bluuebunny/crossref_metadata_2025 huggingface dataset:
Wernicke's encephalopathy and alcohol-related disease
Authors: Naidoo D P , Bramdev A , Cooper K
Published: December 2008

A pilot study of 31 consecutive alcohol-related deaths over an 8-month period revealed the presence of histologically diagnosed Wernicke's encephalopathy in 17 cases. Analysis of the clinical records revealed that a disturbance of the mental state was the commonest finding and neurological signs were present in only 2 of the 17 cases (ataxia 1, peripheral neuropathy 1). Analysis of 22 ward admissions for Wernicke's encephalopathy during the same 8-month period revealed that the diagnosis is easily made when neurological deficits (ophthalmoplegia, ataxia) accompany mental changes and when Wernicke's encephalopathy is the predominant illness.

In patients with established alcohol-related disease attention is often directed to the presenting illness so that Wernicke's encephalopathy may easily be overlooked as a cause of deterioration in the mental state in these patients. It is recommended that routine management of patients with alcohol-related disease should include thiamine even if neurological signs are absent.
Angioma serpiginosum: a simulator of purpura
Authors: Cox N H , Paterson W D
Published: December 2008

We describe two patients with angioma serpiginosum who had both undergone a variety of haematological tests for investigation of purpura, but in whom careful examination of the skin demonstrated abnormal blood vessels rather than extravasated blood. Recognition of vascular disorders which simulate purpura may avoid unnecessary investigations.
Myxoedema presenting with seizures
Authors: Bryce Gillian M , Poyner Fiona
Published: December 2008

The case of a 32 year old female who presented with her first epileptic fit and took over 36 hours to recover is described. Investigations led to a diagnosis of hypothyroidism as the cause. Following treatment with thyroxine she has remained well with no further fits for over 2 years. Hypothyroidism should be considered as a possible underlying cause of epilepsy especially when there is a prolonged recovery time after a fit.
Deficiency of 17 α-hydroxylase associated with absent gonads
Authors: Malcolm P N , Wright D J , Edmonds C J
Published: December 2008

A phenotypic female presented initially at the age of 17 years with amenorrhoea and delay of sexual development. Karyotype was male, 46 XY, and as gonads were absent, a diagnosis of congenital anorchia was made. The patient was treated with oestrogen.

At the age of 23 years, she re-presented with tall stature and hypertension. She then had normal female habitus but absent pubic and axillary hair. Re-investigation showed that sex steroids and cortisol were absent and established the diagnosis as 17 α-hydroxylase deficiency. Treatment with hydrocortisone rapidly corrected the hypertension. Ultrasound examination confirmed the absence of gonads but showed that a small uterus was present.

Measurement of serum cortisol is important for recognition of such patients, but further measurements of sex steroids, particularly progesterone, are needed to prove the diagnosis.

We have found no previous reports of absent gonads in 17 α-hydroxylase deficiency. The association remains unexplained.
An audit of training in public health medicine
Authors: Rous Elizabeth , Guy Margaret , Hayward Peter , Bramleby Peter
Published: December 2008

Postgraduate training is one of the core functions of every specialty. The Trainee Members Committee of the Faculty of Public Health Medicine audited the quality of training in public health medicine according to guidelines set by the Education Committee of the Faculty. The survey identified several weaknesses in training which need to be remedied by Faculty Members. This audit model would prove useful to other specialties and the benefit of trainee involvement in the Committee structure of the Faculty is highlighted.
Renal impairment associated with an acute paracetamol overdose in the absence of hepatotoxicity
Authors: Campbell Norman R C , Baylis Barry
Published: December 2008

This report describes a paracetamol overdose in which renal impairment occurred without biochemical evidence of hepatotoxicity. We are aware of only one similar case. However, it is possible this scenario may be seen more frequently with close biochemical follow-up.
Primary disseminated fusarial infection
Authors: Madhavan M , Ratnakar C , Veliath A J , Kanungo Reba , Smile S Robinson , Bhat Sanjay
Published: December 2008

Among the fungal pathogens the species Fusariam solani causing systemic infection is very rare and generally causes systemic infection only in an immuno-compromised host. We report a systemic infection caused by F. solani in a non-immunocompromised adult male, to our knowledge the first such case report.
Localized scleroderma and hemiatrophy in association with antibodies to double-stranded DNA
Authors: Adebajo A O , Crisp A J , Nicholls A , Hazleman B L
Published: December 2008

Localized scleroderma involves primarily skin but also muscle, bone and synovium. Further associations and transitional forms have been reported. We report here two cases showing associations between localized scleroderma and vasculitis, mononeuritis multiplex, juvenile chronic arthritis and hemiatrophy. In particular our cases both possess antibodies to double-stranded DNA, a finding not previously reported.
Femoral hernia appendix causing small intestinal obstruction
Authors: Wyatt J P , Varma J S
Published: December 2008

An 88 year old woman presented with a painful, irreducible right femoral hernia and small intestinal obstruction. At laparotomy, some distal small intestine was found to have twisted around an uninflamed appendix which was acting as a 'band', with its tip fixed in the femoral hernia sac. Although the association between the appendix and femoral hernia is well recognized, the production of small intestinal obstruction by this particular mechanism has not been previously reported.
Treatment of Raynaud's phenomenon with triiodothyronine corrects co-existent autonomic dysfunction: preliminary findings
Authors: Gledhill R F , Dessein P H , Van der Merwe C A
Published: December 2008

Cardiovascular autonomic function was assessed in 9 subjects with Raynaud's phenomenon. The underlying diseases were systemic lupus erythematosus (n = 5), systemic sclerosis (n = 3) and rheumatoid arthritis (n = 1). Five standard non-invasive tests, 3 of heart rate and 2 of blood pressure, were employed. Compared with age and sex matched controls (n = 25), the number of values abnormal was 24 of 45 (53%) overall and between one and 4 (median, 2) individually. Significant differences were present for 3 tests, two of heart rate and one of blood pressure.

