304 IMPLEMENTING A FRAILTY SPECIFIC PHARMACY PRIORITISATION TOOLKIT IN AN OLDER PERSONS’ REHABILITATION UNIT

Background

Standardised identification of patients for medication review using nurse-delivered, frailty-specific pharmacy prioritisation toolkits should maximise effective use of limited pharmacy resources. A frailty-specific pharmacy prioritisation toolkit was introduced in a 21 bed older persons’ rehabilitation unit to standardise pharmacy referrals and categorise the interventions made.

Methods

The frailty-specific pharmacy prioritisation toolkit was applied to consecutive patients by upskilled rehabilitation nurses to identify patients for weekly senior pharmacist review over a 5-month period from 18th Jan 2022 to 24th May 2022. Regular use of high-risk medication, greater than 10 medications, patients with specific pharmaceutical concerns such as a desire to reduce their medication burden, acute or chronic kidney injury and admission potentially related to medications or admission with non-mechanical falls are included in this toolkit. Pharmacist interventions included recommendations on medications to be weaned or stopped, dose-adjusted, started or restarted and identification of prescribing errors. Age, gender and interventions were recorded onto Excel and data was analysed using descriptive statistics.

Results

The total number of patients screened was 82. Eighty five percent (n=70) fulfilled criteria for a medication review. Mean age (SD) was 77(10.9) years. Female:male ratio was 1.5:1. Review was completed in 50% (n=35) of these cases. In total there were 228 interventions, with a mean (SD) of 6.5 (2.4) per patient. Eighty-four recommendations were made to wean or stop medication and thirty to dose adjust, of which 60% (n=18) were proton pump inhibitor dose reduction. Thirty-eight were to start or restart a medication, 34% (n=13) of which were for bone protection. Eleven prescribing errors were identified.

Conclusion

The pharmacy prioritisation toolkit applied by existing rehabilitation nurses successfully identified patients for medication review. The review rate reflects a need for a twice-weekly senior pharmacy resource.

233 COGNITIVE OUTCOMES AFTER A FIRST EPISODE OF DELIRIUM IN HOSPITAL – RESULTS FROM AN ADVANCED NURSE PRACTITIONER DELIRIUM CLINIC

Background

Cognitive outcomes for frail older adult inpatients with a first episode of Delirium are unknown. Aim: To determine cognitive outcomes of frail older inpatients after a first episode of Delirium.

Methods

Consecutive frail older inpatients with a 4AT score >/= 4, without a previous history of cognitive impairment, over a 12-month period (January to December 2021) were invited for formal cognitive assessment 8-12 weeks after their delirium occurred. Collateral history, medication review, Addenbrookes (ACE III), bloods and CT brain were undertaken. Data was prospectively entered onto Excel and analysed using descriptive statistics.

Results

Fifty-one patients with a mean age of 82 years (SD=6) were referred to the Advanced Nurse Practitioner (ANP) Delirium Clinic. Median Clinical Frailty Score (CFS) was 6 with a male: female ratio of 1:2. Forty- seven percent (n=24) attended; 35 % (n-18) did not attend; 18 % (n=9) died prior to assessment. The ratio of male to female attendees was 1: 2.4. There was no difference in CFS or age between attenders and non-attenders. Thirty-three percent (n=8) of patients who attended had potentially reversible causes (high anti-cholinergic burden, folate deficiency, sleep disorder) of cognitive impairment requiring intervention. Sixty-seven percent (n=16) were diagnosed with dementia at the Delirium Clinic; 16.6% (n=4) were diagnosed with Mild Cognitive Impairment; 4% (n=1) had a resolved delirium; 8% (n=2) were referred to consultant Memory Clinic and one patient remained too unwell to assess. The median ACE III score of patients diagnosed with dementia was 54/100 (SD = 18).

Conclusion

Pro-active follow up of patients with a first episode of Delirium led to early diagnosis of dementia and mild cognitive impairment with supportive interventions. Earlier ANP intervention, during the acute phase of delirium, has been introduced in order to improve clinic attendance.

