bluuebunny/crossref_metadata_2025 huggingface dataset:
Delayed post-anoxic encephalopathy
Authors: Thacker A K , Asthana A B , Sarkari N B S
Published: December 2008

Delayed anoxic encephalopathy, a rare yet clinically and pathologically welldelineated complication of hypoxia with unknown pathogenesis, is described in a 40-year-old man following a drug overdose.
Wheeze in a heart transplant patient with lymphoma
Authors: Sridhar M , Jeffers M , Brankin E , Soukop M , Banham S
Published: December 2008

We report a case of wheeze in a heart transplant patient who was receiving chemotherapy for a transplant-associated lymphoma. The patient was in severe respiratory distress; there were no radiological abnormalities. A diagnosis of invasive bronchopulmonary aspergillosis was made by bronchoscopy and bronchoalveolar lavage. Despite prompt antifungal therapy the patient died. Wheeze in a non-asthmatic immunocompromised patient, even in the absence of radiological abnormalities, is highly suggestive of invasive bronchopulmonary aspergillosis. Diagnosis is best established by bronchoscopy and examination of the fluid obtained by bronchoalveolar lavage; currently the response to treatment is often disappointing.
Gliomatosis cerebri or benign intracranial hypertension?
Authors: Weston P , Lear J
Published: December 2008

Benign intracranial hypertension is a condition of obscure aetiology which presents with episodic headaches and nausea. It is a diagnosis based on the exclusion of other intracranial pathology and computed tomography is usually normal. We present a case of gliomatosis cerebri which was initially diagnosed and treated as benign intracranial hypertension.
Giant hydronephrosis in adults: the great mimic. Early diagnosis with ultrasound
Authors: Yang W T , Metreweli C
Published: December 2008

Giant hydronephrosis in adults is uncommon and often misdiagnosed clinically. We present three cases of giant hydronephrosis in adults secondary to ureteric calculous obstruction, two of whom presented with an acute abdomen and one with an indirect inguinal hernia. All patients were diagnosed promptly with ultrasound.
Pulse oximetry monitoring during non-sedated upper gastrointestinal endoscopy
Authors: Melleney E M , Lambertini L , Willoughby C P
Published: December 2008

Fifty consecutive patients judged fit for non-sedated upper gastrointestinal endoscopy were monitored by pulse oximetry before, during and after the procedure. Transient hypoxia developed during intubation in five subjects (10%) but treatment was not required nor was the test halted. Only one patient with pre-existing respiratory problems became hypoxaemic to the extent that oxygen had to be given and the procedure halted. The chance of hypoxia was unrelated to age, sex, smoking, anxiety, or the duration of intubation. Routine pulse oximetry is not necessary for non-sedated gastroscopy but oximetry monitoring may be important in selected cases.
Guillain-Barré syndrome as an extraintestinal manifestation of Crohn’s disease
Authors: de la Fuente-Fernández R , Rubio-Nazabal E , de la Iglesia-Martínez F
Published: December 2008

A variety of extraintestinal manifestations, probably immune-mediated, may appear during relapses of Crohn’s disease. We report the clinical observation of a 34-year-old woman who developed a Guillain-Barré syndrome, aphthous stomatitis and oligoarthritis during a relapse of Crohn’s ileocolitis. This case suggests that the Guillain-Barré syndrome may be another extraintestinal manifestation of Crohn’s disease.
An unusual cause of dementia
Authors: Vassallo M , Allen S
Published: December 2008

Gliomatosis cerebri is a rare cerebral tumour that presents with personality and mental state changes. Diagnosis can be very difficult and many times is made at post mortem. We describe a 63-year-old man who presented initially with depression that merged into a schizophrenia-like illness, and who developed progressive dementia prior to his death. Two computed tomography (CT) scans of the brain were normal and the diagnosis of gliomatosis cerebri was made at post mortem. The progressively changing mental state was suggestive of an organic cause of his illness. Since this tumour may not be detected by a CT scan, a magnetic resonance imaging scan with T2-weighted images with spin echo sequences of the brain should be performed. Prognosis is very poor but diagnosis is important to plan terminal care. The patient described was unusual because he was older than most people with this tumour, and he presented with psychiatric symptoms which were thought to be non-organic for almost two years.
Neurofibromatosis and insulinoma
Authors: Fung J W , Lam K S
Published: December 2008

A 45-year-old man with neurofibromatosis presented with recurrent seizures due to hypoglycaemia caused by an insulinoma. The attacks were abolished after the successful removal of the insulinoma. This probably represents another example of the association between neurofibromatosis and a tumour consisting of cells with amine-precursor-uptake and decarboxylation.
Cerebral venous sinus thrombosis and antiphospholipid antibodies
Authors: Boggild M D , Sedhev R V , Fraser D , Heron J R
Published: December 2008

We report two cases of cerebral venous sinus thrombosis associated with an antibody to phospholipids, namely the lupus anticoagulant. Both patients later developed further immunologically mediated conditions. The importance of screening for the lupus anticoagulant in addition to anticardiolipin antibodies in this condition and the need for follow-up of such patients is discussed.
Peliosis of the spleen: possible association with chronic renal failure and erythropoietin therapy
Authors: Lam K Y , Chan A C , Chan T M
Published: December 2008

