bluuebunny/crossref_metadata_2025 huggingface dataset:
Tuberculosis of the pancreas
Authors: Varshney S , Johnson C D
Published: December 2008

Tuberculosis of the pancreas is extremely rare. We report a case which demonstrates the diagnostic confusion which may arise in this condition. A 55-year-old alcoholic caucasian man presented with loss of weight and obstructive jaundice. Ultrasonography, endoscopic retrograde cholangiopancreatography and computed tomography showed a mass lesion in the head of the pancreas, diagnosed as probably malignant. He underwent a Whipple’s pancreatoduodencetomy and made a good recovery. Histological examination showed typical features of tuberculosis. In the absence of other foci of active disease chemotherapy was not given. He remains well 12 months after operation.
Management of transient ischaemic attacks and stroke
Authors: Humphrey P R
Published: December 2008

The management of stroke and transient ischaemic attacks (TIAs) has changed greatly in the last two decades. The importance of good blood pressure control is the hallmark of stroke prevention. Large multicentre trials have proven beyond doubt the value of aspirin in TIAs, warfarin in patients with atrial fibrillation and embolic cerebrovascular symptoms, and carotid endarterectomy in patients with carotid TIAs. There seems little doubt that patients managed in acute stroke units are more likely to be independent at six months than those managed in a general medical ward. This article emphasizes the importance of basing clinical management on simple history taking and examination and appropriate investigation. This, combined with knowledge of the natural history risk of TIA and stroke and the results of randomised trials, allows individuals to be managed in the most appropriate manner. This review is designed to be a practical guide, useful in the day to day management of patients with cerebrovascular disease.
The development of healthcare services for drug misusers and prostitutes
Authors: Morrison C L , Ruben S M
Published: December 2008

With the advent of human immunodeficiency virus (HIV) and the increase of drug misuse in the UK, the Government wishes primary care to play a greater part in treating drug problems in the hope of preventing the spread of HIV. Drug misusers do not avail themselves of traditional services and many are not registered with general practitioners. In response to this Liverpool Health Authority and Family Health Service Authority commenced a new salaried post to provide primary care services to special groups such as injecting drug misusers and prostitutes. Judgemental attitudes towards drug misusers, their high mobility and being a transient population play a part in the reasons why drug misusers find it difficult to access primary healthcare. Drug misusers have high morbidity related to their drug misuse. Many of these conditions, if treated early, can prevent the need for more intensive intervention. Although drug misusers may present with a condition requiring immediate treatment, the opportunity is used to provide other healthcare such as hepatitis B vaccinations, sexually transmitted infection screening, contraception and HIV/hepatitis B testing. The sero prevalence of anti-HBc in injecting drug misusers is 45.5%. Due to their high morbidity and associated costs, the requirements of these groups may conflict with the objectives of budget-holding practices. If general practitioners are unable to respond to their problems, then health care providers and purchasers will have to consider similar schemes in areas which have a higher prevalence of drug misuse in order to provide appropriate healthcare for these vulnerable groups.
Successful pregnancy following aplastic anaemia
Authors: Leong K W , Teh A , Bosco J J , Lim J
Published: December 2008

Pregnancy following idiopathic aplastic anaemia is rare and is difficult to manage because of life-threatening episodes of bleeding and infections. Only a handful of cases has been reported in the literature. The pregnancies were unsuccessful in the majority. The present report describes a patient with moderately severe idiopathic aplastic anaemia who was managed with intensive haematological support leading to delivery of a healthy infant by caesarean section. Despite platelet transfusion refractoriness as a result of transfusions prior to pregnancy, adequate platelet transfusions prevented excessive bleeding. The literature is reviewed and management with platelet transfusions is discussed.
Battered granny or spontaneous fractures? A legal dilemma
Authors: Connolly V , McConnell A A , McGarrity G
Published: December 2008

A 70-year-old woman was admitted from a local nursing home with extensive bruising and bilateral hip discomfort. The referring doctor had reported the possibility of elder abuse to the police. Full examination showed that osteomalacia, precipitated by a poor diet and lack of exposure to sunlight, was sufficient to explain the patient’s condition. Caution is recommended in diagnosing elder abuse until other possibilities have been excluded.
The clinical skills unit
Authors: Bligh J
Published: December 2008

Clinical skills units offer exciting and innovative ways of learning about clinical skills. Links between theoretical knowledge and clinical practice are appropriate for both undergraduate and postgraduate training. Students and doctors can practice and acquire technical and examination skills in a standardised and protected environment without being concerned about the distress such learning may cause real patients. Models and simulators used in skills units are being developed to keep pace with demand, with a corresponding increase in standards of quality and durability. As undergraduate medical courses respond to the demands of modern clinical practice the use of such facilities will increase. This paper describes the functions of skills units and provides practical examples of educational strategies in use.
Routine nasal surgery: an audit of outpatient follow-up
Authors: Murthy P , McKerrow W S
Published: December 2008

