bluuebunny/crossref_metadata_2025 huggingface dataset:
Stress and stress counselling
Authors: Matheson K H
Published: December 2008

This is a report by the 1989 National Association of Clinical Tutors Wyeth Travelling Fellow to the United States of America. The stresses of postgraduate training and attempts to modify these are described, including stress counselling. The significance of stress and the relevance of the findings for postgraduate training in the United Kingdom are considered.
Central cretinism in four successive siblings
Authors: Isichei U P , Das S C , Egbuta J O
Published: December 2008

A study of four successive siblings, age 9, 12, 14 and 16 years with cretinism associated with congenitial central hypothyroidism (central cretinism), born to a mother in the endemic goitre region of the Jos Plateau, Nigeria, is presented. Biochemically, the defects were characterized by abnormally low basal thyroxine, triiodothyronine and thyroid stimulating hormone, as well as refractory TSH response to thyrotrophin releasing hormone and gross hyperlipidaemia. Clinically, the intellectual, physical and neurological impairment varied from moderate in the youngest to very severe in the oldest. Contrasting clinical pictures of cretinism, which appeared related to age and previous treatment were found with a spectrum ranging from predominantly myxoedematous in the youngest to predominantly neurological in the 16 year old male. Response to adequate treatment was dramatic, with restoration of severe gait disturbance occurring almost completely, but the imprints of thyroid hormone deficiency on mental defects and intellectual performance remained almost unaltered. The parents and two older sisters were normal with normal thyroid function.
Ursodeoxycholic acid therapy in chronic active hepatitis
Authors: Bateson M C
Published: December 2008

A 41 year old woman developed chronic active hepatitis with prominent cholestasis. She was treated with prednisolone over 3 years with symptomatic benefit and improvement in serum biochemistry. However, various steroid-related side effects were encountered and steatorrhoea eventually occurred with very troublesome nocturnal diarrhoea. Therapy with ursodeoxycholic acid 750 mg daily was started. Serum alanine aminotransferase and gamma-glutamyl transferase normalized for the first time since her illness began. Steatorrhoea was abolished. There was good control of symptoms as prednisolone therapy was gradually reduced. However, when prednisolone was completely withdrawn there was a prompt biochemical deterioration. Addition of low-dose azathioprine has maintained normal blood tests over 24 months without return of the original symptoms. There are no side effects of ursodeoxycholic acid in subjects without gallstones and this agent may be effective treatment for cholestatic liver disease.
Intracavernosal metaraminol for treatment of intraoperative penile erection
Authors: Tsai S K , Hong C Y
Published: December 2008

Four patients developed penile erection when regional anaesthesia was induced with spinal block. In another patient, penile erection developed during fentanyl-induced general anaesthesia. Injection of metaraminol into corpus cavernosum successfully achieved detumescence in all these patients. The dose of metaraminol ranged from 10 to 25 micrograms, much less than that required for the treatment of vasodilator-induced priapism. Intracavernosal injection of metaraminol is a simple, effective and safe method for immediate relief of intraoperative penile erection. It is most useful when urogenital operation would be delayed by penile tumescence.
Intravenous infusions of ifosfamide/mesna and perturbation of warfarin anticoagulant control
Authors: Hall G , Lind M J , Huang M , Moore A , Gane A , Roberts J T , Cantwell B M J
Published: December 2008

We report three patients who had serious disturbance of anticoagulant control while receiving ifosfamide/mesna-containing cytotoxic chemotherapy in association with warfarin. In view of the likely biological potentiation of warfarin by ifosfamide/mesna, close monitoring of anticoagulant control should be performed during the co-administration of these drugs.
Spontaneous iliopsoas haemorrhage—an unusual complication of streptokinase therapy
Authors: Gillanders I A , Nakielny R , Channer K S
Published: December 2008

We report a case of spontaneous iliopsoas haemorrhage following intravenous streptokinase which serves to remind physicians of the potential dangers of this form of therapy.
Small bowel infarction associated with pancreatic glucagonoma
Authors: Earl U , Abbott C R
Published: December 2008

An 88 year old woman presented comatose, hypothermic and hyperglycaemic. She died soon after admission and at autopsy recent small bowel infarction was found. The superior mesenteric artery was encased in a dense pancreatic mass and there was marked luminal narrowing of the vessel. Histology revealed a pancreatic glucagonoma which had metastasized to colonic submucosa and serosa.

Glucagonoma is a rare tumour and this presentation of small bowel infarction associated with pancreatic glucagonoma would appear to be a unique event.
Comparison of fine needle aspiration cytology, radioisotopic and ultrasound scanning in the management of thyroid nodules
Authors: Jones A J , Aitman T J , Edmonds C J , Burke M , Hudson E , Tellez M
Published: December 2008

In 175 patients presenting with thyroid nodules, the diagnostic value in management of fine needle aspiration and cytology (FNAC), pertechnetate (99mTc) scanning and ultrasound imaging was examined. In 82 patients, the diagnosis was confirmed at operation; in the remaining 93, there was a follow-up period of at least 2 years. Thyroid cancer was found in 13 patients. For FNAC the sensitivity, specificity and positive predictive value for thyroid cancer were 92%, 85% and 41% respectively compared with 82%, 34% and 11% for 99mTc pertechnetate scanning, 75%, 61%, 19% for ultrasound and 73%, 58% and 19% for combined pertechnetate and ultrasound scanning. In 14% of patients, the aspirates were inadequate for cytology at the first examination.