Splenic peliosis was identified at necropsy in a 62-year-old woman receiving continuous ambulatory peritoneal dialysis for end-stage renal failure, and erythropoietin therapy for uraemia and anaemia. The immediate cause of death was arrhythmia related to ischaemic heart disease, following an episode of intramuscular haematoma (secondary to platelet dysfunction). The unusual association between peliosis and renal failure, and possibly erythropoietin therapy, is discussed.
Telling parents their child has severe congenital anomalies
Authors: Ryan S
Published: December 2008

A large number of potential malformations exist, but the key skills in communicating with the parents of a malformed baby are the same. Dissatisfaction is common in this situation and has prompted a national initiative in improving standards of disclosure of disability and malformation--the Right from the start strategy (see appendix). Key skills include keeping the family together, ie, not removing the baby unnecessarily, knowing how parents like to be informed, listening, checking that parents have understood, being nonderogatory and, most importantly, emphasizing the positive side of their newborn child.
Normolipemic xanthomatosis
Authors: Handa R , Gupta K , Wali J P
Published: December 2008

A 20-year-old woman presented with tendon and tuberous xanthomas. Plasma lipid levels were normal. Xanthomatosis with normal lipid levels is rare.
Vasospasm causing a cold hemiplegic arm
Authors: Wanklyn P , Bamford J M
Published: December 2008

We report a case of a patient with abnormal coldness of the hemiplegic arm following a stroke.
Soluble interleukin-2 receptor in patients with glomerular diseases
Authors: Chen H S , Wu M S , Yen T S , Chen W Y
Published: December 2008

In this study, we measured the soluble interleukin-2 receptor (sIL-2R) level to evaluate the cellular immune status in 61 patients with different types of glomerular diseases; 40 healthy volunteers were used as control. All patients with glomerular diseases had levels of serum sIL-2R significantly higher than those of the controls (766 +/- 59 vs 280 +/- 23 U/ml; p < 0.05). Even patients with normal renal function still had higher serum sIL-2R levels than the controls, no matter to which subgroups they belonged (primary glomerulonephritis, lupus nephritis or diabetic nephropathy). Serum sIL-2R levels were similar among the three subgroups. The serum levels of sIL-2R correlated well with age and were significantly higher in older patients, although this was not observed in the control group. Serum sIL-2R levels were significantly higher in patients with active urinary sediment and in patients with impaired renal function and showed a significant negative correlation with creatinine clearance (r = -0.56; p < 0.05). Although urinary and serum sIL-2R levels were quite well correlated, (r = 0.35; p < 0.05), the urinary levels of sIL-2R did not differ in patients with different disease activity or different renal functions although they had a significant correlation with 24-hour urinary protein (r = 0.39; p < 0.05). Patients with nephrotic syndrome also had higher urinary sIL-2R levels than other patients (529 +/- 106 vs 280 +/- 31 U/ml; p < 0.05). We conclude that greater T-cell activation might contribute to the pathogenesis of different glomerulonephritis entities, and serum levels of sIL-2R can serve as a useful clinical marker of glomerulonephritis activity. Renal function influenced the serum levels of sIL-2R significantly. This factor must be considered when we interpret the data. Urinary sIL-2R levels did not reflect the disease activity as well. This might be due to the secondary influence of the extent of the glomerular protein leak. Further investigation is needed to define the exact excretory pathway of this substance.
The Babinski reflex
Authors: van Gijn J
Published: December 2008

The plantar response is a reflex that involves not only the toes, but all muscles that shorten the leg. In the newborn the synergy is brisk, involving all flexor muscles of the leg; these include the toe ‘extensors’, which also shorten the leg on contraction and therefore are flexors in a physiological sense. As the nervous system matures and the pyramidal tract gains more control over spinal motoneurones the flexion synergy becomes less brisk, and the toe ‘extensors’ are no longer part of it. The toes then often go down instead of up, as a result of a segmental reflex involving the small foot muscles and the overlying skin, comparable to the abdominal reflexes. With lesions of the pyramidal system, structural or functional, this segmental, downward response of the toes disappears, the flexion synergy may become disinhibited and the extensor hallucis longus muscle is again recruited into the flexion reflex of the leg: the sign of Babinski. A true Babinski sign denotes dysfunction of the pyramidal tract, and should be clearly distinguished from upgoing toes that do not belong to the flexion synergy of the leg. Correct interpretation of the plantar response depends only to a minor degree on the method or site of stimulation of the foot. It is therefore most important to assess the response in the entire leg.
Breast cancer in the elderly
Authors: Bellet M , Alonso C , Ojeda B
Published: December 2008

