Withington Community Hospital

This editorial addresses the rising number of scabies cases seen globally, including within Europe. The authors address scabies treatment failure as a potential contributing factor and the reasons behind this. The authors go on to address the wider social and economic detriments of health in the UK and how these need to be addressed if we are to successfully tackle the rising number of scabies cases.

A 56-year-old man receiving mechanical circulatory support via a biventricular assist device suffered an airway emergency secondary to bleeding into the airway. An improvised solution to gain control of the airway in the short term was devised, and an oxygenator was inserted into the circuit, providing an alternative means of gas exchange while definitive control of the airway was achieved. This case changed practice in our institution, where we now make contingency plans for emergency oxygenator insertion into the circuits of all patients with a biventricular assist device who show any sign of airway hemorrhage.

In the United Kingdom, women at moderate and high risk of breast cancer between the ages of 40 and 49 years are eligible for annual mammographic screening and preventive therapy with tamoxifen. Here, we estimate the numbers of women in a population eligible for this service and the proportion of breast cancers detected in this group compared with the whole population. Women <50 attending for mammographic screening in the National Health Service Breast Screening Programme (NHSBSP) completed a risk questionnaire. The proportion at moderate and high risk according to National Institute of Health Care Excellence (NICE) guidelines was estimated. An estimate was also made using a different model of risk estimation (Tyrer-Cuzick). The numbers of cancers detected in the moderate/high risk groups were compared with numbers detected in the whole population. Completed questionnaires were available for 4,360 women between ages 46 and 49 years. Thirty women [0.7%; 95% confidence interval (CI), 0.5-1.0%] were at high risk and 130 (3.0%, 2.5-3.5%) were at moderate risk according to NICE guidelines. Thirty-seven cancers were detected by mammography in the whole group. Five of these were found in the moderate-/high-risk group giving a 3.2-fold increase in detection compared with the standard risk group. More women were assigned to the moderate- or high-risk group using the Tyrer-Cuzick model (N = 384), but the numbers of cancers in this group were not appreciably increased (N = 8). Systematic assessment of family history in primary care or through population-based screening will identify appreciable numbers of women in their forties, eligible for additional surveillance and chemoprevention.

To demonstrate that Blu-tack is equally effective at attenuating sound as over-the-counter ear plugs. Nineteen healthy volunteers had their hearing thresholds assessed before and after the insertion of over-the-counter ear plugs. The results were compared with hearing thresholds following the insertion of Blu-tack. Thresholds were tested at: 0.5, 1, 2, 3, 4, 6 and 8 kHz. The differences were compared, and p values of less than 0.02 were regarded as significant. Using a visual analogue scale, volunteers were asked to assess the comfort and ease of insertion of the ear plugs and Blu-tack, and their peace of mind whilst using the ear plugs and Blu-tack. Blu-tack was less effective at attenuating sound at low frequencies, but was as effective as over-the-counter ear plugs at attenuating sound above 3 kHz. Blu-tack was significantly more comfortable to wear (p = 0.006). There was no difference in terms of ease of insertion and peace of mind. Blu-tack can be regarded as a comfortable alternative to over-the-counter ear plugs for the attenuation of everyday sound.

Etravirine (ETV) is licensed in the UK for treatment‐experienced patients and existing data suggest ETV is an effective switch for patients intolerant of efavirenz (EFV). ETV has a favourable tolerability profile and therefore may be an attractive non‐nucleoside reverse transcriptase inhibitor (NNRTI) option in first line therapy. We present data of ETV use as a once‐daily first‐line treatment option in naïve patients. 26 treatment‐naïve patients commenced on ETV were identified through pharmacy records up until May 2012. Demographic data were collected with information on hepatitis B and C status, CD4, viral load (VL), liver function and lipids. Patients were followed for 6‐monthly intervals and outcomes recorded. Of the 26 patients identified 25 were male and one female. 19 identified as men who have sex with men (MSM), 4 heterosexual and 3 bisexual. 19 were white British and 3 black African. There were no hepatitis B or C co‐infections. ETV was prescribed as 400 mg once daily, co‐prescribed with Truvada in 24 (92.3%) patients, Kivexa in one patient, and tenofovir/abacavir combination in one patient. 3 (11.5%) patients discontinued ETV therapy, 2 due to erythematous rashes in the first 16 days and one after 5 months due to reports of unpalatability. 10 (38.5%) patients chose to dissolve ETV. Median CD4 count at ETV initiation was 326 and median VL was 30,000c/ml. 6 (23.1%) patients had a starting VL&gt;100,000. 6‐month follow‐up data for 19 (73.1%) patients showed a median CD4 of 461 and 18 (94.7%) patients had a VL&lt;40c/mL. One patient had a viral load of 53c/ml with a reduction from a baseline of&gt;1,000,000c/ml. 12‐month data for 17 (65.4%) patients revealed a median CD4 count of 518 and all with VLs &lt;40c/ml at a year. 18‐month follow‐up data of 11 (42.3%) patients showed a median CD4 of 587 and 9 with a VL&lt;40c/ml. 2 patients had a detectable VL due to documented poor adherence. There was no significant change in median alanine transaminase (ALT), bilirubin, total cholesterol, high density lipoprotein or triglycerides from baseline to 6‐, 12‐ or 18‐month levels. Patient preference was towards a once‐daily treatment for ETV. The availability of 200mg tablets and the ease of dissolvability have further increased acceptability. VL suppression was excellent with 100%&lt;40c/ml at 12 months without any virological failures or significant adverse events. This data has shown that ETV is a highly acceptable, effective and well tolerated first‐line treatment option.

Laparoscopic pyeloplasty is now widely practiced in the United Kingdom and considered the gold standard in the treatment of patients with ureteropelvic junction obstruction. The aim of this audit was to determine the national practice and outcomes for this procedure. The British Association of Urological Surgeons sent out standardized audit proformas in May 2008 to units across the United Kingdom inviting surgeons who were performing laparoscopic pyeloplasties to submit their results over the last 4 years. Data on the presentation, preoperative investigations, intra-perative details, and postoperative follow-up were collected centrally and inserted into a national database for analysis. There were 323 returns from a total of 30 surgeons. At a median follow-up of 4 months (1-24), the overall symptomatic and renographic failure rates were 10.3% and 8.7%, respectively. Mean operative time was 181 minutes (3--425 min); there were 18 (6%) conversions, 33 (10.5%) complications, and one (0.3%) mortality. Surgeons who submitted 10 or more returns had a lower conversion rate than surgeons submitting fewer than 10 (2.9% vs 14.7%). The median hospital stay was 3 days (1-34 d). There was no difference in failure and complication rate for the retroperitoneal and transperitoneal approaches, although the conversion rate was higher with the retroperitoneal approach. The results show that laparoscopic pyeloplasty, although achieving acceptable outcomes at a national level in the United Kingdom, had areas of practice that could be improved. It highlights the importance of a high-volume practice in achieving optimum results and the potential problems associated with the retroperitoneal approach.

There is increasing recognition that migraine with aura may be associated with intra-cardiac shunting because of a patent foramen ovale. Radio-frequency ablation to treat cardiac arrhythmias is an increasingly popular means of treating cardiac arrhythmias. Trans-septal puncture is routinely performed to gain access to the left atrium in order to ablate arrhythmias originating in the left heart. We report several cases of migraine triggered acutely by trans-septal puncture at our center.