THE MANAGEMENT OF RECTAL BLEEDING

Rectal bleeding is a common symptom in the general population;¹ it may signal the presence of serious gastrointestinal disease but more frequently is caused by minor and self-limiting local ano-rectal conditions. Appropriate and accurate evaluation of rectal bleeding requires an investigative approach which balances an appreciation of the need to provide an adequate explanation for the bleeding against over-investigation, excessive referral and wasted resources. As doctors of first contact, general practitioners (GPs) are frequently faced with difficult questions concerning the optimum management of rectal bleeding. This paper was prepared as a result of a series of interactive meetings with over 1,000 GPs from throughout the UK, which revealed wide variations in the possession and use of investigative equipment in the surgery, access to secondary care facilities, estimates of the prevalence and potential seriousness of rectal bleeding and the management strategies adopted in response to a series of case histories. We highlight a number of unresolved issues about the roles of GPs and hospital specialists in the management of rectal bleeding and the need for research directed at answering outstanding questions. In addition, a management strategy is proposed which might form the basis for a protocol for care, shared between general practice and the hospital.     

Wegener's Granuloma. A Series of 265 British Cases Seen Between 1975 and 1985. A Report by a Sub-committee of the British Thoracic Society Research Committee

In order to describe the British experience of Wegener's granuiomatosisHospital Activity Analysis was used to collect cases diagnosedin England, Wales and Scotland between 1975 and 1985. Wherepossible clinical details, histological material and chest radiographswere obtained. Two hundred and sixty five patients were consideredto have Wegener's granuiomatosis. In 109 a single pathologistconfirmed the diagnosis by finding both granulomas and vasculitisin biopsy material. The diagnosis was made on clinical groundsor clinical grounds together with histological diagnosis inthe local hospital in 156 patients. Wegener's granuiomatosiswas confined to the lung or upper respiratory tract in 22 percent of patients and renal disease occurred in 58 per cent.Laboratory tests showed a pattern of mild anaemia, polymorphleucocytosis, eosinophilia and an elevated ESR and hypergammaglobulinaemia,with no specific pattern of changes. Histological confirmation was most frequently obtained by examinationof nasal biopsy specimens, but multiple biopsies were oftenrequired. Renal biopsies showed focal proliferative glomerulonephritisbut granulomatous glomerulonephritis was uncommon. Of availablechest radiographs 61 per cent were abnormal, large opacitiesbeing most common. Small irregular opacities were found lessoften and other abnormalities were uncommon. Treatment varied widely and 10 per cent of patients receivedno drug therapy. This large series illustrates that even withoutspecific treatment, patients with Wegener's granuiomatosis cansurvive for several years and with modern treatment survivalfor more than a decade is possible. Conclusions about the effectivenessof the various therapies cannot be drawn from this restrospectivestudy. Renal failure and disseminated vasculities were the commonestcauses of death; death was considered to result from complicationsof treatment with cytotoxic drugs or prednisolone in 6 per centof patients.     

Italian healthcare workers' views on mandatory vaccination

Background  

Mandatory vaccination has contributed to the success of immunisation programmes but voluntary vaccination allows people to be responsible for their own health. There are benefits from both policies and the arguments between them remain subject to debate within and without the scientific community, both nationally and internationally. The aim of this study is to assess the opinions of those who actually work in the Vaccination Service.     

Endovascular transluminal stent grafting

Iliac vessels are prone to injury during lumbar spine surgery due to their proximity to the lumbar spine. Arterio‐venous fistula formation during lumbar spine surgery is an uncommon complication and can present as an asymptomatic incidental finding to rapidly deteriorating hemodynamics leading to cardiopulmonary collapse. We have reported three patients who had symptomatic iliac arterio‐venous fistula detected soon after lumbar spine surgery. All these patients were successfully treated by endovascular transluminal stent grafting. © 2013 Wiley Periodicals, Inc.