Search

Introduction Ulcerative colitis (UC) has a chronic relapsing course. Infliximab is beneficial in severe disease, but conflicting data exists regarding the subsequent colectomy rates. We aimed to review outcomes post-infliximab usage in acute and sub-acute UC in our clinical practice. Methods We conducted a retrospective review of all patients who had received a maximum of three doses of infliximab for acute or sub-acute exacerbations of UC between January 2010 and October 2011. Medical treatment (initial and subsequent) and colectomy rates were recorded for all patients. Results 21 patients received infliximab during the study period. 12 patients were emergency admissions who had failed to respond to intravenous steroid therapy (acute group). Nine patients had failed to respond to maximum oral therapy, which included immunomodulators and oral prednisolone (sub-acute group). In the acute group, 42% (n=5) of patients had avoided a colectomy at a median follow-up of 467 days (IQR 370–612). The other 58% (n=7) proceeded to colectomy after a median of 69 days (IQR 30–136). Of the patients who proceeded to colectomy, 57% had been prescribed immunomodulator therapy prior to infliximab usage. However, all the patients who avoided colectomy were immunomodulator naive prior to infliximab. In the sub-acute group, only 33% (n=3) of patients required a colectomy after a median follow-up of 153 days (IQR 110–180). The remaining 67% (n=6) were well and off steroids after a median of 303 days (IQR 209–400). Conclusion This review of patient outcomes shows the potential benefits of infliximab for treating both acute and sub-acute UC. After a maximum of three doses of infliximab, 42% of acute and 67% of sub-acute UC patients were able to avoid a colectomy. Our results are comparable to those of Oxford (1 to 7 doses of infliximab as needed) who reported that 43% of acute and 50% of sub-acute were able to avoid a colectomy. 1 Furthermore, our results confirm the greater potential benefit of infliximab in acute, immunomodulator naive patients. In addition, all sub-acute patients, who avoided colectomy, were well and off steroids at the end-of follow-up, compared to only 38% from the Oxford group, suggesting additional benefit from planned infliximab doses. 1 Competing interests None declared. Reference 1. Jakobovits SL , Jewell DP, Travis SPL. Infliximab for the treatment of ulcerative colitis: outcomes in Oxford from 2000 to 2006. Aliment Pharmacol Ther 2007; 25 :1055–60.

Brain haematoma can often elude a junior doctor at the busy Manchester Royal Infirmary Accident and Emergency Department. Here we described an unusual presentation of brain haematoma—a sub acute on chronic subdural haematoma. Radiologic findings of this 82-year-old gentleman on head CT includes the classic mass effect (ipsilateral effacement and contralateral dilatation) and a layered appearance of different densities—a mixture of biconcave isodense (multiple known causes), hypodense (indicative of >21 days bleed), and hyperdense (indicative of 72 h bleed) collection! Here we discussed the type and duration of bleed with multiple CT evidence, also supporting the clinical finding of Hutchinson pupil in our case—a worrying sign of early tentorial herniation! A brief review on thrombolysis is also discussed.

Objectives We aim to present the opinion of sick-listed workers on their own sickness absence course and work resumption possibilities. Methods A Belgian cross-sectional study included 1559 employees, aged 18–50 years, >8 weeks on sick leave. A standardised questionnaire with a 4-point Likert answer scale was used to obtain patient information on 1) sickness absence; the pathology causing the sickness absence, and the relation between the work and the sickness absence; 2) work resumption; the attitude towards work modifications, and the work resumption prognosis. Results 1) Sickness absence. Pathology: 71% reported mainly an orthopaedic disorder, 15% a psychiatric disorder. Work-related pathology: 34% attributed the sick leave (fully or for a large part) to his work conditions. 2) Work resumption. Work modifications: 79% was – in expectation of fully recovery – (very or moderate) positive towards modified work or partial work resumption. Work resumption prognosis: 80% thought to resume work within the following 3 months, 9% feared not being able to work ever again. Conclusions The results underline the need of 1) a multidisciplinary approach of sickness absence by occupational physicians, psychologists and ergonomists to address work-related sickness absences,; 2) temporarily adapted work possibilities to achieve early return to work, and timely detection of patients in need for work resumption initiatives (those fearing not being able to resume work in the next 3 months).

Background Austin health is a 600 bed tertiary hospital with a wide range of acute and sub acute services, including a number of specialist services. Many patients have extremely complex medical and ethical issues that are often raised during the care of these people. In order to address such concerns a ‘clinical ethicist’, who is an experienced doctor has been employed. Aim To perform a retrospective audit of consecutive cases referred to the clinical ethicist. Results 104 patients, mean age 66 (range 19–102), 64% male were seen. ▶Reason for referral - (≥1 reason per patient). ▶Unrealistic patient/family (34%). ▶Poor or unrealistic medical assessment of situation (53%). ▶Patient/family in need of advance care planning (44%). ▶Outcome of referral – treatment related (≥ 1 per patient). ▶Patient died or discharged (63%). ▶Decision to limit treatment (64%). ▶Advance care planning occurred (45%). ▶Treating doctors ignored recommendation of clinical ethicist (5%). ▶Outcome of referral – people related (≥1 per patient). ▶Staff Education (71%). ▶Improved staff morale (31%). ▶Support of medical decision making (41%). ▶Patient/family support (42%). Patient deaths were, on average 70 days (range 1–619) from initial referral. Conclusion Establishment of the clinical ethicist role has provided support and education to staff and patients. Although not specifically set up to focus on end-of-life decision making and care, the majority of patients seen have died. This role also has an important link in referring patients/families for advance care planning.

This report describes an unusual case of a middle-aged man who suffered sub-acute visual loss rendering him blind over a period of 4 weeks, associated with the diagnosis of a right temporal lobe World Health Organization grade 4 astrocytoma (glioblastoma multiforme). Chronic papilloedema had been diagnosed at presentation, and this persisted after his debulking surgery, but there was no radiological evidence of direct involvement (by compression or infiltration) of the visual pathways. This case report describes the sub-acute on chronic nature of his visual loss, and suggests possible causes and preventative measures for visual loss in these patients.