bluuebunny/crossref_metadata_2025 huggingface dataset:
Multiple lymphomatous polyposis and the role of fine needle aspiration cytology
Authors: Carder P J , Gouldesbrough D R
Published: December 2008

Multiple lymphomatous polyposis is an uncommon but distinctive form of gastrointestinal lymphoma. Clinical symptoms may closely resemble those of colorectal carcinoma and diagnostic confusion may result. The condition has a characteristic pathological appearance and immunophenotype which is important in allowing distinction from other less aggressive forms of gastrointestinal lymphoma. We report a case of this unusual condition in which the diagnosis was aided by fine needle aspiration cytology.
Microvascular investigations in diabetes mellitus
Authors: Chittenden Sandra J , Shami Shukri K
Published: December 2008

This paper reviews the current literature concerning the different investigative modalities available to assess the microcirculation in diabetic microangiopathy. The advantages and disadvantages of the different invasive and noninvasive methods available are presented objectively. We have concentrated on the tests that provide a quantitative assessment of the microcirculation, including laser Doppler fluxmetry, capillary microscopy, plethysmography, transcutaneous oximetry and radioactive isotope clearance. Some of the invasive methods described are now being replaced by noninvasive equivalents, providing similar information with less discomfort and risk to the patient.
Shigella bacteraemia in adults
Authors: Trevett A J , Ogunbanjo B O , Naraqi S , Igo J D
Published: December 2008

Shigella infections are usually restricted to the intestine. There are few reports of Shigella isolated from the blood and most of these are from children, usually in neonates and the malnourished. In the small number of adult cases of Shigella bacteraemia which have been reported, there appears to be an association with underlying disease and immunosuppression including acquired immunodeficiency syndrome.

We report three adult cases in which Shigella were isolated from blood. Two of these patients made an uneventful recovery whilst the third died. An underlying cause of immunosuppression was suspected in this patient but unproven.
The age of onset and sex distribution of insulin-dependent diabetes mellitus in Africans in South Africa
Authors: Kalk W J , Huddle K R L , Raal F J
Published: December 2008

Type I (insulin-dependent) diabetes mellitus (IDDM) appears to be rare in indigenous African populations, but little detailed information has been published. We have therefore analysed the age of onset of diabetes in 176 African patients with IDDM (age of onset < 35 years), and in 149 consecutive white patients of European extraction for comparison. In the Africans the peak age of onset occurred at 22-23 years (median 22 years) with an earlier peak from 14 to 17 years. In the Whites, the peak was found at 12-13 years (median 12 years). In only 7% of Africans did diabetes start under the age of 12 years. There was a slight female preponderance in the Africans, especially at the ages of greatest incident (20-25 years)-F:M 1.55:1. When patients with duration of diabetes less than 5 years only were analysed (the period during which early mortality among African patients was greatly reduced) the patterns of age distribution were similar to the total respective groups. A peak incidence in the winter months was noted.
The prevalence of macrovascular disease and lipid abnormalities amongst diabetic patients in Sri Lanka
Authors: Fernando Devaka J S , Siribaddana Sisira , Perera Nilukshi , Perera Shironi , de Silva Deepthika
Published: December 2008

The prevalence of macrovascular disease and hyperlipidaemia was examined in 500 patients with non-insulin-dependent diabetes mellitus attending a diabetic clinic in a Sri Lankan teaching hospital and 250 controls matched for age and gender. Macrovascular disease was assessed using a modified World Health Organisation questionnaire and modified Minnesota coding of electrocardiogram recordings.

Twenty-one per cent of diabetic patients and 14.3% of controls had hypercholesterolaemia (P < 0.05). Macrovascular disease was present in 13.4% of diabetic patients and 8.2% of controls. Significant differences were seen in the prevalence of hypertension (15.6% vs 4.8%, P < 0.05), obesity (16.2% vs 9.7%, P < 0.05), peripheral vascular disease (5.6% vs 2%, P < 0.05) and electrocardiographic abnormalities (12% vs 6%, P < 0.05) in diabetic patients when compared to controls.

Hyperlipidaemia and macrovascular disease is common in non-insulin-dependent diabetic patients in Sri Lanka and accounts for significant morbidity.
The management of male breast cancer in Nigerians
Authors: Ihekwaba F N
Published: December 2008

The outcome in 57 male patients with breast cancer has been analysed. Four patients with early disease had simple mastectomy (one case) and radical mastectomy (three cases). All four completed a 12-cycle cyclophosphamide/methotrexate/5-fluorouracil (CMF) course of chemotherapy. Two required orchiectomy after 23 and 38 months, respectively. Two patients were alive at 79 and 63 months. Fifty-three others with advanced disease had simple mastectomy (10 cases), radical mastectomy (38 cases) and no surgery (five cases), but only 33 completed chemotherapy and 11 were submitted to orchiectomy for recurrence after a mean interval of 19 months. Two patients were alive at 63 and 69 months, respectively. The overall survival rate was 7%. It is considered that in addition to late presentation (mean (SEM): 16.4 (2.1)) months and advanced disease (93%), ineffectiveness of the CMF regimen in male patients may have contributed to the poor survival rate in these Nigerian patients.
Notes: a suitable case for audit
Authors: Twigg Jeremy , Briggs Timothy , Parker Christopher , Miller Ronald
Published: December 2008