The study objective was to assess the value of outpatient follow-up of patients who undergo routine uncomplicated nasal surgery. A total of 177 postoperative patients (117 males, 60 females) undergoing routine nasal surgery at the Raigmore Hospital, Inverness, was selected over a six-month period, 92 of whom (60 males, 32 females) were requested to return to the clinic for a follow-up session. A total of 72 (78.3%) patients attended for post-operative review. Of these, 55 patients (76.4%) had achieved a satisfactory result from surgery and 17 (23.6%) required additional treatment for persistent problems. The former group were pleased with the outcome of their operation and required no further treatment. Of the 25 patients who were prescribed medication at the time of discharge from hospital, 19 (76.0%) were still complying with the medication and required no further specialist assistance. The results suggest that routine follow-up of uncomplicated cases of nasal surgery is unnecessary. The good therapeutic results in the majority of cases indicate a need to decrease the number of routine reviews to reduce the high non-attendance rate and increase the proportion of new patients seen at outpatient clinics. The role played by general practitioners is vital to this cause. This would include minor postoperative care, monitoring of prescribed medication and review of patients with occasional postoperative problems.
A randomised, double-blind, placebo-controlled trial of L-carnitine in suspected acute myocardial infarction
Authors: Singh R B , Niaz M A , Agarwal P , Beegum R , Rastogi S S , Sachan D S
Published: December 2008

In a randomised, double-blind placebo-controlled trial, the effects of the administration of oral L-carnitine (2 g/day) for 28 days were compared in the management of 51 (carnitine group) and 50 (placebo group) patients with suspected acute myocardial infarction. At study entry, the extent of cardiac disease, cardiac enzymes and lipid peroxides were comparable between the groups, although both groups showed an increase in cardiac enzymes and lipid peroxides. At the end of the 28-day treatment period, the mean infarct size assessed by cardiac enzymes showed a significant reduction in the carnitine group compared to placebo. Electrocardiographic assessment of infarct size revealed that the QRS-score was significantly less in the carnitine group compared to placebo (7.4 +/- 1.2 vs 10.7 +/- 2.0), while serum aspartate transaminase and lipid peroxides showed significant reduction in the carnitine group. Lactate dehydrogenase measured on the sixth or seventh day following infarction showed a smaller rise in the carnitine group compared to placebo. Angina pectoris (17.6 vs 36.0%), New York Heart Association class III and IV heart failure plus left ventricular enlargement (23.4 vs 36.0%) and total arrhythmias (13.7 vs 28.0%) were significantly less in the carnitine group compared to placebo. Total cardiac events including cardiac deaths and nonfatal infarction were 15.6% in the carnitine group vs 26.0% in the placebo group. It is possible that L-carnitine supplementation in patients with suspected acute myocardial infarction may be protective against cardiac necrosis and complications during the first 28 days.
Pancreaticopleural fistula: a rare complication of chronic pancreatitis
Authors: Wakefield S , Tutty B , Britton J
Published: December 2008

Pancreaticopleural fistula is an uncommon sequelae of pancreatitis. The condition is often elusive, as respiratory rather than abdominal symptoms usually predominate and the fistula can be difficult to demonstrate radiologically. Confirmation is by demonstrating a high amylase content in the pleural aspirate relative to the serum. About half the fistulae will close with conservative treatment but persistent or recurrent effusions, often associated with stenosis or disruption of the main pancreatic duct, are an indication for surgery. The long-term outcome is good in 80-95% of cases. We report five patients with pleural effusion of pancreatic origin due to pancreaticopleural fistula.
Clomiphene-induced pituitary apoplexy in a patient with acromegaly
Authors: Walker A B , Eldridge P R , MacFarlane I A
Published: December 2008

We describe the case of an acromegalic woman with primary infertility who was treated with clomiphene, and subsequently developed pituitary apoplexy.
The modernisation of general practice in the UK: 1980 to 1995 and beyond. Part I
Authors: Iliffe S
Published: December 2008

The UK is unusual in providing universal free healthcare in which access to specialists is largely controlled by general practitioners with 24-hour responsibility, throughout the year, for a defined list of patients of all ages. It is generally considered that this gatekeeper function has contributed to the relatively low cost of the National Health Service, but major changes in the organisation and clinical role of general practitioners have occurred, culminating in a new contract that aims to re-orientate general practice towards health promotion, disease prevention and the management of chronic disease. The implications of these changes are discussed.
Clinician beliefs underlying autopsy requests
Authors: Birdi K S , Bunce D J , Start R D , Cotton D W
Published: December 2008

The aim of the study was to use psychological theory to identify and evaluate factors influencing clinical autopsy requests. A series of pilot interviews were conducted with 20 clinicians to identify beliefs about the benefits and drawbacks, social groups and circumstances influential in the decision to make an autopsy request. The most common beliefs, together with measures of intention to request autopsies, were incorporated into a questionnaire which was distributed among all appropriate clinicians in four hospitals. Statistical analyses identified which beliefs had the most influence on clinicians’ intentions to request autopsies. A total of 145 clinicians returned the questionnaire, a response rate of 42%. Clinicians were significantly more likely to request autopsy the more they thought that the outcome of requesting would be of educational value, would confirm clinical diagnoses, would not distress relatives, would not be time-consuming and that the request itself would receive support from their consultant. An autopsy request was unlikely in circumstances where clinicians felt uncomfortable when requesting relatives’ permission and when the patients were elderly. The fear of causing distress to relatives and the degree of support from the clinician’s consultant were found to be the strongest predictors of intention to request autopsies. These are two areas in which intervention could help to increase autopsy request rates.
Caval umbrella causing obstructive uropathy
Authors: Flanagan D , Creasy T , Chataway F , Kerr D
Published: December 2008

