bluuebunny/crossref_metadata_2025 huggingface dataset:
Can old people on oral anticoagulants be safely managed as out-patients?
Authors: Joglekar M , Mohanaruban K , Bayer A J , Pathy M S J
Published: December 2008

Of 62 patients (mean age 75, range 65-92 years) referred to an out-patient anticoagulant clinic specifically for those aged 65 years or more, treatment was considered unsafe in only one patient and was discontinued. Minor bleeding which did not require a significant change in management was recorded on 25 (7%) of 381 clinic visits and one major haemorrhage occurred requiring emergency hospital admission. Anticoagulation was maintained within the therapeutic range on 284 (75%) visits. The results confirm that with appropriate out-patient care and supervision, the risks of oral anticoagulant therapy in the elderly need be no greater than in younger patients.
Villous adenomas and carcinoma of the duodenum in Gardner’s syndrome
Authors: Sinha J , Williamson R C N
Published: December 2008

Patients with Gardner’s syndrome are increasingly found to have polyps on routine upper gastrointestinal endoscopy, and their risk of developing periampullary carcinoma is between 3-12%. We report a 45 year old man with Gardner’s syndrome who presented with periampullary carcinoma 5 years after colectomy. Review of the literature amassed another 21 cases of periampullary carcinoma in patients with Gardner’s syndrome.
Hepatic metastases due to choriocarcinoma
Authors: Alveyn C G , Loehry C A
Published: December 2008

A 34 year old female presented with weight loss and hepatomegaly. Liver biopsy revealed clinically unsuspected metastatic choriocarcinoma. Severe haemorrhage occurred, and the patient died following complications after laparotomy. The possibility of choriocarcinoma should be remembered in women of child-bearing age who present with liver metastases; biopsy must be avoided until this diagnosis can be excluded.
Cranial diabetes insipidus caused by giant cell arteritis
Authors: Radhamanohar M
Published: December 2008

A 78 year old woman was admitted with symptoms of diabetes insipidus and was found to have a high ESR, the cause of which was uncertain. Five months later she presented with blindness, and cranial arteritis was confirmed by temporal artery biopsy. The endocrine abnormality returned to normal after steroid therapy. The association between these two conditions is discussed.
Spontaneous aortocaval fistula--preoperative diagnosis and management
Authors: Duffy J P , Gardham J R C
Published: December 2008

Spontaneous aortocaval fistula is an uncommon complication of an abdominal aortic aneurysm. This report details two cases of this condition presenting with symptoms attributable to arteriovenous shunting. Pain was not a prominent feature so that attention was not initially drawn to the abdomen. Diagnosis and management of the condition are discussed.
Fulminant hyperpyrexia induced by bleomycin
Authors: Leung W H , Lau J Y N , Chan T K , Kumana C R
Published: December 2008

Mild and self-limiting fever following bleomycin use is common, and a fatal hyperpyrexial response occurs rarely. In previously reported cases, such hyperpyrexia occurred either after the initial administration of the drug or during subsequent therapy following an initial pyrexial response. We describe a fatal hyperpyrexial reaction after bleomycin in a patient with T-cell lymphoma who had had no febrile response when she received her initial injection 3 weeks earlier. Since the occurrence of this hyperpyrexial response is unpredictable, health care workers as well as patients and relatives should always be alert to this potentially lethal complication and prompt measures should be taken in any patient who develops fever after bleomycin use.
Chronic active hepatitis: a sixteen year survey at a district general hospital
Authors: Tanner A R , Dellipiani A W
Published: December 2008

Over a period of 16 years (1971-87) all cases of chronic active hepatitis (CAH) diagnosed following liver biopsy have been reviewed to assess incidence, aetiology, outcome and response to treatment. North Tees District serves a population of 210,000 and 26 cases were identified (20 female) age range 9-73 years (median 56 years). Incidence remained constant at 1:100,000/year. Twenty cases (77%) had an immune aetiology. Other aetiologies were hepatitis B virus (HBV) infection, alpha-1AT deficiency, non-A non-B hepatitis and a complex multisystem disease. The median follow-up period was 50 months.

There were 7 deaths, three unrelated to liver disease. Survival analysis gives an 86% 5-year survival and 56% 10-year survival. Twenty four patients were treated with steroids (and 6 additionally with azathioprine); 15 (63%) were steroid responsive and 9 were non-responsive. In five patients steroids were successfully discontinued but in 10 patients severe symptomatic relapse occurred on steroid reduction below 7.5-10 mg/day. Steroid non-responders were not typical CAH, 5 with predominantly a rise in alkaline phosphatase, one multisystem disease and one HBV positive. Steroid discontinuation was only possible in one third of the patients responding. Eighteen subjects (69%) were cirrhotic at initial biopsy; 9 had follow-up biopsies, 6 were unchanged but three had progressed to cirrhosis despite apparent steroid responsiveness.
Malignant fibrous histiocytoma of sternum: an unusual cause of pyrexia of undetermined origin
Authors: Grieco A , Caputo S , Silvestri E , Caradonna P , Bertoli A , Greco A V
Published: December 2008

Malignant fibrous histiocytoma of the bone is a very rare tumour mainly affecting long bones, and the most common presenting symptom is local pain. A case of malignant fibrous histiocytoma presenting with pyrexia of undetermined origin and arising in the sternum, a localization not previously described, is reported. The patient died with septic shock after multi-drug chemotherapy including high dose methotrexate treatment with citrovorum factor rescue.
Staphylococcus aureus meningitis from osteomyelitis of the spine
Authors: Markus H S , Allison S P
Published: December 2008