FNAC is therefore the preferable initial investigation and usually gives results adequate for a decision on surgical or medical management. With medical management and follow-up, ultrasound is of value in defining the nodule and the appearance of the rest of the gland.
Submandibular chronic sialadenitis presenting with alcohol-induced pain
Authors: Okany C C , Akinsete I , Akinyanju O O
Published: December 2008

A 32 year old man with alcohol-induced pain over a right submandibular swelling is described. Excision biopsy of this swelling revealed chronic sialadenitis and the symptoms promptly ceased following this excision. We speculate on the possible pathophysiological mechanism.
Localized neuropathy following jellyfish sting
Authors: Peel N , Kandler R
Published: December 2008

This report describes the case of an 18 year old female who sustained a jellyfish sting on her right wrist. She subsequently developed complete radial, ulnar and median nerve palsies distal to the site of the sting, which recovered fully over the next 10 months. We believe this to be due to a direct neurotoxic effect of the jellyfish venom.
Hepatic infarction: an unusual complication of nephrotic syndrome in a patient with diabetes mellitus
Authors: Martinez Vea A , Garcia Ruiz C , Sauri Conejero A , Mayayo Artal E , Oliver Rotellar J A
Published: December 2008

A 67 year old woman with widespread atherosclerosis and diabetic nephropathy manifested by nephrotic syndrome and moderate renal failure developed multiple hepatic infarctions. The infarctions were documented by computed tomographic scan and needle aspiration biopsy of the liver. Except for the nephrotic syndrome and the atherosclerosis no other cause of hepatic infarction was found.

We suggest that hepatic infarction should be considered in the thrombotic complications of the nephrotic syndrome secondary to diabetic nephropathy.
The drug management of severe alcohol withdrawal syndrome
Authors: Gillman M A , Lichtigfeld F J
Published: December 2008

We describe the various phases of the alcohol withdrawal syndrome with special reference to the pitfalls of using neuroleptics. We outline the importance of adequate sedation using either benzodiazepines or chlormethiazole. We provide a critical appraisal of the currently employed anti-epileptic medication in the alcohol withdrawal syndrome. We also indicate the usefulness of analgesic nitrous oxide as a screening test in differentiating the cases of alcohol withdrawal syndrome needing further intensive therapy to prevent progression to delirium tremens.
An inverse relationship between serum zinc and C-reactive protein levels in acutely ill elderly hospital patients
Authors: Craig G M , Evans S J , Brayshaw B J
Published: December 2008

Serum zinc and C-reactive protein (CRP) levels were measured in two groups of acutely ill geriatric hospital in-patients. Serum CRP levels were greater than 10 mg/l in 62% of the first group and 47% of the second. There was a significant negative correlation between zinc and CRP in both groups (r = −0.33, P < 0.001, n = 103) and (r = −0.29, P < 0.001, n = 135 respectively).

The serum CRP was raised in 30% of long stay patients (n = 50) and 23% of a control group of elderly hospital patients with a normal serum albumin (n = 71), but there was no correlation between zinc and CRP in these patient groups. The results indicate that an acute phase response influences serum zinc levels in acutely ill geriatric patients. There is reason to believe that a distinction should be made between true zinc deficiency and a low serum zinc secondary to acute zinc redistribution during an inflammatory response. Measurement of CRP may help to distinguish between these two situations. We advise that if the serum zinc is low and CRP is significantly raised, zinc supplements should be avoided and a source of infection should be sought. Following recovery from severe infection low serum zinc levels return to normal while elevated CRP levels fall.
Contamination of blood cultures during venepuncture: fact or myth?
Authors: Shahar E , Wohl-Gottesman B-S , Shenkman L
Published: December 2008

Contamination of blood cultures is believed to occur mainly during the venepuncture procedure. Consequently, meticulous preparation of the venepuncture site is widely recommended. To determine whether the contamination rate is indeed affected by the quality of the antiseptic procedure at the venepuncture site, 181 paired cultures were collected from 176 patients during a 6-month period after either strict antiseptic cleansing of skin with alcohol followed by povidone-iodine, or after brief disinfection with alcohol alone.

The contamination rate was not influenced by the antiseptic procedure, and corresponded to the accepted percentage reported in most other studies. Eight false positive cultures (4.4%) were obtained after strict antisepsis of the skin and 6 (3.3%) after short simple cleansing with alcohol (P = 0.39). Our results suggest that contamination of blood cultures may not be related to the venepuncture procedure—regardless of the antiseptic technique used—but may be due to later stages of laboratory handling and processing of the specimens. Review of the literature has provided further indirect evidence to support this conclusion.
Spinal sensory radiculopathy due to Angiostrongylus cantonensis infection
Authors: Wood G , Delamont S , Whitby M , Boyle R
Published: December 2008

The most common cause of eosinophilic meningitis is the rat lung worm Angiostrongylus cantonensis, a parasite which is endemic in the South East Asian and Pacific regions. While the typical clinical presentation is that of meningitis associated with an eosinophilic pleocytosis, a 45 year old man presented with a radiculomyelopathy, associated with an eosinophilic pleocytosis and cerebrospinal fluid antibodies to A. cantonensis but without signs or symptoms of meningitis. A worm was demonstrated on both computed tomographic myelography and magnetic resonance imaging scan of the spinal cord.
The use of erythropoietin in renal failure
Authors: Macdougall I C , Hutton R D , Coles G A , Williams J D
Published: December 2008