The increasing emphasis on management responsibilities and audit led us to investigate the state of surgical notes in our hospital. Twelve criteria were evaluated regarding information that should be contained in the notes and the absence of this important information was documented. Deficiencies were revealed in all criteria selected. Until hospital patients files are well kept and maintained, retrospective audit whether financial or medical will not be valid. A significant injection of resources is required to redress the situation. Hospitals which have not carried out detailed studies into the contents of their notes need to do so as a matter of urgency.
Pseudotumour cerebri associated with arteriovenous malformations
Authors: Cockerell O C , Lai H M , Ross-Russell R W
Published: December 2008

The association of intracranial hypertension and arteriovenous malformations is described in two patients. Both patients had the typical clinical features of pseudotumour cerebri and were found to have intracranial arteriovenous malformations on arteriography. The mechanism of raised intracranial pressure in patients with arteriovenous malformations is discussed.
Malignant change in dermatitis artefacta
Authors: Alcolado J C , Ray K , Baxter M , Edwards C W , Dodson P M
Published: December 2008

Dermatitis artefacta is a chronic skin lesion produced by self-trauma. Avoidance of further trauma, topical steroids and psychological therapy all play a part in the treatment of such lesions. Unresolved lesions may become large and disfiguring and subject to infection. We report a case of one such lesion in an elderly woman who persistently excoriated a cholecystectomy scar over 40 years. Malignant transformation occurred in a manner analogous to the neoplastic change observed in other types of chronic ulcer (Marjolin's ulcer). The squamous cell carcinoma presented with widespread metastases from which the patient eventually died. Recent literature concerning Marjolin's ulcers is reviewed and it is noted that this is the first reported case of death caused by malignant change in dermatitis artefacta.
Haemolytic-uraemic syndrome with thrombotic microangiopathy of the retina following cytomegalovirus infection: postmortem findings
Authors: Catón Blanca , Díaz de Otazu Ramón , Aldamiz-Echebarria Mikel , Viguri Amparo
Published: December 2008

Haemolytic-uraemic syndrome is characterized by thrombotic microangiopathy of the glomeruli and smaller arterial vessels of the kidney. Extrarenal thrombotic microangiopathy occurs, but ocular involvement is rarely demonstrated microscopically. We describe a 33 year old woman with a 3 week febrile episode and seropositivity for cytomegalovirus infection who developed acute renal failure, blindness and severe encephalopathy which was the cause of death. Thrombotic microangiopathy of retinal vessels may be more common than is expected from the literature. The exclusion of ocular structures in postmortem examinations explains the lack of anatomoclinical correlation.
Sclerosing cholangitis associated with Crohn's disease and autoimmune haemolytic anaemia
Authors: Eilam Oron , Goldin Eran , Shouval Daniel , Gimon Tzvi , Brautbar Chaim
Published: December 2008

A middle-aged man was found to have autoimmune haemolytic anaemia. Seven years after the first manifestations of the anaemia, he developed jaundice without haemolysis and a diagnosis of primary sclerosing cholangitis was made by endoscopic retrograde cholangiography. Crohn's colitis was later confirmed by X-rays and colonoscopy. This association is unique to the best of our knowledge and suggests that genetic and immunological mechanisms may be involved in the pathogenesis of these diseases.
Gram-negative meningitis and chronic constipation: an unusual presentation of caudal regression syndrome
Authors: Benson S , King M , Coulter C , Boyle R S
Published: December 2008

Congenital malformations may present as meningitis caused by enteric organisms, but this is extremely rare and occurs almost exclusively in the paediatric population. We report an unusual case of a young man with chronic constipation presenting with spontaneous Gram-negative meningitis due to an underlying congenital spinal malformation known as the caudal regression syndrome.
Is clubbing a feature of the anti-phospholipid antibody syndrome?
Authors: Harris A W , Harding T A C , Gaitonde M D , Maxwell J D
Published: December 2008

A patient with the anti-phospholipid antibody syndrome and digital clubbing is described. No recognized cause for the clubbing was found. It is suggested that platelet aggregation and microthrombi formation as a result of anti-phospholipid antibody may be involved in the pathogenesis of the digital clubbing. This may be a new feature of the anti-phospholipid antibody.
Uterocutaneous fistula
Authors: Gupta S K , Shukla V K , Varma D N , Roy S K
Published: December 2008

Fistulous communications of the uterus are relatively unknown. We report in this paper the first case to our knowledge of uterocutaneous fistula which developed following a septic abortion induced by introduction of Laminaria tent into the uterus.
Abdominal wall abscess--an unusual primary presentation of a transverse colonic carcinoma
Authors: Andaz S , Heald R J
Published: December 2008

Carcinoma of the transverse colon presenting as an abscess of the anterior abdominal wall is a rare occurrence. Such a case is presented, where all investigations failed to show the nature of the lesion. The literature has been reviewed and the pathology that characterizes such lesions, and their management in the light of their favourable prognosis, is discussed. Occult colonic carcinoma should be considered in the differential diagnosis of such abscesses.
A case of Churg-Strauss vasculitis complicated by small bowel necrosis
Authors: Schoretsanitis G N , Wakely D M , Maddox T , Wastell C
Published: December 2008