The subjects were given triiodothyronine, 60 to 80 micrograms per day, for vasospastic attacks. Autonomic function was reassessed between weeks 4 and 9 (9 subjects) and between weeks 12 and 18 (8 subjects) after introduction of triiodothyronine. Test results showed a considerable improvement. At the second reassessment, the number of values abnormal was now 5 of 40 (12.5%) overall and nil (n = 4) or one (n = 4) individually. Significant differences remained for one heart rate test only. Adverse side effects to triiodothyronine occurred in a single subject and were readily controlled.

Evidence of somatic neuropathy was present electrophysiologically in all 9 subjects and clinically in 8. Triiodothyronine may have corrected autonomic dysfunction by increasing blood flow to ischaemic peripheral nerves or by acting on the autonomic system more directly.

Further study of triiodothyronine in autonomic insufficiency appears merited.
Mitral stenosis in the Maroteaux-Lamy syndrome: a treatable cause of dyspnoea
Authors: Marwick Thomas H , Bastian Bruce , Hughes Clifford F , Bailey Brian P
Published: December 2008

The case is reported of a young woman with the Maroteaux-Lamy syndrome (mucopolysaccharidosis type VI) who presented with rapidly progressive dyspnoea due to mitral stenosis. Mitral valve replacement was performed and the appearance of the valve was typical of mucopolysaccharide infiltration. Dyspnoea in patients with the Maroteaux-Lamy syndrome may be due primarily to cardiac valve involvement, and in this setting, valve surgery is safe and effective.
Colonoscopy in patients aged 80 years or older and its contribution to the evaluation of rectal bleeding
Authors: Bat Leon , Pines Amos , Shemesh Eliahou , Levo Yoram , Zeeli Doron , Scapa Eitan , Rosenblum Yosef
Published: December 2008

Colonoscopies performed in patients aged 80 years or older at the Sheba Medical Center were analysed according to the primary indication for the procedure: 101 colonoscopies were performed because of rectal bleeding of at least 2 months duration, and 335 for all other indications. Carcinoma of the large bowel was found in 29 (28.7%) bleeders, with the rectum being the most frequently involved site (12 patients). Among the non-bleeders, the prevalence of cancer was significantly lower (33 cases, 9.8%; P less than 0.001), and rectal carcinoma was less common (five patients, P = 0.04), but proximal tumours were more frequent. Of patients with cancer who had operations, the majority (72%) had a tumour confined to the bowel wall (Dukes A or B). The rate of adenomas was similar for both groups (34% vs 29%). The non-bleeders complained more frequently of abdominal pain or a change in bowel habits as compared to the bleeders, but both groups had similar rates for anaemia and weight loss.

In all, 47% of these octogenarians with cancer, and 26% with adenomas were referred for colonoscopy because of rectal bleeding. This procedure was found to be safe in old age, as we recorded only four (0.9%) non-fatal complications among our series, a similar figure to the overall incidence of complications at our Institute. In conclusion, our data indicate that rectal bleeding in octogenarians warrants a complete colonic investigation, preferably by total colonoscopy.
Recurrent intra-cranial granulomata presenting as space-occupying lesions in a patient with common variable immunodeficiency
Authors: Misbah S A , Spickett G P , Esiri M M , Hughes J T , Matthews W B , Thompson R A , Chapel H M
Published: December 2008

A patient with profound panhypogammaglobulinaemia due to common variable immunodeficiency developed two discrete intra-cranial space-occupying lesions, 10 years apart, requiring craniotomy. Histological examination revealed the intra-cranial masses to be granulomata of unknown aetiology on both occasions.
Primary pulmonary hypertension and functional hyposplenism
Authors: Fahy Gerard , Robinson Killian , Deb Binayak , Graham Ian
Published: December 2008

Primary pulmonary hypertension is a rare disease of unknown case. Functional hyposplenism is characterized by the appearance of abnormal circulating erythrocytes despite the presence of a spleen and is associated with a variety of disease states. A case of primary pulmonary hypertension associated with functional hyposplenism is described in this report.
The late presentation of postero-lateral congenital diaphragmatic hernias
Authors: Heaton N. D. , Adam G. , Howard E. R.
Published: December 2008

Four patients presenting after the neonatal period with a combination of respiratory and gastro-intestinal symptoms and signs which point to the diagnosis of congenital postero-lateral diaphragmatic hernias are discussed. Late presentation is more common than previously acknowledged. Early correct diagnosis and treatment are associated with an excellent clinical outcome.
Is bed rest useful after diagnostic lumbar puncture?
Authors: Spriggs D A , Burn D J , French J , Cartlidge N E F , Bates D
Published: December 2008

