Walsall, United Kingdom
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Clayton R.N.,Staffordshire University | Raskauskiene D.,Keele University | Reulen R.C.,Walsall Manor Hospital | Jones P.W.,University of Birmingham
Journal of Clinical Endocrinology and Metabolism | Year: 2011

Context: Pituitary ACTH-dependent Cushing's disease (CD) is uncommon, and there are very limited data on long-term mortality. Objective: The aim was to summarize what is known about mortality in ACTH-dependent CD, to report on our own data, and to provide a meta-analysis of six other reports that addressed mortality of CD. Design and Methods: Vital status of 60 CD patients was recorded as of December 31, 2009, and the standardized mortality ratio (SMR) was calculated and compared with the general population of England and Wales, United Kingdom. A meta-analysis of SMRs from seven studies (including ours) was performed for overall mortality in CD. Where reported (four studies), a similar meta-analysis was performed for those patients whose hypercortisolism was in remission after treatment compared to those patients from the same center with persistent disease. Results: 1. From Stoke-on-Trent, 51 of 60 patients were female, median age at diagnosis was in the range of 36-46 yr, and median follow-up was 15 yr. There were 13 deaths, nine due to cardiovascular disease. Overall SMR for the whole cohort was 4.8 (95% confidence interval, 2.8-8.3) (P < 0001). SMR for vascular disease was 13.8 (7.2-36.5) (P < 0001). For persistent disease (n = 6), SMR was 16 (6.7-38.4) vs. remission (n = 54) SMR of 3.3 (1.7-6.7); after adjustment for age and sex, relative risk of death for persistent disease was 10.7 (2.3-48.6) (P = 0.002). Hypertension and diabetes mellitus were associated with significantly worse survival. 2. Using a random effects model meta-analysis revealed an overall (remission plus persistent disease) SMR of 2.2 (1.45-3.41) (P < 0.001). Pooled SMR was 1.2 (0.45-3.2) (P = not significant) for patients in remission and 5.5 (2.7-11.3) (P = 0.001) for patients with persistent disease. Persistence of disease, older age at diagnosis, and presence of hypertension and diabetes are the main determinants of mortality. Conclusions: Overall mortality in CD is double that of the general population. However, patients with CD in remission fare much better than those with persistence of hypercortisolism, and they appear not to have an increased mortality rate. Hypertension and diabetes mellitus are risk factors for worse outcome. Because diagnosis and treatment of patients are at a young age, much longer follow-up of patients in remission is required before one can be confident that their mortality outcome is no different from that of the general population, especially because cardiovascular risk factors may persist after successful biochemical control of the disease. Copyright © 2011 by The Endocrine Society.


Pappachan J.M.,Walsall Manor Hospital | Raskauskiene D.,Walsall Manor Hospital | Sriraman R.,Lincoln County Hospital | Edavalath M.,Staffordshire University | Hanna F.W.,Staffordshire University
Current Hypertension Reports | Year: 2014

Pheochromocytomas (PCCs) are rare catecholamine producing neuroendocrine tumors. The majority of these tumors (85 %) arise from the adrenal medulla. Those arising from the extra-adrenal neural ganglia are called paragangliomas (PGLs). Paroxysmal hypertension with sweating, headaches and palpitation are the usual presenting features of PCCs/ PGLs. Gene mutations are reported in 32-79 % of cases, making genetic screening mandatory in all the cases. The malignancy rates are 10-15 % for PCCs and 20-50 % for PGLs. Measurement of plasma or 24-hour urinary fractionated metanephrines is the best biochemical diagnostic test. Computed tomography or magnetic resonance imaging has high sensitivity (90-100 %) and reasonable specificity (70-90 %) for the anatomical localization. The functionality is assessed by different radionuclide imaging modalities such as metaiodobenzylguanidine (MIBG) scintigraphy, positron emission tomography or single photon emission computed tomography. The only modality of curative treatment is tumor excision. Proper peri-operative management improves the surgical outcomes. Annual follow up with clinical and biochemical assessment is recommended in all the cases after treatment. Children, pregnant women and older people have higher morbidity and mortality risk. De-bulking surgery, chemotherapy, radiotherapy, molecular agents like sunitinib and everolimus, radionuclide agents and different ablation procedures may be useful in the palliation of inoperable/metastatic disease. An update on the diagnostic evaluation and management of PCCs and PGLs is presented here. © 2014 Springer Science+Business Media.


