• MRI findings in herniation of the spinal cord.

      Kwong, Yune; Jakanani, George; Rao, Nitin; Fang, Christopher (2010)
      Herniation of the spinal cord is a rare condition that causes non specific neurological deficits that are often a diagnostic challenge to clinicians. Despite several reports in the neurosurgical literature, it is only recently that the imaging appearances of this condition have come to be recognised, due mainly to the widespread adoption of spinal MRI. It is important for radiologists to recognise the telltale MRI features of this condition, as several cases have undergone initial misdiagnosis, resulting in delayed treatment We present a case with typical imaging features to familiarise radiologists with this condition, as it is likely that more cases will come to the fore, with more spinal MRIs being performed.
    • Teaching medical students rehabilitation medicine.

      Gibson, Jeremy; Lin, Xia; Clarke, Karen; Fish, Helen (2010)
      PURPOSE: The principles of rehabilitation medicine will become ever more important across many medical and surgical specialties in view of the rising prevalence of chronic and disabling conditions. Yet rehabilitation medicine has traditionally been unpopular with medical students. This article aims to review the existing evidence of problems in teaching medical undergraduates in rehabilitation medicine and provide published recommendations and practical approaches from our own experience. METHOD: A literature review was carried out to search for publications relating to teaching rehabilitation medicine to undergraduates in order to identify problems that potentially affect undergraduate education in rehabilitation medicine and its future as a medical speciality. CONCLUSION: The lack of consistent undergraduate curriculum, knowledge of rehabilitation medicine and academic opportunities contribute to the inadequate perception of the speciality to the undergraduates. The attitude of medical students towards rehabilitation medicine is important for its future development as a specialty. Further standardisation of teaching rehabilitation medicine at a national level, promoting research activity in this area and increasing the profile of rehabilitation medicine are warranted.
    • Hepatitis C virus-infected patients with a persistently normal alanine aminotransferase: do they exist and is this really a group with mild disease?

      Lawson, A (2010-01)
      Opinion varies on whether or not hepatitis C virus (HCV) infected patients with persistently normal aminotransferase (PNALT) levels represent a group with mild disease. To evaluate the risk of ALT flare and fibrosis progression in patients with PNALT followed up as part of the Trent HCV cohort. Treatment-naïve patients with an elevated ALT (n = 1140) or PNALT, the latter defined as either an ALT < or = 30 IU/L (n = 43) or an ALT < or = 40 IU/L (n = 87) on > or =2 occasions in the 6 months following diagnosis, and no ALT > 40 U/L were included. The likelihood of maintaining a PNALT < or = 30 IU/L was 42.2% and PNALT < or = 40 IU/L 41.7% at 3 years. The Ishak fibrosis score was > or =3 in 3.7%, 8.3% and 29.6% of patients with PNALT < or = 30 IU/L, PNALT < or = 40 IU/L and elevated ALT, respectively. Fibrosis progression between paired biopsies was similar for patients with PNALT < or = 30 IU/L (0.33 +/- 0.94 Ishak fibrosis points/year), PNALT < or = 40 IU/L (0.35 +/- 0.82) and elevated ALT (0.19 +/- 0.48). The majority of those defined as PNALT subsequently have an abnormal ALT. They have a similar risk of disease progression to other HCV infected patients and, therefore, warrant the same consideration with regard to treatment.
    • Accuracy of clinical diagnosis in tremulous parkinsonian patients: A blinded video study