A randomized study of 110 patients undergoing their first diagnostic lumbar puncture was performed to compare the effect of immediate mobilization with 4 hours bed rest on the incidence of post lumbar puncture headache. There was no difference between the mobile (n = 54) and bed rest (n = 56) groups in the incidence of post lumbar puncture headache (32% versus 31%, respectively). We conclude that bed rest following lumbar puncture may be an unnecessary imposition on the patient, as well as on nursing staff.
Cerebellar manifestations of prostatic carcinoma
Authors: McLoughlin J , Gingell J C , Harper G , Hinchliffe A
Published: December 2008

We present two patients known to have prostate cancer who presented with acute cerebellar signs. The neurological deficit of the first patient was due to a paraneoplastic cerebellar manifestation and progressed, despite evidence of response of the primary prostate tumour to hormonal manipulation. The second case, resulting from a solitary cerebellar metastasis, was amenable to surgical intervention and subsequent hormonal manipulation. This latter patient has experienced no recurrent neurological signs after a period of 7 years follow-up. This is the first report of a paraneoplastic cerebellar deficit and, to our knowledge, only the sixth case of parenchymatous cerebellar metastasis of prostatic origin to appear in the literature.
The value of urinary red cell shape in the diagnosis of glomerular and post-glomerular haematuria. A meta-analysis
Authors: Offringa M , Benbassat J
Published: December 2008

The proportion of dysmorphic red cells (DRC) in the urinary sediment and their mean corpuscular volume (MCV) have been claimed to discriminate between glomerular and postglomerular sources of haematuria. To determine the diagnostic value of urinary DRC and MCV, we searched the literature and critically reviewed 21 published studies using a predetermined set of criteria for evaluation.

All studies originated from referral centres. Interobserver variability in identifying urinary DRC was reported in four studies and found to be unacceptably large in one. Although reproducible over different samples of the same individual, urinary MCV was unreliable in cases of low-grade haematuria because of interfering debris. Weighted averages and 95% confidence limits of the sensitivity and specificity of the DRC proportion for glomerular disease were 0.88 (0.86-0.90) and 0.95 (0.93-0.97), respectively; those of a low MCV were 1.00 (0.98-1.00) for sensitivity and 0.87 (0.80-0.91) for specificity. Sensitivity and specificity values derived from in-patients were slightly higher than those in referred outpatients. No studies of urinary DRC or MCV in patients with incidentally detected microhaematuria in the primary care setting were found.

We conclude that at present the diagnostic value of urinary DRC and MCV is limited. In referral centres, that is, in patients with a high probability of postglomerular haematuria, the test cannot rule out urological lesions, because its specificity for glomerular disease may be as low as 0.80. In the primary care setting, that is, in unselected patients with incidentally detected low-grade haematuria, the accuracy of the test has not been studied but may be even lower. The use of urinary DRC or MCV as an indicator of the source of haematuria is in need of further experimental development and confirmation.
'Pseudo-Alzheimer's' and primary brain tumour
Authors: O'Mahony D , Walsh J B , Coakley D
Published: December 2008

Primary brain tumour may present in the elderly purely as a dementing illness before the onset or detection of sensorimotor neurological symptoms or signs. Although neurological examination may indicate no definite signs, close attention to accepted DSM-IIIR and NINCDS-ADRDA diagnostic criteria for primary degenerative dementia and 'probable' Alzheimer's disease respectively will suggest a process other than a degenerative one. This was the case in two patients with primary brain tumour presenting clinically with dementing illness similar to but distinct from Alzheimer's disease.
Yersinia enterocolitica endocarditis on a prosthetic valve
Authors: Pras E , Arber N , Pinkhas J , Sidi Y
Published: December 2008

Yersinia entercolitica endocarditis has rarely been described before. This is the first report of prosthetic valve Yersinia enterocolitis endocarditis, complicated by infected brain embolization. The patient, however, completely recovered after 6 weeks of combined therapy with ceftriaxone and gentamicin.
Naproxen-associated vasculitis
Authors: Jahangiri Marjan , Jayatunga A P , Bradley J W P , Goodwin T J
Published: December 2008

Three cases of digital vasculitis attributable to naproxen ingestion are reported. The vasculitic changes were reversed by withdrawal of the drug. These three cases emphasize the need to consider drug sensitivity as a cause of unexplained digital vascular lesions.
Leg ulceration in venous disease
Authors: Shami S K , Shields D A , Scurr J H , Smith P D
Published: December 2008

We have given a brief summary of the scale of the problem caused by venous ulceration in the UK, and have then reviewed the various theories of causation, including a historical survey, and presented the evidence for and against the two main current theories of fibrin cuffs and white cell trapping. We also outline previous hypotheses of the aetiology of venous ulceration, including arteriovenous microanastomoses, stasis and oedema. The contribution of superficial venous incompetence in the pathogenesis of ulceration is also examined.
A randomized trial of one versus three doses of Augmentin as wound prophylaxis in at-risk abdominal surgery
Authors: Bates Tom , Roberts Jonathan V , Smith Kevin , German Karl A
Published: December 2008

In a randomized prospective trial of prophylactic antibiotics in at-risk abdominal surgery, one dose of intravenous Augmentin (amoxycillin 250 mg and clavulanic acid 125 mg) on induction has been compared with three 8 hourly doses in 900 patients. Wound infection rates which included minor and delayed infections were very similar in those given one dose: 48/449 (10.7%) compared with those given three doses: 49/451 (10.9%) 95% confidence limits - 4.25% + 3.9%.