Pappachan J.M.,Walsall Manor Hospital | Raskauskiene D.,Walsall Manor Hospital | Kutty V.R.,Sree Chitra Tirunal Institute for Medical Science and Technology | Clayton R.N.,Staffordshire University
Journal of Clinical Endocrinology and Metabolism | Year: 2015

Context: Several previous observational studies showed an association between hypopituitarism and excess mortality. Reports on reduction of standard mortality ratio (SMR) with GH replacement have been published recently. Objective: This meta-analysis assessed studies reporting SMR to clarify mortality risk in hypopituitary adults and also the potential benefit conferred by GH replacement. Data Sources: A literature search was performed in Medline, Embase, and Cochrane library up to March 31, 2014. Eligibility Criteria: Studies with or without GH replacement reporting SMR with 95% confidence intervals (95% CI) were included. Data Extraction and Analysis: Patient characteristics, SMR data, and treatment outcomes were independently assessed by two authors, and with consensus from third author, studies were selected for analysis. Meta-analysis was performed in all studies together, and those without and with GH replacement separately, using the statistical package metafor in R. Results: Six studies reporting a total of 19 153 hypopituiatary adults with a follow-up duration of more than 99 000 person years were analyzed. Hypopituitarism was associated with an overall excess mortality (weighted SMR, 1.99; 95% CI, 1.21-2.76) in adults. Female hypopituitary adults showed higher SMR compared with males (2.53 vs 1.71). Onset of hypopituitarism at a younger age was associated with higher SMR. GH replacement improved the mortality risk in hypopituitary adults that is comparable to the background population (SMR with GH replacement, 1.15; 95% CI, 1.05-1.24 vs SMR without GH, 2.40; 95% CI, 1.46-3.34). GH replacement conferred lower mortality benefit in hypopituitary women compared with men (SMR, 1.57; 95% CI, 1.38-1.77 vs 0.95; 95% CI, 0.85-1.06). Limitations: There was a potential selection bias of benefit of GH replacement from a post-marketing data necessitating further evidence from long-term randomized controlled trials. Conclusions: Hypopituitarism may increase premature mortality in adults. Mortality benefit from GH replacement in hypopituitarism is less pronounced in women than men. Copyright © 2015 by the Endocrine Society.


Prowse S.J.,Walsall Manor Hospital | Mulla O.,General Infirmary
Journal of Laryngology and Otology | Year: 2014

Objective: Cerumen impaction is a common problem, and aural microsuction is a technique frequently employed for its management. This study aimed to quantify the patient perception, safety and efficacy of this procedure. Methods: Patients were asked to complete a questionnaire following cerumen clearance by microsuction. The perceived severity of pain, noise-related discomfort and vertigo was scored on a scale of 1 to 10. Patients with mastoid cavities and those who had used a cerumenolytic agent in the preceding week were analysed separately. Results: A total of 159 questionnaires were returned. Mean scores (95 per cent confidence intervals) were: pain, 2.34 (2.06-2.62); noise discomfort, 3.03 (2.71-3.35); and vertigo, 1.95 (1.66-2.25). There was successful clearance (i.e. sufficient to view the tympanic membrane) in 91 per cent of cases. Patients who had used cerumenolytics reported significantly less pain and vertigo (p = 0.008 and p < 0.001, respectively) compared with those who had not, whilst patients with mastoid cavities reported greater levels of vertigo (p < 0.001) than those without. Conclusion: Aural microsuction is well tolerated. Side effects are mild, and the prior use of cerumenolytics appears to further reduce their severity. Copyright © JLO (1984) Limited 2014.


Pandya D.,Walsall Manor Hospital | Puttanna A.,Walsall Manor Hospital | Balagopal V.,Walsall Manor Hospital
Open Respiratory Medicine Journal | Year: 2014

Inhaled corticosteroids (ICS) are common medications, used in respiratory medicine for controlling conditions such as asthma and other obstructive airway diseases. The systemic effects of oral corticosteroids are well known and established; inhaled steroids have been known to cause relatively minor and localized adverse effects such as oral candidiasis. However, less attention has been paid to their systemic effects. Although currently there is a paucity of prospective studies demonstrating the systemic effects of inhaled corticosteroids, there are numerous retrospective studies adding evidence to this link. Inhaled corticosteroids can affect the hypothalamo-pituitary-adrenal axis, bone density and growth, eyes, skin and immunity including an increased risk of pneumonia. Clinicians are recommended to aim for the lowest possible dose to avoid these systemic side effects. Fluticasone is more likely to cause systemic effects compared to budesonide. Newer ICS molecules such as ciclesonide may be more beneficial in reducing such systemic complications on prolonged use. This paper provides an updated overview of the common systemic effects encountered with ICS treatment. © Pandya et al.