254 OPTIMISING COMMUNICATION WITH FAMILIES OF PATIENTS ON ACUTE STROKE AND GERIATRIC MEDICINE WARDS IN A LARGE TERTIARY HOSPITAL

Background

Good communication with patients and families is important for older adults admitted to acute stroke or geriatric medicine wards, particularly with COVID19-related restricted visiting. These patients often have communication difficulties including aphasia, delirium, cognitive or hearing impairment, limiting their own communication with relatives. Using the Plan, Do, Study, Act (PDSA) approach we undertook a quality improvement project to optimise communication with families of patients on above wards in a large tertiary hospital.

Methods

PDSA cycle 1: Staff were surveyed to identify satisfaction level with communication and ways to optimise communication. Inpatients on study wards were identified, we recorded demographic and clinical details and prevalence of communication difficulties. We created a designated folder with individual ‘communication sheets’ in conjunction with ward doctors and the nurse manager. PDSA cycle 2: We performed a rapid interval audit of the communication folder use. ‘Outlier’ patients were excluded as their teams did not receive education about folder use.

Results

PDSA cycle 1: A total of 90 inpatients on three wards were included, mean age 78y (SD ±14.4y), 47% were male. Three-quarters (73%) had a communication difficulty noted, reported by nursing staff. Two patients were intubated and six had stroke-related aphasia. Half of surveyed staff reported communication with families was suboptimal. Most (86%) suggested a centrally-located communication logbook would be helpful. PDSA cycle 2: Over two weeks, communication sheets were reviewed for all included patients. Median frequency of calls to families was 4 days (range 0–14). Most (79%) had the name of the primary contact clearly documented. Many (52%) included no contact number. Only 9% had secondary contact information documented.

Conclusion

Communication with families of patients on acute stroke and geriatric medicine wards was suboptimal. Over a short interval this improved with regular phone calls using specific centrally-located communication folders. Further optimisation of their use is needed.

Closing the Osteoporotic-Fracture Care Gap for Frail Older Persons

Aim To implement standardised fracture risk assessment in the frail older person. Methods Frail older patients underwent opportunistic screening for fracture risk. Roadblocks to standardised assessment were identified. An Integrated Care Team for older persons (ICT) trained in fracture risk assessment using FRAX. Clinical assessment was via a locally agreed algorithm. Data was entered onto Excel. The SQUIRE guidelines for quality improvement programmes were used to report the results. Results Of 96 patients opportunistically screened, the average age was 84 years. FRAX was completed for 19% (n=18). 89% (n=16) met the pharmacotherapy threshold. Nine were recommended pharmacotherapy. Of sixteen patients recommended for DXA, just 31% (n=5) were booked. Following implementation of a quality improvement project, 100 patients were assessed, and average age was 80 years. FRAX was completed for 62% (n=63) and 95% (n=60) required pharmacotherapy. 24% (n=14) had untreated prior fracture. All had pharmacotherapy prescribed. 59% (n=59) required DXA scanning. 70% (n=41) had DXA ordered. Conclusion ICT ownership increased FRAX assessment 3-fold and point of contact prescribing to 100%.

A clinical investigation into the ability of subjects with lung disease to provide breath specimens using the EvidenzerIRL evidential breath analyser in alcohol intoxicant driving in criminal justice evidence

The EvidenzerIRL instrument has been in use as an evidential breath analyser in the application of drink driving laws in the Republic of Ireland since 2011. The result of the analysis is used as evidence in prosecutions before the Courts in per se offences of driving under the influence of alcohol as distinct from screening results at the roadside. This study aims to assist doctors, lawyers and judges in assessing drivers' failure to provide valid evidential breath specimens. Since the introduction of the EvidenzerIRL, approximately 10% of evidential breath tests annually result in failure or refusal to provide a successful breath specimen, this is an offence under Irish road traffic laws. The presence of lung disease has been given as a reason for the driver failing to provide evidential breath specimens. The aim of this study is to assess the ability of subjects with lung disease to provide breath specimens using the EvidenzerIRL. Pulmonary function tests (PFT) were carried out on volunteers from outpatients of the pulmonary laboratory in St Vincent's University Hospital, Dublin (n = 58) and a control group with no underlying lung disease (n = 19). After the PFTs all volunteers were asked to provide breath specimens using the EvidenzerIRL. Fourteen (24%) out of 58 lung disease volunteers failed to provide a breath specimen, no one from the control group was unsuccessful. Thirteen females and one male volunteer could not successfully provide. Female volunteers were more likely to fail to provide than male volunteers. A significant difference was found between the median age of successful (62.2 years) and unsuccessful (69.2 years) lung disease volunteers. Only one PFT, percentage predicted of Forced Expiratory Volume in 1 second (FEV₁)_, had a significant difference between the mean of successful (86.6%) and unsuccessful (66.5%) lung disease volunteers. A subject with lung disease was more likely to be successful than unsuccessful. Drivers' effort and operators' guidance through the process were found to be crucial parts to a successful outcome.

