Ash Samanta

Comparative study of bone mineral density, calcium, and vitamin D status in the Gujarati and white populations of Leicester

Objectives: To evaluate differences in bone mineral density (BMD), calcium, and vitamin D status between the Gujarati (South Asian) and white populations resident in Leicester and to determine whether this was linked to lifestyle factors. Design: An observational cross sectional study of randomly selected Gujarati and white volunteers aged from 20–40 years. Setting: City of Leicester. Participants: Subjects were randomly selected by age (20–40 years) and ethnicity. A total of 262 individuals volunteered to participate, of which 201 (51 white females, 71 Gujarati females, 37 white males, 42 Gujarati males) were eligible for the study. Main outcome measures: Results of questionnaire, BMD at the hip and lumbar spine, and measurement of serum calcium, albumin, alkaline phosphatase, and 25-hydroxyvitamin D. Results: Male and female white subjects were significantly taller and heavier than their Gujarati counterparts. There was a statistically significant difference in BMD both at the spine (p<0.001) and hip (p<0.001) between the white and Gujarati females with the Gujaratis having a lower BMD. There was a trend for Gujarati males to have a lower BMD at the hip and spine than their white counterparts but these figures did not reach statistical significance. The intensity of cigarette smoking and the amount of alcohol consumption were both higher in the white male and female subjects. Sunlight exposure (>4 hours per day) was significantly higher in white subjects compared with Gujaratis. There were no significant differences in the mean level of serum calcium or alkaline phosphatase between the Gujaratis and whites. A significantly higher proportion (p<0.001) of the Gujarati men and women had a vitamin D level that was not measurable (that is, below the lower limit of the laboratory range of normal). Of those who had a measurable level (that is, in the normal range) mean levels of vitamin D were lower (p<0.05) in the Gujarati men and women. Conclusion: The present study is the first of its kind to note a low BMD in Gujarati subjects of South Asian origin compared with their white counterparts, living in Leicester. This study also confirms the presence of low serum vitamin D levels in Gujaratis. There is a need for more research in South Asians with regard to the collection of normal BMD values. This could provide a more meaningful reference range for identifying South Asians at risk of osteoporotic fractures and may have public health implications of relevance to this ethnic group.

Should anti-TNF therapy be discontinued in rheumatoid arthritis patients undergoing elective orthopaedic surgery? A systematic review of the evidence

Anti-tumour necrosis factor (TNF) therapies have revolutionized the management of rheumatoid arthritis (RA). A high proportion of RA patients are now established users of anti-TNF agents. Unfortunately, many RA patients with longstanding disease still require elective orthopaedic procedures. Published studies on the influence of TNF antagonist on infection rates in RA patients undergoing surgery are conflicting. However, national registries of RA patients on anti-TNF reported an increased risk of infection. The risk of anti-TNF-related infection is highest at the start of treatment with frequent involvement of the skin and subcutaneous tissue. Infection at these sites could negatively influence the healing of surgical wound. Current guidelines suggest that treatment with biologics should be discontinued prior to surgery. Patients with established disease are more likely to flare compared to those with early disease on stopping treatment. Consequently, TNF blockers need to be reinstated promptly after surgery to avoid the risk of RA flare.

A systematic medline analysis of therapeutic approaches in ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disorder involving the sacroiliac joints (SIJs), spine and less frequently the peripheral joints. Traditionally, it is well recognised that AS is a challenging disease to manage due to the lack of effective therapeutic options. Current evidence would suggest this has changed and there are now a number of therapies available that provide persistent control of inflammatory symptoms with improvement in daily function. NSAIDs remain the first step in patient treatment. Sulphasalazine may be effective in peripheral arthritis and there are emerging data to support its use in early inflammatory back pain. Studies have shown that pamidronate and steroid injection into SIJ have a symptom-modifying effect in AS. Current data suggest that anti-TNF treatment promises early benefit which is likely to continue in the longer term. Treatment with biologics should be considered sooner rather than later in the management of AS.

Sciatica: which intervention?