There were more septic and sepsis-related deaths in those patients given one dose (14 deaths) than in those given three doses (7 deaths) P > 0.1 95% CL - 0.4% + 3.0%. However, there were more very elderly patients in the one dose group: 64% of the deaths were aged over 80 and all but one had an emergency operation. There was no difference in the other outcome measures studied which included non-fatal deep sepsis, length of postoperative hospital stay, duration of postoperative fever or the use of antibiotics for postoperative infection.

One dose of a suitable intravenous antibiotic gives prophylaxis against wound infection in at-risk abdominal surgery which is at least as effective as multiple doses. However, there may be a risk of overwhelming systemic sepsis in very elderly patients having emergency surgery.
Pyrexia of unknown origin: changing spectrum of diseases in two consecutive series
Authors: Barbado F J , Vázquez J J , Peña J M , Arnalich F , Ortiz-Vázquez J
Published: December 2008

Comparison was made of the aetiology and methods of diagnosis in two series of patients meeting the classic criteria of pyrexia of unknown origin during 1968-1981 and during 1982-1989 seen in the Department of Internal Medicine at La Paz University Hospital, Madrid, Spain. There was a statistically significant decrease in the percentage of infections and an increase in neoplasms and connective tissue disorders in the second series. The percentage of patients diagnosed by laparatomy was similar in both series but the diagnosis yield at laparotomy was greater in the second period. Pyrexia of unknown origin continues to be a condition which can defy clinical expertise in in spite of advances in diagnostic techniques.
What are the benefits of routine breast cancer follow-up?
Authors: Morris S , Corder A P , Taylor I
Published: December 2008

The value of follow-up after potentially curative treatment of breast cancer remains controversial. Recurrence-free women (n = 402) attending a breast clinic over a 3 month period were studied. The women attended 423 appointments, 412 of which were routine. Eleven were requested by the patient or general practitioner (interval appointments). All 11 interval and 19 of the routine appointments resulted in investigations for possible recurrence. Three (27%) interval appointments and four (1%) routine appointments resulted in the diagnosis of a recurrence (P < 10(-5).

The attitudes of 285 patients to follow-up were investigated by questionnaire. Two hundred and twenty-three (78%) questionnaires were completed. Regular follow-up in the breast clinic was preferred to attendance only when symptomatic by 190 (85%) women and 169 (76%) preferred regular breast clinic visits to general practitioner follow-up. Most women (n = 174) (81%) said they felt reassured and less anxious having attended the breast clinic. Routine follow-up after potentially curative treatment of breast cancer is inefficient in the detection of recurrence. It is, however, highly rated for providing reassurance and reducing anxiety. Reassurance rather than detection of recurrence may be the most important function of the breast cancer follow-up clinic.
Endogenous sex hormones and bone mineral density among community-based postmenopausal women
Authors: Murphy Sean , Khaw Kay-Tee , Sneyd Mary Jane , Compston Juliet E
Published: December 2008

In order to describe the relationships between endogenous sex hormones and bone mineral density in healthy postmenopausal women, we carried out a cross-sectional study of 90 community-based women, all at least one year since their last menstrual period (mean 9.6 +/- 4.9 years, range 1-22) and with a serum oestradiol level less than 100 pmol/l. None was currently using hormone replacement therapy. Serum oestradiol, testosterone, sex hormone binding globulin, dehydroepiandrosterone sulphate, and androstenedione were measured using standard techniques. Free oestradiol and testosterone indices were derived as the ratio of total hormone to sex hormone binding globulin, respectively. Total body, spine and hip bone mineral density (g/cm2) were measured by dual energy X-ray absorptiometry.

Significant positive correlations were found between the free oestradiol and testosterone indices and bone mineral density at all sites. These relationships remained significant for the free oestradiol index after adjustment for age and body mass index. By stepwise multiple regression analysis, the free oestradiol index was an independent predictor of total body, spine and hip bone mineral density, accounting for 4-17% of the variance.

These findings suggest an independent positive relationship between endogenous free oestradiol and total body, spine and hip bone mass even in the late postmenopause.
Prediction of mortality in patients in acute medical wards using basic laboratory and anthropometric data
Authors: Woo J , Mak Y T , Lau J , Swaminathan R
Published: December 2008

The value of anthropometric and biochemical indices in predicting short-term mortality among patients in general medical wards was assessed in 294 patients admitted consecutively to a district hospital over a one month period. Using a stepwise logistic regression model and supported by the linear discriminant analysis method, mortality within 3 months could be predicted with sensitivity of 83% and specificity of 84% using the following variables: sex, functional ability, urea, total protein, alkaline phosphatase and albumin-adjusted calcium. Addition of anthropometric values and biochemical nutritional indices did little to improve the accuracy of the prediction, contrary to previous findings among surgical patients and elderly residents of long-term care institutions.
Complications associated with percutaneous needle biopsy of the liver when one, two or three specimens are taken
Authors: Maharaj Breminand , Bhoora Ishan G
Published: December 2008