Two cases of vertebral osteomyelitis presenting with secondary Staphylococcus aureus meningitis are described. In staphylococcal meningitis a search for a primary source should include the lower vertebral spine.
Biopsy of neck lumps in adults should be preceded by examination of the upper aerodigestive tract
Authors: Premachandra D J , McRae D , Prinsley P
Published: December 2008

Premature biopsy of a potentially malignant neck node compromises patient survival. Despite documented evidence that biopsy of a malignant neck mass prior to a search for a primary source will increase the incidence of regional recurrence and distance metastasis, patients are often referred for head and neck assessment having already had a positive neck node biopsy. We maintain that biopsy of an asymmetrically enlarged cervical lymph node in an adult should be preceded by full upper aerodigestive tract evaluation to include indirect laryngoscopy, a high resolution computed tomography scan and panendoscopy with free field biopsy.
Endometrial oxytocin binding sites in normal women and in subfertile patients
Authors: Baker P N , Peat M L , Symonds E M , Maynard P V
Published: December 2008

Specific binding of oxytocin to high affinity sites in endometrial membrane preparations has previously been shown in sheep. Endometrial tissue preparations from 27 ‘normal’ women of proven fertility were incubated with tritiated oxytocin and the existence of significant binding sites in human endometrium was shown. Furthermore, the level of binding sites underwent a cyclical variation with the highest concentration of binding at midcycle. A cyclical pattern of binding site concentration not unlike that found in the normal women was shown in 19 subfertile patients taking clomiphene.

However, in 20 subfertile patients not taking clomiphene, no cyclical pattern emerged with significantly lower levels of binding sites in the mid-portion of the cycle (P < 0.02) and significantly higher levels in the mid-late luteal phase (P < 0.01), as compared to the normal women. In the mid-portion of the cycle levels were significantly lower in the subfertile patients not taking clomiphene (P < 0.03) as compared to those taking clomiphene. No significant differences were shown between the normal women and those patients taking clomiphene.
Ergotamine-induced solitary rectal ulcer
Authors: Shpilberg O , Ehrenfeld M , Abramowich D , Samra Y , Bat L
Published: December 2008

A rare case of ergotamine-induced solitary rectal ulcer is described in a 41 year old woman who used high doses of ergotamine tartrate-containing suppositories for severe migraine headaches. Complete recovery of the ulcer was noticed after cessation of treatment with the suppositories. The relevant literature is discussed.
Heparin-associated skin necrosis
Authors: Fowlie J , Stanton P D , Anderson J R
Published: December 2008

A case of skin necrosis at the sites of injection of subcutaneous heparin is described. The patient went on to develop heparin-induced thrombocytopenia and pulmonary embolism. Review of the previously described cases of heparin-associated skin necrosis reveals that this sequence of events is not uncommon.
Synchronous adenocarcinoma and primary malignant lymphoma of the stomach
Authors: Akosa A B , Clark D M , Desa L
Published: December 2008

A synchronous presentation of an adenocarcinoma and a primary low grade B cell lymphoma of the stomach is reported in a 79 year old man. Both diagnoses were made on endoscopic biopsies and immunocytochemistry was essential in confirming the lymphoma. The true incidence, aetiology and spatial relations of these tumours are unknown since only few cases of such synchronous gastric tumours have been reported in the literature.
Continuing medical education for general practitioners in North Devon
Authors: Abernethy R D
Published: December 2008

The establishment of a continuing medical education system for established Principals in a semi-rural area is described. The essential requirement is a ‘link man’ in each general practice in the area. Clinical tutors, course organisers and regional advisers are all actively involved to produce a regional educational policy.
Thrombotic thrombocytopenic purpura with terminal pancytopenia
Authors: Ng S-C , Adam B A
Published: December 2008

A 27 year old housewife developed thrombotic thrombocytopenic purpura during the twelfth week of pregnancy. She had partial response to initial plasma infusion and subsequent plasmapheresis. However, her clinical course was complicated by the development of severe pancytopenia the consequence of a hypocellular marrow. She succumbed to septicaemic shock one month after diagnosis. The development of hypocellular marrow in thrombotic thrombocytopenic purpura has not been reported before.
A review of typhoid fever in South African black children
Authors: Ellis M E , Moosa A , Hillier V
Published: December 2008

Typhoid fever continues to escape swift diagnosis, even in an endemic country, and its multi-system nature led to delayed diagnosis in 25% of the patients in this study. This may have been an avoidable factor, leading to death in some patients through delay in instituting appropriate antimicrobial therapy. Neurological features and diarrhoea were particularly common in this paediatric population. Relative bradycardia has been shown to be a highly statistically significant finding for our group as a whole. Amoxycillin remains an effective and useful alternative to chloramphenicol. The mortality rate of 2.5% remains unchanged over the last 10 years. The relative inaccessibility to good primary health care, acceptable water supplies and sanitation that the black South African child encounters cannot be ruled out as a co-factor.
An oral treatment for lead toxicity
Authors: Thomas P S , Ashton C
Published: December 2008

Chronic lead poisoning has traditionally been treated by parenteral agents. We present a case where a comparison of ethylene diaminetetra-acetic acid was made with 2,3-dimethyl succinic acid (DMSA) which has the advantage of oral administration associated with little toxicity and appeared to be at least as efficacious.
The association between haemospermia and severe hypertension
Authors: Close C F , Yeo W W , Ramsay L E
Published: December 2008