A case of Churg-Strauss syndrome causing mesenteric intestinal ischaemia and small bowel necrosis is described in a 29-year-old man. Despite conservative management, the patient's condition deteriorated and he underwent five laparotomies. Small and medium-sized arteries within the mesentery and lymph nodes showed necrotizing vasculitis. Currently he is doing well on oral nutrition and medical management.
Is the hot appendix really hot?
Authors: Davies M S , Cunningham Sally , Cooke D A P , Donaldson D R , Thomas M H
Published: December 2008

The skin temperature in the right and left iliac fossae was recorded in 100 patients who were referred with a provisional diagnosis of acute appendicitis. This was not found to be a reliable aid in diagnosis of acute appendicitis nor an indicator to the need for surgery in patients with right iliac fossa pain.
Bilateral anterior tibial compartment syndrome in association with hypothyroidism
Authors: Thacker A K , Agrawal Dilip , Sarkari N B S
Published: December 2008

Local vascular and traumatic involvement are well-recognized causes of anterior tibial compartment syndrome (ATCS) terminating as myoneural ischaemia. However, in a large number of patients the cause of ATCS remains unidentified. We document the occurrence of bilateral ATCS in a patient of hypothyroidism, to our knowledge a previously unrecorded association.
Haemoglobin-H disease presenting with microcytic hypochromic anaemia in an 81 year old woman
Authors: Jolobe O M P
Published: December 2008

Over an 11 year period, the diagnosis of haemoglobin-H (Hb-H) disease was missed in a Caucasian woman of British stock who first presented with microcytic hypochromic anaemia at the age of 81. The diagnosis was confirmed at the age of 92, when the typical inclusions of Hb-H disease were demonstrated in erythrocytes stained with brilliant cresyl blue, and the presence of Hb-H was documented by haemoglobin electrophoresis. She subsequently developed biliary obstruction due either to an inflammatory polyp associated with choledocholithiasis or ampullary carcinoma.
Cerebral infarction due to moyamoya disease in an 18 year old female
Authors: Houlston R S , Saadeh I K , Barker S , Hughes P J , Lawton N F
Published: December 2008

Moyamoya disease was diagnosed as the cause of cerebral infarction in an 18 year old white female. The clinical features, pathology and treatment of this occlusive cerebrovascular disorder are discussed.
Chronic hypothermia and water intoxication associated with a neurodegenerative disease
Authors: Corbett E L , Sisodiya S , Sarkar D
Published: December 2008

We describe a 71 year old man with a neurodegenerative condition who developed chronic inappropriate antidiuretic hormone secretion and hypothermia resulting in recurrent episodes of impaired consciousness. This combination of abnormalities is attributable to hypothalamic disease and has not to our knowledge been previously reported with clearly documented antidiuretic hormone excess.
Multilobated B-cell lymphoma of the spleen
Authors: Farrell D J , Bloxham C A , Lucraft H H
Published: December 2008

We report a case of multilobated B-cell lymphoma presenting with primary splenic involvement. This is a very unusual tumour occurring in an uncommon site.
Bilateral parotid enlargement as a presenting feature of bulimia nervosa in a post-adolescent male
Authors: Buchanan J A G , Fortune F
Published: December 2008

An unusual case of bulimia nervosa in a post-adolescent male is reported. The clinical presentation was one of painless parotid swelling of 3 years duration with marked weight loss and underlying metabolic alkalosis. The diagnostic significance of parotid salivary gland swellings is discussed.
Benign intracranial hypertension after pituitary surgery for Cushing's disease
Authors: Parfitt V J , Dearlove J C , Savage D , Griffith H B , Hartog M
Published: December 2008

An 11 year old girl underwent successful transsphenoidal pituitary adenomectomy for pituitary-dependent Cushing's syndrome. Three months after operation, just after stopping glucocorticoid replacement therapy, she developed benign intracranial hypertension. This resolved when exogenous glucocorticoids were restarted but occurred again when they were later stopped. On restarting glucocorticoids again, this second episode of intracranial hypertension resolved. This complication may have been due to the large fall in endogenous cortisol production after removal of her adenoma and subsequent persistent mild endogenous hypocortisolism.
Do acute diseases transiently impair anterior pituitary function in patients over the age of 75? A longitudinal study of the TRH test and basal gonadotrophin levels
Authors: Impallomeni M , Kaufman B M , Palmer A J
Published: December 2008

Several studies have shown that anterior pituitary function is affected by the ageing process. Little is known, however, about the effect acute diseases have on the anterior pituitary. Should they be associated with a disturbance of anterior pituitary hormone production, they might make anterior pituitary function tests difficult to interpret when they are most needed.

To test this hypothesis, we studied the thyrotrophin (TSH) releasing hormone (TRH) test and basal plasma gonadotrophins, taken as indicators of anterior pituitary function and reserve, in 74 consecutive patients (49 women) mean age 82 +/- 5.1 suffering from acute diseases soon after admission to hospital. A total of 44 (30 women) were followed up and retested after 3 disease-free months following recovery and discharge home. Seventy-one age- and sex-matched healthy controls (47 women), mean age 82 +/- 5.0 living in the community were also studied.

The mean peak TSH increment after TRH (mean delta max TSH) increased from 5.7 soon after admission, to 7.7 U/l at follow-up (P = 0.01). The mean plasma LH increased from 25 to 35 U/l in women (P = 0.0004) and from 9.7 to 14 U/l in men (P = 0.03). The mean plasma FSH increased from 21 to 25 U/l in women (P = 0.04) and from 7.5 to 9.4 U/l in men (P = 0.01). Controls had greater TSH responses to TRH and higher plasma gonadotrophins levels when compared with acute patients (LH women P = 0.17, for all other tests P < 0.05).