Management referral triaging process pilot study: a 'telephone first' approach

BACKGROUND

In this Occupational Health Department (OHD), a 'telephone first' approach was introduced to triage management referrals with potential to convert to Telephone Independent Medical Assessment (TIMA). Telephone consultation has been widely used in the UK's NHS in the occupational health setting.

AIMS

To evaluate TIMA effectiveness and efficiency of OHD resources; comparing the outcome of a triage call compared to previous default allocation of next available appointment, percentage of telephone triage calls converted to TIMA and appointment waiting times. To assess use of OHD resources arising from TIMA. To evaluate service user satisfaction following TIMA. To examine service user characteristics.

METHODS

As management referrals were received, service users were given a telephone contact. Data were collected and anonymized regarding service users, who also consented to receive feedback questionnaire. Cross-sectional analysis of this management referral cohort was carried out.

RESULTS

Two hundred and sixty-one management referrals were received in the specified period. Eighty per cent had a TIMA carried out (n = 208); 64% of management referrals with TIMA had a report issued (n = 166). Response rate to feedback questionnaire was 38% (n = 70); 94% of survey participants found TIMA acceptable going forward for management referrals (n = 66).

CONCLUSIONS

Introduction of a 'telephone first' approach resulted in improved efficiency of this OHD, allowing maximum workforce planning, and positive service user feedback.

Remote monitoring of oxygen saturation in individuals with COVID-19 pneumonia

Coronavirus disease 2019 (COVID-19), an illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has spread rapidly worldwide, resulting in significant mortality and placing major strain on healthcare systems. Although the clinical course is variable, one in five patients will require hospitalisation for management, with older age and the presence of comorbidities increasing the risk of more severe disease [1–3]. The median time from first onset of symptoms to development of acute respiratory distress syndrome in those who progress to severe disease is estimated to be 8.0 days [4].

Remote monitoring of oxygen saturation in cases of COVID-19 pneumonia may facilitate discharge, relieving burden on bed demand and allowing safe follow-up for this disease in which the sequelae are unknownhttps://bit.ly/3cTXnZU

What is the role of bronchial thermoplasty in the management of severe asthma?

Asthma is a common chronic inflammatory condition of the airways. Conventional therapy comprises inhaled corticosteroid and bronchodilators as well as trigger avoidance and management of comorbid conditions. A small group remain symptomatic despite these strategies and novel therapies have been developed. Bronchial thermoplasty is a nonpharmacological therapy which targets airway smooth muscle to improve asthma control. Clinical trials to date have shown the efficacy and safety of bronchial thermoplasty with a persistent effect on extended follow up. Questions remain regarding the exact mechanism of action of bronchial thermoplasty, the cost effectiveness of the procedure and the ideal criteria for patient selection.

[Study of the relations between the pain of childbirth and postpartum, and depressive and traumatic symptoms]

OBJECTIVES

This study aims to determine the incidence of pain in childbirth and postpartum on depressive and post-traumatic symptomatology 6weeks after delivery.

METHODS

One hundred and nine women who gave birth in maternity hospitals of type 2$participated in the study. Two to four days after delivery they have completed five self-administered questionnaires to assess pain of childbirth (QDSA), dramatization of pain (PCS-CF), satisfaction of childbirth (CEQ), peri-traumatic distress (IDP) and depressive symptoms (EPDS) and visual analogue scales to measure immediate postnatal pain. Six weeks after birth they have again completed questionnaires to measure pain (QDSA and visual analogue scales) and depressive symptoms (EPDS) and a scale measuring posttraumatic symptomatology (IES-R).