A 49-year-old woman had a vena caval filters inserted having suffered multiple pulmonary emboli and a large upper gastrointestinal bleed. She re-presented five years later with loin pain and obstructive uropathy. She was found to have a right pelvi-ureteric obstruction due to inferior vena caval wall perforation from the vena caval filter.
Acute pancreatitis: assessment and management
Authors: Skaife P , Kingsnorth A N
Published: December 2008

In the 1920s Moynihan described acute pancreatitis as "..the most terrible of all intra-abdominal calamities". He established a practice of immediate surgical intervention to remove the toxic products accumulating in the peritoneal cavity, and this treatment was endorsed by most centres, remaining the standard therapy for the next 20 years. In the 1940s, the mortality of patients treated surgically was shown to be far higher than those treated conservatively, and a more conservative line of management was recommended, comprising nasogastric stomach decompression, intravenous fluid therapy, opiate analgesia, and the administration of atropine. Despite half a century passing, a clinician would not be criticised for adopting such a regime today, which in part reflects the lack of understanding of this condition and the failure of seemingly appropriate therapy. Reduction in mortality is a consequence of advances in intensive care preventing the high early mortality of organ failure, but the area of specific therapy remains elusive. While this is so, the mortality rates for these patients will remain static, while the doctor continues to feel clinically impotent.
Deep cerebral venous thrombosis presenting as an encephalitic illness
Authors: Silburn P A , Sandstrom P A , Staples C , Mowat P , Boyle R S
Published: December 2008

Three cases of deep cerebral vein thrombosis presenting as encephalitic illnesses are described. Thyrotoxicosis was present in one case, ulcerative colitis in one case and an anticardiolipin antibody was detected in two cases. All three patients were on oestrogen and progesterone. Magnetic resonance imaging and angiography allowed rapid confirmation of the diagnosis and permitted non-invasive follow up of this condition. The first two patients made complete clinical recoveries despite having thalamic infarction, in one case bilaterally, demonstrable radiologically.
Bilateral endogenous Escherichia coli endophthalmitis: a devastating complication in an insulin-dependent diabetic
Authors: Walmsley R S , David D B , Allan R N , Kirkby G R
Published: December 2008

We report a case of bilateral endogenous Escherichia coli endophthalmitis in an insulin-dependent diabetic. This condition appears to occur almost exclusively in diabetics, and is invariably related to a urinary tract infection. Treatment of any infection in diabetics should be aggressive, and any deterioration in vision should be addressed promptly.
Insulin resistance and development of diabetes mellitus associated with megestrol acetate therapy
Authors: Jain P , Girardi L S , Sherman L , Berelowicz M , Smith L G
Published: December 2008

We describe a case of diabetes mellitus induced by megestrol acetate in a patient with the acquired immunodeficiency syndrome. Metabolic studies including an arginine infusion test excluded an insulinopenic state and suggested insulin resistance as the underlying mechanism for hyperglycaemia. Withdrawal of megestrol acetate resulted in rapid correction of all metabolic abnormalities and eliminated the need for exogenous insulin therapy.
Somatostatin analogue treatment of neuroendocrine tumours
Authors: de Herder W W , van der Lely A J , Lamberts S W
Published: December 2008

The long-acting analogues of somatostatin have an established place in the medical treatment of patients with neuroendocrine tumours. They act through binding with specific, high-affinity membrane receptors. Somatostatin analogue therapy is an effective and safe treatment for most growth hormone and thyrothropin-secreting pituitary adenomas. The potential therapeutic consequences of the presence of somatostatin receptors on clinically ‘nonfunctioning’ pituitary tumours are still uncertain. Somatostatin analogues are not useful in the treatment of patients with prolactinomas, or adrenocorticotropin (ACTH)-secreting adenomas. However, the somatostatin analogue octreotide suppressed pathological ACTH release in some patients with Nelson’s syndrome and ACTH and cortisol secretion in several patients with Cushing’s syndrome caused by ectopic ACTH secretion. Somatostatin analogues are effective in the sympatomatic treatment of most (metastatic) pancreatic islet cell tumours and most (metastatic) carcinoids. In some of these patients, they also induce tumour stabilisation or reduction. In some patients with (metastatic) medullary thyroid carcinomas, continuous treatment with very high doses of octreotide can be of temporary relief. The clinical effectiveness of somatostatin analogues in patients with small cell lung cancer is currently under investigation. Long-term therapy with somatostatin analogues of catecholamine-secreting (malignant) paragangliomas and phaeochromocytomas has not shown clinical benefits.
Serum bone Gla protein and carboxyterminal cross-linked telopeptide of type I collagen in patients with Cushing’s syndrome
Authors: Sartorio A , Conti A , Ferrario S , Passini E , Re T , Ambrosi B
Published: December 2008