The association between haemospermia and hypertension was examined in a case-control study comparing 5 hypertensive patients with haemospermia to 20 age-matched hypertensive men. Patients with haemospermia had much higher blood pressures than hypertensive controls (200/131 mmHg vs 147/90 mmHg; P < 0.0005/P < 0.0001), higher left ventricular voltage on ECG (P < 0.02), and higher concentrations of serum creatinine, proteinuria and renovascular disease (all P = 0.06 vs controls). Haemospermia is associated with severe uncontrolled hypertension. It is not, however, associated with hypertension per se, as the prevalence of hypertension in published series of patients with haemospermia is no higher than that expected in the general population. Men presenting with haemospermia should have their blood pressure measured carefully as they may require antihypertensive treatment urgently.
Hyperhomocysteinaemia and multiple aneurysms
Authors: Colwell N , Clarke R , Robinson K , Keane F , O'Briain S , Graham I
Published: December 2008

Homozygous homocystinuria, the most common genetic disorder of transulphuration, is associated with elevated plasma concentrations of homocystine, homocysteine, multiple clinical abnormalities and life-threatening thromboembolism. Several instances of vascular aneurysms have also been documented. More recently, an association between premature occlusive vascular disease and the heterozygous state has been proposed. We now report an unusual case in whom multiple aneurysms were associated with heterozygous homocystinuria.
Acute aortic valve prolapse in Marfan's syndrome
Authors: Carr N J , Cullen S A
Published: December 2008

A 22 year old man with Marfan's syndrome died suddenly following acute aortic valve prolapse. Although aortic root involvement in Marfan's syndrome is common, we have found no previous description of this particular complication in the literature.
Post 131I carcinoma of the thyroid
Authors: Adamson A S , Gardham J R C
Published: December 2008

A case of post-radioiodine follicular carcinoma of the thyroid is presented. Current evidence suggests no causal relationship. The evidence for this assertion is reviewed with the conclusion that a note of caution is still required.
A preliminary study of the ocular hypotensive effects of bromocriptine in diabetic patients with autonomic neuropathy
Authors: al-Sereiti M R , Turner P , Gale E A
Published: December 2008

The effect of bromocriptine on intraocular pressure has been investigated in a group of 8 diabetic patients with autonomic neuropathy, to test the hypothesis that bromocriptine exerts its ocular hypotensive action through presynaptic dopamine receptors. Bromocriptine eye drops (0.025%) produced a significant fall in intraocular pressure in a control group of 8 matched normal volunteers, but this effect was not seen in the eyes of the diabetic patients. These results are consistent with a presynaptic site of action of bromocriptine.
Congestive heart failure and converting enzyme inhibition: failure of current prognostic criteria for predicting subsequent renal insufficiency
Authors: Odum J , Carson P , Russell G
Published: December 2008

Angiotensin-1-converting enzyme inhibitors have an effective and established role in the treatment of patients with congestive heart failure. However, a small number of such patients will subsequently develop renal insufficiency. These patients may be identified prior to, or shortly after, commencement of therapy by recognized criteria. This report describes 4 patients with congestive heart failure who developed severe renal insufficiency secondary to either enalapril or captopril therapy in the absence of any currently recognized predisposing factors. One patient died.
Influenza A infection with rhabdomyolysis and acute renal failure—a potentially fatal complication
Authors: Berry L , Braude S
Published: December 2008

This paper describes a case of influenza A infection complicated by rhabdomyolysis and acute renal failure. This very rare complication is particularly important as symptoms may be non-specific and therefore ascribed to the underlying influenzal illness.
Shrinkage of thyrotrophin secreting pituitary adenoma treated with octreotide
Authors: Orme S M , Lamb J T , Nelson M , Belchetz P E
Published: December 2008

Thyrotrophin secreting pituitary adenomas are a rare cause of recurrent thyrotoxicosis. We report on a 47 year old woman with an 8-year history of this condition. In this case the somatostatin analogue, octreotide, normalized thyroid hormone levels. It was associated with marked tumour shrinkage, with striking reduction of the suprasellar extension and improved appearances in the region of the left cavernous sinus shown by high resolution computerized tomography. Following surgery she developed a biochemical relapse which responded to the reinstitution of octreotide. On long term treatment she developed stomach cramps and gallstones. Octreotide was discontinued. We review previous reports of this condition and discuss the role of octreotide in its management.
Primary hyperparathyroidism presenting as unilateral visual loss
Authors: Chappel D , Farrington K
Published: December 2008

A 58 year old woman presented with unilateral visual loss due to ischaemic optic neuropathy. Investigations revealed severe hypercalcaemia due to hyperparathyroidism. Excision of a large parathyroid adenoma restored normocalcaemia. Visual acuity was unchanged. There was no evidence of any condition known to be associated with ischaemic optic neuropathy, or of any abnormal clotting tendency. The association between primary hyperparathyroidism and ischaemic optic neuropathy may be causal and related to vascular damage mediated by hypercalcaemia.
Primary HIV-I infection associated with pneumonitis
Authors: Ong E L C , Mandal B K
Published: December 2008

A 21 year old homosexual man presented with an acute pneumonitis during symptomatic seroconversion for human immunodeficiency virus (HIV-I) infection. The symptoms resolved spontaneously without any therapeutic interventions needed. Acute pneumonitis should be added to the ever-increasing spectrum of clinical manifestations in primary HIV-I infection.
Lipid profile studies in long term thiazide treated hypertensives
Authors: Rao R A C , Hegde B M , Bhat E K , Vidyavathi U , Rao R R
Published: December 2008

