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Goddard A.F.,Royal Derby Hospital | James M.W.,Nottingham Digestive Diseases Center | McIntyre A.S.,Wycombe Hospital | Scott B.B.,Lincoln County Hospital
Gut | Year: 2011

Background: ▶ Iron deficiency anaemia (IDA) occurs in 2-5% of adult men and postmenopausal women in the developed world and is a common cause of referral to gastroenterologists. Gastrointestinal (GI) blood loss from colonic cancer or gastric cancer, and malabsorption in coeliac disease are the most important causes that need to be sought. Defining iron deficiency anaemia: ▶ The lower limit of the normal range for the laboratory performing the test should be used to define anaemia (B). ▶ Any level of anaemia should be investigated in the presence of iron deficiency (B). ▶ The lower the haemoglobin the more likely there is to be serious underlying pathology and the more urgent is the need for investigation (B). ▶ Red cell indices provide a sensitive indication of iron deficiency in the absence of chronic disease or haemoglobinopathy (A). ▶ Haemoglobin electrophoresis is recommended when microcytosis and hypochromia are present in patients of appropriate ethnic background to prevent unnecessary GI investigation (C). ▶ Serum ferritin is the most powerful test for iron deficiency (A). Investigations: ▶ Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss (A). ▶ All patients should be screened for coeliac disease (B). ▶ If oesophagogastroduodenoscopy (OGD) is performed as the initial GI investigation, only the presence of advanced gastric cancer or coeliac disease should deter lower GI investigation (B). ▶ In patients aged >50 or with marked anaemia or a significant family history of colorectal carcinoma, lower GI investigation should still be considered even if coeliac disease is found (B). ▶ Colonoscopy has advantages over CT colography for investigation of the lower GI tract in IDA, but either is acceptable (B). Either is preferable to barium enema, which is useful if they are not available. ▶ Further direct visualisation of the small bowel is not necessary unless there are symptoms suggestive of small bowel disease, or if the haemoglobin cannot be restored or maintained with iron therapy (B). ▶ In patients with recurrent IDA and normal OGD and colonoscopy results, Helicobacter pylori should be eradicated if present. (C). ▶ Faecal occult blood testing is of no benefit in the investigation of IDA (B). ▶ All premenopausal women with IDA should be screened for coeliac disease, but other upper and lower GI investigation should be reserved for those aged 50 years or older, those with symptoms suggesting gastrointestinal disease, and those with a strong family history of colorectal cancer (B). ▶ Upper and lower GI investigation of IDA in postgastrectomy patients is recommended in those over 50 years of age (B). ▶ In patients with iron deficiency without anaemia, endoscopic investigation rarely detects malignancy. Such investigation should be considered in patients aged >50 after discussing the risk and potential benefit with them (C). ▶ Only postmenopausal women and men aged >50 years should have GI investigation of iron deficiency without anaemia (C). ▶ Rectal examination is seldom contributory, and, in the absence of symptoms such as rectal bleeding and tenesmus, may be postponed until colonoscopy. ▶ Urine testing for blood is important in the examination of patients with IDA (B). Management: ▶ All patients should have iron supplementation both to correct anaemia and replenish body stores (B). ▶ Parenteral iron can be used when oral preparations are not tolerated (C). ▶ Blood transfusions should be reserved for patients with or at risk of cardiovascular instability due to the degree of their anaemia (C).


Rajapakse A.,Newark Hospital | Rajapakse S.,University of Colombo | Sharma J.C.,University of Nottingham | Sharma J.C.,Lincoln County Hospital
Stroke | Year: 2011

Carotid intervention in severe carotid stenosis after an anterior circulation ischemic event reduces the risk of further infarcts if the surgery is performed soon after the incident event. At present, there is no recommendation to differentiate among subtypes of anterior circulation infarcts or transient ischemic events. However, evidence is mounting that demonstrates a difference in pathophysiology of lacunar and nonlacunar (large artery) infarcts. The natural history of lacunar strokes is different from large artery infarcts for recurrence and mortality. Stroke is a heterogenous disease and consideration needs to be directed to manage different stroke subtypes differently. Lacunar infarcts mostly do not arise from large artery atheromatous disease or by cardioembolic phenomena, and there is a negative predictive value for severe carotid stenosis in lacunar strokes. Thus, current evidence suggests that lacunar strokes may not warrant investigation for carotid stenosis. © 2010 American Heart Association, Inc.