Serum bone Gla protein, a marker of bone formation, and carboxyterminal cross-linked telopeptide of type I collagen levels, an index of bone resorption, were evaluated in eight patients with active Cushing’s syndrome and in four with ‘preclinical’ Cushing’s syndrome, before and after surgery. In basal conditions, serum bone Gla protein levels were significantly lower (p < 0.0001) in patients with active Cushing’s syndrome (1.0 +/- 0.35 ng/ml) than in controls (5.4 +/- 0.15 ng/ml); two out of four patients with the ‘preclinical’ form had reduced bone Gla protein levels, while in the other two cases levels were in the normal range. Serum levels of carboxyterminal cross-linked telopeptide of type I collagen (3.0 +/- 0.4 ng/ml), although slightly reduced, were similar to those recorded in controls (4.1 +/- 0.3 ng ml), both in patients with active and with preclinical Cushing’s syndrome. After surgery serum levels of both marker proteins significantly increased in seven out of eight patients with active Cushing’s syndrome; in one patient, who was not cured after surgery, bone Gla proteins levels remained lower than in normals, while levels of carboxyterminal cross-linked telopeptide of type I collagen had a transient increase after six months. In the two patients with a ‘preclinical’ Cushing’s syndrome who underwent surgery, a significant rise of the levels of both marker proteins was observed, similar to that observed in patients with active Cushing’s syndrome. It was concluded that serial determinations of these new markers of bone formation and resorption may be usefully employed to follow-up the clinical course of Cushing’s syndrome and provide information on the rate of bone turnover in response to medical and/or surgical therapies. Moreover, the evaluation of these markers in preclinical states of Cushing’s syndrome might suggest the need for surgery.
ANCA-associated vasculitis: diagnosis and treatment in the elderly
Authors: Parry R , Sherwin S , Fletcher V , Medcalf P
Published: December 2008

We report the successful treatment of three patients with ANCA-associated vasculitis aged 79, 80, and 80 years. We also review other published reports of treatment in the elderly and discuss complications of treatment with emphasis on elderly patients.
Treatment of thyrotoxicosis resistant to carbimazole with corticosteroids
Authors: Jude E B , Dale J , Kumar S , Dodson P M
Published: December 2008

We report two patients whose thyrotoxicosis failed to respond to conventional treatment with carbimazole. The patients remained persistently hyperthyroid, both clinically and biochemically, despite several months of carbimazole therapy at the maximum recommended doses. Prednisolone 20 mg per day was then given in addition to the antithyroid drug and a dramatic response observed in both cases. They were then successfully treated with radioiodine. Prednisolone has not been previously used to treat patients with hyperthyroidism who have not responded to thionamide drugs. Our experience suggests that corticosteroids may be potentially useful for controlling thyrotoxicosis in combination with carbimazole before definite treatment can be instituted.
The Vogt-Koyanagi-Harada syndrome: association with autoimmune polyglandular syndrome type 1
Authors: Jovic N S , Nesovic M , Vranjesevic D N , Ciric J , Marinkovic D M , Bonaci B
Published: December 2008

We describe a young woman with primary adrenal insufficiency, hypoparathyroidism (autoimmune polyglandular syndrome type 1), Graves disease, vitiligo, and alopecia universalis. Five years after the diagnosis, she presented with recurrent ophthalmological and neurological disorders as features of Vogt-Koyanagi-Harada syndrome. A marked therapeutic response was noted on systemic high-dose corticosteroid treatment. To the best of our knowledge, such a spectre of autoimmune diseases has not been reported previously.
The advantages of problem-based curricula
Authors: Dolmans D , Schmidt H
Published: December 2008

Problem-based curricula provide a learning environment in which competence is fostered not primarily by teaching to impart knowledge, but through encouraging an inquisitive style of learning. Preliminary discussion in small groups, contextual learning, integration of knowledge and an emphasis on patient problems, have several cognitive effects on student learning. These effects are increased retention of knowledge, enhancement of integration of basic science concepts into clinical problems, the development of self-directed learning skills, and the enhancement of students’ intrinsic interest in the subject matter. In this paper a number of studies will be reviewed that provide empirical evidence for these premises.
Junior hospital doctors’ views on their training in the UK
Authors: Panayiotou B N , Fotherby M D
Published: December 2008

To ascertain the views of senior house officers and registrars on the educational and training component of their posts, a questionnaire was sent to all full-time doctors working in training posts in general and/or geriatric medicine at three district general and three teaching hospitals. Completed questionnaires were received from 64 (61%) of 105 doctors who were contacted. Most had a careers counsellor or tutor, although less than two-thirds thought they had benefited from this arrangement. The majority of doctors attended at least two medical tutorials or meetings per week; most wanted to attend more but were unable to because of other work commitments. Supervision by more senior staff on the ward was deemed by most to be satisfactory, but less so in out-patient clinics. Overall, one-third of doctors thought that training was inadequate and three-quarters wanted a greater amount of formal education. The majority of junior doctors’ time was spent on routine work and most considered :training’ constituted less than 10% of their working time. Doctors in training require more sessions designated as educational, with protected time to attend these.
The trauma team--a system of initial trauma care
Authors: Adedeji O A , Driscoll P A
Published: December 2008