Serum cholesterol and its subfractions were estimated in 23 patients on thiazide diuretics, for treatment of mild hypertension, for at least 30 months. The results were compared with those obtained in a matched set of 25 untreated mild hypertensives. It was found that while there was no difference in the level of total cholesterol, the LDL-cholesterol was significantly lower and HDL-cholesterol significantly higher in the treated group. It was also found that the total:LDL-cholesterol ratio was more in the treated group and the total:HDL-cholesterol ratio was less in the treated group. These findings suggest that coronary risk attributable to cholesterol and its subfractions does not seem to operate in long term thiazide treated patients.
A comparative study of danazol and norethisterone in dysfunctional uterine bleeding presenting as menorrhagia
Authors: Bonduelle M , Walker J J , Calder A A
Published: December 2008

This randomized open study compared the efficacy and safety of norethisterone, 5 mg three times a day from day 19 to 26, and danazol, 200 mg daily, in the treatment of dysfunctional uterine bleeding presenting as menorrhagia. Clinical criteria were employed to confirm the diagnosis, and subjective assessment of the condition was performed during one pre-treatment and three treatment cycles. Fourteen patients commenced norethisterone and 10 danazol.

Bleeding intensity scores were significantly lower with danazol than with norethisterone, and patients assessed their blood loss to be significantly less with danazol than with norethisterone. Associated symptoms of backache and abdominal pain were improved to a similar degree by both treatments. Adverse reactions were reported with similar frequency and were of a similar nature in both treatment groups.
Small bowel infarction mimicking Crohn's ileitis
Authors: Thuluvath P J , Feher M D , Wiggins J
Published: December 2008

A case of superior mesenteric arterial embolic occlusion with radiological features mimicking small bowel Crohn's disease is reported.
Doppler echocardiography in elderly patients with ejection systolic murmurs
Authors: McKillop G M , Stewart D A , Burns J M A , Ballantyne D
Published: December 2008

Thirty-nine elderly patients, mean age 77 years (range 65 to 96), with ejection systolic murmurs were studied to evaluate the functional significance of these murmurs. Subjects were evaluated clinically, by 2-D echocardiography, and by a full Doppler echocardiography study. Good quality Doppler signals were obtained in 35 subjects. Mitral regurgitation was found to be the only significant valvular lesion in 6 patients (17%). Doppler gradients in systole across the aortic valve were less than 30 mmHg in 28 subjects (80%) and were considered not significant. Gradients of greater than 30 mmHg representing significant aortic stenosis were found in 7 subjects (20%). The clinical sensitivity in detecting significant aortic stenosis was 44% and specificity was 81%. Doppler evidence of significant aortic stenosis was found in a substantial proportion of these elderly subjects. Neither clinical assessment nor 2-D echocardiography can be relied on to exclude this condition.
Cerebral arteriovenous malformation in Noonan's syndrome
Authors: Schon F , Bowler J , Baraitser M
Published: December 2008

Noonan's syndrome involves the association of multiple congenital abnormalities including neck webbing, pectus excavatum, facial anomalies with a variety of cardiac defects. In this paper the association of Noonan's syndrome with a large cerebral arteriovenous malformation is reported. Congenital cerebrovascular abnormalities are not a recognized feature of the syndrome. The paper also reviews previous reports of neurological associations with Noonan's syndrome, the commonest being mild intellectual impairment and ptosis.
The law and medical fitness to drive--a study of doctors' knowledge
Authors: King D , Benbow S J , Barrett J A
Published: December 2008

We assessed doctors' knowledge on laws and recommendations regarding fitness to drive in certain medical conditions by a questionnaire survey. A total of 646 doctors consisting of 400 general practitioners and 246 hospital doctors of all grades were circulated with the questionnaire. The survey was anonymous so non-responders could not be re-circulated. The response rate was 26% general practitioners and 32% (hospital doctors). The results show the poor knowledge of doctors on several aspects of fitness to drive.

It is necessary for all doctors to have a basic knowledge on the laws and recommendations on fitness to drive so that they can advise their patients correctly. Our survey clearly shows that doctors' knowledge is poor. Many drivers may therefore be placing themselves and others at risk. It is mandatory that this subject receives more attention in undergraduate and postgraduate education and that doctors should be regularly updated on new recommendations from the Driver and Vehicle Licensing Agency.
Acute renal failure in a case of paraquat poisoning with relative absence of pulmonary toxicity
Authors: Florkowski C M , Bradberry S M , Ching G W K , Jones A F
Published: December 2008

A 37 year old male presented after the ingestion of paraquat ('Gramoxone', 20% w/v). Plasma paraquat concentrations indicated that he had a greater than 50% probability of death. The patient survived following a period of acute oliguric renal failure and with only mild pulmonary toxicity.
Miliary tuberculosis presenting with thyrotoxicosis
Authors: Nieuwland Y , Tan K Y , Elte J W F
Published: December 2008

A male patient is described who presented with thyrotoxicosis, and a large painful neck mass. From the excised mass and stomach aspiration Mycobacterium tuberculosis was cultured and a diagnosis of miliary tuberculosis was made. The thyrotoxicosis was attributed to tuberculous thyroiditis.
Ménétrier's disease in a child
Authors: Vujanić Gordan M , Miladinović Mirko
Published: December 2008

A case of Ménétrier's disease in a 3 year old child presenting with subtotal pyloric stenosis and fatal outcome due to postoperative complications is reported. It is emphasized that although radiographic and gastroscopic studies are helpful, a full-thickness mucosal biopsy is essential for the diagnosis of Ménétrièr's disease.
The prevalence and nosocomial acquisition of Clostridium difficile in elderly hospitalized patients
Authors: Rudensky B , Rosner S , Sonnenblick M , van Dijk Y , Shapira E , Isaacsohn M
Published: December 2008

Rectal swabs obtained from 10 of 49 chronic-care geriatric patients were positive for Clostridium difficile, for a prevalence rate of 20.4%. Simultaneous sampling of 29 patients in an acute geriatric ward revealed four colonized patients, for a prevalence rate of 13.7%.