The treatment of renal anaemia by recombinant human erythropoietin (EPO) is now well established. Several studies have examined the pharmacokinetics and efficacy of the drug given intravenously, intraperitoneally and subcutaneously and there is increasing evidence that the subcutaneous route has several advantages including the requirement for a lower dose. It is also important to stress the need for careful determination of baseline iron status of all patients before commencing EPO therapy. In the long term the extremely high iron stores of transfusion dependent patients will disappear. In the short term, however, the majority of the patients whose serum ferritin is less than 100 micrograms/l will require iron supplementation to allow an appropriate haemoglobin response. Alternatively, a fall in transferrin saturation to less than 20% is certainly an indication for iron supplementation and if oral iron therapy is not adequate then intravenous preparations may have to be considered. Although the anaemia of renal failure can be fully corrected by EPO, partial correction may be sufficient to reverse the problems of reduced exercise capacity, myocardial ischaemia and cardiomegaly which are frequently associated with end-stage renal disease. Partial correction will also result in a lesser rise in whole blood viscosity and, in turn, possibly reduce hypertension, thrombosis and increased peripheral resistance and thus lessen the side effects of EPO therapy.
Traumatic neuroma at the tail of the pancreas following splenectomy
Authors: Geddy P M , Venables C W
Published: December 2008

A 50 year old man presented with abdominal pain and weight loss after a splenectomy performed 26 years ago for abdominal trauma. At laparotomy, a mass was found at the tail of the pancreas. Pathological examination showed this was a traumatic neuroma and revealed evidence of chronic pancreatitis. Traumatic neuroma may be a rare cause of a pancreatic mass, especially after previous surgery or trauma.
Serum lipoproteins and apolipoproteins in young normocholesterolaemic, non-diabetic Indian men with myocardial infarction
Authors: Sewdarsen M , Desai R K , Vythilingum S , Shah N , Rajput M C
Published: December 2008

Serum total cholesterol, triglycerides, high density lipoprotein cholesterol, low density lipoprotein cholesterol, apolipoprotein A-I and apolipoprotein B were evaluated as potential indicators of the risk of coronary artery disease in young (< 46 years) normocholesterolaemic, non-diabetic men who had previously sustained a myocardial infarction (n = 50) and in healthy age and sex matched controls (n = 122) with a similar socioeconomic background.

Significant differences were observed between patients and controls in the mean concentrations of serum total cholesterol, triglycerides, low density lipoprotein cholesterol, high density lipoprotein cholesterol and apolipoprotein B, as well as in the ratios of total cholesterol to high density lipoprotein cholesterol and apolipoprotein A-I to apolipoprotein B. No significant difference was demonstrated in the concentration of apolipoprotein A-I between the two groups. Stepwise discriminant analysis indicated that apolipoprotein B was the best discriminant between patients and controls. The percentage of exact classification was 74% in patients and 66% in controls.

When the patients were compared to a subset of controls (n = 50) matched for age and total cholesterol, significant differences were demonstrated only in the mean concentrations of apolipoprotein B. Discriminant analysis confirmed that the best single discriminating variable was apolipoprotein B.

The results therefore indicate that in young normocholesterolaemic, non-diabetic Indian men with myocardial infarction, apolipoprotein B is superior to other lipid parameters studied, as a marker for coronary artery disease.
Medical audit and formulary management: a policy for rational use of thrombolytic drugs
Authors: Morgan D J R , Sutters C A , Pugh S
Published: December 2008

In this article we report on the development, introduction, and maintenance of a policy to promote rational use of thrombolytic drugs by hospital doctors. The work was undertaken within the framework of the voluntarily operated Riverside East drugs guide (formulary) management system (FMS). The policy was introduced in October 1988 and revised in November 1989 to coincide with the launch of the new, expensive thrombolytic drugs, alteplase (rt-PA, Actilyse) in 1988 and antistreplase (APSAC, Eminase) in 1989. Streptokinase was recommended as the first-line drug for patients who had not received it within the last 6 months. The policy was communicated to all staff in meetings and a drugs guide bulletin and reinforced by ward pharmacists.

Results over a 15 month period show voluntary compliance by prescribers with the recommended policy. One hundred and seventy-four patients (22% cardiac admissions) presented with acute myocardial infarction. Of these 43 (25%) received streptokinase, the first-line recommended drug, 7 received alteplase and none received anistreplase. The savings in drug expenditure from using streptokinase rather than alteplase or anistreplase for the 15-month period of investigation were over pounds 27,000. This work represents an example of the effectiveness of the Riverside East FMS model in influencing prescribing behaviour.
Sjögren-like pluriglandular exocrine insufficiency after drug-induced toxic epidermal necrolysis
Authors: Sabán J , Pais J R , Rodríguez J L , Boixeda D
Published: December 2008

We present the case of a patient that progressively developed xerophthalmia, xerostomia, cutaneous xerosis and exocrine pancreatic insufficiency 3 months after metamizole-induced toxic epidermal necrolysis. Though the association of Sjögren's syndrome and exocrine pancreatic impairment is well established, the Sjögren-like syndrome after drug-induced toxic epidermal necrolysis in association with such a wide exocrine glandular insufficiency has not been previously described, to our knowledge.
Investigation of acute stroke: what is the most effective strategy?
Authors: Dunbabin D W , Sandercock P A G
Published: December 2008