Trauma remains the leading cause of death under the age of 35 years. England and Wales lost 252,000 working years from accidental deaths, including poison, in 1992. In this country, preventable deaths from trauma are inappropriately high. In many hospitals there are not enough personnel; in the majority, there are no recognisable trauma care systems, which can reduce preventable deaths to a minimum. The appropriateness of trauma centres for this country is being assessed in Stoke-on-Trent, and a report is due out later this year. Even if the recommendation is made to establish such centres, it is unlikely that many will be set up. Consequently most hospitals will have to rely on their own resources to set up and run a trauma team. This type of trauma care system is the subject of this article.
Acromegaly presenting with diabetic ketoacidosis
Authors: Katz J R , Edwards R , Khan M , Conway G S
Published: December 2008

Diabetes in acromegaly is usually non-insulin dependent and is secondary to insulin resistance caused by growth hormone excess. Diabetic ketoacidosis is a result of relative insulin deficiency and is a rare feature of acromegaly. We describe a case of acromegaly presenting with diabetic ketoacidosis. We demonstrate that growth hormone excess can cause diabetic ketoacidosis in the presence of relative, but not absolute insulin deficiency.
Stroke and transient ischaemic attacks in association with substance abuse in a young man
Authors: Lawson T M , Rees A
Published: December 2008

A 22-year-old man with a five-year history of drug and alcohol abuse presented with a left hemiparesis preceded by three transient ischaemic attacks, two of which occurred whilst smoking cannabis. Substance abuse was the only identifiable risk factor for cerebrovascular disease.
Ophthalmic complications of HIV/AIDS
Authors: Ah-Fat F G , Batterbury M
Published: December 2008

As a result of improved treatment and patient survival, ophthalmic complications are now being seen with increasing frequency in AIDS, occurring in up to 75% of patients during the course of the disease. The eye may be involved by an AIDS-related microvasculopathy, which gives rise to cotton wool spots, and by opportunistic infections caused by a wide range of organisms, including cytomegalovirus, herpes simplex virus, varicella zoster, Toxoplasma gondii, Mycobacterium avium-intracellulare, Treponema pallidum, Pneumocystis carinii and various fungal agents. Opportunistic infections may be the presenting sign of disseminated infection. The eye may also be involved by neoplasms such as Kaposi’s sarcoma and lymphoma, and by intracranial disease. Ocular involvement may lead to blindness if untreated and prompt ophthalmological referral is essential. This article reviews the range of ocular diseases seen in HIV and AIDS, current therapeutic options and outcome.
Typhoid fever with severe pancytopenia
Authors: Sood R , Roy S , Kaushik P
Published: December 2008

A patient suffering from typhoid fever with severe pancytopenia is presented. Bone marrow examination revealed extensive haemophagocytosis which possibly contributed to the pancytopenia.
Spontaneous contralateral pneumothorax following pneumonectomy
Authors: Hubbard J G H , Nkere U U , Bhatnagar N K
Published: December 2008

A case of a spontaneous pneumothorax occurring three days post-pneumonectomy is presented. Difficulties in diagnosis and management are discussed.
Endobronchial inflammatory pseudotumour exacerbating asthma
Authors: Jayne D , Bridgewater B , Lawson R A M
Published: December 2008

Primary pulmonary tumours are rare in the paediatric population. Of the benign tumours, the most common is the inflammatory pseudotumour (plasma cell granuloma). It can present as a variety of non-specific symptoms which may delay diagnosis. It usually occupies a peripheral pulmonary location and gives rise to symptoms due to its local mass effect and destructive invasion. We report the case of an endobronchial inflammatory pseudotumour presenting as an exacerbation of asthma in a 10-year-old girl. Appropriate investigation lead to pre-operative diagnosis and early complete surgical resection. A good prognosis is anticipated.
Direct injection of anti-cancer drugs into endobronchial tumours for palliation of major airway obstruction
Authors: Çelikoğlu S I , Karayel T , Demirci S , Çelikoğlu F , Çağatay T
Published: December 2008

Patients with tracheal or major airway obstruction due to inoperable carcinomas are at a high risk of developing respiratory failure or post-obstructive pneumonia, or both. This often leads to death in days or weeks. In such cases there is usually an urgent need to restore the airway. This report details the short-term results and techniques used for the treatment of airway obstruction by direct intratumoural injection of several anti-cancer drugs. A total of 93 patients with nearly complete extrinsic obstruction of at least one major airway were treated by injection of anti-cancer drugs directly into the endobronchial tumours or infiltrated bronchial mucosa through a flexible fiber-optic bronchoscope. At every session of treatment 1–3 ml each of 50 mg/ml 5-fluorouracil, 1 mg/ ml mitomycin, 5 mg/ml methotrexate, 10 mg/ml bleomycin and 2 mg/ml mitoxantrone were injected separately at different sites without pre-mixing. Local intratumoural chemotherapy relieved the obstruction in 81 of the 93 patients. Endoscopically visible tumours were reduced in size, and infiltrative changes were also improved. Obstruction was not relieved in 12 patients. The therapy was well tolerated and had no systemic side-effects, and no serious complications. Intratumoural chemotherapy can be considered a new life-saving palliative method in patients with life-threatening airway obstruction.
Advanced colonic carcinoma in children
Authors: Khan A M , Doig C M , Dickson A P
Published: December 2008