A prospective study of C. difficile colonization in 100 consecutive patients admitted to an acute geriatric ward was carried out. All patients were sampled upon admission and biweekly during hospitalization. Two patients (2%) were positive on admission, and 12 of the 98 initially negative patients became colonized, representing a nosocomial acquisition rate of 12.2%. A major determinant for C. difficile colonization in asymptomatic patients appears to be length of hospitalization. Previous antibiotic administration was not found to be a significant factor.
Subcutaneous versus intravenous administration of heparin in the treatment of deep vein thrombosis; which do patients prefer? A randomized cross-over study
Authors: Robinson A M , McLean K A , Greaves M , Channer K S
Published: December 2008

Patient preference for intravenous or subcutaneous heparin in the treatment of deep venous thrombosis was assessed in a randomized cross-over study. Twenty patients with venographically proven deep venous thrombosis were randomized to receive subcutaneous or intravenous heparin for 3 days followed by 3 days of the other treatment. Discomfort at the injection site, assessed by visual analogue scale, was significantly less for the subcutaneous than the intravenous administration route (P < 0.001), mobility was thought to be better when receiving subcutaneous heparin (P < 0.005) and patients' overall preference was for subcutaneous treatment (P < 0.001).
Useless hand of Oppenheim--magnetic resonance imaging findings
Authors: Coleman R J , Russon L , Blanshard K , Currie S
Published: December 2008

A patient with multiple sclerosis developed a useless, deafferented left hand, as described previously by Oppenheim. Magnetic resonance imaging demonstrates that this is caused by an ipsilateral plaque of demyelination in the posterior columns of the cervical cord.
Blind drunk: alcoholic pancreatitis and loss of vision
Authors: Steel James R , Cockcroft John R , Ritter James M
Published: December 2008

Acute loss of vision and alcoholic intoxication suggests the possibility of methanol poisoning. In this report we describe an alcoholic patient who complained of blindness after recovering from alcoholic pancreatitis and delirium tremens. Visual acuity was severely impaired and fundoscopy revealed florid bilateral cotton wool spots and a cherry red spot at the right macula. Such appearances have previously been reported in cases of post-traumatic visual loss, and may share a common aetiology of fat embolization. The association between alcoholic pancreatitis and visual loss is rare, and fundal examination should be performed on all patients with pancreatitis, especially those who complain of visual disturbance.
Raising HDL cholesterol with low-dose nicotinic acid and bezafibrate: preliminary experience
Authors: Luria Myron H , Sapoznikov Dan
Published: December 2008

Nicotinic acid is an effective agent for elevating HDL cholesterol but is limited by side effects. In order to improve tolerance and lipid levels, we combined low-dose nicotinic acid with bezafibrate. We gave low-dose (mean 435 mg/day) nicotinic acid to 37 patients with low HDL cholesterol, bezafibrate (mean 476 mg/day) to 58 patients with elevated total cholesterol and both agents (mean nicotinic acid 435 mg/day and bezafibrate 512 mg/day) to 25 patients with low HDL cholesterol and elevated total cholesterol. A total of 53 additional patients were followed as controls. Three intervals of treatment were studied: 0-6, 6-12 and > 12 months.

The combination of drugs resulted in significant (P < 0.05) percentage changes in total cholesterol, triglycerides and total/HDL cholesterol compared to nicotinic acid alone and significant (P < 0.04) percentage changes in HDL cholesterol compared to bezafibrate alone. It is concluded that low doses of nicotinic acid may result in significant changes in HDL cholesterol; when combined with bezafibrate significant alterations in total cholesterol, triglycerides and total/HDL cholesterol also result.
Angina and myocardial infarction presenting with pain confined to the ear
Authors: Rothwell P M
Published: December 2008

Two cases are described in which cardiac ischemia presented with pain confined to the ear. In both cases the correct diagnosis was missed and treatment delayed. Angina and myocardial infarction may present with pain in the ear due to referral via the vagus nerve.
Adrenocorticosteroid deficiency: an unusual cause of fever of unknown origin
Authors: Page R C L , Alford F
Published: December 2008

We report the case of a lady with multiple presentations and admissions with fever. The eventual diagnosis was made of adrenocorticosteroid deficiency.
Timing of intervention in acute pancreatitis
Authors: Johnson C D
Published: December 2008

This review examines the appropriate timing of intervention in acute pancreatitis. In gallstone pancreatitis, it is now clear that cholecystectomy during the primary admission carries no greater risk of complications than delayed cholecystectomy and enables earlier recovery to normal activity. This course of action pre-empts a second, possibly fatal attack of acute pancreatitis. Cholecystectomy should be done after the acute phase has settled, before discharge from hospital. Patients with gallstones should now be offered endoscopic sphincterotomy within 48 hours of admission. This approach is safe, and reduces the risk of complications.