Low back pain with sciatica is one of the most common complaints for which patients seek medical advice, and the condition has considerable economic consequences in terms of healthcare resources and lost productivity. Most patients return to their normal activities within six months. For many patients, such as the one described below, a lengthy spell off work can have serious repercussions, and a rapid return to work is imperative. #### Summary points Conservative management of sciatica may fail to bring relief, and a more invasive treatment is required Evidence shows that an epidural injection of corticosteroids produces short term relief; adverse effects are few and not usually serious Chemonucleolysis or discectomy have higher success rates but a greater risk of more serious adverse events Long term results after surgery are only slightly better than non-surgical intervention Patients require an individualised approach using best evidence and the application of clinical art and expertise A man of 27 presented with low back pain of acute onset that was complicated by pain radiating down his right leg. The problem had coincided with a recent spell of gardening and had worsened progressively over the next few days, ultimately developing into numbness and tingling of the right foot. Although analgesics had controlled the pain, his foot had become noticeably weaker. At this stage he had consulted his general practitioner. He was found to be fit and healthy; he had no history of similar complaints Physical examination showed that he had reduced forward flexion of the lumbar spine; straight leg raising was limited to 45° on the right hand side. A sciatic stretch test on his right leg had positive results, and responses to light touch and pin prick were reduced on the lateral side and over the dorsum of the right foot. …

Update on biologic therapies in ankylosing spondylitis: a literature review

The present paper aims to review the recent advances in diagnosis and management of ankylosing spondylitis (AS).

Evidence‐based medicine: A clinical governance tool for rationalising or rationing health care?

Purpose – The purpose of this article is to provide a viewpoint on a controversial aspect of evidence‐based medicine (EBM) and its application to clinical decision making and healthcare policy. To draw attention to the potential for using EBM as a rationalising tool, as opposed to rationalising treatment options, and to discuss how legitimacy in the decision‐making process may be secured.Design/methodology/approach – A range of academic commentary and case law is reviewed. A model for the legitimacy of due process is suggested through the application of the framework for the “accountability for reasonableness”.Findings – Provides information about sources indicating their relevance and where they can be found. Emphasises that NHS organisations and trusts need to enhance the legitimacy of due process through clinical governance.Research limitations/implications – Presents a viewpoint designed to stimulate debate, which is based on a critical evaluation of the literature as well as contemporary quality init...

NICE guidelines and law: clinical governance implications for trusts

Clinical guidelines from National Institute of Clinical Excellence (NICE) have been developed by a rigorous process using the highest‐level evidence base. Their objectives are to reduce the variations in clinical care and end the postcode lottery of healthcare delivery. They are backed strongly by the governments agenda, are expected to be implemented and to be monitored, and this is to be monitored by CHAI. Up until now, clinical guidelines have had a secondary status to expert witness testimony in determining the standard of care in law in medical litigation. However, guidelines from NICE may have a more influential role in determining the standard of care in law by setting the standard of expected clinical practice. Trusts need to be sensitive to this as part of their risk management strategy. Trusts should facilitate the implementation of guidelines from NICE and audit their use through the framework of clinical governance. In the rare event that a trust should decide to positively diverge from such guidelines, it should do so only through a mechanism of due process that is required in public law for the accountability of the reasonableness of such a decision.

Primary pulmonary hypertension associated with systemic lupus erythematosus.

SummaryA 24-year-old West Indian woman with a four-year history of systemic lupus erythematosus presented with progressive dypsnoea due to primary pulmonary hypertension. Despite showing a response to vasodilators, these failed to control the condition. Her pulmonary hypertension increased in severity, eventually resulting in her death. We believe primary pulmonary hypertension to be an unusual complication of systemic lupus erythematosus. We suggest that this diagnosis should be considered in all patients with systemic lupus erythematosus and progressive dypsnoea, as optimum benefit can only be obtained by early institution of vasodilator therapy.

Peripheral neuropathy, polymyalgia and arthralgia: A paraneoplastic syndrome associated with myeloma

SummaryWe describe a patient with peripheral neuropathy, polymyalgia, arthralgia and cervical vertebral osteosclerosis who was subsequently diagnosed to have fatal multiple myeloma with IgG gammopathy and lambda urinary chains. The initial presentation and clinical features are discussed.

Do not attempt resuscitation orders: the role of clinical governance

Purpose – The purpose of this paper is to provide a viewpoint on decision making in do not attempt resuscitation (DNAR) orders from the perspective of a competent patient who requests cardiopulmonary resuscitation (CPR) when their clinical prognosis is poor. This issue will be examined from the position of patient autonomy and self determination.Design/methodology/approach – The literature is reviewed including academic commentary, case law and statute.Findings – The paper finds that factors such as futility and quality of life that engage in DNAR considerations should be gauged from the patients perspective. There is a definite argument for supporting a competent patients positive autonomous choice for CPR. This should feature clearly within the framework of clinical governance.Research limitations/implications – Presents a viewpoint designed to stimulate debate based on a contemporary perspective of patient autonomy.Practical implications – End‐of‐life care is assuming a greater importance as evidence...