We conclude that a transient reduction of anterior pituitary function is a common occurrence in patients over the age of 75 suffering from acute diseases. This has diagnostic relevance and therapeutic implications.
Comparison of asthmatic patients admitted to hospital from health districts experiencing high and low asthma mortality rates
Authors: Littlejohns P , Hollowell J , Hayward P , Prance S
Published: December 2008

Geographical variation in asthma mortality rates within the United Kingdom could be a reflection of variability in effectiveness of medical care services, or epidemiological variation. In order to ascertain whether differing hospital admission processes could contribute to this variation, asthmatic patients admitted from two districts, experiencing above and below average mortality rates were compared. The present study was part of a cohort study of 1,200 consecutive acute adult admissions in 1987/88. In the main study, social data and information on referral were collected by interview for all patients. The admitting doctors' perception of the patient's severity was assessed on the basis of the severity of symptoms, and likelihood of morbidity or mortality if the patient was not admitted. Further information on asthmatic patients (treatment and physiological measurements) was retrieved from the notes.

Sixty-six asthmatic patients resident in Wandsworth (a district with high asthma mortality rates) were admitted to St George's Hospital or St James' Hospital (WW) and 31 patients resident in East Surrey (ES) (a district with low asthma mortality rates) were admitted to the East Surrey Hospital (ESH). Notes were obtained on 55 (83%) and 27 (87%) of patients in the two districts, respectively. WW received significantly more patients by self-referral: 68% of patients called an ambulance or came directly to casualty compared with 30% in ES (chi-squared = 13.7, d.f. = 2, P = < 0.001). There was a tendency for more admissions to ESH to be taking oral steroids (chi-squared = 3.2, d.f. = 1, P = 0.07). Patients admitted in WW tended to have more severe disease: 39 (85%) of patients admitted to WW had peak expiratory flow less than 200 1/minute on admission compared to 14 (58%) in ES (chi-squared = 6, d.f. = 1, P = 0.01). In WW the mean first recorded peak expiratory flow on admission was 154 1/minute compared to 172 1/minute in ES; their mean peak flow on discharge was 318 1/minute compared with 377 1/minute in ES. Twenty-one (38%) of admissions in WW were considered to be very urgent by the admitting hospital doctor compared to four (15%) in ESH (chi-squared = 4.67, d.f. = 1, P = 0.03).

This opportunistic study found that, in an area experiencing high mortality rates, more patients with severe disease were admitted to hospital compared to a low mortality area. This does not appear to be due to differing hospital practices but rather to increased levels of morbidity in the community. As patients with more severe asthma are at a greater risk of dying, these finding reinforce the need to standardize asthma treatment in the community.
The educational component of senior house officer posts: differences in the perceptions of consultants and junior doctors
Authors: Baker M , Sprackling P D
Published: December 2008

The aims of this study were to elicit general practitioner (GP) trainee's perceptions of the educational structure of their hospital posts, to compare them with those of consultants who had GP trainees as senior house officers (SHOs) in their departments and to examine the use of educational objectives in the hospital component of vocational training for general practice. A confidential postal questionnaire was sent to all the GP trainees (165 doctors) in the hospital component of their vocational training schemes (VTS) for general practice in Trent Region and all the consultants (161 doctors) in Trent who had GP trainees in their SHO posts on that date.

Responses were received from 136 trainees (82%) and 134 consultants (83%). Educational objectives were stated as existing in the SHO post by 31 trainees (23%) and by 62 consultants (46%). Of those doctors who said that objectives existed, 19 of the trainees (61%) and 40 of the consultants (65%) said that the objectives were useful. Only nine (29%) of the trainees who stated that educational objectives existed felt that they were being put into practice by senior staff, compared with 41 (66%) of consultants who had made that statement. Of all respondents, 113 trainees (87%) and 100 consultants (77%) agreed or strongly agreed that the use of educational objectives would be beneficial to the trainees.

Only 10 (7%) of trainees said that they received no teaching in their current posts. Forty trainees (32%) and 88 consultants (67%) said that teaching took place in protected time. Both groups cited consultants as the member of staff giving the most teaching. Ninety-six consultants (73%) replied that it was possible for GP trainees to obtain study leave, but 102 trainees (75%) either had experienced difficulties in obtaining study leave or had not attempted to obtain study leave. Trainees and consultants differed appreciably in their perceptions of the amount of assessment and feedback which was provided for GP trainees.

The use of educational objectives in the hospital component of vocational training was felt to be beneficial by both consultants and GP trainees. Consultants were more likely than trainees to report the use of educational objectives, protected teaching time, GP-orientated teaching, ability of trainees to attend VTS half-day release and the provision of assessment and feedback to trainees.
Progressive encephalopathy in a Crohn's disease patient on long-term total parenteral nutrition: possible relationship to selenium deficiency
Authors: Kawakubo Keishi , Iida Mitsuo , Matsumoto Takayuki , Mochizuki Yuichi , Doi Kosei , Aoyagi Kunihiko , Fujishima Masatoshi
Published: December 2008

The case of a patient with Crohn's disease complicated by progressive and irreversible encephalopathy, who had been on long-term total parenteral nutrition due to short bowel syndrome, is described. He initially experienced a disturbance of his vision, which was followed by various neurological symptoms during the next 3 years. These symptoms rapidly progressed until he finally developed consciousness disturbance. He also manifested erythrocytic macrocytosis, a low serum level of tri-iodothyronine and a high level of thyroxine. His blood levels of various trace minerals and vitamins were normal, except for selenium, which showed extremely low values. In addition, impaired plasma glutathione peroxidase activity was confirmed. After intravenous supplementation of selenium, macrocytosis, tri-iodothyronine and thyroxine values, and glutathione peroxidase activity all became normalized, yet he improved little neurologically.