      Bajaj, Nin; Gontu, Vamsi; Birchall, James (2010-11)
      Background: This study examines the clinical accuracy of movement disorder specialists in distinguishing tremor dominant Parkinson's disease (TDPD) from other tremulous movement disorders by the use of standardised patient videos. Patients and methods: Two movement disorder specialists were asked to distinguish TDPD from patients with atypical tremor and dystonic tremor, who had no evidence of presynaptic dopaminergic deficit (subjects without evidence of dopaminergic deficit (SWEDDs)) according to ¹²³I-N-ω-fluoro-propyl- 2β-carbomethoxy-3β-(4-iodophenyl) nortropane ([¹²³I] FP-CIT) single photon emission computed tomography (SPECT), by ‘blinded’ video analysis in 38 patients. A diagnosis of parkinsonism was made if the step 1 criteria of the Queen Square Brain Bank criteria for Parkinson's disease were fulfilled. The reviewer diagnosis was compared with the working clinical diagnosis drawn from the medical history, SPECT scan result, long term follow-up and in some cases the known response to dopaminergic medications. This comparison allowed a calculation for false positive and false negative rate of diagnosis of PD. Results: High false positive (17.4-26.1%) and negative (6.7-20%) rates were found for the diagnosis of PD. The diagnostic distinction of TDPD from dystonic tremor was reduced by the presence of dystonic features in treated and untreated PD patients. Conclusion: Clinical distinction of TDPD from atypical tremor, monosymptomatic rest tremor and dystonic tremor can be difficult due to the presence of parkinsonian features in tremulous SWEDD patients. The diagnosis of bradykinesia was particularly challenging. This study highlights the difficulty of differentiation of some cases of SWEDD from PD.
    • Learning about research: How can trainees in rehabilitation medicine become competent in appraising and conducting research?

      Phillips, Margaret (2010-12)
      This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘The trainee is able to critically appraise scientific, clinical and sociological research literature’ and ‘The trainee is able to complete a clinical audit study from the planning to final report stage’.
    • Using systemic approaches, methods and techniques in rehabilitation medicine

      Ward, Christopher; Smith, Alison; Bruder, Mel (2011-01)
      This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is 'The trainee demonstrates a knowledge of benefits and limitations of counselling approaches, specifically in this article systemic family therapy.'
    • Breast pain

      Goyal, Amit (2011-01)
      INTRODUCTION: Breast pain may be cyclical (worse before a period) or noncyclical, originating from the breast or the chest wall, and occurs at some time in 70% of women. Cyclical breast pain resolves spontaneously in 20% to 30% of women, but tends to recur in 60% of women. Non-cyclical pain responds poorly to treatment but tends to resolve spontaneously in half of women. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for breast pain? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 24 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, bromocriptine, combined oral contraceptive pill, danazol, diuretics, evening primrose oil, gestrinone, gonadorelin analogues, hormone replacement therapy (HRT), lisuride, low-fat diet, progestogens, pyridoxine, tamoxifen, tibolone, topical or oral non-steroidal anti-inflammatory drugs (NSAIDs), toremifene, and vitamin E.
    • A comparison of the natural history and outcome of treatment for Asian and non-Asian hepatitis C-infected patients.

      Lawson, A (2011-07)
      Ethnicity is an important host variable, but its impact on disease progression and response to therapy in Hepatitis C infection is unclear. Here we compare the natural history and outcome of therapy in white and Asian (Indian subcontinent) Hepatitis C infected patients. A total of 2123 White and 120 Asian HCV infected patients were identified within the Trent HCV study. Response to therapy was assessed in 224 white and 46 Asian patients with genotype 3 infection who received pegylated interferon and ribavirin. Asian patients were more likely to be older, female, infected with genotype 3 and to consume no alcohol. At time of first biopsy, fibrosis stage was significantly higher in Asian patients than in Whites (3.0 ± 2.3 vs 1.8 ± 2.0, P < 0.001), as were necro-inflammation and steatosis scores. However, in those patients where duration of infection could be estimated, fibrosis progression was similar for both groups (0.25 ± 0.31 vs. 0.16 ± 0.54 Ishak points/year, P = 0.068). 78.3% of Asian and 67.9% of White genotype 3 patients had a sustained virological response following Pegylated Interferon and Ribavirin. Cirrhosis and increased levels of GGT, but not ethnicity were associated with a reduction in the likelihood of a sustained virological response on multivariate analysis. Asian patients with Hepatitis C are more likely to be female, less likely to give a history of risk factors, present to medical services at an older age, and have more severe liver disease at diagnosis, but disease progression and response to treatment are similar to white patients.
    • Occult breast carcinoma in breast reduction specimens in European women.

