ANCA-negative Granulomatosis with Polyangiitis: A Difficult Diagnosis

Granulomatosis with polyangitiis (GPA) is a systemic small and medium vessel vasculitis, commonly associated with anti-neutrophil cytoplasmic antibodies (ANCAs). Presenting signs and symptoms in GPA are varied and patients may present with constitutional, nonspecific symptoms, which can delay the diagnosis. Tissue biopsy of the site of active disease can confirm the diagnosis of GPA, in which necrotising granulomatous inflammation is seen. However, surrogate markers may be used for diagnosis without a tissue biopsy. They include upper and lower airway symptoms, signs of glomerulonephritis and a positive ANCA. However, approximately 10–20% of patients with GPA are ANCA negative, allowing for the diagnosis to be overlooked, particularly in those patients with non-specific findings. The reason for the absence of ANCAs is unclear

Single or double headed capsules for the investigation of suspected small bowel bleeding: Are two heads better than one

BackgroundCapsule endoscopy is now the accepted first line investigation for suspected small bowel (SB) bleeding. Recent evidence suggests the diagnostic yield for SB pathology may be higher for tailored double headed (DH) SB capsules. Whether other forms of bidirectional capsules offer a similar advantage is less clear.AimTo compare the efficacy of single headed versus bidirectional capsules in detecting pathology in patients with suspected small bowel bleeding.MethodsA single centre prospective comparison study was conducted over an 8 month period in a tertiary care hospital. Patients referred with overt or suspected SB bleeding were assigned to either SB3 Medtronic SB capsule (SH) during the initial four months or PillCam Colon 2 Medtronic capsule (DH) during the subsequent four months. Studies were analysed by trained Capsule Endoscopists and approved by our institutions capsule review board. Findings were compared between SH and DH capsules using a chi2 or t-test as appropriate. A p value of <0.05 was considered significant.Results201 subjects were included, mean age 61.8 years, 90 (45%) male. Majority referred with occult bleeding, 153 (76%). DH and SH capsule used in 100 and 101 cases, respectively. 90% (n=181) capsules were complete and overall diagnostic yield was 57% (n=114). Diagnostic yield was similar between both groups - DH 53% (n=53), SH 60% (n=61). Positive finding in overt bleeding; SH 85% (n=22) versus DH 50% (n=11), p<0.02. SH capsules more frequently detected SB inflammation, 27 (27%) versus 9 (9%), p<0.002. More patients had another diagnosis in the DH (19) than the SH (9), p<0.04, the majority were type 1a vascular lesions, “red spots” or diminutive colonic polyps.ConclusionSingle head and double head capsules perform similary in terms of diagnostic yield overall. This supports the continued use of standard small bowel capsules for investigation of the small bowel

Website malfunction: a case report highlighting the danger of using electrical insulating tape for buddy strapping

A case of injury to the third web space of the right hand of a rugby player, as a result of buddy strapping with electrical insulating tape of the little and ring finger, is presented. A deep laceration of the web space and distal palmar fascia resulted, necessitating wound exploration and repair. This case highlights the danger of using electrical insulating tape as a means to buddy strap fingers

A randomised controlled trial of home based rehabilitation versus outpatient based rehabilitation for patients suffering from chronic schizophrenia

Background: Outpatient-based treatments for patients suffering from chronic schizophrenia inadvertently exclude a significant proportion of subjects because they are often too poorly motivated to attend for treatment. In addition there are also concerns about whether the skills that are learnt in a hospital setting will generalise to situations when the individuals are at home. This study attempted to redress some of these potential deficiencies and followed on from an earlier local study which found that a community-based team met more of the needs of patients suffering from chronic schizophrenia. Method: Seventy-five patients suffering from chronic schizophrenia were allocated randomly to receive traditional outpatient-based or home-based rehabilitation from a clinical psychologist and an occupational therapist. They were assessed before and after 9 months of treatment on a range of clinical, social and quality of life outcomes. Distress to carers was also assessed. Readmission to hospital was recorded for each subject. Results: There were significant reductions in socially embarrassing behaviour (SBS), increases in interpersonal functioning and recreational activities and a trend for quality of life to improve in the home-based group. There were fewer admissions in the home-based group but the differences, although financially substantial, were not statistically significant. Conclusions: The home-based rehabilitation service was well received by the majority of patients suffering from chronic schizophrenia and led to some improvement in social behaviour, interpersonal functioning, recreational activities and quality of life