Techniques of investigation of acute stroke syndromes have progressed rapidly in recent years, outpacing developments in effective stroke treatment. The clinician is thus faced with a variety of tests, each with different cost implications and each altering management to a greater or lesser extent. This review will concentrate on the basic tests which should be performed for all strokes (full blood count, ESR, biochemical screen, blood glucose, cholesterol, syphilis serology, chest X-ray and electrocardiogram). Additional tests may be required in selected cases: CT scan to diagnose ‘non-stroke’ lesions, to exclude cerebral haemorrhage if anti-haemostatic therapy is planned, and to detect strokes which may require emergency intervention (such as cerebellar stroke with hydrocephalus); echocardiography to detect cardiac sources of emboli; and in a few cases lumbar puncture and specialized haematological tests. Other tests, which are currently research tools, may be suitable for widespread use in the future including NMR, SPECT and PET scanning.
Primary shunt hyperbilirubinaemia: a variant of the congenital dyserythropoietic anaemias
Authors: Bird A R , Knottenbelt E , Jacobs P , Maigrot J
Published: December 2008

A 19 year old Mauritian male presented with episodic nausea, abdominal discomfort and jaundice. Unconjugated hyperbilirubinaemia and erythroid hyperplasia without dyserythropoiesis led to the diagnosis of primary shunt hyperbilirubinaemia. The similarity between congenital dyserythropoietic anaemia and this entity suggests that patients with these lesions can be considered within a single spectrum of disorders, characterized as congenital ineffective erythropoiesis.
Cerebral neoplastic angioendotheleosis complicated by hypercalcaemia
Authors: Wierzbicki A S , Gibbs J M , Lidov H G W , Lolin Y , Thomas P K
Published: December 2008

This is a case report of a 67 year old man who presented with a fluctuating level of consciousness and myoclonic jerks caused in part by hypercalcaemia. The diagnosis of cerebral neoplastic angioendotheleosis was only made later on brain biopsy and is the first report of the occurrence of hypercalcaemia in neoplastic angioendotheleosis.
Lung function abnormalities and decline of spirometry in scleroderma: an overrated danger?
Authors: Abramson M J , Barnett A J , Littlejohn G O , Smith M M , Hall S
Published: December 2008

To document the prevalence and progression of pulmonary involvement in scleroderma (systemic sclerosis including the CREST syndrome), the clinical notes and lung function records of 113 cases were reviewed. Lung function was normal in 39 cases, isolated impairment of DLCO was found in 38 patients, a restrictive defect was present in 27 cases and there was evidence of airflow obstruction in 9 cases. The median duration of symptoms was 10 years. Dyspnoea and an interstitial pattern on chest X-ray were associated with impaired lung function. Death during the period of review was significantly related to initial impairment of the DLCO. Sixty-six patients (53 women and 13 men) underwent repeat spirometry at least 1 year after initial testing. The rates of change in VC and FEV1 were no more rapid than would be expected for normal subjects. There was no significant difference in rates of change between men and women or between dyspnoeic patients and those who were asymptomatic. The extent of skin involvement and the presence of interstitial fibrosis on chest X-ray were unrelated to the rate of loss of lung function. It is concluded that most scleroderma patients in this study had abnormal lung function when first tested, but overall significant worsening of spirometry was not found.
A solitary jejunal vascular abnormality: a source of massive rectal bleeding
Authors: Saunders M P
Published: December 2008

Haemorrhage of small bowel origin may prove to be a clinical and diagnostic challenge, particularly when the bleeding is massive and continuous. Such a case is described where the source of blood loss was a jejunal vascular abnormality.
Syringomyelia associated with post-meningitic spinal arachnoiditis due to Candida tropicalis
Authors: Phanthumchinda K , Kaoropthum S
Published: December 2008

A 63 year old man who suffered from syringomyelia related to post-meningitic spinal arachnoiditis caused by Candida tropicalis is reported. The clinical syndrome of syringomyelia developed gradually and a definite diagnosis was delayed for more than 10 years. The patient has partially recovered after surgical treatment. This form of fungal infection and its delayed neurological complication in the form of syringomyelia has not been reported previously, to our knowledge.
Spiral shaped microorganisms in the human duodenal mucosa
Authors: Nakshabendi I M , Peebles S E , Lee F D , Russell R I
Published: December 2008

A new spiral shaped microorganism, Gastrospirillum hominis, distinct from Helicobacter pylori, has recently been described in the gastric mucosa. We report a patient with duodenal erosions who was found to have these organisms in his duodenal mucosa. This bacterium is not necessarily specific to the stomach, and its association with peptic damage needs to be studied further.
Extrapulmonary lymphomatoid granulomatosis presenting as Pancoast's syndrome
Authors: Dolan G , Smith J , Reilly J T
Published: December 2008

We report the case of a 55 year old man who presented as Pancoast's syndrome associated with a left sided Horner's syndrome, a mass in the left supraclavicular fossa and marked weakness with wasting of the left arm consistent with a left sided brachial plexus lesion. Biopsy revealed the typical features of lymphomatoid granulomatosis. Neurological involvement is a rare presenting manifestation of this uncommon disease. Lymphomatoid granulomatosis should be considered as a rare but potentially treatable cause of Pancoast's syndrome.
The successful medical management of gastric outflow obstruction associated with the use of non-steroidal anti-inflammatory drugs in the elderly
Authors: Geraghty R J , Black D , Bruce S A
Published: December 2008