Our case suggests that long-term selenium deficiency may cause progressive and irreversible encephalopathy, and that careful monitoring of this mineral is necessary when an excessive period of total parenteral nutrition is being considered in the clinical setting.
Lymphocytic hypophysitis causing hypopituitarism and diabetes insipidus, and associated with autoimmune thyroiditis, in a non-pregnant woman
Authors: Paja M , Estrada J , Ojeda A , Ramón y Cajal S , García-Uría J , Lucas T
Published: December 2008

A 25 year old non-pregnant woman presented with a one-year history of amenorrhoea and polyuria. Three months before her admission, she had suffered lymphocytic meningitis. Hormonal studies revealed hypopituitarism and central diabetes insipidus, with associated primary autoimmune hypothyroidism. Computed tomographic scan and magnetic resonance imaging showed a pituitary mass with suprasellar extension and thickened stalk. Transsphenoidal surgery was performed and the histological study revealed fibrosis and diffuse lymphocytic infiltration with predominance of CD4 lymphocytes. This further case of lymphocytic hypophysitis was not related to pregnancy and produced diabetes insipidus, two uncommon associations. We discuss the features that can lead to a preoperative suspicion of this rare disorder.
Selenium deficiency, reversible cardiomyopathy and short-term intravenous feeding
Authors: Levy J B , Jones H W , Gordon A C
Published: December 2008

We report the case of a patient with Crohn's disease receiving short-term postoperative parenteral nutrition supplemented with trace elements who nevertheless became selenium deficient with evidence of a cardiomyopathy. This was fully reversible with oral selenium supplementation. Current parenteral feeding regimes may not contain enough selenium for malnourished patients.
Unified European higher medical degrees
Authors: Breimer Lars H , Mikhailidis Dimitri P
Published: December 2008

Unequal access to higher medical degrees, which are important for career advancement, is a problem that is likely to plague UK medicine as integration within Europe proceeds. This paper analyses the characteristics of M.D.s at the Royal Free Hospital School of Medicine and proposes a solution of creating a common European doctorate.
Graves' disease mimicking beta-thalassemia trait
Authors: Akasheh M S
Published: December 2008

A case of Graves' disease associated with splenomegaly, lymphadenopathy, microcytic hypochromic anaemia, and a raised haemoglobin A2 is presented. The haematological indices returned to normal after conventional treatment with anti-thyroid medication.
Splenic epidermoid cysts presenting as an acute abdomen
Authors: Thomas Mark , Taiwo Bola
Published: December 2008

Two patients with splenic epidermoid cysts who presented as acute abdominal emergencies are reported.
Do carotid bruits predict disease of the internal carotid arteries?
Authors: Davies Keren N , Humphrey Peter R D
Published: December 2008

A carotid bruit is often thought of as a reliable sign of extracranial carotid artery disease. In addition finding a bruit may precipitate a referral to hospital. Carotid endarterectomy has now been shown to be beneficial in patients with symptomatic carotid territory ischaemia and 70-99% stenosis of the relevant carotid artery, therefore it is important that such patients are detected and referred.

In this study of 331 consecutive patients referred to a specialist cerebrovascular clinic we examined the practical value of a carotid bruit mentioned by the referring practitioner. All patients underwent clinical assessment, evaluation of risk factors and Doppler duplex scanning of the carotid arteries. A bruit was stated in the referral letter of 110 (33%) patients. Moderate (30-69%) or severe (70-99%) stenosis was present in 37% of patients with, and 17% of those without a carotid bruit (P < 0.001). We found a carotid bruit was a poor predictor of such disease (positive predictive value, 37%). The false negative rate for severe disease was 43%. Normal carotid arteries were found in 32% of patients with a bruit. We therefore suggest that all patients with suspected carotid territory ischaemia should be referred for assessment whether there is a bruit present or not.
Aneurysm of the inferior thyroid artery
Authors: Seenu V , Baliga S , Misra M C
Published: December 2008

A case of aneurysm of the inferior thyroid artery is presented. It is usually not possible to diagnose the exact site of origin clinically. Digital subtraction angiography can determine the precise site and type of aneurysm. In view of the high incidence of complications, early surgical treatment is recommended.
Spontaneous splenic rupture in typhoid fever
Authors: Ali Gazanfar , Kamili M A , Rashid Samia , Mansoor Aijaz , Lone Bashir A , Allaqaband G Q
Published: December 2008

Three cases of multidrug-resistant Salmonella typhi infection presenting as spontaneous splenic rupture are presented. One patient died and two recovered completely. This is a previously unreported presentation of typhoid fever.
Phytosterolaemia in three unrelated South African families
Authors: Berger G M B , Deppe W M , Marais A D , Biggs M
Published: December 2008