Hoyles K.,Lincoln County Hospital | Sharma J.C.,Lincoln County Hospital | Sharma J.C.,University of Nottingham
Journal of Neurology | Year: 2013

There is ample evidence from a large number of clinical and pathological studies of an early involvement of olfactory bulbs and cortex in the Lewy body pathology in idiopathic Parkinson's disease (iPD), the olfactory system being one of the first targets of degeneration in this condition. The olfactory dysfunction may be measurably present at the time of initial presentation and progresses in a proportion of patients as the disease advances. Patients with iPD have a more severe olfactory loss as compared to multisystem atrophy whereas the syndromes of corticobasal degeneration and progressive supranuclear palsy have no olfactory loss. A proportion of drug induced parkinsonism may have olfactory loss indicative of primary pathology of dopaminergic degeneration in these patients. Unlike single photon emission tomography, formal measurement of olfaction would provide a supportive role in diagnosing or excluding iPD depending on the duration of an individual patient's parkinsonian symptoms. Whilst olfaction may be only minimally impaired in early stages and may thus not help to differentiate from other syndromes, an intact olfaction in patients with parkinsonism of few years' duration would indicate a non-iPD pathology. Olfactory measurement is easy, cheap and now easily available in a number of tests, and olfactory assessment at different stages of parkinsonism should be used as a diagnostic aid for idiopathic PD and would enhance the diagnostic accuracy of iPD when used in conjunction with the UK Parkinson's disease society Brain Bank supportive criteria for diagnosis of idiopathic Parkinson's disease. © 2013 Springer-Verlag Berlin Heidelberg.


Lewis N.R.,University of Nottingham | Scott B.B.,Lincoln County Hospital
Alimentary Pharmacology and Therapeutics | Year: 2010

Background: Following the appreciation of the importance of gliadin deamidation in the immunopathogenesis of coeliac disease, diagnostic tests based on antibodies to deamidated gliadin peptides have been developed and shown to have high sensitivity and specificity. Aim To compare the performance of the deamidated gliadin peptides antibody test with the current standard, the tissue transglutaminase antibody test, through a meta-analysis of published studies. Methods Databases from 1998 to 2008 were searched for relevant studies. These were assessed for methodological quality and standard statistical tests were applied to compare particularly the sensitivity and specificity of the two tests for the diagnosis of coeliac disease. Results Most studies had methodological flaws, especially ascertainment bias. The pooled sensitivities for the deamidated gliadin peptides antibody and tissue transglutaminase antibody tests were 87.8% (95% CI, 85.6-89.9) and 93.0% (95% CI, 91.2-94.5) respectively and the pooled specificities were 94.1% (95% CI, 92.5-95.5) and 96.5% (95% CI, 95.2-97.5) respectively. Conclusion Although both tests perform well, the tissue transglutaminase antibody test outperforms the deamidated gliadin peptides antibody test and remains the preferred serological test for the diagnosis and/or exclusion of coeliac disease. © 2010 Blackwell Publishing Ltd.


Haoula Z.,University of Nottingham | Salman M.,Lincoln County Hospital | Atiomo W.,University of Nottingham
Human Reproduction | Year: 2012

Background Given the current lack of clarity in the published literature, we performed a systematic review of the literature to determine the exact strength of the association between polycystic ovary syndrome (PCOS) and endometrial cancer (EC). Methods All published studies on the association between PCOS and EC identified through MEDLINE (1966-April 2011), EMBASE (1980-April 2011) and Cochrane (1998-April 2011). Original data were abstracted where available and summarized on a separate Microsoft Excel (2007) database for analysis. A total of 14 studies comparative and non-comparative were identified and included. Results The non-comparative and comparative data suggested that women with PCOS were more likely to develop EC. A meta-analyses of five comparative studies showed an increased risk of EC in women with an odds ratio of 2.89 with a 95 confidence interval of 1.525.48. Conclusions Women with PCOS are about three times more likely to develop EC compared with women without it. This translates into a 9 lifetime risk of EC in Caucasian women with PCOS compared with 3 in women without it. Although most women (91) with PCOS will not develop endometrial cancer, our study has shown that they are more likely at increased risk. More studies are required to clarify the exact molecular mechanisms, determine the best way of screening and preventing disease progression. © 2012 The Autho.