RESULTS

The pain of childbirth and immediate postpartum was associated with depressive (r=0.27 and r=0.31 respectively) and traumatic symptomatology (r=0.30 and r=0.34 respectively) in postpartum. Regression analysis, however, revealed that only the depressive symptomatology and the affective dimension of postpartum pain at six weeks post-partum was related to post-traumatic stress.

CONCLUSION

The results of this study highlight the importance to support the pain of childbirth but also the pain occurring in the postpartum period.

The efficacy and safety of bronchial thermoplasty in severe persistent asthma on extended follow-up

BACKGROUND

Asthma is a common condition and there remains a subset of patients who are poorly controlled on maximal therapy. Bronchial thermoplasty (BT) is a bronchoscopic therapy using radiofrequency energy to reduce airway smooth muscle, which has been shown to improve asthma control although further evidence regarding long-term efficacy and safety is required.

AIM

We aimed to demonstrate safety and efficacy of BT on extended follow-up. Our initial experience with this group was previously reported in 2016, where patients were shown to have a significant improvement in asthma control test (ACT) scores 1-year post-treatment.

DESIGN

We carried out a retrospective observational study of seven patients who underwent BT between 2012 and 2013 in an Irish severe asthma centre. The primary endpoint was change in ACT scores from baseline to present.

METHODS

Seven patients underwent BT at a tertiary referral centre in Ireland. ACT scores and data on hospital admissions, exacerbations, maintenance corticosteroid requirements, rescue bronchodilator use and forced expiratory volume for 1 s (FEV1) prior to the procedure and on extended follow-up were collected. Mean follow-up was 49.42 months.

RESULTS

A trend towards improvement was seen in median hospitalisations (respective values for median over 12 months 3, 1 P = 0.059) and ACT scores, from 9 to 13 (P = 0.249). Mean FEV1 was 1.68 l prior to treatment and 1.46 l 4 years post-treatment (P = 0.237). There was no mortality among the group.

CONCLUSIONS

These data support the safety of BT and suggest extended efficacy.

Madarosis: a qualitative study to assess perceptions and experience of Australian patients with early breast cancer treated with taxane-based chemotherapy

PURPOSE

Eyebrow and eyelash loss (madarosis) is a common and distressing side effect of chemotherapy for which no protective strategies have yet been developed. The purpose of this study was to develop an overview of perceptions and experiences of women undergoing taxane-based treatment for early breast cancer.

METHODS

A total of 25 women with a diagnosis of invasive early breast cancer participated in a focus group (n = 5), ages ranging from 35 to 64 (median 50), all had completed therapy with a taxane-based chemotherapy treatment. This focus group used targeted questions to explore participants' perceptions and experience of madarosis during and following chemotherapy and identified issues associated with impact of madarosis on quality of life (QoL). Thematic analysis was conducted to identify important issues experienced by participants.

RESULTS

Seven themes emerged from the data: (1) timing of regrowth and permanent changes, (2) meaning/importance of eyebrow/eyelashes, (3) preparedness/information given, (4) impact of the hair loss of self, (5) impact of hair loss on others, (6) physiological side effects of loss of eyebrows/eyelashes, and (7) management of loss of eyebrows/eyelashes. In addition, participants noted physical symptoms of eye irritation during their treatment that they attributed to madarosis.

CONCLUSION

This study highlights the significant impact of madarosis on patients, providing the first published analysis of patient's attitude and perception of eyelash and eyebrow loss during chemotherapy. Further research in this area is required and will be benefitted from the development of a dedicated instrument/questionnaire that can capture and measure the impact of madarosis on QoL and allow development of clinical trial strategies.

Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study

BACKGROUND

Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis.

OBJECTIVES

To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit.

DESIGN

Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention).

SETTING

Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London.

PARTICIPANTS

Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital.

METHODS

Women were screened for GBS at 35-37 weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0-6 days of birth.