Phytosterolaemia (beta-sitosterolaemia), a rare, autosomal recessive disorder, has not hitherto been reported in Southern Africa. We report four new homozygous patients, from three unrelated families with significant beta-sitosterolaemia (6.6-11.3%), campesterolaemia (2.2-4.6%) and clearly detectable, though unquantified, levels of cholestanol. Three of the four patients had characteristic cutaneous and tendinous xanthomas within the first decade of life. The fourth patient, a 5 year old, was free of xanthomas despite persistently elevated concentrations of plant sterols in her plasma. All our patients were female bringing the male:female ratio in reported cases to 8:23. All were at or below the 50th percentile for height and weight, and presented at some stage with borderline, hypochromic anaemia associated with red cell abnormalities and thrombocytopaenia. The oldest patient showed suggestive clinical evidence of atherosclerosis affecting her aorta, ileofemoral bifurcation and possibly coronary arteries. All homozygotes responded to a diet restricted in phytosterols and the administration of cholestyramine with falls in plasma sterols of up to 68%.

The recent discovery of a possible inherited defect in the synthesis of HMG CoA reductase in patients with phytosterolaemia makes this disorder a model system for studying the biological role of this enzyme in regulating the absorption and clearance of sterols other than cholesterol, and the factors governing the sterol composition of cell membranes.
An unusual cause of dysphagia: a vascular ring
Authors: Hall R J , Treasure Tom
Published: December 2008

A 40 year old woman presented with dysphagia which was due to one of the forms of vascular ring. Her symptoms were relieved by relatively conservative surgery. The means of diagnosis and the surgical approach are discussed.
Unstable angina and exposure to carbon monoxide
Authors: Balzan M V , Cacciottolo J M , Mifsud S
Published: December 2008

Inhalation of small amounts of carbon monoxide diminishes the pain threshold in patients with stable angina pectoris. The aim of this study was to identify and describe patients who had been exposed unknowingly to toxic inhalations of this gas and subsequently presented to hospital with a clinical picture of unstable angina. Blood carboxyhaemoglobin levels of 104 patients referred with unstable angina to a coronary care unit were determined on admission. The likely source of carbon monoxide was identified in all patients. Three patients had definite carbon monoxide intoxication. Another five patients had evidence of minor exposure. When the three cases with carbon monoxide poisoning were excluded, the mean carboxyhaemoglobin level was 2.5% (+/- 1.3) for smokers (n = 30) and 0.6% (+/- 0.5) for non-smokers (n = 71). Use of fossil fuel combustion in an enclosed environment was responsible for the three most serious intoxications and one of the minor cases. We suggest that a number of patients admitted for coronary care with unstable angina may have significant carbon monoxide poisoning. This intoxication is often overlooked by attending physicians with the result that high concentration oxygen therapy is not administered, when it is in fact a necessary part of treatment.
Cardiac tamponade as the initial presentation of malignancy: is it as rare as previously supposed?
Authors: Muir K W , Rodger J C
Published: December 2008

Advanced malignant disease frequently involves the heart and pericardium, and pericardial effusion is a common postmortem finding in such patients. Identification of pericardial effusions in life is uncommon, however, even when symptomatic. Cardiac tamponade occurring as the first presentation of malignancy appears to be uncommon.

We present five cases of cardiac tamponade due to undiagnosed malignancy which presented to a general medical unit over 18 months. The availability of echocardiography was an important factor in correct diagnosis, since clinical features were non-specific. Bronchial adenocarcinoma was the cause in three of the five cases.

Review of the literature confirms adenocarcinomas of the bronchus as the most common cause of this complication. The majority of cases have presented with large volume, haemorrhagic effusions, and cytology (with or without carcinoembryonic antigen measurement) was diagnostic in most patients. Immediate treatment with subxiphoid pericardiotomy is recommended; the role of balloon catheter pericardiotomy remains to be established. Combined chemotherapy and radiotherapy appears to extend survival, which in some cases may be prolonged.

We recommend that early echocardiography should be obtained in all patients presenting with apparent cardiac failure, since early treatment of malignant effusions provides symptomatic relief.
A comparative study of postgraduate medical education in North East Thames Region
Authors: Barker A , Scotland A D , Challah S , Gainey B , Bayley I
Published: December 2008

As a prelude to more detailed formal contracting, North East Thames Region undertook a review to examine whether the content of postgraduate medical education (PGME) varies according to the type of hospital in which junior doctors are trained. The study covered a sample of 83 trainees at different grades in four types of hospital (postgraduate, university, district general hospital involved in off-site undergraduate medical education, and district general hospital with no formal involvement in undergraduate medical education) and was designed as a qualitative comparative study. The results of the study point to a perceived lack of structure in PGME and indicate that hospital type alone does not determine a trainees' PGME experience. Moreover, different training grades have different educational needs, which will need to be addressed under more formal contracting arrangements. The Region plans to take this work forward by convening one or more consensus conferences to examine how a more structured approach to PGME could be implemented.
Endocrine assessment of impotence—pitfalls of measuring serum testosterone without sex-hormone-binding globulin
Authors: Hardy K J , Seckl J R
Published: December 2008

The pitfalls of measuring only total serum testosterone are illustrated by a 52 year old man whose hyperprolactinaemia was associated with normal total serum testosterone but a raised sex-hormone-binding globulin, giving a low free testosterone. Prolactin suppression with bromocriptine normalized sex-hormone-binding globulin and free testosterone, and restored potency and energy after 30 years of impotence and tiredness.
Post lumbar puncture discitis and vertebral collapse
Authors: Bhatoe H S , Gill H S , Kumar N , Biswas S
Published: December 2008