When complications develop, early necrosectomy is only indicated if conservative measures fail. Delayed (> 10 days) necrosectomy is appropriate if there is evidence of sepsis, or clinical failure to improve. Pancreatic pseudocysts can often be managed expectantly; a high proportion will resolve spontaneously. After a delay of 12 weeks, persistent cysts require evaluation by endoscopic pancreatography, which gives crucial information in the choice between percutaneous or surgical drainage of the pseudocyst.

A patient with pancreatitis is usually treated under the care of a surgeon, who has traditionally taken the decision on the timing of any intervention, and has performed such intervention at open operation. Recently, the development of alternative techniques has enabled the surgeon to call on the skills of his colleagues in endoscopy and interventional radiology. However, the availability of these alternatives to surgery should not affect the timing of intervention unless it can be clearly shown that such a change in timing combined with the minimally invasive technique can improve the outcome for the patient.

Intervention may be required to deal with gallstones in the gallbladder or in the bile duct, to deal with, or ideally prevent, the deleterious systemic effects of pancreatic and peripancreatic necrosis, or to drain a peripancreatic abscess. Peripancreatic fluid collections and pancreatic pseudocysts may also require either internal or external drainage to relieve symptoms or prevent complications.
Serum lipids and coronary heart disease in British elderly
Authors: Mangion D M , Roy S S
Published: December 2008

To assess the relationship between serum lipids and coronary heart disease (CHD) in an elderly population (mean age = 77.4; SEM +/- 0.4; range 70-92 years), serum total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) were measured in 84 (males = 52) subjects with evidence of definite myocardial infarction and 125 (males = 77) age- and sex-matched controls free of CHD on Rose questionnaire and resting electrocardiogram.

On multivariate logistic regression analysis, CHD showed inverse association with HDL-C (odds ratio for decrease by 1 s.d. = 1.6, P = 0.02) in males and positive association with TC (odds ratio for increase by 1 s.d. = 1.8, P = 0.03) and LDL-C (odds ratio for increase by 1 s.d. = 1.8, P = 0.04) in females. Of the other variables only diabetes in males (odds ratio 2.4, P = 0.05) and left ventricular hypertrophy in females (odds ratio 8.8, P = 0.03) were associated with CHD.

The results suggest that further prospective studies to further evaluate the relation of serum lipids with CHD in this age group are indicated.
Osteomyelitis of symphysis pubis following renal transplantation
Authors: Jindal R M , Idelson B , Bernard D , Cho S I
Published: December 2008

We describe what we believe is the first reported case of osteomyelitis of the symphysis pubis following renal transplantation. Computed tomographic and magnetic resonance imaging scans were useful in establishing the diagnosis.
Spontaneous rupture of the spleen in association with idiopathic thrombocytopaenic purpura
Authors: Winslet M C , Webberley M J , Melikian V , Donovan I A
Published: December 2008

Spontaneous rupture of the spleen is rare and has not been previously reported in association with idiopathic thrombocytopaenic purpura. Its rarity makes familiarity with its presentation difficult and may result in a potentially fatal delay in diagnosis and treatment.
Open access endoscopy: is the lost outpatient clinic of value?
Authors: Saunders B P , Trewby P N
Published: December 2008

To test the value of an outpatient visit in patients with dyspepsia, 79 patients considered suitable for open access endoscopy by their general practitioners were instead seen in the medical outpatient clinic first. In 35 patients immediate endoscopy was seen as an inappropriate investigation and 23 of these were spared endoscopy. In 11 patients important extra diagnoses were made in the clinic which would have been delayed or missed had the patients been sent straight for open access endoscopy. Sixty-eight per cent of patients, when asked by questionnaire, said they preferred to be seen in the clinic first rather than come for open access endoscopy. These results lend support to the traditional medical clinic appointment followed by endoscopy if and when appropriate rather than the open access endoscopy system.
Thyroid storm in a young woman resulting in bilateral basal ganglia infarction
Authors: Page S R , Scott A R
Published: December 2008

We describe a 30 year old woman who presented with thyroid storm. She had non-specific symptoms and few clinical signs of hyperthyroidism despite markedly raised thyroid hormone concentrations. Soon after admission her behaviour became abnormal and her level of consciousness deteriorated. Despite the rapid restoration of thyroid hormone concentrations to normal using conventional therapies, and correction of hypoxia resulting from acute pulmonary oedema, her level of consciousness did not improve. Cranial CT scanning revealed extensive bilateral basal ganglia infarction, a previously unreported complication of thyroid storm. This observation suggests that thyroid storm may predispose to hypoxic neurological damage.
New markers of bone and collagen turnover in children and adults with growth hormone deficiency
Authors: Sartorio A , Conti A , Monzani M
Published: December 2008

Serum bone Gla protein (BGP), a marker of osteoblastic function, serum carboxyterminal cross-linked telopeptide of type I collagen (ICTP), a marker of bone resorption, and serum aminoterminal propeptide of type III procollagen (PIIINP) levels, an index of collagen synthesis, were determined in seven children and eight adults with congenital growth hormone deficiency (GHD).