Repper J.,University of Nottingham | Carter T.,Lincoln County Hospital
Journal of Mental Health | Year: 2011

Background. Although mutual support and self-help groups based on shared experience play a large part in recovery, the employment of peer support workers (PSWs) in mental health services is a recent development. However, peer support has been implemented outside the UK and is showing great promise in facilitating recovery. Aims. This article aims to review the literature on PSWs employed in mental health services to provide a description of the development, impact and challenges presented by the employment of PSWs and to inform implementation in the UK. Method. An inclusive search of published and grey literature was undertaken to identify all studies of intentional peer support in mental health services. Articles were summarised and findings analysed. Results. The literature demonstrates that PSWs can lead to a reduction in admissions among those with whom they work. Additionally, associated improvements have been reported on numerous issues that can impact on the lives of people with mental health problems. Conclusion. PSWs have the potential to drive through recovery-focused changes in services. However, many challenges are involved in the development of peer support. Careful training, supervision and management of all involved are required. © 2011 Informa UK, Ltd.


Medical ethical analysis remains dominated by the principlist account first proposed by Beauchamp and Childress. This paper argues that the principlist model is unreflective of how ethical decisions are taken in clinical practice. Two kinds of medical ethical decisions are distinguished: biosocial ethics and clinical ethics. It is argued that principlism is an inappropriate model for clinical ethics as it is neither sufficiently action-guiding nor does it emphasise the professional integrity of the clinician. An alternative model is proposed for decision making in the realm of clinical ethics.


Kyriazi V.,Lincoln County Hospital | Theodoulou E.,Lincoln County Hospital
Archives of Pathology and Laboratory Medicine | Year: 2013

Context.-Cancer is characterized by the development of a prothrombotic state Approximately 15% to 20% and 1.5% to 3.1% of cancer patients develop venous and arterial thrombosis, respectively, whereas 18% to 20% of idiopathic venous events are caused by an occult neoplasia. The highest risk is observed in hematologic, gastrointestinal, and lung malignancies, as well as in patients with active disease, especially in the first 3 months after cancer diagnosis. Hospitalization, surgical interventions, and implanted venous devices increase the thrombotic risk. Patients with metastatic disease, febrile neutropenia, infections, and severe comorbidities experience more frequently a thrombotic event. A contemporary prechemotherapy predictive model incorporates both clinical and biologic parameters, such as the primary cancer site, platelet count, white blood cell count, hemoglobin, use of erythropoietic agents, and body mass index. Several studies aim to clarify the prognostic value of tissue factor, P-selectin, thrombin generation, microparticles, and Ddimers. Objectives.-To summarize current views on epidemiology, risk factors, and predictive variables, discussing the future perspectives and existing limitations in clinical practice. Data Sources.-Review of published literature, including review papers, epidemiologic studies, and clinical trials, in online medical databases. Conclusions.-The thrombogenic properties of tumor cells affect the prognosis and quality of life for the cancer population. Despite the improved awareness and prompt use of thromboprophylaxis, recent studies reported increased rates of thrombotic events, whereas the annual risks for thrombosis recurrence and bleeding are 21% and 12%, respectively. The clinical use of risk factors and prognostic parameters could allow for patient risk stratification and individualization of anticoagulant treatment.


Botchu R.,Lincoln County Hospital
The Iowa orthopaedic journal | Year: 2012

Pneumorachis or epidural emphysema is defined as free air in the spinal canal which is seen following trauma, head trauma, manipulations, epidural injections, and spinal surgery. We report on the case of a 62-year-old with cervical and thoracic pneumorachis following a traffic accident.


Rothwell A.,Lincoln County Hospital
Journal of perioperative practice | Year: 2011

Alexis Carrel was awarded the 1912 Nobel Prize for Physiology or Medicine for pioneering surgical techniques in vascular surgery. His triangulation technique enabled successful anastomosis of blood vessels and subsequently led to advances in blood vessel and organ transplantation. However, Alexis Carrel did not limit his research to the vascular speciality. During the First World War he developed the Carrel-Dakin method of wound irrigation and later his interests lay in aging cells.

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