Breast cancer in the elderly has attracted considerable interest in recent years for three main reasons. Firstly, information concerning the profile (clinical and biological) of the disease in the geriatric population is scarce; secondly, the number of patients is increasing, and thirdly there are conflicting data regarding the actual effectiveness of the different treatments. The present review attempts to outline the specific characteristics of this malignancy in the elderly in terms of histological pattern, stage at diagnosis, and outcome. The feasibility of standard therapies (mastectomy/lumpectomy, axillary clearance, and radio-therapy) in the elderly is carefully analysed, and compared to the efficacy of less aggressive procedures. The use of tamoxifen as a primary treatment, instead of surgery, is critically reconsidered, as well as its use as an adjuvant therapy. Finally, the effectiveness of systemic therapy in advanced disease is also discussed.
Rehabilitation medicine
Authors: Cozens J A , Chamberlain M A
Published: December 2008

The nature of rehabilitation medicine is outlined in terms of its objectives, its methods, the patient groups which it seeks to help and its relationships to other specialties. Some major advances of recent years are discussed, such as the development of the impairment/disability/handicap framework. With particular emphasis upon neurological rehabilitation, the breadth of the specialty is then illustrated with examples of current preoccupations. These include recovery patterns of the damaged nervous system, testing the efficacy of existing therapies, applying new treatment techniques and developing quantitative measures of disability and handicap. Looking to the future, some key areas are identified where further advances might be sought.
The investigation of a patient with unexpected venous thrombosis
Authors: Wilde J T
Published: December 2008

Over recent years a number of hereditary and acquired defects of the circulation’s natural anticoagulant mechanisms have been characterised and shown to predispose affected individuals to thrombosis. It is important to attempt to diagnose a thrombophilia state in patients with a thrombotic tendency in order to provide appropriate management, especially during at-risk situations, both for themselves and asymptomatic relatives identified through family studies. This review defines the patients who should be investigated for an underlying thrombophilia state and describes the hereditary and acquired disorders which should be screened for within an investigation profile. The recently identified factor V Leiden mutation which appears to be the most common hereditary cause of a thrombotic tendency is described in detail and descriptions of the more established thrombophilia states are included. Although the factor V Leiden mutation accounts for a significant proportion of cases fulfilling the criteria for thrombophilia screening, a predisposing cause for thrombosis remains unidentifiable in a large number of patients making it likely that over the years to come new thrombophilia states will continue to be identified.
An audit of echocardiograms in acute left ventricular failure
Authors: Morgan R , King D
Published: December 2008

All patients with heart failure should have an echocardiogram to establish a diagnosis, both to aid treatment as well as for prognostic reasons. An audit of 100 case notes of patients admitted with acute left ventricular failure over a 12-month period found that 26 patients had not had an echocardiogram. Of the 74 who did have an echocardiogram 68 patients had reduced systolic function (mean ejection fraction 42%). Almost all (93%) were commenced on an angiotension-converting enzyme (ACE) inhibitor. Those who did not receive an ACE inhibitor had no contraindications to these drugs. Seventeen patients had a confirmed myocardial infarction. Of these, 11 had an echocardiogram and 10 were discharged home on an ACE inhibitor. Despite appropriate indications some patients are deprived of echocardiography as well as the benefits of ACE inhibitors.
Cutaneous metastases of lung cancer
Authors: Kamble R , Kumar L , Kochupillai V , Sharma A , Sandhoo M S , Mohanti B K
Published: December 2008

The reported incidence of skin metastases from lung cancer varies from 2.8-7.5%. In the present study 8.7% of patients had skin metastases, with head and neck being the most common sites, nodular lesions the most common, and adenocarcinoma the most frequent histology. Although most patients develop these lesions during the course of a known progressive disease, they may be the presenting manifestation of a primary tumour in the lung. The occurrence of skin lesions in lung cancer announces an ominous prognosis. The response to chemotherapy is poor, possibly due to poor blood supply to the skin; monitoring response to chemotherapy, however, is easier when such lesions are present.
Actinomycosis presenting as carcinoma
Authors: Hinnie J , Jaques B C , Bell E , Hansell D T , Milroy R
Published: December 2008

Actinomycosis is rare compared to carcinoma, but the two conditions can present with very similar clinical pictures. Two cases of actinomycosis are reported, one thoracic and one pelvic-abdominal which presented as carcinoma and proceeded to surgery without a histological diagnosis having been established.
Asthma
Authors: Calverley P M
Published: December 2008

Bronchial asthma is now recognised to be a major cause of morbidity and even mortality in people of all ages. Two important ideas have changed our approach to asthma management. The first is understanding that asthma is a chronic inflammatory disorder which needs regular treatment with anti-inflammatory drugs such as inhaled corticosteroids to prevent further attacks. The second development is the availability of prescribable peak flow meters, which allows both confident diagnosis and early prediction of relapse. Asthma management guidelines provide a logical treatment framework for most patients, but a few difficult cases still consume large amounts of medical time. The commonest problem is one of compliance with treatment which may respond to patient education, although this is not universally so. Other problems include misdiagnosis, acid reflux and, rarely, true corticosteroid-resistant asthma. Several potentially important new treatments have been developed. These include longer acting anticholinergic drugs, drugs with bronchodilator and some anti-inflammatory properties which antagonise or inhibit the production of leukotrienes, sub-types of phosphodiesterase inhibitor with anti-inflammatory properties and immunosuppressive drugs such as cyclosporin. Ultimately these new treatments must be rigorously tested and integrated into a care plan that remains centred on patient education.
Discussing the diagnosis and prognosis with cancer patients
Authors: Bennett M , Alison D
Published: December 2008