The diagnostic yield of blind percutaneous liver biopsy is improved when two or three specimens are taken during the procedure by redirecting the needle through a single entry-site, without exposing the patient to a greater risk of complications provided that standard precautions are taken. This study was designed to obtain further data on the safety of this procedure at King Edward VIII Hospital, Durban. During the period 1984-1990 (inclusive) a total of 2,646 biopsies were carried out: a single specimen was obtained in 834 patients, two specimens in 983 patients and three in 829 patients. Complications directly attributable to the procedure occurred in 24 patients who had one specimen, 20 who had two, and 19 who had three specimens taken during the biopsy. A single specimen had been obtained from three of the eight patients who had died, two specimens had been taken from another patient, and three specimens were obtained from the other four patients, i.e. patients in whom two or three specimens were taken did not have a higher incidence of pain, symptomatic hypotension, biliary peritonitis or death than those in whom one specimen was taken. Accordingly, when blind percutaneous needle biopsy of the liver is carried out, two specimens should be obtained by redirecting the needle through a single entry site as this improves the diagnostic yield without increasing complications. The morbidity and mortality associated with liver biopsy in this hospital is, however, high. Good technique, careful monitoring of patients after biopsy and prompt and aggressive resuscitation are essential if the mortality rate is to be reduced.
Stroke in patients aged over 75 years: outcome and predictors
Authors: Kalra L , Smith D H , Crome P
Published: December 2008

The outcome and predictors of stroke rehabilitation were studied prospectively in 96 patients (mean age 81.3 +/- 5.4 years) admitted to geriatric wards from a well-defined area over one year. Of these, 32 (33%) died (median survival 11 days), 52 (54%) returned home (median hospital stay 69 days) and 12 (13%) required long-term care (median hospital stay 164 days). Deaths and discharges showed a bimodal pattern; nearly 40% of the patients died or were discharged within 2 weeks of admission. Early death correlated with level of consciousness (P = 0.02), neurological deficit (P = 0.01) and prestroke Barthel scores (P = 0.04) on admission. Patients with right- rather than left-sided hemiparesis (P = 0.02), good motor power (P = 0.002) and without sensory deficit/inattention (P = 0.002) were discharged early. Discharge home was adversely affected by poor awareness of deficit (P = 0.02), hemianopia (P = 0.03) and incontinence (P = 0.02) assessed at 2 weeks. Stroke survivors with Barthel score < 6 and Mental Test Score < 4 at 2 weeks after stroke required long-term care.
Paracetamol cardiotoxicity
Authors: Armour A , Slater S D
Published: December 2008

A 29 year old man with a significant paracetamol overdose was found to have an abnormal electrocardiograph which, in the absence of hepatic encephalopathy, was considered due to a direct cardiotoxic effect of the drug. A functional coronary insufficiency resulting from inhibition of endothelium-derived relaxing factor secondary to depletion of sulphydryl groups is postulated, and it is suggested that in paracetamol poisoning evidence of cardiotoxicity alone may be sufficient justification for treatment with acetylcysteine.
Pyomyositis complicating pneumococcal meningitis
Authors: Robertson-Mackay F , Al-Hillawi A H
Published: December 2008

A young male with a previous splenectomy presented with Streptococcus pneumoniae meningitis complicated by pyomyositis. Pneumococcal meningitis in asplenic patients is well recognized, but the association of pyomyositis as a complication has not to our knowledge been previously reported.
Idiopathic calcification of the basal ganglia
Authors: Chiu H F K , Lam L C W , Shum P P S , Li K W
Published: December 2008

Idiopathic calcification of the basal ganglia is a rare disorder characterized by neuropsychiatric abnormalities, a movement disturbance of parkinsonian and/or choreoathetoid type and dense calcification of the basal ganglia. We report a 60 year old patient diagnosed as having delusional disorder and tardive dyskinesia who was subsequently found to be suffering from idiopathic calcification of the basal ganglia.
Overweight--a common problem among women treated for hyperthyroidism
Authors: Jansson Svante , Berg Gertrud , Lindstedt Göran , Michanek Annika , Nyström Ernst
Published: December 2008

We sent out a questionnaire to 112 women treated for diffuse toxic goitre 2-5 years earlier to evaluate the prevalence of problems with overweight after the disease. Of 87 responders, about 50% (irrespective of surgical or radioiodine treatment) reported weight problems, and we randomly selected 40 of these women (20 with and 20 without reported weight problems) for a clinical follow-up (32 appearing).

At the follow-up examination (mean 4 years after treatment for hyperthyroidism), 27 women had a higher weight than their estimated premorbid weight. The weight gain correlated with the estimated premorbid body mass index (BMI; P < 0.005), indicating that excess weight gainers may have had a premorbid problem now exaggerated in the post-hyperthyroid period. However, many women with a BMI within the limits stated to be ideal (21-25 kg/m2) also showed dramatic increases in weight. In contrast, the average middle-aged woman in our region did not appear to have gained in weight during a corresponding time period as judged from a longitudinal population study. Women with reported weight problems (mean weight increase 15.6%, n = 16) did not differ from women without (mean weight increase 6.7%, n = 16) as regards pretreatment hormone levels, method of treatment, (change of) smoking habits or post-treatment levothyroxine administration, or in serum concentrations of thyroid hormones, thyrotrophin, cortisol, procollagen-III-peptide, cholesterol, HDL cholesterol or triglycerides.