MAIN OUTCOME

Incidence of early-onset GBS infections.

RESULTS

6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05).

CONCLUSIONS

Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.

Review of Time to Surgical Decompression in Traumatic Spinal Cord Injured Patients

Interventions which may improve neurological outcomes, including time to surgical decompression, in traumatic spinal cord injury (TSCI) evoke much interest. The majority of TSCI patients in Ireland are managed acutely at the National Spinal Injuries Unit (NSIU). A retrospective review of healthcare records of TSCI patients, who had surgical management there, in 2010, 2011, 2012, was performed. From the information gathered, the duration of each stage of the patient pathway was calculated. Median duration between onset of injury and time of arrival at local hospital was 1 hour 25 minutes, between arrival at local hospital and referral to NSIU was 4 hours 17 minutes, between referral to and arrival at NSIU was 6 hours 25 minutes, between onset of injury and arrival at NSIU was 13 hours 7 minutes, between onset of injury and surgical decompression was 27 hours. A number of factors have been identified which could influence these time durations.

p53 is an important regulator of CCL2 gene expression

The p53 protein is a sequence-specific DNA-binding factor that regulates inflammatory genes such as CCL2/MCP-1 that may play a role in various diseases. A recent study has indicated that the knockdown of human p53 leads to a strong negative regulation of CCL2 induction. We are therefore interested in how p53 regulates CCL2 gene expression. In the following study, our findings indicate that UV-induced p53 accumulation in mouse macrophages significantly decreases LPS-induced CCL2 production, and that p53 binds to CCL2 5'UTR in the region (16-35). We also found that a p53 domain (p53pep170) mimics full length p53 to down-regulate CCL2 promoter activity. Treatment of p53-deficient mouse primary macrophages with synthetic p53pep170 was found to decrease LPS-induced production of CCL2 without association with cellular endogenous p53. CCL2 production induced by lentiCLG in human monocytes or mouse primary macrophages was blocked in the presence of p53pep170. Overall, these results demonstrate that p53 or its derived peptide (p53pep170) is an important regulator of CCL2 gene expression via its binding activity, and acts as a novel model for future studies linking p53 and its short peptide to pave the way to possible pharmaceutical intervention of CCL2-mediated inflammatory and cancer diseases.

p53 peptide prevents LITAF-induced TNF-alpha-mediated mouse lung lesions and endotoxic shock

Abnormal and prolonged inflammatory reaction is seen in a wide variety of disorders, and high level of Tumor Necrosis Factor alpha (TNF-α) has been linked to these disorders. Therefore, modulation of TNF-α expression is important in the regulation of inflammatory disorders. In our previous study, we have shown that a transcription factor LPS-induced TNF factor (LITAF) significantly induces TNF-α production. Furthermore, we found that p53 and its synthetic peptide 162-motif specifically downregulate LITAF/TNF-α gene expression in human cells in vitro. Thus, in the present study, the role of p53 in regulating TNF-α-mediated inflammation was investigated. Our data showed that a synthetic peptide, named 162-motif, corresponding to this region functions independently from p53 to cause a significant suppression of TNF-α gene expression in mouse primary macrophages. The 162-motif, when delivered into cells and organs, reduces serum TNF-α level in mice and prevents TNF-α-induced lung lesions and endotoxic shock. Our findings highlight the regulation of LITAF/TNF-α by p53 and its short peptide 162-motif. These in vitro and in vivo observations serve to pave the way for pharmacotherapeutic approaches in the treatment of inflammatory diseases.