Effective doctor-patient communication is an integral part of good clinical care. Telling a patient that he/she has cancer can be a daunting task. If done with empathy and sensitivity it can create an important bond between the doctor and patient. If done brusquely and without tact it can create barriers and lasting hostility. Several key steps help make the breaking of bad news easier for doctors and patients. There is not one ‘right formula’ but appreciation of and responsiveness to the patient’s verbal and non-verbal signals are core skills which can be developed.
Vasculitis and rapidly progressive glomerulonephritis in the elderly
Authors: Higgins R M , Goldsmith D J , Connolly J , Scoble J E , Hendry B M , Ackrill P , Venning M C
Published: December 2008

The proportion of patients with vasculitis and rapidly progressive nephritis aged 70 years or over has risen from about 10% in the 1980s to over 30% in series reported in the 1990s. This study was undertaken to examine the presentation and outcome of such older patients. Seventeen of 56 patients (30%) who presented at two renal units were aged 70 years or over. Mean creatinine level at presentation was 530 mumol/l, and five patients received dialysis at presentation. Outcome was dependent on three factors, namely comorbid pathology, response to immunosuppressive therapy, and the occurrence in three cases of temporary spontaneous partial remission. Overall patient survival at one and two years was 62.5% and 50%, respectively, and 90% and 100% of surviving patients were independent of dialysis at one and two years, respectively. Response to chemotherapy was excellent, with full rehabilitation in many cases and no deaths directly attributable to adverse effects of immunosuppressive therapy. We conclude that diagnosis of vasculitis and rapidly progressive glomerulonephritis by renal biopsy and the subsequent administration of chemotherapy (including cyclophosphamide in many cases) resulted in a worthwhile benefit in these elderly patients.
Cerebral vasculitis following allopurinol treatment
Authors: Rothwell P M , Grant R
Published: December 2008

A 45-year-old man developed cerebral vasculitis associated with a systemic hypersensitivity response shortly after commencing treatment with allopurinol. The illness settled on withdrawal of the drug and no other cause was found.
Impaired glucose tolerance and unidentified diabetes
Authors: Heine R J , Mooy J M
Published: December 2008

The epidemiology of impaired glucose tolerance and undiagnosed non-insulin-dependent diabetes mellitus is reviewed and the implications for screening strategies discussed.
The specialist nurse in HIV/AIDS medicine
Authors: Whitehead C M
Published: December 2008

The management of patients with human immunodeficiency virus infection requires a multidisciplinary holistic approach. Hospital-based specialist nurses can both co-ordinate and facilitate their hospital care, and also ensure early and effective discharge back into the community.
The tight pants syndrome--a sporting variant
Authors: Jowett N I , Robinson C G
Published: December 2008

Tight neoprene ‘warm pants’ are increasingly utilised by sportsmen to prevent muscular injury. However, they may impede venous flow from the legs. We describe a case of extensive proximal deep vein thrombosis with subsequent pulmonary embolism in a fit young man with previous hip trauma.
Adult respiratory distress syndrome due to mycoplasma pneumonia
Authors: Shah D C , Muthiah M M
Published: December 2008

A previously fit 48-year-old man was admitted with an acute respiratory failure due to mycoplasma pneumonia that was confirmed by raised mycoplasma titre on complement fixation test. It was also associated with disseminated intravascular coagulopathy. The patient made a full recovery but required intermittent positive pressure ventilation.
The diabetic patient with hypertension
Authors: Leese G P , Savage M W , Chattington P D , Vora J P
Published: December 2008

Hypertension and diabetes co-exist more commonly than would be expected from their individual prevalences. Elevated blood pressure is most commonly due to coexisting essential hypertension, or diabetic renal disease. Early stages of diabetic renal disease can be identified by detecting microalbuminuria. Standard measures of blood pressure are not necessarily raised, but 24-hour ambulatory measures frequently identify a loss of nocturnal drop in blood pressure. Treating hypertension aggressively is important in slowing the inexorable decline in glomerular filtration rate. In diabetes there appears to be no ‘J’-shaped relationship between blood pressure and cardiovascular events, thus removing any concern about attaining low blood pressures as long as the patient is asymptomatic. Morbidity and mortality in these patients is usually associated with cardiovascular events, and it is important to assess the effect of drugs on left ventricular hypertrophy and metabolic parameters. Many drugs are effective at lowering blood pressure, but angiotensin-converting enzyme inhibitors may have an additional renoprotective action. alpha-Adrenergic antagonists may improve lipid profiles and calcium antagonists are probably lipid neutral, making these drugs useful alternatives. Dihydropyridine calcium antagonists (eg, nifedipine) may augment protein-uria, and hence non-dihydropyridine calcium antagonists (eg, verapamil, diltiazem) would be preferred. beta-Blockers and thiazide diuretics have the disadvantage of causing a deterioration in glycaemic and lipid profiles, but can be useful on occasions.
Contract learning, clinical learning and clinicians
Authors: Parsell G , Bligh J
Published: December 2008