Women with hyperthyroidism should be informed about the risk of gaining weight after therapy and given early support as to dietary and lifestyle change.
Histopathological examination of specimens removed during directional coronary atherectomy in patients presenting with crescendo angina show mural thrombus
Authors: Bellamy Christopher M , Grech Ever D , Ashworth Michael T , Ramsdale David R
Published: December 2008

Thrombus formation over a fissured coronary atheromatous plaque has been shown by post mortem histological examination to be the pathophysiological mechanism responsible for myocardial ischaemia in those patients who died following a crescendo pattern of angina. Histological examination of plaques responsible for a crescendo pattern of angina in patients who do not die has not been available until recently. We describe two patients who presented with a crescendo pattern of angina. A new technique of coronary revascularization, directional coronary atherectomy, produced symptomatic relief and resolution of myocardial ischaemia. Histological examination of material from the stenosis responsible for their myocardial ischaemia, obtained using this technique, confirmed thrombus formation overlying a fissured atheromatous plaque.
Primary tumours of the duodenum
Authors: Kaminski Naftali , Shaham Dorit , Eliakim Rami
Published: December 2008

Six primary duodenal tumours were diagnosed in our 300 bed institute during a period of 10 years. Two patients had benign tumours (leiomyoma and carcinoid) and four had malignant tumours (adenocarcinoma). The most common manifestation was severe iron deficiency anemia. Diagnosis was usually delayed (with a mean time of 7.7 months from initial complaints), endoscopy being the most common and useful diagnostic tool. A curative procedure was performed in two patients. Patients with unexplained chronic iron deficiency anaemia should undergo thorough gastrointestinal evaluation, including the small intestine, as a curable disease may be found to be the source of the complaint.
Optochiasmatic tuberculoma causing progressive visual failure: when has medical treatment failed?
Authors: Poon Wai S , Ahuja A , Li A K C
Published: December 2008

A 5 year old girl with tuberculous meningitis developed progressive visual failure during in-patient anti-tuberculous chemotherapy due to an ophthochiasmatic tuberculoma. This was successfully managed by prolonged high-dose corticosteroids and continued anti-tuberculous therapy resulting in complete visual and psychosocial recovery.
Solitary plasmacytoma of bone--a rare disorder with an unusual evolution
Authors: Ganjoo R K , Malpas J S , Plowman P N
Published: December 2008

A 40 year old woman presented with a spinal epidural tumour, which on histology was shown to be a plasmacytoma. At that time she had no evidence of multiple myeloma. Ten months later, she developed a second isolated plasmacytoma in the spleen, for which she underwent splenectomy. Two years after her initial presentation she had another recurrence in the liver, followed by a full-blown picture of multiple myeloma. The myeloma was progressive and resistant to all forms of chemotherapy. She finally died of a massive gastrointestinal haemorrhage. The clinical features, natural evolution and management of solitary plasmacytomas are discussed.
Intimal sarcoma of the superior vena cava
Authors: Downes A J , Jones T J , Wilson R S E
Published: December 2008

A case of superior vena cava syndrome caused by a primary intimal sarcoma of the superior vena cava is described. The known causes of superior vena caval obstruction are discussed, together with the difficulties in identifying the underlying lesion. The possibility of a primary superior vena caval neoplasm as a cause of superior vena caval obstruction should be considered in patients presenting with superior vena caval syndrome.
The impact of a short course of three lipid lowering drugs on fat oxidation during exercise in healthy volunteers
Authors: Head A , Jakeman P M , Kendall M J , Cramb R , Maxwell S
Published: December 2008

We examined the impact of three lipid lowering drugs on fat oxidation during a 120 minute treadmill walk, at an exercise intensity of 50% maximal oxygen uptake (VO2 max). Subjects (N = 24) were healthy male volunteers with normal serum chemistry, assigned to three groups (n = 8). Group A received simvastatin 20 mg twice daily, Group B received gemfibrozil 600 mg twice daily, Group C received acipimox 600 mg twice daily. Each subject performed two 120 minute walks, once with drug, and once with placebo (4 days treatment plus a final dose on the morning of the exercise trial). Treatment order was reversed for half of each group.

Compared to placebo, simvastatin treatment, had no impact on fat oxidation (40.9 +/- 8.6% vs 40.9 +/- 9.7%), or on plasma concentration of free fatty acids (FFA), glycerol or glucose. Treatment with gemfibrozil, showed lower fat oxidation (32.3 +/- 13.9% vs 39.7 +/- 7.9%), and lower plasma concentrations of FFA and glycerol, but differences did not reach significance at the 0.05 level. Acipimox treatment, produced significantly lower fat oxidation (36.9 +/- 12.8% vs 50.2 +/- 16.1%, P = 0.011), and lower plasma concentrations of FFA and glycerol (P = < 0.0001 and P = < 0.0001, respectively). Plasma glucose showed a trend toward lower values with acipimox (P = 0.088). These data demonstrate that selective lipid lowering drugs can reduce fat availability for exercise metabolism, placing increased demands on carbohydrates which may reduce exercise tolerance.
Spontaneous rupture of the oesophagus (Boerhaave's syndrome)
Authors: Nehra D , Beynon J , Pye J K
Published: December 2008

Five cases of spontaneous rupture of the oesophagus are reported. All cases had surgery within 12 hours, and all survived, illustrating the value of early diagnosis in this rare condition. None had their diagnosis made before admission to the hospital. Myocardial infarction is the commonest misdiagnosis and frequently results in delayed treatment. We believe that a simple direct question to enquire of the patient whether or not vomiting preceded the onset of the severe pain would significantly reduce the rate of misdiagnosis.
Behavioural approaches to anxiety disorders
Authors: Drummond Lynne M
Published: December 2008