We report two cases of colorectal carcinoma in children with a delay in diagnosis due to the low index of suspicion of this pathology as the cause of presenting symptoms. We conclude that any child presenting with unexplained rectal bleeding and abdominal pain should be investigated with endoscopy and barium enema.
Prognosis and management of Crohn's disease in the over-55 age group
Authors: Walmsley R S , Gillen C D , Allan R N
Published: December 2008

The course, prognosis and management of 62 patients with Crohn's disease aged 55 years or over at diagnosis has been reviewed. The distal ileus was the commonest site of disease in the older patient, where the characteristic presentation was acute after initially mild symptoms. Early local resection was often required, particularly where there was diagnostic doubt or suspicion of caecal malignancy. Recurrence rates were much lower in the older patient than after resection in younger patients. Medical treatment played a minor role in the management of patients with distal ileal disease, in part because stricture formation was present at diagnosis and the acute nature of symptoms at presentation led to early surgical treatment. Colonic Crohn's disease was usually confined to the distal or left side of the colon and initially could be difficult to distinguish from diverticular disease. Extensive colonic Crohn's disease was rare. The apparently limited disease was not necessarily associated with a good prognosis, since disease at this site sometimes progressed rapidly, necessitating urgent surgical resection.

Medical treatment (corticosteriod therapy, with or without azathioprine) was usually effective initially for treatment of symptomatic colonic Crohn's disease, but sustained remission was rare. Those patients with persistent symptoms were restored to good health with surgical treatment but at a price, in that nearly half eventually required a permanent stoma.
Painless stress fractures in diabetic neuropathic feet
Authors: Gill G , Benbow S , Tesfaye S , Kaczmarczyk E , Kaye L
Published: December 2008

We describe two patients with diabetes mellitus and associated neuropathy, who presented with painless foot swelling and no history of trauma. X-Rays revealed recent underlying fractures-in one of a metatarsus, and the other of a proximal phalanx. These were assumed to be ‘stress’ fractures unassociated with pain because of the severe sensory neuropathy. Though spontaneous fractures in neuropathic feet have been previously described, they almost always occur in association with Charcot joints, and are usually painful. The differential diagnosis of acute swelling in the foot of a diabetic patient with sensory neuropathy should include stress fracture.
Permanent cardiac pacing in elderly patients with recurrent falls, dizziness and syncope, and a hypersensitive cardioinhibitory reflex
Authors: Crilley J G , Herd B , Khurana C S , Appleby C A , de Belder M A , Davies A , Hall J A
Published: December 2008

The study was designed to assess the outcome of treatment with permanent dual-chamber pacing of elderly patients with falls, dizziness and syncope associated with the demonstration of a hypersensitive cardioinhibitory reflex. Questionnaires were sent to patients (and their general practitioners) who had been referred to a regional pacing centre with recurrent falls, dizziness or syncope diagnosed as likely to be secondary to cardioinhibitory carotid sinus syndrome or predominantly cardioinhibitory vasovagal syndrome. After pacemaker insertion, 84% of patients had no further syncope over a mean follow-up period of 10 (range 1.5 to 30) months. Minor symptoms persisted in only 40% of all patients. Symptoms were unchanged in 22%. It was concluded that permanent dual-chamber pacing is an effective treatment for elderly patients with recurrent falls, dizziness and syncope in whom a hypersensitive cardioinhibitory reflex is found. Good results were obtained in this group with a simple diagnostic work-up.
Diagnostic difficulties in periodic Cushing's syndrome
Authors: Walker A B , Leese G P , Vora J P
Published: December 2008

A 22-year-old black woman presented with symptoms suggestive of Cushing's syndrome three years after chemotherapy for a presumed teratoma with cervical lymphadenopathy. Initially, the absence of clinical signs and the demonstration of two normal 24 h urinary free cortisols appeared to exclude the diagnosis, but an ectopic adrenocorticotropin-producing thymic carcinoid was subsequently removed surgically. Cushing's syndrome due to ectopic adrenocorticotropin production can be difficult to diagnose, particularly if there is periodic hormonogenesis.
Tumour seeding following percutaneous endoscopic gastrostomy placement in head and neck cancer
Authors: Thorburn D , Karim S N , Soutar D S , Mills P R
Published: December 2008

We report the case of a patient with advanced squamous carcinoma of the supraglottic larynx and hypopharynx who developed metastatic gastric deposits occurring at the site of a percutaneous endoscopic gastrostomy tube, inserted 10 months previously by the pull technique. We review seven previous reports of tumour deposits occurring at the site of placement of a percutaneous endoscopic gastrostomy in patients with head and neck cancer, and consider alternative methods of enteral feeding in such patients.
A double-blind, multicentre, placebo-controlled study of tiludronate in Paget's disease of bone
Authors: Fraser W D , Stamp T C , Creek R A , Sawyer J P , Picot C
Published: December 2008