Current trends in education and training emphasise that learners, whether they are school children, students or adults, need to acquire generic skills and personal characteristics which will enable them to become independent self-directed learners. This will enable them to continue the process of learning throughout their lives. Recent recommendations for the reform of undergraduate medical education, for training of hospital doctors and general practitioners, and the higher profile now being given to continuing medical education, reflect the strength of this particular educational current sweeping through all levels of medical education. Learning contracts, developed through negotiation between a teacher and a learner, are especially effective educational tools for stimulating independent learning. This paper examines the theoretical basis of contract-learning and its relevance to clinical settings.
Polymicrobial brain abscess involving Haemophilus paraphrophilus and Actinomyces odontolyticus
Authors: Simpson A J , Das S S , Mitchelmore I J
Published: December 2008

A case of brain abscess involving Haemophilus paraphrophilus and Actinomyces odontolyticus is presented. This combination of organisms has not previously been described. All brain abscess specimens should routinely be processed rapidly and cultured for a prolonged period to ensure recovery of fastidious organisms which may have implications for antibiotic therapy.
Accreditation of residency training in the US
Authors: Armbruster J S
Published: December 2008

In the US, accreditation and certification of residency training are functions of separate public sector agencies. Accrediting decisions are made directly by 26 Residency Review Committees, which represent the primary medical specialties and function under the authority of the Accreditation Council for Graduate Medical Education. The accrediting bodies may consider only educational issues and are prohibited by the government from controlling physician supply. Only the programme, not the institution in which it is conducted, is accredited. The US residency is a structured educational programme that is expected to provide comparable experience to all enrolled residents. Length of training may vary from two to six years depending on the specialty. Additional training may be obtained in subspecialty programmes, which are subsets of the primary specialty residencies and are also reviewed for accreditation. These have increased in significant number in recent years as subspecialisation has proliferated in the US.
Purtscher’s retinopathy
Authors: Buckley S A , James B
Published: December 2008

Purtscher’s retinopathy presents to the clinician as loss of vision in a patient with a history of a possible precipitating event such as recent major trauma, pancreatitis, childbirth or renal failure. The ophthalmological picture is one of ischaemia at the posterior pole with white patches of oedema and haemorrhages concentrated around the optic disc. The most probable pathological cause is embolisation of the peripapillary terminal arterioles supplying the superficial peripapillary capillary net. The nature of the embolic particles remains uncertain. Complement-mediated aggregates, fat, air, fibrin clots and platelet clumps may all be involved in what is most likely to be a multifactorial process. There is at present no recognised treatment for the condition.
The use of liver grafts infested with Clonorchis sinensis for orthotopic liver transplantation
Authors: Yeung C K , Ho J K , Lau W Y , Lee K H , Li A K
Published: December 2008

In the Orient, millions are known to have Clonorchis sinensis (biliary trematodiasis) infestation. When these infested livers become available as donor organs, there are potentially serious implications that the transplant team would need to consider. We report the use of two such infested livers, one from a cadaveric donor and the other from a live related donor, for orthotopic liver transplantation. The parasite was encountered not only during organ procurement, but also caused early postoperative blockage of the hepatico-jejunostomy splintage tube and cessation of bile flow in the second recipient. Upon follow-up for four and two years, respectively, no other ill effect has been observed in either patient. Repeated examination of stool for ova of C sinensis in both patients during follow-up visits had been negative, indicating that all the parasites probably had been killed by the cold perfusion. In view of the severe shortage of liver grafts and the lack of serious morbidity associated with the use of these infested livers, we have adopted the policy to include these livers for future transplantation. Special considerations and precautions are, however, required during the perioperative period and on long-term follow-up.
‘Relapse’ of chronic active hepatitis--not always what it seems
Authors: Muller A F , Toghill P J , Smith P
Published: December 2008

Immune chronic active hepatitis is a disease notorious for its unpredictability. In a patient with chronic hepatitis who has already suffered relapses a search for a second cause of jaundice is not usually necessary. This report emphasises the essential role of liver biopsy.
Developing the role of the tutor/facilitator
Authors: Wetzel M S
Published: December 2008

The effective training of facilitator/ tutors is crucial to the success of a problem-based learning approach to medical education. New skills are needed to accomplish the change from giver of information to facilitator of learning, coach, and guide. This paper outlines considerations for the design of a tutor training programme and describes the Harvard Medical School programme in detail.
The role of the radiologist in surgical management: an audit of clinico-radiological conferences
Authors: Dennison A R , Kerrigan D D , Oakley N , Paraskevopoulos J A , Peck R , Collins M C , Johnson A G
Published: December 2008

A prospective analysis of the radiological findings and final diagnoses of 342 patients discussed at joint surgical/radiological conferences over a seven-month period was undertaken in an attempt to define the role of the radiologist in the clinical management of surgical patients. Although the diagnosis had already been correctly made on clinical or radiological grounds in 38% (130/342) of patients presented at the X-ray conferences, careful review of the films resulted in an immediate firm diagnosis in a further 9% (31/342), or promoted further radiological investigations which were responsible for an eventual definitive diagnosis in 20% of the remainder (32/169). The input of the radiologist in selecting the most appropriate additional investigation was particularly valuable in the management of more complex clinical problems.
Congestive cardiac failure following laxative withdrawal
Authors: Riley J A , Brown A R , Walker B E
Published: December 2008