Powerful behavioural treatments for many patients with anxiety disorders have been widely available since the 1970s. Despite this, the majority of such patients have continued to be treated with psychotrophic drugs. Recent litigation against the manufacturers of benzodiazepine drugs has made the public increasingly concerned about the prescription of anxiolytic agents. In parallel with the fall in popularity of drug treatment, advances have been made which increase the availability and applicability of behavioural treatments for these patients. This paper examines the impact of the development of self-exposure and cognitive methods on a number of common anxiety syndromes. Clinical examples of self-exposure are given to demonstrate the simplicity of the technique.
Resolution of danazol-induced cholestasis with S-adenosylmethionine
Authors: Bray Gary P , Tredger J Michael , Williams Roger
Published: December 2008

In a case of danazol-induced cholestasis, the anti-cholestatic agent S-adenosylmethionine was given intravenously for 3 weeks and then orally for 6 weeks. This was well tolerated and led to prompt resolution of both jaundice and associated renal impairment.
Primary infertility in a phenotypic male with 46XX chromosomal constitution
Authors: Tan T T , Khalid B A K
Published: December 2008

The case of a 32 year old male with normal male adrenarchal hair pattern, bilateral gynaecomastia, a small phallus, hypospadias and bilateral poorly developed testes presenting with primary infertility secondary to azoospermia and a pelvic cyst is described. Repeated chromosomal analysis showed 46XX chromosomal constitution. Laparotomy revealed a simple cyst between the urinary bladder and the rectum.

XX male syndrome is a rare cause of male infertility. The majority of cases is due to interchange of a fragment of the short arm of the Y chromosome containing the region that encodes the testes determining factor with the X chromosome. The presence of a simple cyst in the anatomical location of the uterus to our knowledge has not been reported in the literature.
Ultrasound-guided needle aspiration of amoebic liver abscess
Authors: Ramani Ananthakrishnan , Ramani Rama , Kumar M S , Lakhkar B N , Kundaje G N
Published: December 2008

This prospective study was carried out on 200 patients with clinically, ultrasonographically and serologically confirmed amoebic liver abscess. The role of ultrasound-guided needle aspiration in addition to medications was evaluated compared to drug treatment alone. Both the groups were monitored clinically and sonographically for up to 6 months after diagnosis. The initial response (after 15 days) was better in the aspirated group (P < 0.05) but resolution of abscess after 6 months were similar. There was a more rapid clinical response in the aspirated group, particularly in those with larger (> 6 cm) abscesses and there were no complications. Percutaneous ultrasound-guided needle aspiration is a safe diagnostic and therapeutic approach which enhances clinical recovery, accelerates resolution, especially in large abscesses, and prevents complications.
Use of intravenous cannulae by junior hospital doctors
Authors: Yentis S M
Published: December 2008

One hundred junior hospital doctors were surveyed to investigate their use of intravenous cannulae. Anaesthetists inserted more cannulae per day than non-anaesthetists and were more likely to use local anaesthetic and wear gloves, although most doctors never or rarely did so. Anaesthetists were also more knowledgeable than non-anaesthetists about the sizes of cannulae they used and the sizes available, although there was considerable ignorance overall in this regard. Many doctors regularly place themselves at risk and expose their patients to unnecessary pain during intravenous cannula insertion, and have little knowledge about the cannulae they use.
Pyrexia of unknown origin in association with bladder diverticulum tumour
Authors: Agarwal M , Azzopardi A , Mufti G R
Published: December 2008

A case of pyrexia due to a rapidly growing undifferentiated transitional cell carcinoma in a bladder diverticulum is described. The literature is reviewed and the causes of pyrexia associated with neoplasia briefly discussed.
ACE inhibition versus calcium antagonism in the treatment of mild to moderate hypertension: a multicentre study. Ireland-Netherlands Lisinopril-Nifedipine Study Group
Authors: Hart W , Clarke R J
Published: December 2008

The efficacy of lisinopril 10-40 mg once daily was compared with that of nifedipine tablets 20-40 mg twice daily in a multicentre double-blind randomized parallel group study of 16 weeks duration involving 127 patients with mild to moderate hypertension. The groups randomized to lisinopril or to nifedipine were not significantly different with respect to any demographic variable. An analysis of the pooled data from all centres demonstrated a significantly greater fall in both lying and standing systolic blood pressure (SBP) on lisinopril than on nifedipine treatment (difference between treatments 7.70 +/- 3.34 mmHg; P = 0.02 and 10.2 +/- 3.30 mmHg; P = 0.003 for lying and standing SBP, respectively). However, this difference may be accounted for by the slightly higher mean SBP in the lisinopril treatment groups compared with the nifedipine group at the end of the placebo run-in period.

Both treatments lowered lying and standing diastolic blood pressures (DBP) to the same extent and the response rates to the two treatments were the same. The effects of the two drugs on heart rate were indistinguishable from each other.

There were six lisinopril and 12 nifedipine-treated patients withdrawn during randomized treatment (P = 0.22). Nineteen per cent of lisinopril patients reported an adverse event compared with 36% of nifedipine patients. The relative risk of an adverse event on lisinopril compared with nifedipine was 0.42 (confidence limits 1.027-0.172) a difference which approached statistical significance (P = 0.0573).