Targeting AML through DR4 with a novel variant of rhTRAIL

Despite progress in the treatment of acute myelogenous leukaemia (AML) the outcome often remains poor. Tumour necrosis factor related apoptosis-inducing ligand (TRAIL) is a promising therapeutic agent in many different types of tumours, but AML cells are relatively insensitive to TRAIL-induced apoptosis. Here we show that TRAIL-induced apoptosis in AML cells is predominantly mediated by death receptor 4 (DR4) and not DR5. Therefore, we constructed a variant of TRAIL (rhTRAIL-C3) that is a strong inducer of DR4-mediated apoptosis. TRAIL-C3 demonstrated much stronger pro-apoptotic activity than wild-type (WT) TRAIL in a panel of AML cell lines as well as in primary AML blasts. The higher pro-apoptotic potential was further enhanced when the TRAIL mutant was used in combination with BMS-345541, a selective inhibitor of inhibitor-κB kinases. It illustrates that combination of this TRAIL variant with chemotherapeutics or other targeted agents can kill AML with high efficacy. This may represent a major advantage over the currently used therapies that have serious toxic side effects. The high efficacy of rhTRAIL-C3 containing therapies may enable the use of lower drug doses to reduce the toxic side effects and improve patient outcome. Our findings suggest that the rational design of TRAIL variants that target DR4 potentiate the death-inducing activity of TRAIL and offer a novel therapeutic strategy for the treatment of AML.

Stem cells are resistant to TRAIL receptor-mediated apoptosis

New therapeutic approaches aim to eradicate tumours by expression of tumouricidal proteins in the tumour stroma. One such anti-neoplastic protein is tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) because it induces apoptosis in cancerous cells, but not in non-transformed cells. Stem cells can migrate to, survive and proliferate in tumours. We examined the suitability of bone marrow-derived adult mesenchymal stem cells (bmMSC), foetal-MSC and umbilical cord matrix stem cells (Wharton’s Jelly MSCs) as TRAIL-delivery vehicles. Although all MSC types expressed DR4 and/or DR5, none of them were sensitive to TRAIL-induced apoptosis. Selective activation of DR4 or DR5 with agonistic antibodies or DR5-selective TRAIL-mutant (D269H/E195R) revealed that the TRAIL receptors are inactive in MSCs. In fMSC DR5 was not fully inactivated, its activity however was minimal in comparison to the colon carcinoma cell, Colo205. The intracellular components of the TRAIL-apoptotic pathway, such as pro-caspase-8 and -9 were also expressed at very low; almost undetectable levels in all three MSC types. In conclusion, the MSC species examined are resistant to TRAIL and thus can be suitable tools for TRAIL delivery to tumours.

The use of transscleral cyclophotocoagulation with a diode laser for the treatment of glaucoma occurring post intracapsular extraction of displaced lenses: a retrospective study of 15 dogs (1995-2000)

The objective of this retrospective study was to evaluate transscleral cyclophotocoagulation (TSCP) using a diode laser for treating aphakic glaucoma that developed after intracapsular lens extraction (ICLE) had been performed for displaced lenses. Records of 15 dogs (21 eyes) were reviewed. The intraocular pressure (IOP) and the presence of vision were recorded at the time of ICLE and TSCP and at 1, 3, 6-9, 12 and 24 months post TSCP. The glaucoma was considered controlled if the IOP was less than 25 mmHg. The results indicated that the effectiveness of TSCP using a diode laser for treating aphakic glaucoma was of a short-term duration (1-3 months), with three patients needing repeat TSPC. In addition, adjunctive antiglaucoma medications were often required to maintain an adequately controlled IOP. Over the 24-month period the number of dogs requiring intrascleral prosthesis, intraocular gentamicin or enucleation, or that were lost to follow-up, increased.

Exophthalmos due to a wooden foreign body in a dog

An 8-year-old Golden Retriever dog was presented with a 10-month history of right-sided exophthalmos. Radiographs and CT demonstrated a linear density, suggestive of a foreign body, in the region of the ramus of the right mandible. A 7 cm stick, located medial to the right zygomatic arch, was removed during exploratory surgery. The dog recovered with the aid of antibiotics, however was left with a residual facial nerve paralysis.

Colonic variceal bleeding in a patient with mesenteric venous obstruction due to an ileal carcinoid tumour

Colonic varices are a recognized cause of rectal bleeding in portal hypertension. We report here a patient who presented with melaena several months after resection of an ileal carcinoid tumour. Subsequent colonoscopy for continued episodes of rectal bleeding demonstrated extensive colonic varices. In the absence of portal hypertension, the varices appeared to be related to mesenteric venous obstruction. The management of bleeding colonic varices, in these circumstances, is discussed.