      Goyal, Amit (2011-08)
      Breast reduction is a common surgical procedure performed by plastic and oncoplastic breast surgeons. The authors report on the incidence and management of cancer and atypical hyperplasia in breast reduction specimens from one institution over a 10-year period. All patients who underwent breast reduction surgery at Northern General Hospital, Sheffield were identified from an electronic prospective database. The histopathology reports were analyzed. Case records of all patients with significant abnormalities were retrieved and examined to identify their management and follow-up. Between October 1999 and April 2010, 1,588 patients underwent breast reduction. Nine specimens showed atypical hyperplasia (0.57%). Five cancers were detected (0.31%). Four of the five patients had normal screening mammograms 1-3 years before the reduction operation. Of these cancers, four were invasive (three lobular, one ductal) (0.25%) and one was DCIS (0.06%). A lump was felt macroscopically by the pathologist in two of the four patients with invasive cancer. The patients with DCIS did not undergo further surgery, whereas those with invasive disease underwent mastectomy (three patients) and axillary nodal staging (four patients). None of the patients with normal post-reduction breast imaging had residual cancer on histology. The incidence of occult carcinoma in breast reduction specimens is low. Patients should be counseled with regards to the possible consequences preoperatively.
    • Oncological outcomes after laparoscopic and open radical nephroureterectomy: results from an international cohort.

      Walton, Tom (2011-08)
      OBJECTIVE: • To compare oncological outcomes in patients undergoing open radical nephroureterectomy (ONU) with those in patients undergoing laparoscopic radical nephroureterectomy (LNU). PATIENTS AND METHODS: • A total of 773 patients underwent radical nephroureterectomy at nine centres worldwide; 703 patients underwent ONU and 70 underwent LNU. • Demographic, perioperative and oncological outcome data were collected retrospectively. • Statistical analysis of data was performed using chi-squared, Mann-Whitney U- and log-rank tests, and Cox regression analyses. • The median (interquartile range) follow-up for the cohort was 34 (15-65) months. RESULTS: • The two groups were well matched for tumour stage, presence of lymphovascular invasion (LVI) and concomitant carcinoma in situ (CIS). • There were more high-grade tumours (77.1% vs. 56.3%; P < 0.001) but fewer lymph node positive patients (2.9% vs. 6.8%; P= 0.041) in the LNU group. • Estimated 5-year recurrence-free survival (RFS) was 73.7% and 63.4% for the ONU and LNU groups, respectively (P= 0.124) and estimated 5-year cancer-specific survival (CSS) was 75.4% and 75.2% for the ONU and LNU groups, respectively (P= 0.897). • On multivariable analyses, which included age, gender, race, previous endoscopic treatment for bladder cancer, technique for distal ureter management, tumour location, pathological stage, grade, lymph node status, LVI and concomitant CIS, the procedure type (LNU vs. ONU) was not predictive of RFS (Hazard ratio [HR] 0.80; P= 0.534) or CSS (HR 0.96; P= 0.907). CONCLUSION: • The present study is the second large, independent, multicentre cohort to show oncological equivalence between ONU and LNU for well selected patients with upper urinary tract urothelial cancer, and the first to suggest parity for the techniques in patients with unfavourable disease.
    • Poor tolerability of thalidomide in end-stage oesophageal cancer.

      Wilkes, Emilie; Selby, A; Cole, Andrew; Freeman, Jan; Rennie, M; Khan, Z (2011-09)
      Oesophageal cancer cachexia is a significant clinical problem, resulting in excessive morbidity and mortality. In a pilot study, 10 patients with cachexia due to advanced cancer of the oesophagus gained weight, including lean tissue, after 14-day treatment with thalidomide. Here, we present randomised placebo controlled trial data over a 6-week period to test the hypothesis that thalidomide is superior to placebo in terms of weight gain in patients with cachexia caused by oesophageal cancer. Thalidomide, 200 mg daily, or an identical placebo was given to patients with advanced oesophageal cancer. Total body weight and lean body mass were assessed in addition to drug tolerability and performance indices. Thirty-four patients were recruited. Of these, six given thalidomide and 16 given placebo completed the protocol; all withdrawals were due to adverse drug reactions or complications of disease. Thalidomide showed no benefit over placebo in participants who completed the protocol. These data suggest that thalidomide is poorly tolerated in patients with advanced cancer of the oesophagus and may not ameliorate the progression of cachexia. In the absence of hard supportive evidence, off-licence treatment with thalidomide should be used with great caution as an adjunct to nutritional support in patients with advanced cancer.
    • The experience of patients with complex wounds and the use of NPWT in a home-care setting.