In children with GHD, serum BGP (mean +/- s.e.: 12.9 +/- 0.7 ng/ml), ICTP (8.3 +/- 1.3 ng/ml) and PIINP (3.5 +/- 0.5 ng/ml) levels were significantly lower (P < 0.001) than those recorded in normal children (BGP 18.9 +/- 0.8 ng/ml, ICTP 14.4 +/- 0.5 ng/ml and PIIINP 6.7 +/- 0.7 ng/ml). Total alkaline phosphatase (184.7 +/- 13.4 IU/l) and bone alkaline phosphatase (77.8 +/- 4.1 IU/l) levels were also significantly lower (P < 0.0001) than in controls (338.1 +/- 14.9 IU/l and 181.0 +/- 7.8 IU/l, respectively). Serum BGP, ICTP and PIIINP levels were not significantly correlated with height velocity values.

In adults with GHD, mean BGP levels (3.8 +/- 0.3 ng/ml) were significantly lower (P < 0.0001) than those recorded in normals (5.4 +/- 0.1 ng/ml). On the contrary, serum ICTP levels were similar to those found in controls (patients: 4.7 +/- 0.8 ng/ml vs normals: 4.1 +/- 0.3 ng/ml), suggesting the presence of a normal resorption activity associated with a reduced osteoblastic function. This finding was also confirmed by the presence of reduced bone alkaline phosphatase levels (GHD: 44.9 +/- 6.9 IU/I vs controls: 58.3 +/- 2.0 IU/I; P<0.02), while the less specific total alkaline phosphatase levels (119.5 +/- 14.8 IU/I) were similar to those recorded in normal subjects (122.3 +/- 4.0 IU/I). Serum PIIINP levels (3.7 +/- 0.6 ng/ml) were similar to those recorded in normals (3.2 +/- 0.2 ng/ml), suggesting that in adulthood the collagen turnover is not negatively influenced by the chronic GHD. No significant correlations were found between BGP/ICTP/PIIINP and IGF-I levels.

In conclusion, our data show that in children with GHD the lack of GH insulin-like growth factor-I (IGF-I) effects on bone and collagen turnover is associated with a significant reduction of bone turnover (low bone formation plus low bone resoRption) and collagen synthesis. On the contrary, adult GHD seems to exert less relevant effects on bone and collagen turnover, probably due to the fact that in adult life further hormones or local factors might partially counteract the negative consequences of chronic GH-IGF-I deficiency.
Community-acquired bacteraemic Acinetobacter pneumonia with survival
Authors: Achar Kesarakodi N , Johny Molly , Achar Mohini N , Menon N Kochunny
Published: December 2008

A 65 year old man was admitted with segmental consolidation of the left upper lobe after having stayed in a hotel for 2 days. He deteriorated rapidly on conventional antibiotic therapy and required ventilatory support. Acinetobacter calcoaceticus var. anitratus was grown from the sputum and blood cultures, which was treated with a combination of anti-pseudomonal agent, aminoglycoside and cotrimoxazole. He made a slow but remarkable recovery from the pneumonia. Acinetobacter is a rare potentially fatal cause of community-acquired pneumonia.
Autonomic neuropathy in African diabetic patients
Authors: Tuch P S , Gill G V , Huddle K R L
Published: December 2008

To determine the prevalence and extent of autonomic neuropathy amongst Africans with insulin-dependent diabetes mellitus (IDDM), we investigated 50 such patients at our clinic. Mean age (+/- 1 s.d.) was 26 +/- 6 years, male:female ratio was equal (25M:25F) and duration of diabetes was 4.0 +/- 3.0 years. A battery of six validated tests of autonomic function was performed, testing both sympathetic and parasympathetic systems. Overall 16 (32%) had evidence of autonomic damage, affecting parasympathetic only in 14, and both sympathetic and parasympathetic in two. Those with autonomic neuropathy had a significantly longer diabetes duration than those without (6.0 +/- 2.8 years versus 3.1 +/- 2.7 years, P < 0.005), but there was no difference in glycosylated haemoglobin (HbA1) between the two groups. Autonomic neuropathy was also not significantly associated with peripheral neuropathy or other diabetic complications. Autonomic neuropathy carries a poor prognosis in IDDM and this high prevalence in a group of patients with relatively short diabetes duration gives cause for concern.
Air pollution and asthma
Authors: Barnes Peter J
Published: December 2008

The role of air pollution in the increased prevalence and morbidity of asthma has been widely debated, but results to date indicate that the normally encountered levels of air pollution are unlikely to contribute to a worsening of asthma. When the levels of sulphur dioxide (SO2) are exceptionally high it is possible that asthmatic patients may have increased symptoms after exertion, since this irritant gas acts as a trigger to bronchoconstriction. There is also evidence that suspended particles may also act as an inciter of asthma symptoms when concentrations are high. Experimentally, ozone in high concentrations may increase airway responsiveness in both normal and asthmatic subjects by inducing airway inflammation, but asthmatic individuals show the same responses as normal subjects and there is little or no evidence to link increases in ambient ozone with an increase in asthma. There is little evidence that nitrogen dioxide (NO2), even at the peak levels recorded, has any significant effect on airway function in normal or asthmatic individuals.

Other air pollutants which are present in lower concentrations have not been studied as extensively, but there is no convincing evidence that they cause significant respiratory symptoms in asthmatic patients. It is still possible that combinations of air pollutants may have greater effects on airway function than exposure to a single pollutant, although there is little evidence to support this. Epidemiological evidence provides little support for the idea that atmospheric pollution levels are related to the frequency of asthma symptoms or the frequency of attacks. More importantly, there is no evidence that asthma prevalence or aetiology is related to the level of air pollution.