One hundred and nineteen consecutive elderly patients with endoscopically diagnosed peptic ulceration were reviewed. Associated gastric outflow obstruction was present in 10.1%. The presenting clinical features differed significantly from typical younger patients and most (11/12) were taking non-steroidal anti-inflammatory drugs, suggesting a possible role for these agents in the pathogenesis of gastric outflow obstruction. These elderly patients have been successfully managed by medical therapy alone.
Staphylococcal enterotoxins in scarlet fever complicating chickenpox
Authors: Brook M G , Bannister B A
Published: December 2008

Two cases of scarlet fever are described, both following super-infection of chickenpox. Enterotoxin B and C producing staphylococci were the only pathogens identified. The role of staphylococcal and streptococcal toxins in the pathogenesis of scarlet fever and toxic shock syndrome is discussed.
Clubbing associated with oesophageal adenocarcinoma
Authors: Polkey M I , Cook G R J , Thomson A D , Taylor N F
Published: December 2008

A patient with an oesophageal adenocarcinoma, recent onset of digital clubbing, and evidence of increased oestrogen synthesis is presented. In the discussion, some of the theories of the pathogenesis of clubbing are reviewed, together with previous reports of clubbing in gastro-oesophageal disorders. A possible unifying theory is proposed for our case which we believe is the first report of this triple association.
Accidental golf club injuries
Authors: Pennycook A G , Morrison W G , Ritchie D A W
Published: December 2008

Over a 2 month period, 33 patients with injuries caused by golf clubs were identified among attenders at the accident and emergency department at Glasgow Royal Infirmary. The vast majority of these were to the face and head, including three compound skull fractures. Attention is drawn to the average age of those injured (8.1 years) and to the fact that only one of the injuries occurred on a golf course. The dangers of unsupervised experimentation with golf clubs by young children are emphasized.
Mania in association with hydrocortisone replacement for Addison's disease
Authors: Ur E , Turner T H , Goodwin T J , Grossman A , Besser G M
Published: December 2008

A 32 year old woman with untreated primary adenocortical insufficiency presented with prominent depressive symptoms. Upon treatment with physiological doses of glucocorticoids she developed a self-limiting acute manic illness. We suggest that up-regulation of hippocampal glucocorticoid receptors as a consequence of prolonged hypocortisolaemia resulted in increased cerebral sensitivity to exogenous corticosteroids, which are known to precipitate manic symptoms in some normal individuals when given in supraphysiological doses.
Post-infectious encephalomyelitis associated with Mycoplasma pneumoniae and Legionella pneumophila infection
Authors: Easterbrook Philippa J , Smyth Edward G
Published: December 2008

A case of severe acute encephalomyelitis associated with a serological diagnosis of both Mycoplasma pneumoniae and Legionella pneumophila infection is reported. Serological co-positivity between these two pathogens has been reported previously, and has, in general, been attributed to cross-reactivity. This is the first documented case of co-infection using more sensitive and specific serological techniques. The potential significance of these findings is discussed in the context of the considerable problems in the interpretation of serological data.
Osteomalacia should be sought and treated before withdrawal of anticonvulsant therapy in UK Asians
Authors: Macallan D C , Maxwell J D , Eastwood J B
Published: December 2008

Individuals from the Asian sub-continent in the United Kingdom are at particular risk of developing osteomalacia. We report a Gujarati woman who developed osteomalacia whilst taking anticonvulsant drugs; withdrawal of anticonvulsant therapy was followed by a seizure complicated by femoral neck fracture.

In patients with other risk factors for osteomalacia, as is the case for Asians living in Britain, anticonvulsant drugs should not be reduced or withdrawn until osteomalacia, which puts the skeleton at increased risk of fracture, and its associated hypocalcaemia, which reduces seizure threshold, have been sought and adequately treated.
Difficulties in localization and treatment of insulinomas in type 1 multiple endocrine adenomatosis (MEA)
Authors: Winocour Peter H , Moriarty Kieran J , Hales C Nicholas , Adams Judy , Reeve Roy , Wynick David , Allison David , Bloom Steven R , Anderson David C
Published: December 2008

A 15 year old girl with a family history of type 1 multiple endocrine adenomatosis presented with reversible neurological disturbances, hypoglycaemia and hyperinsulinaemia. Initial radiology was normal, but portal venous sampling suggested an insulinoma in the tail of the pancreas which was removed with conservation of the spleen. Hypoglycaemia persisted despite high doses of diazoxide and intravenous dextrose. A second laparotomy revealed a pancreatic endocrine tumour and sub-total pancreatectomy was performed. Histology revealed islet cell microadenomatosis. Hypoglycaemia persisted despite treatment with somatostatin analogues and 40% intravenous dextrose was required to maintain normoglycaemia. A possible lesion near the splenic hilum on computed tomographic scan was reported as a splenunculus although further peripheral, hepatic and portal venous sampling suggested hepatic or systemic lesions. A positron emission scan and selective visceral angiography suggested a lesion in the left upper quadrant. Acute lactic acidosis, rhabdomyolysis and renal failure supervened. Post mortem revealed the putative 'splenunculus' to be a residual insulinoma, whilst the splenic vein was thrombosed, accounting in part for discrepant venous sampling data.