      Moffatt, Christine; Murray, Susan; Morgan, PA (2011-11)
      OBJECTIVE: To explore the experience of patients living with complex wounds and the impact of undergoing negative pressure wound therapy (NPWT) as part of their treatment. METHOD: Qualitative data were collected from eight patients, using semi-structured interviews. A purposive, stratified sampling approach was used to identify participants with a range of wound types, as well as age and gender. Participants were recruited from one primary care trust and were interviewed, following 10 days of treatment with NPWT. The matrix-based 'Framework' approach, from the National Centre for Social Research, was used to structure the analysis. RESULTS: Of the eight participants recruited, five were female and three male, with an age range of 46-77 years. Five overarching categories, with their constituent themes, were identified from the data. The first, developing a wound through crisis, has three themes: a failing body, missed diagnosis and failed professional intervention. The second category, decreased control, has four related themes: poor communication; failed wound healing; poor discharge planning and failure to recover. The third category, increased control, has four themes: understanding what is happening; symptom control; positive professional relationships and returning to health. The fourth category, using NPWT, has two themes: information and understanding of NPWT and expectations and experience of NPWT. The final category sets out participant recommendations about the device and has two themes: device issues and improving professional practice. CONCLUSION: This study investigated the experience of patients undergoing NPWT for complex wounds in the home setting and reveals a number of the psychosocial effects of using this therapy in this environment. Participants saw NPWT as an active intervention, associated with improved wound healing and symptom control. The participant experience described in this study, and the recommendations they make, provide a valuable resource to inform service improvement programmes and wound research.DECLARATION OF INTEREST: This study was supported by a research grant from Smith & Nephew Ltd.
    • Initial experience with a new fenestrated stent graft.

      Bungay, Peter; De Nunzio, Mario (2011-12)
      OBJECTIVES: The Anaconda fenestrated stent graft (Vascutek, Inchinnan, United Kingdom) is a new device that can easily be repositioned during deployment. This study evaluated its feasibility for treating abdominal aortic aneurysms with inadequate infrarenal sealing zones. METHODS: Patients undergoing stent graft placement at two institutions in the United Kingdom were recruited. RESULTS: A total of 12 visceral vessels were accommodated with 8 fenestrations for renal arteries and 4 superior mesenteric artery valleys/scallops in 4 successfully treated. CONCLUSIONS: The Anaconda fenestrated stent graft device can be used for the repair of abdominal aortic aneurysms with hostile anatomy and has acceptable immediate and short-term results.
    • Bone health in multiple sclerosis.

      Gibson, Jeremy; Summers, Greg (2011-12)
      People who are disabled with multiple sclerosis (MS) may be at increased risk of osteoporosis. This review discusses issues relevant to bone health in MS and makes practical recommendations regarding prevention and screening for osteoporosis and fracture risk in MS. A search of the literature up until 5 April 2011 was performed using key search terms, and articles pertinent to bone health in MS were analysed. Bone mineral density (BMD) is reduced at the lumbar spine, hip and total body in MS, with the degree of reduction being greatest at the hip. A strong relationship exists between the disability level, measured by the Expanded Disability Status Score, and BMD at the lumbar spine and femoral neck, particularly the latter. The rate of loss of BMD also correlates with the level of disability. Pulsed corticosteroids for acute episodes of MS, even with a high cumulative steroid dose, do not significantly affect BMD, but an effect on fracture risk is yet to be elucidated. There appears to be no correlation between vitamin D levels and BMD, and the relationship between disability and vitamin D levels remains unclear. Falls and fractures are more common than in healthy controls, and the risk rises with increasing levels of disability. The principal factor resulting in low BMD and increased fracture risk in MS is immobility. Antiresorptive therapy with bisphosphonates and optimising vitamin D levels are likely to be effective interventions although there are no randomised studies of this therapy.
    • Is patient-centred care a good thing?