A review of currently available information therefore provides little evidence for the widely expressed view that atmospheric pollution is related to increased prevalence or morbidity of asthma or is related to the causation of asthma.
Hashimoto's thyroiditis, Sjogren's syndrome and orbital lymphoma
Authors: Ko G T C , Chow C C , Yeung V T F , Chan H , Cockram C S
Published: December 2008

A 69 year old Chinese housewife presented with periorbital puffiness, and dry eyes and mouth. Subsequent investigations confirmed the presence of Hashimoto's thyroiditis, Sjogren's syndrome and orbital lymphoma. This unusual combination is discussed with reference to previous publications.
Adenomatous polyp at the ureterocaecal anastomosis
Authors: Coen L D , Raftery A T
Published: December 2008

A case of adenomatous polyp occurring at a ureterocaecal anastomosis, 25 years after urinary diversion following a total cystectomy for carcinoma of the bladder, is reported. Bilateral nephrectomy for chronic pyelonephritis was carried out 25 years after the initial surgery and, following this, a sinus formed at the incision at the right loin. A sinogram showed contrast filling the right ureter and caecum, and outlined a lobulated filling defect at the ureterocaecal anastomosis. Subsequent histology revealed a dysplastic tubulovillous adenoma. The clinical presentation and management of tumours at the ureterointestinal junction are discussed.
Myositis and eosinophilia in a patient with sarcoidosis
Authors: Al-Saffar Z S , Kelsey C R , Kennet R P , Webley M
Published: December 2008

We present a patient with muscle manifestations of sarcoidosis associated with raised creatine kinase levels, eosinophilia and interstitial lung disease. She had significant improvement on prednisolone 30 mg per day.
Symptomatic IgG3 deficiency successfully treated with intravenous immunoglobulin therapy
Authors: Snowden J A , Milford-Ward A , Reilly J T
Published: December 2008

We report the case of a 35 year old female who presented with an 8 year history of repeated upper respiratory tract infection, lymphadenopathy and sinusitis associated with IgG3 deficiency. Courses of monthly intravenous immunoglobulin therapy (0.4 g/kg) resulted in a dramatic clinical improvement on three different occasions. We suggest that investigation of adults with features of immunosuppression, despite normal levels of total IgG, should include IgG3 subclass analysis and that symptomatic patients should be given a trial of immunoglobulin replacement therapy.
Primary pelvic hydatid cyst presenting with obstructive uropathy and renal failure
Authors: Seenu V , Misra M C , Tiwari S C , Jain R , Chandrashekhar C
Published: December 2008

Primary pelvic hydatid cyst is a rare entity. Pelvic hydatid cysts usually present with pressure symptoms involving adjacent organs (bladder and rectum usually). A case of primary pelvic hydatid cyst presenting with obstructive uropathy leading to chronic renal failure is presented. A combination of preoperative albendazole therapy of 1.2 g/day for 8-12 weeks and surgical excision were effective in alleviating the symptoms and improving the renal function.
Late cardiac effects after treatment for childhood Hodgkin’s disease with chemotherapy and low-dose radiotherapy
Authors: Ilhan I , Sarialioglu F , Özbarlas N , Büyükpamukçu M , Akyüz C , Kutluk T
Published: December 2008

Twenty-four patients under 18 years when treated for Hodgkin’s disease (20 male, four female) were examined no less than five years after the completion of the treatment. The mean age was 17 years (range 9.5-25.0 years) at the time of study. All patients received six courses of cyclophosphamide-oncovin-procarbazine-prednisolone chemotherapy; in addition, nine patients received low-dose radiotherapy excluding the mediastinum and eight of 24 patients received mediastinal radiotherapy; the dose was between 20-30 Gy. All patients had normal cardiovascular findings on clinical examination. ECG and chest radiography were within normal limits in all patients. Resting left ventricular ejection fraction and fractional shortening were decreased in only one patient (4%), but there was no significant difference between the patient group and a control group for left ventricular systolic function (p > 0.05). In the patient group, early diastolic peak velocity, peak velocity at atrial contraction, left ventricular isovolumic relaxation time, and the rate of decrease of flow velocity in early diastole were significantly different from that of the control group (p < 0.05). In conclusion, the late effects of our treatment protocol for Hodgkin’s disease appear to be minimal. These observations support combined modality, low-dose irradiation regimens in children and adolescents and suggest the need for careful cardiac screening of treated patients.
The clinical and laboratory correlates of an increased urinary 5-hydroxyindoleacetic acid
Authors: Tormey W P , FitzGerald R J
Published: December 2008

Over a five-and-a-half-year period, there were 298 laboratory requests for urinary 5-hydroxyindoleacetic acid (5-HIAA). The clinical and laboratory associations of the 24 patients in which there were 43 urinary 5-HIAA 24-h collection results greater than the laboratory upper reference limit are detailed. Four were confirmed carcinoid tumours and two were phaeochromocytomas. Flushing was a prominent symptom in 46% and diarrhoea or altered bowel habit in 37%. Associated with the raised urinary 5-HIAA values were increased levels of 4-hydroxy-3-methoxymandelic acid and homovanillic acid in 14.3% and 21%, respectively, of those collections where the metabolites were requested. Diagnostic imaging was performed in 57%. While the specificity was 88%, 5-HIAA is relatively insensitive in the diagnosis of carcinoid tumours and a more widespread use of diagnostic imaging including isotope scanning with labelled metaiodo-benzylguanidine, vasoactive intestinal peptide and octreotide is suggested.