A multicentre, randomised, placebo-controlled, dose-ranging study was conducted to investigate the therapeutic activity and sustained efficacy of tiludronate (200 mg, 400 mg and 600 mg once daily) taken orally for 12 weeks in patients with Paget's disease. Serum alkaline phosphatase concentrations were compared with baseline at weeks 12 and 24; treatment success was defined as a 50% reduction compared with baseline. Changes in the hydroxyproline: creatinine ratio were also measured. Pain was assessed using the Huskisson Visual Analogue Scale and by questionnaire. Patients completing at least 11 weeks of treatment were followed-up 18 months later by postal questionnaire. Significantly greater numbers of patients in the tiludronate groups successfully responded to treatment compared with the placebo group. A dose-response was observed; the percentage of patients responding to treatment being 31% (200 mg), 52% (400 mg) and 82% (600 mg) at week 12 and 45% (200 mg), 70% (400 mg) and 82% (600 mg) at week 24. Tiludronate treatment also significantly reduced hydroxyproline: creatinine ratios compared with placebo, again showing a dose response. Dose-related gastrointestinal symptoms were the commonest adverse events, occurring in 2.4%, 11.0%, 5.5% and 18.9% of patients receiving placebo and tiludronate 200, 400 and 600 mg daily, respectively. The response to oral tiludronate was sustained for more than 18 months in some patients and there was evidence of a reduction in the longer term complications of the disease. These results show that oral tiludronate is an effective, well-tolerated treatment for Paget's disease; the 400 mg once daily dose appears to offer the optimum balance of efficacy and tolerance.
Abnormal movements associated with severe hyponatraemia
Authors: Nagaratnam N , Icao E , Peric H
Published: December 2008

An elderly woman with severe hyponatraemia manifested transient choreoathetoid movements of the upper extremities and dyskinetic movements of the face and mouth. She showed more than one type of hyponatraemia and a precise diagnosis was not possible. The movements were abolished with treatment of the hyponatraemia with no recurrence or sequelae.
Quality of life as an outcome measure
Authors: Bulpitt C J
Published: December 2008

It is important to identify unknown and unquantified benefits and risks of therapeutic intervention that are reflected in the quality of life. This is especially important when the benefit: risk analysis is not clearly in favour of treatment. Quality of life is defined and target areas identified. The steps in the measurements of quality of life are discussed, including the validity, repeatability and sensitivity to change of existing methods; their acceptability, analytical problems; the presentation of the results; and the use of the results in economic evaluations. The Sickness Impact Profile, the Nottingham Health Profile and the Quality of Well-Being scale are compared for the assessment of patients with angina. The advantages and disadvantages of each is discussed together with the results from a double-blind trial of treatment in angina where the Sickness Impact Profile was employed. Generic and disease-specific instruments are compared. The advantages and disadvantages of economic evaluations employing quality-of-life outcomes are discussed. Methods should be employed that withstand rigorous scientific evaluation. Both a health profile and a summary statistic such as a Health Status Index should be measured. If different treatments are to be compared, a randomised controlled trial should be employed. If the more expensive treatment is likely to be superior then costs should be collected and a cost-utility analysis performed.
Crohn's disease presenting with acute colonic perforation
Authors: Roy M K , Delicata R J , Carey P D
Published: December 2008

Crohn's disease is well known for its multiple intestinal complications. The chronic nature and fibrous inflammation which invariably accompanies this disease explains the relative rarity of free intestinal perforation. The true incidence of free bowel perforation is difficult to assess but 1–2% is the anticipated occurrence during the course of illness. We present a case of Crohn's disease which presented for the first time with acute colonic perforation, an extremely rare entity, and review the current world literature.
Diffuse soft tissue emphysema as a complication of anorexia nervosa
Authors: Hatzitolios A I , Sion M L , Kounanis A D , Toulis E N , Dimitriadis A , Ioannidis I , Ziakas G N
Published: December 2008

We describe a case of a young woman with anorexia nervosa with a 35% weight loss, amenorrhea and behavioural disturbances complicated by spontaneous diffuse soft tissue emphysema (subcutaneous, pneumomediastinum, epidural and retroperitoneal).
Retrieval of intravascular iatrogenic foreign bodies using a nonsurgical technique
Authors: Martin Lee , Strahan Keith , Murphy Gerry
Published: December 2008

Two cases are presented in which interventional radiology was used to retrieve foreign bodies from in and around the vascular system.
Cryptosporidiosis in persons with HIV infection
Authors: Ramratnam B , Flanigan T P
Published: December 2008

Cryptosporidium parvum is an ubiquitous protozoan parasite that is a major cause of diarrhoea in individuals infected with human immunodeficiency virus. The hallmarks of infection include profuse watery diarrhoea which may become chronic in the severely immunosuppressed individual. No uniformly effective therapy exists. Current treatment relies upon a trial of anti-retroviral and specific anti-cryptosporidial medications, adequate fluid and nutritional support, and anti-motility agents.
Hypopituitarism due to lymphocytic hypophysitis in a patient with retroperitoneal fibrosis
Authors: Alvarez A , Cordido F , Sacristán F
Published: December 2008