      Ward, Christopher (2012-01)
      The problem: Rehabilitation professionals recognize the need to adopt a social as well as a medical model of disability, but the full implications of a social orientation towards disability are less easily accepted. If the physical environment can both produce and alleviate disability, so also can the social environment. If disablement is not to be seen as the problem of one individual then problems in rehabilitation must be ‘owned’ not solely by a single patient but also by other people implicated in a situation. It follows that ‘patient-centred care’, where a professional directs assessments and interventions towards one person, has shortcomings in rehabilitation. Theoretical considerations: A human systems model, shifting the focus of rehabilitation towards relationships, enables rehabilitation problems to be seen as provisional and context-dependent; the relational context of problems is clarified, and the positive and negative effects of professional power are more apparent. Clinical implications: Rehabilitation practitioners using a systemic approach would no longer view ‘carers’ and other significant individuals as mere bystanders but would integrate them within rehabilitation’s ethical and therapeutic system. Professionals would more readily recognize their roles within such a system, and would be better positioned to manage their negative as well as their positive effects. (
    • A preliminary randomized controlled study to determine the application frequency of a new lymphoedema bandaging system.

      Moffatt, Christine (2012-03)
      BACKGROUND:  Bandaging plays an important role in the treatment of lymphoedema. OBJECTIVE: To investigate efficacy and safety of the 3M™ Coban™ 2 compression system (Coban 2 system) with different application frequencies in comparison to short-stretch bandaging. METHODS: A multicentre, randomized, prospective study was performed with 82 patients suffering from arm or leg lymphoedema stage II or late stage II. Patients were allocated to traditional short-stretch bandaging five times per week or to the Coban 2 system applied two, three or five times per week for 19 days. Limb volume and adverse events were recorded at each study visit. The primary endpoint was percentage volume reduction. RESULTS: The highest lymphoedema volume reduction was achieved with the Coban 2 system applied two times per week. A mean reduction of 18•7% (SD 14•5) in legs and 10•5% (SD 8•3) in arms was achieved. More frequent bandage changes of three and five times per week did not demonstrate additional benefits. Short-stretch bandaging five times per week showed a mean volume reduction of 10•9% (SD 5•2) and 8•2% (SD 3•1) for legs and arms, respectively. Bandage slippage was low for all treatment groups. A relevant change in overall mobility was achieved during the use of the Coban 2 system. The adverse reactions were in agreement with already known side-effects and did not differ remarkably between the treatment groups. CONCLUSION: The 3M™ Coban™ 2 compression system applied twice weekly demonstrated a high rate of volume reduction and a good safety profile. Oedema reduction was still effective with 4 days between bandage change, which allows a constant therapeutic effect in routine practice. This should give the patient a high degree of independence and mobility.
    • A multidisciplinary approach to Parkinson's disease.

      Lindop, Fiona (2012-04)
      Overview of the Parkinson's Disease Service model developed by the multidisciplinary team (MDT) at Derby Hospitals NHS Foundation Trust. The importance of understanding basal ganglia function and subsequent dysfunction in Parkinson disease, cues and strategies in MDT management of basal ganglia dysfunction and the roles of different members of the Derby MDT are discussed
    • MRI in T staging of rectal cancer: How effective is it?

