics, may predispose to hyponatraemia, yet a causative role for most has not been firmly established and the effect is most likely to be more idiosyncratic. The SSRIs have been associated with hyponatraemia in a small number of case reports. The mean age and sex of patients in reported cases is over 70 years and predominantly female, and patients were often receiving concomitant diuretic therapy. The frequency of hyponatraemia in elderly female patients receiving fluoxetine has been estimated to be as high as eight per 1000. The risk of developing hyponatraemia appears to be highest during the first few weeks of treatment. Because of the potential seriousness of hyponatraemia, if an elderly patient receiving an SSRI develops unexplained symptoms during the first few weeks of therapy, it is necessary to measure the serum sodium level.

A number of psychiatric and behavioural symptoms have been described in relation to silent cerebral infarction. At least four symptom clusters were identified, namely, affective, paranoid delusional, confusional state and changes in mood with behavioural disturbances. The mechanisms involved are unclear. Biochemical changes involving neurotransmitter mechanisms, vascular compromise or structural damage to the anatomical pathways may be contributory if not causal. It is clear that in patients presenting with behavioural or psychiatric manifestations without any previous history of mental illness and without any focal or lateralising neurological signs, cerebrovascular disease should be a diagnostic consideration.

Patients who have prolonged stays on acute psychiatric wards are a feature of many modern community psychiatric services. The present study aimed to determine if the care delivered to these patients could be improved by reflecting back to practitioners easily auditable components of the patients' care. The subjects comprised patients resident on the acute psychiatric units in Sheffield for more than six months. These patients were surveyed in April 1995 and again in February 1996. After the first survey, clinicians received a presentation and feedback regarding aspects of their patients' care. The results demonstrated there had been little change in the percentage of acute bed capacity occupied by patients with inpatient stays in excess of six months, despite improvement in many of the audit standards. The main reason for prolonged inpatient treatment was continued mental state or behavioural disturbance. The mean length of stay of patients in this category actually increased. The results suggest that a simple audit exercise can improve the quality of care delivered to this group of patients, but that they will continue to occupy a substantial proportion of acute bed capacity in the absence of suitable alternative treatment settings.

Intraoperative cholangiograms and exploration of the common bile duct (CBD) during laparoscopic cholecystectomy are technically more demanding than during open cholecystectomy. This has led to many surgeons using a selective policy for cholangiography. In this study we prospectively assessed whether biliary ultrasound (CBD diameter > or = 6 mm) or one or more abnormal liver function tests (LFTs) performed in the 24 hours preoperatively could predict the need for cholangiography. Forty-five patients were studied (14 male, 31 female), mean age 47.8 years. All patients with one or both tests abnormal preoperatively (19 patients) underwent intraoperative cholangiograms. Seven CBD stones were identified (16%). There was no evidence of CBD stones in patients not undergoing cholangiography at a median follow-up of 18 months. In patients with stones, three underwent open CBD exploration, and four underwent endoscopic retrograde choledochopancreatography (ERCP) and sphincterotomy in the early postoperative period without complications. CBD diameter > or = 6 mm is a useful predictor of CBD stones. These may be treated successfully by postoperative ERCP.

A patient with a greatly prolonged international normalised ratio (INR) during the combined use of warfarin and indomethacin is described. In patients on warfarin, non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided as far as possible. If NSAIDs are absolutely necessary, patients should be closely monitored for prolongation of INR and bleeding.

Self-expandable oesophageal stents are being increasingly used in the management of malignant oesophageal strictures. Most benign peptic oesophageal strictures can be successfully managed using endoscopic oesophageal dilatation combined with long-term Proton pump inhibition therapy. Although endoscopic oesophageal dilatation can be performed on an outpatient basis, it often requires repeated hospital visits. There is a small risk of oesophageal perforation, while cardio-respiratory complications may be encountered during the use of intravenous sedation in an elderly population. The use of self-expandable Strecker stents in three elderly patients with benign peptic oesophageal strictures is described.

Narcolepsy is a chronic condition that usually afflicts the patient for decades. It is more common than is generally appreciated. However, it is likely to be misdiagnosed because doctors are unfamiliar with some of the symptoms. Its significant socioeconomic impact on the patient's quality of life warrants prompt medical attention.

A total of 323 children aged 4-11 years who were receiving, or had symptoms indicating a clinical requirement for, inhaled corticosteroid at a daily dose of 400 micrograms budesonide (BUD) or beclomethasone dipropionate (BDP), or 200 micrograms fluticasone propionate (FP), were randomised into this multicentre, open-label, parallel group study. Patients received either FP 100 micrograms b.d. administered via the Accuhaler/Diskus inhaler (n = 159) or BUD 200 micrograms b.d. administered via a Turbohaler inhaler (n = 164) for four weeks and recorded daily their morning and evening peak expiratory flow (PEF), asthma symptoms and use of relief medication. Device handling was assessed by a questionnaire, with responses recorded on three- or five-point ordinal scales. The primary efficacy parameter was mean percent predicted morning PEF. The device handling results showed the Accuhaler/Diskus inhaler was rated more favourably than the Turbohaler inhaler in terms of ease of correct inhaler use, ease of telling how many doses were left, ease of knowing whether a dose had been inhaled and overall liking of the device. More patients in the Accuhaler/Diskus group (85%) than in the Turbohaler group (58%) said they would be happy to receive the same device again, while 8% and 25% respectively said they would not be happy to be given it again. In addition, the change from baseline to week 4 of treatment in mean percent predicted morning PEF was greater in the FP Accuhaler/Diskus group, indicating that FP 200 micrograms daily via Accuhaler/Diskus inhaler is at least as clinically effective as BUD 400 micrograms daily via the Turbohaler inhaler.

Reactive arthritis (ReA) is one of the most common arthritides affecting young adults. In most cases it follows urogenital or enteric bacterial infection, but its pathogenesis is not fully understood. It is generally considered a sterile arthritis which appears to involve immune response to bacterial organisms and genetic host susceptibility associated with the presence of HLA-B27 antigen. New findings suggest that in some ReA cases, viable bacteria are present inside the joints, and these organisms may cause the disease and trigger the inflammatory response. ReA manifests clinically as a rheumatoid factor negative oligoarthritis associated with enthesopathy and certain mucosal and skin lesions. Laboratory findings in ReA are non-specific. Although concepts of its pathogenesis are still evolving, so-called ReA remains an important condition to be distinguished from rheumatoid arthritis. Prognosis is generally better. Treatments with known effects in some cases include non-steroidal anti-inflammatory drugs, intra-articular corticosteroids, oral tetracyclines and sulphasalazine. The occasional chronic and severe ReA may be very difficult to treat.