We report the case of a 60-year-old woman who presented with weakness and hypokalaemia due to excessive use of laxatives. When the laxatives were withdrawn, she developed severe congestive cardiac failure requiring treatment with a diuretic and angiotensin-converting enzyme inhibitor. There was no underlying cardiac abnormality, and these drugs were eventually stopped with no recurrence of the cardiac failure. The possible mechanisms of heart failure following laxative withdrawal is discussed.
Myocardial infarction following sternal surgery
Authors: Aggarwal R K , Morrison W L
Published: December 2008

We report a case of myocardial infarction in a 32-year-old man undergoing sternal surgery. Thrombotic occlusion of the right coronary artery with no underlying atheromatous disease was demonstrated angiographically and successfully treated with intracoronary thrombolysis.
Homocystinuria: what about mild hyperhomocysteinaemia?
Authors: van den Berg M , Boers G H
Published: December 2008

Hyperhomocysteinaemia is associated with an increased risk of atherosclerotic vascular disease and thromboembolism, in both men and women. A variety of conditions can lead to elevated homocysteine levels, but the relation between high levels and vascular disease is present regardless of the underlying cause. Pooled data from a large number of studies demonstrate that mild hyperhomocysteinaemia after a standard methionine load is present in 21% of young patients with coronary artery disease, in 24% of patients with cerebrovascular disease, and in 32% of patients with peripheral vascular disease. From such data an odds ratio of 13.0 (95% confidence interval 5.9 to 28.1), as an estimate of the relative risk of vascular disease at a young age, can be calculated in subjects with an abnormal response to methionine loading. Furthermore, mild hyperhomo-cysteinaemia can lead to a two- or three-fold increase in the risk of recurrent venous thrombosis. Elevated homocysteine levels can be reduced to normal in virtually all cases by simple and safe treatment with vitamin B6, folic acid, and betaine, each of which is involved in methionine metabolism. A clinically beneficial effect of such an intervention, currently under investigation, would make large-scale screening for this risk factor mandatory.
Severe pulmonary dysfunction following acute respiratory distress syndrome
Authors: Smith H R , Sinclair D G
Published: December 2008

Recovery of lung function following the acute respiratory distress syndrome (ARDS) is thought to be related to the severity of the initial insult. We report a case demonstrating virtually complete functional recovery following severe ARDS. The significance of this and the need for comprehensive follow-up of such patients is discussed.
Acute renal failure due to sulphadiazine crystalluria in AIDS patients
Authors: de Sequera P , Albalate M , Hernandez J , Vazquez A , Abad J , Ramiro E , Fernández Guerrero M , Caramelo C , Casado S , Ortiz A
Published: December 2008

We report two AIDS patients who developed acute renal failure while receiving sulphadiazine for cerebral toxoplasmosis. Renal ultrasound revealed diffuse bilateral echogenic shadowing material. ‘Sheaves of wheat’ crystals, typical of sulphadiazine crystalluria, were present in the urine. One patient required a percutaneous nephrostomy. Hydration and urine alkalinisation resulted in rapid improvement of renal function and ultrasonographic findings. Sulphadiazine-induced crystalluria and acute renal failure is increasingly frequent. Awareness of its existence may lead to prevention and early conservative treatment.
Diagnosis and management of heart failure in the elderly
Authors: King D
Published: December 2008

Heart failure is common in the elderly and is associated with a significant morbidity and mortality. It accounts for about 5% of adult medical admissions and the expenditure of 1% of the total National Health Service budget. Clinical presentation in old age may be with the classical symptoms of heart failure but often, due to multiple pathology and low functional ability, presentation is atypical. Both nonspecific symptoms and signs of heart failure, are often a delayed presentation in this population, make diagnosis difficult. Treatment of the failing heart in an older person is similar to the young however, diligence is required when prescribing due to age-related pharmacokinetic changes and co-existent morbidity. This may result in polypharmacy and an increase in drug interactions which themselves may have deleterious consequences. However, knowledge of the aetiology of heart failure in old age and the possible atypical presentation as well as available treatments, will result in better management and improved quality of life and reduced mortality in the elderly heart failure population.
The knowledge of hospital patients about vascular diseases and their risk factors
Authors: Gariballa S E , Peet S M , Fotherby M D , Parker S G , Castleden C M
Published: December 2008