      Mulla, Mulbashir; Deb, Rahul; Singh, Rajeev (2012-05)
      BACKGROUND: Rectal cancer constitutes about one-third of all gastrointestinal (GI) tract tumors. Because of the high recurrence rates (30%) in rectal cancer, it is vitally important to accurately stage these tumours preoperatively so that appropriate surgical resection can be undertaken. MRI is the ideal technique for the preoperative staging of these tumours. AIM: To determine the accuracy of local T staging of rectal cancer with MRI, using histopathological staging as the gold. MATERIALS AND METHODS: Forty consecutive patients admitted with rectal cancer over a period of 18 months were included in this retrospective study. MRI scans were performed prior to surgery in all patients, on 1.5T scanners. Two radiologists, with a special interest in gastrointestinal imaging reported all images. Two dedicated histopathologists reported the histology slides. The accuracy of preoperative local MRI T staging was assessed by comparison with postoperative histopathological staging. RESULTS: There was agreement between MRI and histopathology (TNM) staging in 12 patients (30%). The sensitivity and specificity of MRI for T staging was 89% and 67% respectively. The circumferential resection margin (CRM) status was accurately staged in 94.1% of the patients. CONCLUSIONS: Preoperative staging with MRI is sensitive in identifying CRM involvement, which is the main factor affecting the outcome of surgery.
    • A pilot study of a crossover trial with randomized use of ankle-foot orthoses for people with Charcot–Marie–Tooth disease

      Phillips, Margaret (2012-06)
      Objectives: This was a pilot and feasibility study of a crossover trial with randomized use of ankle-foot orthoses by people with Charcot–Marie–Tooth (CMT) disease, investigating the effects of these on gait parameters, practical aspects of use and achievement of goals. Design: A randomized crossover trial. Setting: The community and ambulatory care. Participants: Eight adults with CMT disease type 1 or 2. Interventions: Ligaflex™, custom-made polypropylene and silicone ankle-foot orthoses worn in randomized order for three weeks each, with a washout week in-between; the orthoses of each participant’s choice were then worn until 28 weeks. Main outcome measures: The primary outcome measure was gait velocity; other outcome measures included Goal Attainment Scaling; Likert scores, concerning aspects of orthosis use and gait analysis parameters. Results: Gait velocity was greatest wearing polypropylene orthoses, median 0.96 (interquartile range (IQR) 0.75–1.18) ms −1, compared with silicone orthoses, median 0.88 (0.71–1.12) ms −1, and no orthosis, median 0.79 (0.56–0.84) ms −1, P = 0.006. The silicone orthoses met goals more successfully and scored more favourably for comfort, 5.0 (5.0–6.0), P = 0.003 and pain, 5.5 (4.0–7.0), P = 0.015. Future modifications to study methodology were identified, such as a longer period of wear and measurement of walking in different situations. Conclusions: This study confirmed the feasibility of a larger trial. It indicated differences in walking velocity and parameters concerning wear of the orthoses that could be explored further. A further crossover trial would require 27 participants in order to show a clinically meaningful difference in velocity of 0.13 ms −1 with 90% power and alpha of 5%.
    • DrivAbility: teaching medical aspects of driving.

      Gibson, Jeremy; Whiteman, Leo (2012-06)
      CONTEXT: Teaching medical aspects of fitness to drive (FTD) is currently inconsistent across UK medical schools, with almost one-third of UK medical schools offering no tuition on medical aspects of FTD. It is, therefore, not surprising to find that medical students and doctors tend to lack confidence regarding the medical aspects of FTD and Driver and Vehicle Licensing Agency (DVLA) medical standards. INNOVATION: In response to this inconsistency we developed an innovative new learning module to teach our medical students the importance of giving appropriate advice to patients about driving, the role of the DVLA regarding medical aspects of FTD, how to recognise when patients should be referred to a driving assessment centre and what adaptations are available to allow patients with physical disabilities to drive safely. As far as we are aware Derby is the first centre in the world to incorporate the practical experience of driving adapted vehicles (at a driving assessment centre) into the undergraduate medical curriculum as an aid to teaching medical aspects of FTD. This practical learning module has proven popular with the students. IMPLICATIONS: Driving these adapted vehicles has allowed our students to appreciate some of the practical difficulties disabled drivers experience when learning new driving techniques. However, as only 18 driving assessment centres exist within the UK, an exact replication of this learning module will be limited elsewhere. Nevertheless, we would encourage other medical schools to evaluate the local resources that could enhance the delivery of their undergraduate curricula.