We present a 78-year-old woman with clinical acute hypopituitarism in whom pathologic findings showed lymphocytic hypophysitis and retroperitoneal fibrosis. Lymphocytic hypophysitis should be included in the differential diagnosis of hypopituitarism at any age. The association with idiopathic retroperitoneal fibrosis suggest an autoimmune origin for this entity.
Adrenocorticotropin-secreting carcinoid tumour identified and treated 12 years after presentation with Cushing's syndrome
Authors: Vaidya B , Richardson D , Hilton C J , Kendall-Taylor P
Published: December 2008

A case of Cushing's syndrome due to an adrenocorticotropin (ACTH) secreting bronchial carcinoid tumour is described. Endocrine assessment suggested ectopic ACTH syndrome, but imaging revealed no tumour. Bilateral adrenalectomy was performed, and computed tomographic scans of chest and abdomen were performed annually. A small nodule became apparent in the right lung 12 years after the presentation, which postoperatively was confirmed as the bronchial carcinoid tumour responsible for the ectopic ACTH syndrome.
How to pass the MRCP (UK) examination—ask a successful candidate!
Authors: Salter R , Smith S
Published: December 2008

Recently successful MRCP (UK) candidates were asked to rate the value of clinical experience, reading, practice with past or simulated examination papers and commercially organised courses as preparation for parts 1 and 2 of the examination. With respect to part 1, practice with past and simulated papers was unanimously felt to be of crucial importance with examination-focused reading helpful. Clinical experience was deemed irrelevant and commercially organised courses a matter of individual choice. For part 2, clinical experience was felt to be of fundamental importance but needed to be practised in an ‘examination atmosphere’. Both general reading and practice with past and simulated papers were judged helpful and commercially organised courses were perceived to be of more value than for part 1. Trainees should be advised to seek advice on examination preparation from both ‘authoritative sources’ and their recently successful colleagues.
Complications associated with different insertion techniques for Hickman catheters
Authors: Ahmed Z , Mohyuddin Z
Published: December 2008

A dependable central venous access is an essential prerequisite for the delivery of care to the cancer patients. This has become easier since the introduction of indwelling central venous catheters. However, pancytopenia, often encountered in haematological malignancies, does influence the morbidity associated with these catheters. In this study the effects of two different placement techniques of Hickman catheters were evaluated. A total of 177 Hickman catheters were inserted in patients suffering from haematological malignancies. In 112 patients the catheters were placed percutaneously into subclavian veins without prior tunnelling; in the other 65 patients these were introduced, after having been tunnelled, into cephalic/external jugular veins by a cut-down technique. The catheters remained in use in each patient for between 18 and 253 days. Excessive bleeding and haematoma formation occurred in a significantly higher proportion of patients from the cut-down group (61% and 41%, respectively) compared to patients from the percutaneous group (8% and 0%, respectively). These in turn had a profound impact on the incidence of infective complications. Catheter exit site infection, tunnel infection and septicaemia were observed in 26%, 18%, and 41%, respectively, of the patients from the cut-down group, while in patients from the percutaneous group, skin exit site infection was noted only in 7% and septicaemia in 19% of patients. It was concluded that the placement technique of these catheters exerts a significant influence on the immediate as well as delayed complications. The results indicate that the insertion technique requiring minimal dissection is more beneficial. It is therefore recommended that percutaneous insertion without tunnelling should be the technique of choice for catheter placement.
Cell and molecular mechanisms of pathogenesis and treatment of cancer
Authors: Rew D A
Published: December 2008

Surgery remains the mainstay of treatment for most classes of human solid tumours, with the principal exception of lymphomas, but it is insufficient in many cases to guarantee cure. With few exceptions, recurrent and metastatic solid tumours continue to defy attempts to develop effective adjuvant therapies. Recent insights into tumour biology reveal an increasingly complex picture of cell and molecular processes which confer heterogeneity and resistance to treatment upon tumours. These insights may also yield new targets for more effective adjuvant therapies.
Variability in management of symptomless microhaematuria in schoolchildren
Authors: Benbassat J , Gergawi M , Offringa M , Bearman J E , Drukker A
Published: December 2008

The evaluation of incidentally detected symptomless microhaematuria in schoolchildren is controversial. Some authors advocate varying numbers of immediate tests, while others recommend investigations only in cases who develop systemic symptoms or signs, or a decline in renal function. The objective of this study was to estimate the extent to which this uncertainty affects the declared habits of practising physicians. A sample of 16 family physicians, 42 primary care paediatricians and 26 full-time hospital-based paediatric nephrologists in Israel were asked to complete a survey using a written case of a hypothetical eight-year-old boy with incidentally detected symptomless microhaematuria. Responses were received from 16 (100%), 18 (43%) and 18 (69%), respectively. The mean number of requested tests, other than follow-up examination of the urine, were 1.5 (range 0–5) for family physicians, 2.5 (1–5) for primary care paediatricians and 5.3 (2–12) for paediatric nephrologists, at an average cost of NIS 408 (US$ 136), NIS 454 (US$ 151) and NIS 860 (US$ 286), respectively. There was also a marked variability within subspecialty groups, so that some family physicians recommended more tests at a higher cost than some of the paediatric nephrologists. There was a marked and unexplained variability within and among the three groups of respondents regarding the extent of the evaluation. The main reason for this variability is probably the uncertainty about the scientifically appropriate way to approach this condition in a symptomless child.