The knowledge of 28 stroke patients on the nature, consequences, treatment and risk factors of stroke and ischaemic heart disease was examined using a questionnaire and compared with that of 26 patients with ischaemic heart disease and 41 controls without evidence of vascular disease. Information was also collected on the patients’ willingness to change their life-style, the information and advice they had received and their desire for more information. It was found that about half of the elderly stroke and heart disease patients had a reasonable knowledge of the condition and its related risk factors. Only eight (14%) patients remembered receiving information and advice in relation to their condition during their hospital stay compared with one (2%) control. There was a significant difference between the number of stroke and heart disease patients who wanted to know more about their condition compared with the control group (32 vs 14; p = 0.03). A quarter of the patients and half of the controls knew that fruit and vegetables were good for you and excessive fat and alcohol were less inducive to good health. Most patients with a risk factor were willing to exercise more, stop smoking, cut down on their drinking, or lose weight. These results suggest that elderly hospital patients have a reasonable basic knowledge about vascular diseases, but that a significant number want to know more and would be willing to change their life-style.
Continuous infusion of methylene blue for septic shock
Authors: Brown G , Frankl D , Phang T
Published: December 2008

Nitric oxide has been determined to be a potential mediator of the haemodynamic changes associated with sepsis. The haemodynamic eects of nitric oxide can be partially antagonised by methylene blue, through inhibition of the enzyme, guanylate cyclase. The case report presented here demonstrates a beneficial haemodynamic eect of continuous infusion of methylene blue during sepsis. These findings could be extrapolated to other patients or prompt additional research.
Poliomyelitis
Authors: Kidd D , Williams A J , Howard R S
Published: December 2008

1996 is polio awareness year. This paper reviews the clinical syndrome of acute paralytic poliomyelitis and its sequelae. We discuss epidemiological studies of the syndrome of late functional deterioration many years after the acute infection and the current hypotheses of the pathophysiology of such disorders. Recent evidence has suggested that potentially treatable factors may be implicated in the majority of such patients and it is therefore important to exclude such disorders before attributing late functional deterioration to progressive post-polio muscular atrophy.
Supporting relatives following a cot death
Authors: Phillips B M
Published: December 2008

The incidence of sudden infant death syndrome or cot death has decreased by 60 to 70% in the last 10 years. The largest decrease has been following the Back to sleep campaign in 1991. The epidemiology of cot death now emphasises its association with poverty and smoking in the home. The compassionate reception of the ‘cot death’ baby and his family in the Accident and Emergency department is the first step in enabling families to come to terms with the grief that the death produces. Accident and Emergency staff can facilitate the early grieving process by an understanding of the family’s needs and the provision of appropriate information.
Intracardiac thrombus formation in cardiac impairment: the role of anticoagulant therapy
Authors: Lip G Y
Published: December 2008

The presence of intracardiac thrombus has been associated with many diseases and clinical states, although cardiac impairment is commonly also present. Despite this, there continues to be a lack of consensus on which patients with cardiac impairment should have anticoagulant therapy. This review discusses the relationship between thromboembolism and cardiac impairment secondary to ischaemic heart disease, and suggests possible mechanisms, methods of diagnosis and therapeutic strategies for anticoagulation in such patients. In particular, warfarin has been established as thromboprophylaxis in certain subgroups of patients with cardiac impairment secondary to ischaemic heart disease. A large-scale randomised controlled trial in ambulant patients with cardiac impairment to evaluate the effectiveness of anticoagulant therapy and antiplatelet therapy is, however, long overdue.
Comparative efficacy and safety of ciprofibrate and sustained-release bezafibrate in patients with type II hyperlipidaemia
Authors: Betteridge D J , O’Bryan-Tear C G
Published: December 2008

The hypolipidaemic efficacy and safety of ciprofibrate were compared with a sustained-release formulation of bezafibrate (Bezalip Mono) in 174 patients with type II hyperlipidaemia. This multicenter, open, parallel-group study was conducted in general practice. A total of 83 patients received 100 mg ciprofibrate once daily and 91 received 400 mg bezafibrate once daily for eight weeks. Concentrations of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides were measured at baseline (after stabilisation on a lipid-lowering diet) and after eight weeks. Safety was assessed from reports of adverse events and by measuring haematological and biochemical parameters. After eight weeks, ciprofibrate produced a significantly greater decrease in total cholesterol (-17.8% vs -12.5%), low-density lipoprotein cholesterol (-22.4% vs -17.2%), and triglycerides (-33.9% vs -26.1%). High-density lipoprotein cholesterol concentrations were increased significantly by both drugs (19.6% with ciprofibrate, 24.9% with bezafibrate) but the differences between drugs were non-significant. Both drugs were well tolerated, with headache the most widely reported adverse event.
A patient with hepatitis B, antimicrosomal antibodies, and autoimmune hypothyroidism
Authors: Catapani W R , Valente O , Aguiar C
Published: December 2008

A 37-year-man with chronic hepatitis B was diagnosed as having antimicrosomal antibodies and subclinical hypothyroidism. The association of autoimmune manifestations with hepatitis B has been less frequently reported than with hepatitis C virus. It is discussed whether this patient illustrates a case of spontaneous development of antimicrosomal antibodies, only casually associated with the presence of hepatitis B virus, or there is a real causative relationship between both conditions.
Consultants' study leave--value for money?
Authors: Bennett J R
Published: December 2008