Hyperinsulinaemia in type 1 multiple endocrine adenomatosis may require more aggressive surgical and hormonal intervention than when dealing with solitary insulinomas. Insulinomas may mimic developmental abnormalities on computed tomographic scanning.
Glomerulonephritis in sarcoidosis: causal relationship unproven
Authors: Howard R S , Gabriel Roger
Published: December 2008

Two patients with sarcoidosis and glomerular mesangial proliferative lesions are described. Although a causative relationship between sarcoidosis and glomerulonephritis has been suggested, critical review of the literature fails to confirm this.
Systemic calciphylaxis presenting as a painful, proximal myopathy
Authors: Edelstein C L , Wickham M K , Kirby P A
Published: December 2008

A renal transplant patient who presented with a painful, proximal myopathy due to systemic calciphylaxis is described. The myopathy preceded the characteristic skin and soft tissue necrosis. Systemic calciphylaxis should be considered in a dialysis or a renal transplant patient presenting with a painful proximal myopathy even in the absence of necrotic skin lesions.
Adult-onset mitochondrial myopathy
Authors: Fernandez-Sola J , Casademont J , Grau J M , Graus F , Cardellach F , Pedrol E , Urbano-Marquez A
Published: December 2008

Mitochondrial diseases are polymorphic entities which may affect many organs and systems. Skeletal muscle involvement is frequent in the context of systemic mitochondrial disease, but adult-onset pure mitochondrial myopathy appears to be rare.

We report 3 patients with progressive skeletal mitochondrial myopathy starting in adult age. In all cases, the proximal myopathy was the only clinical feature. Mitochondrial pathology was confirmed by evidence of ragged-red fibres in muscle histochemistry, an abnormal mitochondrial morphology in electron microscopy and by exclusion of other underlying diseases. No deletions of mitochondrial DNA were found.

We emphasize the need to look for a mitochondrial disorder in some non-specific myopathies starting in adult life.
Sotalol-induced torsade de pointes: management with magnesium infusion
Authors: Arstall Margaret A , Hii John T Y , Lehman Ronald G , Horowitz John D
Published: December 2008

A 69 year old woman was treated with sotalol (320 mg daily) for intermittent atrial fibrillation. Sotalol was initially well tolerated and reversion to sinus rhythm with sinus bradycardia occurred 4 weeks after initiation of therapy. Shortly thereafter, the patient developed recurrent syncope due to torsade de pointes. This was treated successfully with intravenous magnesium infusion and withdrawal of sotalol. Subsequently, the atrial fibrillation was adequately managed using amiodarone, with no recurrence of torsade de pointes. Development of bradycardia associated with reversion to sinus rhythm represents a potential cause of 'late' pro-arrhythmic effects of sotalol.
Extended transduodenal sphincteroplasty for bile duct stones associated with a periampullary diverticulum
Authors: Akoglu Musa , Sahin Burhan , Davidson Brian R
Published: December 2008

Extended transduodenal sphincteroplasty has been suggested as an alternative to choledochoduodenostomy for the surgical management of bile duct stones associated with a periampullary diverticulum but its value has not previously been investigated. Over a 3 year period, nine patients underwent extended transduodenal sphincteroplasty for common bile duct calculi associated with a periampullary diverticulum with no operative or post-operative mortality and minimal morbidity. Follow-up ranging from 20 to 60 months has shown remission of pain in all but one patient, who has had a normal endoscopic cholangiogram and no further episodes of jaundice or cholangitis. Extended transduodenal sphincteroplasty is a safe and effective alternative to choledochoduodenostomy for the surgical management of choledocholithiasis associated with a periampullary diverticulum.
Blastomycosis-like pyoderma in a case of chronic myeloid leukaemia
Authors: Dutta Tarun K , James Joseph , Baruah M C , Ratnakar C
Published: December 2008

Blastomycosis-like pyoderma, a rare skin lesion which may clinically resemble true blastomycosis, is seen in immuno-compromised individuals. We report one such case in chronic myeloid leukaemia.
Lipid and lipoprotein metabolism in familial combined hyperlipidaemia during treatment of sporadic phaeochromocytoma: a case study
Authors: Winocour Peter H , Masud Tahir , Clark Frederick , Cooper Brendan G , Laker Michael F , Alberti K George M M
Published: December 2008

Lipid metabolism was evaluated during management of phaeochromocytoma in a 41 year old non-obese post-menopausal women with familial combined hyperlipidaemia. The main effect of the excess catecholamine secretion on lipid metabolism was increased lipolytic activity, lower serum triglyceride and increased HDL cholesterol concentrations, compared with findings following removal of the tumour. Before removal of the tumour, the use of beta blockers alone led to marked deterioration of the hyperlipidaemic state, and combined α and beta blockade additionally led to a marked reduction in fat oxidation and lipoprotein lipase activity. Overactivity of the adrenergic system leads to changes in lipid metabolism in phaeochromocytoma. Treatment of the phaeochromocytoma may lead to worsening of hyperlipidaemia pre-existing in such individuals.
Systemic lupus erythematosus in 50 year olds
Authors: Domenech I. , Aydintug O. , Cervera R. , Khamashta M. , Jedryka-Goral A. , Vianna J. L. , Hughes G. R.
Published: December 2008