Lisinopril produced a greater reduction in both lying and standing SBP than nifedipine and both were associated with equivalent reductions in DBP. Lisinopril may be better tolerate than nifedipine.
Hurricane growth of malignant trophoblastic teratoma
Authors: Raja M A , Oliver R T D , Blomley M
Published: December 2008

The case history of a 27 year old male ex-intravenous drug user who presented with haemoptysis and indistinct lung shadowing is reviewed. During a 3 week period of investigation his lung shadowing increased dramatically and it became apparent that he had metastases from chorionic gonadotropin-producing testis cancer which had undergone spontaneous regression of the primary tumour. Unfortunately by the time he was referred for treatment he was in respiratory failure and died 48 hours after treatment started. The critical importance of the urinary pregnancy test (available in most casualty departments to diagnose ectopic pregnancy) in accelerating diagnosis and treatment of such a case is highlighted.
Fatal diltiazem overdose: report of four cases and review of the literature
Authors: Roper T A , Sykes R , Gray C
Published: December 2008

Four fatal cases of diltiazem overdose are described and compared with previously published cases. Clinical sequelae include all grades of heart block, hypotension and ultimately death. Management includes gastric lavage and oral administration of activated charcoal at presentation. Further symptomatic treatment with inotropic agents and temporary cardiac pacing may be required. If these measures are successful, recovery occurs within 36 hours in uncomplicated cases. Toxicological data have been reviewed but currently drug levels can only offer a retrospective analysis of the severity of overdoses.

As the use and risk of abuse of diltiazem increases, these reports serve to highlight the possible hazards and to alert physicians to what must be regarded as a dangerous and potentially lethal drug in overdosage.
Takayasu's disease presenting as a nephrotic syndrome due to amyloidosis
Authors: Sousa Ana E , Lucas Margarida , Tavora Isabel , Victorino Rui M M
Published: December 2008

We report an 18 year old black woman who presented with nephrotic syndrome in whom the investigations led to the diagnosis of diffuse Takayasu's disease, renal amyloidosis of AA type and interstitial lung disease. Proteinuria in Takayasu's disease is usually ascribed to hypertension or more rarely to glomerulonephritis. This case suggests that amyloidosis should be considered also in the investigation of proteinuria in these patients in view of the serious prognostic implications. This case represents further evidence that Takayasu's disease can be the cause of systemic reactive amyloidosis which may also be the presenting feature.
Primary lymphoma of the gallbladder
Authors: Friedman E P , Lazda E , Grant D , Davis J
Published: December 2008

A case of primary lymphoma of the gallbladder is described which is rare in the medical literature. A 76 year old man presented with acute cholecystitis and septicaemia. Investigation showed a lung abscess and a gallbladder mass. The mass was thought to be an empyema and cholecystostomy was performed. Biopsy of the gallbladder wall showed high-grade B cell lymphoma. The patient unfortunately succumbed to overwhelming septicaemia in the postoperative period. Postmortem examination confirmed primary lymphoma of the gallbladder without dissemination.
Naftidrofuryl treatment for rest cramp
Authors: Young J B , Connolly M J
Published: December 2008

A double-blind placebo-controlled study was carried out in 14 subjects to investigate the effect of naftidrofuryl in the treatment of rest cramp. Naftidrofuryl caused a significant reduction in cramp frequency (median naftidrofuryl = 5; median placebo = 17; P < 0.004) and a significant 34% increase in cramp free days (median naftidrofuryl = 22; median placebo = 14; P < 0.004). Naftidrofuryl is an effective alternative to quinine in the treatment of this painful condition.
Acquired C1 inhibitor deficiency with lymphoma causing recurrent angioedema
Authors: Mathur R , Toghill P J , Johnston I D A
Published: December 2008

A 52 year old man who developed recurrent, massive and generalized angioedema for the first time during adult life was found to have an acquired deficiency of C1q esterase inhibitor (C1 INH) in association with a B cell lymphoma producing a paraprotein. He had low levels of C4 and C1 INH during the attacks which returned to normal after the successful treatment of lymphoma. An underlying lymphoproliferative disease should always be considered in adult patients with this immunological profile, recurrent angioedema and a negative family history.
Restless legs syndrome in the elderly
Authors: O'Keeffe S T , Noel J , Lavan J N
Published: December 2008

The prevalence and significance of restless legs syndrome was assessed in 307 patients presenting to an acute-care geriatric medical service. Fifteen patients (5%) had restless legs syndrome; 13 (87%) of these patients had insomnia and 10 (67%) reported troublesome or frequent leg symptoms. Of 147 patients with current insomnia, iron deficiency (serum ferritin < 18 ng/ml) was present in 4/13 (31%) patients with restless legs and 8/134 (6%) patients without restless legs (P < 0.025). Improvement in symptoms of restless legs was noted with iron repletion.

These findings suggest that restless legs syndrome is relatively common in the elderly and causes significant discomfort and sleep disturbance. Iron deficiency is a common and treatable cause.
Cardiac arrest: a rare complication of pallid syncope?
Authors: Taiwo Bola , Hamilton Alex H
Published: December 2008

Cardiac arrest is rare in children. Breath-holding, on the other hand, is fairly common. We report a case in which one complicated the other with serious consequences. A review of the literature on the subject was undertaken.