The consultants in a single large acute hospital trust were given a personal allocation of £500.00 pounds for study leave and asked to supply reports on the purpose and value of that leave. The majority of consultants (82%) took leave during the 12-month period at an average cost of £182.80 pounds for each episode. Most was regarded of value and the majority was shared with other members of staff.
False aneurysm with median nerve palsy after iatrogenic brachial artery puncture
Authors: Yip K M H , Yurianto H , Lin J
Published: December 2008

We report on a case in which a patient on oral anticoagulation for her aortic valve replacement, with an International Normalised Ratio of 2.13, developed a false aneurysm of the brachial artery after a routine arterial puncture, despite direct pressure to the aspiration site. The false aneurysm was complicated by the development of median nerve palsy.
Carcinoma of the sigmoid colon presenting as a scrotal swelling
Authors: Bryan N P , Jackson A , Raftery A T
Published: December 2008

A case of adenocarcinoma of the sigmoid colon, presenting as a testicular mass, is described. At sigmoid colectomy widespread metastases were found and only palliative care could be offered thereafter. The incidence and age of such a presentation and manner of spread of the occult primary are discussed.
Regression of a large gastric MALT lymphoma with antibiotic treatment to eradicate Helicobacter pylori
Authors: Martin J , Boyle S , Jacyna M
Published: December 2008

We report a case of a large low-grade gastric lymphoma of mucosa-associated lymphoid tissue (MALT), which regressed following the eradication of concurrent Helicobacter pylori infection. This case lends further support to a policy of H pylori eradication as a first line therapy for all these lesions, irrespective of size. The long-term prognosis of tumours treated in this way, however, needs further evaluation.
The role of cell migration and microchimerism in the induction of tolerance after solid organ transplantation
Authors: Jindal R M , Sahota A
Published: December 2008

A new hypothesis has been proposed which states that microchimerism is the basis for the clinical tolerance seen in long-term survivors of solid organ transplants. Efforts to enhance microchimerism include simultaneous infusion of bone marrow of donor origin and transplantation of a solid organ. Studies are in progress to verify the phenomenon of microchimerism and its role in clinical tolerance.
Interstitial nephritis
Authors: Dhillon S , Higgins R M
Published: December 2008

Interstitial nephritis is an inflammatory process within the renal interstitium, and was one of the first observations made in the description of renal histopathology. Many different conditions are associated with an interstitial nephritis, and as a clinical diagnosis the term has little use unless causation is defined. However, there has been recent interest in the possibility of a common mechanism causing irreversible renal damage and eventually renal failure in many different types of interstitial nephritis. Such damage could take place due to blood-borne inflammatory mediators, or could be due to renal tubular inflammation related to abnormal components of the glomerular filtrate in renal failure, such as proteins or lipids. If such research were to result in effective therapy for interstitial nephritis, the progression of many forms of renal disease to end stage renal failure could be ameliorated.
Severe pneumococcal disease and temporary splenic dysfunction
Authors: Pelly M D E , Huo Z , Henderson D C , Soni N
Published: December 2008

We report a patient presenting with pneumonia in whom temporary splenic dysfunction was diagnosed by counting pitted red blood cells. This under-recognised condition caused a transient immunosuppression which may have had serious implications for our patient's recovery.
The management of congestive heart failure
Authors: McAlister F A , Teo K K
Published: December 2008

Despite the remarkable advances in cardiovascular therapeutics over the past four decades, little impact has been made on either the incidence or mortality rate of congestive heart failure and it remains a major clinical and public health problem. Recent practice audits have suggested that proven efficacious therapies are not maximally applied in patients with this condition. An approach to the patient with congestive heart failure is presented, emphasizing the two distinct syndromes of systolic dysfunction and diastolic dysfunction. Treatment recommendations are derived from consideration of the underlying pathophysiology and the evidence from randomised clinical trials.
The significance of arterial hypertension at the onset of clinical lupus nephritis
Authors: Naiker I P , Chrystal V , Randeree I G , Seedat Y K
Published: December 2008

The prognostic importance of hypertension at the onset of clinical lupus nephritis is not well established. We studied retrospectively 44 patients with lupus nephritis in order to ascertain the prevalence of hypertension at presentation and to investigate a possible association between hypertension and renal functional impairment. A correlation was also sought between hypertension and histological class of lupus nephritis. Hypertension was graded as mild (diastolic 95–99 mmHg), moderate (100-114) or severe (> 115). Impaired renal function (creatinine > 120 mumol/l) was graded as mild (120-200 mumol/l), moderate (200-350 mumol/l), or severe (> 350 mumol/l). Histological class and the presence of hypertensive renal vascular lesions was recorded. The prevalence of hypertension was 38%. There were 17 hypertensives and 27 normotensives. The incidence of renal impairment was greater in the hypertensives, 47% vs 18.5% (p = 0.04). Mean serum creatinine was also higher higher in this group (p = 0.02). The presence of hypertensive renal vascular lesions identified a high-risk subgroup who had a higher incidence of renal functional impairment and worse renal function than the hypertensive group as a whole. Even at an early stage, hypertension and hypertensive renal vascular lesions correlated well with renal functional impairment. Aggressive treatment of hypertension is therefore essential in early lupus nephritis in order to prevent further deterioration of renal function as the disease evolves.