We compared the clinical and serological characteristics of 15 patients with onset of systemic lupus erythematosus after the age of 50 with those of 232 younger patients. The sex distribution was similar in both groups. All 15 patients were Caucasian. Autoimmune thyroiditis was found in 20% of the elderly patients. Initial manifestations, which presented more frequently in the older group, included thrombocytopenia (P < 0.05), sicca syndrome (P < 0.01) and cardiomyopathy (P < 0.005), whereas butterfly rash (P < 0.05) presented more frequently in the younger group. Analysis of cumulative clinical symptoms showed that butterfly rash (P < 0.05) and livedo reticularis (P < 0.05) were less frequent in the elderly. However, this group presented a significantly increased incidence of sicca syndrome (P < 0.005) and cardiomyopathy (P < 0.005). Antibodies to double-stranded DNA tended to occur less frequently in older patients (P < 0.05).
Intussusception in the adult: clinical, radiological and histological features
Authors: Courtney Stephen P. , Ibrahim Nassif , Longstaff Andrew J. , Davidson Colin M.
Published: December 2008

Intussusception in the adult is an unusual cause of bowel obstruction. Unlike in childhood the clinical presentation is not clear cut and there are no distinct pathognomonic features. The radiological features are variable. Five patients presented to Frenchay Hospital over a five month period. The patients' clinical courses demonstrate the differing presenting features. Ultrasound investigation and CT scanning may show characteristic signs. Surgical treatment is mandatory as there is nearly always an underlying pathological abnormality which may be malignant.
Lipomatosis of the ileocaecal valve simulating Crohn's disease
Authors: Bhupalan A.J. , Forbes A. , Lloyd-Davies E. , Wignall B. , Murray-Lyon I.M.
Published: December 2008

A case of lipomatosis of the ileocaecal valve mimicking Crohn's disease of the terminal ileum is reported.
Influence of cigarette smoking on the outcome of coronary care unit admissions with chest pain
Authors: Mallya S , Calverley P M A , MacFarlane I A , Hughes S , Johnston G , van Heyningen C
Published: December 2008

We studied the effect of current smoking habits in the period immediately before admission to hospital in 90 consecutive patients presenting with chest pain, 50 of whom were shown to have myocardial infarction. Urine cotinine/creatinine (cot/creat) ratio measured within 4 hours of admission was used as an objective marker of cigarette smoking in the preceding 18 hours. Fifty-seven patients had urine cot/creat ratios suggesting recent smoking, although four of these denied smoking. Patients with myocardial infarction had higher median cot/creat ratios (3.31 micrograms/mg, range 0-17.8) compared with patients with non-infarct chest pain (0.5 microgram/mg, range 0-37.2). Sixteen patients with cardiac rhythm disturbances following infarction had significantly higher cot/creat ratios than the 34 infarct patients without this complication (median and range 8.34 micrograms/mg; 0-17.8 V. 1.87 micrograms/mg; 0-16.4, P < 0.01). Tobacco use in the 24 hours before myocardial infarction may predispose to cardiac rhythm disturbance, irrespective of infarct size.
An overview of survival studies in patients with heart failure
Authors: Oldershaw Paul J
Published: December 2008

Heart failure is associated with poor prognosis, but recent large-scale investigations have generated valuable and practical information to help improve clinical management and patient survival. This review presents an overview of the findings of recent heart failure survival studies and how these may affect therapeutic strategy for patients with this condition.
Costovertebral joint dysfunction: another misdiagnosed cause of atypical chest pain
Authors: Arroyo J F , Jolliet Ph , Junod A F
Published: December 2008

The diagnostic work-up of atypical chest pain frequently leads to invasive procedures. However, this painful symptomatology can sometimes be of benign origin and respond to simple therapeutic manoeuvres. A number of musculoskeletal conditions such as costovertebral joint dysfunctions should be carefully considered. We report five cases in which patient discomfort and high costs could have been avoided if awareness of these conditions had led to a correct diagnosis upon initial physical examination.
Malignant fibrous histiocytoma of the pulmonary vein with prolapse through the mitral valve orifice
Authors: Khan Miqdad Ali , Davidson Robert C
Published: December 2008

We present the case of a 33 year old white woman with malignant fibrous histiocytoma arising from the pulmonary vein and prolapsing through the mitral valve, causing acute heart failure. The patient underwent emergency cardiothoracic surgery with resection of the tumour while on cardiopulmonary bypass. The patient's heart failure improved immediately following the resection, demonstrating the benefit of palliative surgery. Adjuvant chemotherapy was recommended and the patient did well for 18 months of follow-up.
Primary renal renin secretion responding to angiotensin converting enzyme inhibition
Authors: Newrick P G , Millar N , Penney M , Corrall R J M
Published: December 2008

A case of primary renal renin secretion of probable neoplastic origin is reported. Investigation demonstrated renin secretion to be incompletely autonomous with suboptimal suppression to posture and hypervolaemia. Easy control of the hypertension and hypokalaemia was achieved with an angiotensin converting enzyme inhibitor. Such treatment may prove to be a preferable option to surgery.
Safety of anticoagulation in the elderly: reasons for discontinuing therapy
Authors: O'Neill P A , Crossley D , Taberner D A , Fairweather D S
Published: December 2008

We have conducted a retrospective study on the reasons for discontinuing anticoagulants in 50 patients over the age of 75 years compared with 198 adults under 75 years to determine the safety of therapy in the elderly. Venous thromboembolism and arterial embolization were the most common indications for therapy in the elderly and the median duration of therapy in all patients was 7 months (9 days-22 years). There were no deaths attributable to anticoagulants. There was no significant difference in the proportion of elderly patients who stopped treatment because of bleeding compared with 198 patients under 75 years (5/50 (10%) vs 12/198 (6.1%), P = 0.26), nor in the rate of bleeding between the two groups (5/52.5 (9.5%) treatment-years vs 12/249 (4.8%) treatment-years, P = 0.15). This complication rate does not suggest that age per se is a risk factor in the use of oral anticoagulants.
Biliary peritonitis secondary to perforation of common bile duct: an unusual presentation of chronic calcific pancreatitis
Authors: Kumar Arvind , Kataria R , Chattopadhyay T K , Karak P K , Tandon R K
Published: December 2008