Chee C.,University of Nottingham | Sellahewa L.,Royal Derby Hospital | Pappachan J.M.,Walsall Manor Hospital
Open Respiratory Medicine Journal | Year: 2014

Inhaled corticosteroids (ICS) are the cornerstones in the management of bronchial asthma and some cases of chronic obstructive pulmonary disease. Although ICS are claimed to have low side effect profiles, at high doses they can cause systemic adverse effects including bone diseases such as osteopenia, osteoporosis and osteonecrosis. Corticosteroids have detrimental effects on function and survival of osteoblasts and osteocytes, and with the prolongation of osteoclast survival, induce metabolic bone disease. Glucocorticoid-induced osteoporosis (GIO) can be associated with major complications such as vertebral and neck of femur fractures. The American College of Rheumatology (ACR) published criteria in 2010 for the management of GIO. ACR recommends bisphosphonates along with calcium and vitamin D supplements as the first-line agents for GIO management. ACR recommendations can be applied to manage patients on ICS with a high risk of developing metabolic bone disease. This review outlines the mechanisms and management of ICS-induced bone disease. © Chee et al.


Ismail A.Q.T.,Walsall Manor Hospital | Lahiri S.,Walsall Manor Hospital
Journal of Perinatal Medicine | Year: 2013

Over a 20-month period we identified several cases of neonatal pneumonia associated with prelabour rupture of membranes (PROM) at term. PROM complicates 8%-10% of all pregnancies, yet 60% of cases occur at term. Ascending infection is a contributing factor and the incidence of chorioamnionitis in these patients is relatively high, especially with prolonged membrane rupture. The signs and symptoms NICE recommends patients look out for are not always present as the majority of infections are subclinical, yet associated maternal and neonatal morbidity of chorioamnionitis is potentially devastating. A survey of maternity units in the West Midlands reveals significant variance in management of these cases. Given the lack of consensus and clear evidence on optimal management of PROM at term, we believe early detection of developing infections could be enhanced by using a combination of investigations (at presentation, 12 and 24 h), as well as current advice to self-monitor temperature and vaginal loss.


Waterfield J.,Walsall Manor Hospital
BMJ Case Reports | Year: 2014

A 27-year-old man with a history of migraines, epilepsy and pulmonary stenosis presented to the emergency department with symptoms of vomiting, headache, visual disturbance and problems with balance. The team considered the possibility of intracranial pathology and an urgent CT head with contrast showed what appeared to be a large posterior fossa mass with an appearance suggestive of a primary haemangioblastoma, which was causing considerable mass effect. The patient had neurosurgery to relieve the obstruction and a biopsy of the area showed the mass to be an ischaemic infarct rather than a tumour. Further investigations following the stroke confirmed that the cause was due to having antiphospholipid syndrome and a patent foramen ovale. The patient made a good recovery following the operation and remains well. Copyright 2014 BMJ Publishing Group. All rights reserved.


Nasr H.,Walsall Manor Hospital | Hobbs S.,Russells Hall Hospital | Abrew C.,Walsall Manor Hospital
Annals of Vascular Surgery | Year: 2015

Background: The incidence of localized popliteal disease is rare. Currently, patients presenting with symptomatic popliteal disease are offered femoropopliteal or tibial bypass if the disease is not amenable to radiologic intervention. We feel that popliteal endarterectomy by means of a posterior approach with patch angioplasty as a primary procedure is a viable surgical option. Our aim was to assess the durability of popliteal endarterectomy in patients with localized popliteal disease, in which radiologic intervention is not feasible. Methods: This is a retrospective review of all patients who underwent popliteal endarterectomy for localized popliteal disease in our institution over the past 3 years. All patients underwent a preoperative assessment with computed tomography angiography. Angioplasty was attempted in all patients before surgical intervention. Patency was assessed radiologically 6 weeks after operation. Patients had follow-up appointments at intervals of 6 weeks, 3 months, 6 months, and a year after surgery. Results: A total of 7 patients (5 men and 2 women) underwent popliteal endarterectomy. The mean age was 64.3 years, with a mean follow-up period of 9.9 months (range, 2-26 months). Four patients were treated for activity-limiting claudication (<100 yards), whereas 3 patients were treated for ischemic rest pain. The procedural success rate was 100% without mortalities or in-hospital morbidities. Symptomatic resolution was achieved in 6 patients. One patient occluded 1 month after endarterectomy because of a critical stenosis at the tibial bifurcation. Conclusions: Popliteal endarterectomy through posterior approach is advantageous in managing popliteal artery pathology restricted to the popliteal fossa. It is safe with good short-term results. © 2015 Elsevier Inc. All rights reserved.


Kudiyirickal M.G.,Alchemy Dental Practice | Pappachan J.M.,Walsall Manor Hospital
Endocrine | Year: 2015

The oral health is influenced by systemic health, and one of the most common chronic diseases encountered in dental practice is diabetes mellitus. Diabetes can worsen oral infections and vice versa. In the literature, periodontitis and diabetes in the young to middle-aged adults have been the most widely researched area. Understanding the patho-physiology, clinical manifestations and management of different types of orofacial diseases in diabetic patients are important to the diabetologist and the dentist for the optimal care of patients with these diseases. This review explores the inter-link between diabetes and oral health. © 2014, Springer Science+Business Media New York.

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