Discitis and vertebral collapse are rare but serious complications of lumbar puncture. Clinical profile, management and course of post lumbar puncture discitis in five patients is presented. Such a complication should be kept in mind whenever any invasive procedure is carried out on the spine.
Cyclosporin A in refractory idiopathic nephrotic syndrome: 5 years clinical experience
Authors: Delaney M P , Dukes D C , Edmunds M E
Published: December 2008

The use of cyclosporin A (Cy A) in idiopathic nephrotic syndrome, particularly lesions of focal segmental glomerular sclerosis, is controversial. A retrospective study of 10 adult patients with nephrotic syndrome treated with Cy A was performed. Histological diagnosis was established in all patients: focal segmental glomerular sclerosis (n = 6), focal global sclerosis (n = 1), mesangial proliferative glomerulonephritis (n = 1), focal proliferative glomerulonephritis (n = 1) and minimal change disease (n = 1).

All patients had previously received immunosuppressive therapy (duration of steroids 1-76 months; 35.0 +/- 12.1, mean +/- SEM). Cy A in a dose of 3-5 mg/kg/day, reduced proteinuria from 16.85 +/- 6.67 to 3.37 +/- 1.48 g/24 hours (P = 0.008), with an associated increase in serum albumin from 15.2 +/- 2.6 to 34.3 +/- 2.5 g/l (P < 0.001).

In six patients steroid therapy was discontinued. Cy A was well tolerated for up to 5 years. There was no significant nephrotoxicity.

In conclusion, Cy A was effective treatment of refractory idiopathic nephrotic syndrome, including those cases with focal segmental glomerular sclerosis.
Acute renal failure with ACE inhibition in aortic coarctation
Authors: Woodmansey P A , Yeo W W , Jackson P R , Ramsay L E
Published: December 2008

A 43 year old man with inoperable aortic coarctation and severe hypertension requiring near maximal anti-hypertensive treatment was admitted in severe heart failure. After 2 weeks of treatment the heart failure and blood pressure were incompletely controlled and angiotensin converting enzyme (ACE) inhibitor was started. Serum creatinine was normal before starting the ACE inhibitor and on discharge from hospital. The patient was re-admitted a week later with gross fluid retention and in renal failure. In the absence of alternative causes, a diagnosis of ACE inhibitor-induced renal failure was made and treatment was stopped. The patient required haemodialysis for 2 days and within 1 week the renal function had reverted to normal and has remained so for 1 year. We propose that the renal haemodynamics in severe aortic coarctation are similar to those in bilateral severe renal artery stenosis and advise caution in the use of ACE inhibitors for adults with aortic coarctation.
Adenocarcinoma of the duodenum with a duodeno-colic fistula occurring after childhood Wilms' cancer
Authors: Beales Ian L P , Scott Humphrey J
Published: December 2008

A case of a 44 year old man with a duodeno-colic fistula secondary to an adenocarcinoma of the second part of the duodenum is described. An asymptomatic leiomyoma of the second part of the duodenum was also present. The patient had been treated successfully for a right Wilms' cancer in childhood with surgery and radiotherapy. There are no previous reports of a duodenal carcinoma arising following a Wilms' tumour and cases of gastrointestinal adenocarcinoma arising as second malignancies following Wilms' tumours are reviewed. The aetiology of duodeno-colic fistulas is reviewed. Duodenal carcinoma is a unusual cause of duodeno-colic fistulas and this case may be unique in that respect.
Chronic suppurative lung disease with associated vasculitis
Authors: Bruce I N , McAteer J A , Gardiner P V , McFarland R J , Sloan J M , Bell A L
Published: December 2008

We report a patient with chronic bronchiectasis who developed systemic vasculitis. The patient was initially treated with immunosuppression; however, the addition of antibiotic therapy improved control of her vasculitis and the need for immunosuppression was reduced. Chronic bronchial suppuration may have an aetiological role in the pathogenesis of this condition.
Acute respiratory distress secondary to Morgagni diaphragmatic herniation in an adult
Authors: Wong N A C S , Dayan C M , Virjee J , Heaton K W
Published: December 2008

Diaphragmatic hernias of the Morgagni type are generally thought to be asymptomatic in adults. This traditional assumption led to a delay in diagnosing a Morgagni hernia as the cause of acute respiratory distress in a chronic schizophrenic man. While Morgagni hernias are usually considered to be long-standing, we present radiological evidence of an acutely expanding hernia. The patient’s symptoms were relieved by surgical repair of the hernia. We advise caution before dismissing Morgagni hernias in adults as being long-standing and clinically insignificant.
Intra-arterial administration of adriamycin-loaded albumin microspheres for locally advanced breast cancer
Authors: Doughty J C , Anderson J H , Willmott N , McArdle C S
Published: December 2008

Regional chemotherapy is an attractive but underevaluated method of treating locally advanced breast cancer. We have combined two novel methods of targeting by delivering a single pulse of adriamycin-loaded albumin microspheres down a radiologically placed internal mammary artery catheter. A complete response was observed and prolonged local control achieved.
Non-ulcer dyspepsia: does Helicobacter pylori matter?
Authors: Sahay P , Axon A T R
Published: December 2008