Common bile duct perforation causing biliary peritonitis is an unusual entity and a pancreatic calculus causing this perforation is all the more rare, and to our knowledge has not been reported previously. Such an unusual presentation of chronic calcific pancreatitis is herein reported.
The role of rigid oesophagoscopy in oesophageal carcinoma
Authors: Ritchie A J , McManus K , McGuigan J , Stevenson H M , Gibbons J R P
Published: December 2008

The efficacy and safety of rigid oesophagoscopy in diagnostic and therapeutic settings in a consecutive series of 404 patients with oesophageal carcinoma were studied and compared to that for flexible oesophagoscopy in the same group. In addition, we examined the same parameters in a smaller group who had undergone radiotherapy with subsequent malignant stricturing. We performed 328 rigid procedures and 118 flexible procedures in a single regional surgical referral unit over a 7 year period. The combined perforation rate was 1.3%, with an overall mortality of 1% from 446 procedures.

We conclude that rigid oesophagoscopy in the presence of carcinoma retains an important diagnostic and therapeutic role which can be achieved with low incidence of perforation in high-risk patients.
Streptococcus bovis endocarditis as a presenting manifestation of idiopathic ulcerative colitis
Authors: Moshkowitz M , Arber N , Wajsman R , Baratz M , Gilat T
Published: December 2008

Streptococcus bovis bacteraemia and endocarditis have been associated with several gastrointestinal diseases, mainly malignant or potentially malignant tumours, and less commonly non-malignant gastrointestinal disorders. We describe a 73 year old man in whom Streptococcus bovis endocarditis developed, and was the presenting manifestation of undiagnosed quiescent ulcerative colitis. Such an association has not been described previously.
Cigarette smoking and Helicobacter pylori infection
Authors: Bateson Malcolm C
Published: December 2008

The direct urease test was used in 462 patients with normal upper digestive tracts, 108 with duodenal ulcers and 43 with gastric ulcers who attended for upper digestive endoscopy in a prospective study. There was a strong association between Helicobacter pylori infection and current cigarette smoking in patients with normal endoscopy (49.6% vs 35.5%, P < 0.01). The associations of peptic ulcer both with H. pylori infection and cigarette smoking were also confirmed.

The excess of peptic ulcer disease in cigarette smokers may be explained by their increased susceptibility to H. pylori infection.
Acute mesenteric ischaemia: the continuing difficulty in early diagnosis
Authors: Heys Steven D , Brittenden Julie , Crofts Trevor J
Published: December 2008

Five cases of acute intestinal ischaemia due to occlusion of the superior mesenteric artery, all with a delay in diagnosis, are reported here. These cases illustrate the continuing difficulties, in clinical practice, in recognizing mesenteric ischaemia before intestinal infarction has occurred, despite the clinical awareness of this condition.
Keloid of the penis after circumcision
Authors: Warwick D J , Dickson W A
Published: December 2008

We report what we believe is the first documented case of keloid formation on the penis following circumcision.
Intestinal infarction following carbon monoxide poisoning
Authors: Balzan M , Cacciottolo J M , Casha A
Published: December 2008

A 65 year old patient admitted with carbon monoxide poisoning developed acute pulmonary oedema during treatment with hyperbaric oxygen. After initial recovery he developed extensive intestinal ischaemia which rapidly led to death. It is suggested that intestinal vasoconstriction due to left ventricular failure made the gut much more vulnerable to the hypoxic effects of carbon monoxide than the brain and heart.
Obstructive sleep apnoea associated with syringomyelia
Authors: Ellis C , Curzen N , Katifi H
Published: December 2008

We present a case of obstructive sleep apnoea in association with syringomyelia. We describe the successful treatment of the respiratory obstruction by continuous positive airway pressure and then by surgical means. This rare combination of conditions and the management is reviewed.
Toxic megacolon with late perforation in Campylobacter colitis - a cautionary tale
Authors: Vyas Samir K , Law Nicholas N , Hill Simon , Loehry Christian A
Published: December 2008

We report a case of Campylobacter-induced colitis complicated by toxic megacolon which led to colonic perforation requiring a total colectomy and ileostomy.
Combined transhepatic and endoscopic procedures in the biliary system
Authors: Verstandig Anthony G , Goldin Eran , Sasson Talia , Weinberger Gerald , Wengrower Dov , Fich Alex , Lax Emeric
Published: December 2008

Endoscopic biliary procedures are 89-97% successful in skilled hands. The commonest causes of failure are inability to cannulate the papilla of Vater due to difficult anatomy or tortuosity of the distal common bile duct and failure to cross a rigid biliary stricture. In nearly all of these cases, successful endoscopic procedures can be completed after percutaneous antegrade placement of a small catheter or guidewire to the duodenum. In 44 such combined procedures on 42 patients, the success rate was 43 (98%). There were two severe and eight mild complications. Combined procedures overcome the difficulties caused by tortuous biliary ducts and rigid strictures while obviating the need for more extensive percutaneous procedures and transhepatic tract dilatation.