Non-ulcer dyspepsia is a heterogenous disorder characterised by chronic or recurrent abdominal or retrosternal discomfort lasting for more than four weeks for which no cause can be determined. Helicobacter pylori has been implicated as a potential cause in a subset of patients but the association has not been proven and H pylori eradication in patients with non-ulcer dyspepsia has had variable results. Large well-controlled studies are needed to clarify the relationship.
Fatal bronchospasm after oral ingestion of isphagula
Authors: Hulbert D C , Thorpe P J , Winning A J , Beckett M W
Published: December 2008

We report the case of a 40-year-old asthmatic who suffered fatal bronchospasm following oral ingestion of a laxative containing isphagula.
Syndrome X--angina and normal coronary angiography
Authors: Chauhan A
Published: December 2008

It is clear that angina pectoris with normal coronary arteries is a heterogeneous and ill-defined syndrome that encompasses different pathogenic entities. Differences in patient selection and in definition of ‘syndrome X’ has made comparison between different study groups rather difficult. Two decades of investigations have not revealed a specific cause of this syndrome. There is now a general belief that syndrome X probably encompasses several pathophysiological disease entities and the mechanisms involved in syndrome X remain to be fully elucidated.
Spinal cord compression by spontaneous spinal subdural haematoma in polycythemia vera
Authors: Kalina P , Drehobl K E , Black K , Woldenberg R , Sapan M
Published: December 2008

A woman with an eight-year history of polycythemia vera presented with numbness and weakness of both legs. A large spinal haematoma was revealed on magnetic resonance imaging which was treated clinically and which subsequently resolved.
The management of anticoagulation in patients with prosthetic heart valves undergoing non-cardiac operations
Authors: Busuttil W J , Fabri B M
Published: December 2008

Prosthetic valve thrombogenicity and bleeding complications associated with life-long anticoagulation are constant potential causes of morbidity and mortality following prosthetic valve implantation. The conflict between over- and under-anticoagulation is even more of a problem when other surgical interventions are required. Very few clinical trials have addressed this issue. We propose some guidelines based on the concept of risk-adjusted intensity of anticoagulation but stress the need for caution with interpretation of these recommendations.
The triple-phase response--problems of water balance after pituitary surgery
Authors: Lindsay R S , Seckl J R , Padfield P L
Published: December 2008

A 29-year-old woman presenting with persistent headache and oligomenorrhoea was found to have a pituitary adenoma which was treated surgically. Postoperatively she developed diabetes insipidus which resolved on treatment with desmopressin acetate. She represented 11 days post surgery with nausea and vomiting and inappropriate antidiuresis was diagnosed in an infectious diseases unit. On re-admission to our unit cranial diabetes insipidus was confirmed by water deprivation. This case demonstrates the need for careful monitoring of patients after pituitary and suprasellar surgery or head injury.
An audit of fatal acute pancreatitis
Authors: Banerjee A K , Kaul A , Bache E , Parberry A C , Doran J , Nicholson M L
Published: December 2008

Acute pancreatitis has a mortality of about 10%: this figure has not changed over the last 20 years. A retrospective audit of fatal acute pancreatitis was performed in a teaching hospital with a catchment population of about 750,000 patients to examine patient characteristics. Using Hospital Activity Analysis code 577.0, all fatal cases of acute pancreatitis were studied in a six-year period 1987-93. Additionally, all post mortem diagnoses of acute pancreatitis were traced. The overall post mortem rate in Nottingham at the time of the study was about 35%. All available records, X-ray and biochemical data were studied and appropriate information recorded and analysed for 65 fatal cases. Only 15% were post mortem diagnoses, lower than in previous series; 72% had respiratory and 67% had renal complications. Only 34% had been admitted to the intensive care unit. A third of patients had had surgery; 67% of these was some form of external drainage. Of the 14 patients with proven gallstone pancreatitis only three had endoscopic retrograde cholangiopancreatography; 42% of patients had idiopathic disease. Not all the patients diagnosed ante mortem had the full biochemical predicted severity criteria analysed: pO2 and calcium analysis was performed in about 80%. Pre-mortem diagnoses of pancreatitis was achieved more frequently than in other comparable series.
Dysphagia due to secondary achalasia as an early manifestation of squamous cell carcinoma
Authors: Makker H K , Chisholm R , Rate A J , Bancewicz J , Bernstein A
Published: December 2008

A 59-year-old man, a smoker, presented with features of airflow obstruction due to squamous cell carcinoma of central airways mimicking chronic obstructive airways disease. He also had pronounced dysphagia. Computed tomographic and magnetic resonance imaging scans showed mediastinal tumour invasion but no direct oesophageal involvement. Oesophageal manometry studies revealed that dysphagia was due to the oesophageal motility disorder, secondary achalasia.
Doubly disabled: diabetes in combination with an eating disorder
Authors: Ward A , Troop N , Cachia M , Watkins P , Treasure J
Published: December 2008

We present a series of patients with both an eating disorder and diabetes mellitus and compare these to a group of non-diabetic patients from the same clinic. Significantly more of the diabetic patients had previous attempts at treatment for their eating disorder. A high incidence of diabetic complications was noted with clear implications, both clinically and economically, for early intervention. The incidence of childhood trauma was lower in the diabetic than the non-diabetic group. In the majority of patients, diabetes developed before the eating disorder, suggesting that diabetes itself may provide the vulnerability and increase the risk of developing an eating disorder. Early intervention in diabetic clinics may prevent the development of serious eating disorders.