bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessment of pancreatic duct damage following trauma: is endoscopic retrograde cholangiopancreatography the gold standard?
Authors: Doctor N , Dooley J S , Davidson B R
Published: December 2008

A 12-year-old girl was admitted as an emergency with blunt pancreatic trauma. Computed tomography (CT) showed an intact pancreas. She failed conservative treatment. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated division of the pancreatic duct at the neck of pancreas. At laparotomy, however, there was complete necrosis of the pancreatic head. She recovered well following enteric drainage of the body of pancreas. CT and ERCP are considered the optimal imaging for pancreatic trauma but the findings may be misleading.
Dysphagia, a reversible cause not to be forgotten
Authors: Thomas M , Haigh R A
Published: December 2008

An 84-year-old man presented with dysphagia two years after the onset of symptoms. Repeated assessments at both ENT and neurology clinics had not recorded any of the more classical signs of Parkinson’s disease and these did not become apparent until intercurrent illness had been treated. Once diagnosed, treatment was started and dramatic improvement was seen.
Resuscitation training
Authors: Shepherd A
Published: December 2008

All physicians, dentists, nurses and health care personnel should be adequately and regularly trained in cardiopulmonary resuscitation. Guidelines for acquiring the necessary skills in basic and advanced life support are now available.
Occult small bowel adenocarcinoma complicating Crohn’s disease: a report of three cases
Authors: Gillen C D , Wilson C A , Walmsley R S , Sanders D S A , O’Dwyer S T , Allan R N
Published: December 2008

Three patients with Crohn’s disease are described who were treated by ileal resection for intestinal obstruction. Histological examination of the resected specimen in each case established the diagnosis of adenocarcinoma of the small intestine complicating Crohn’s disease. This diagnosis should be considered in patients with longstanding macroscopic Crohn’s disease who present with severe or recurrent symptoms. The diagnosis may not be apparent on routine radiological examination or even macroscopically at laparotomy.
Role of TSH measurements in predicting the outcome of treatment for Graves’ disease following drug therapy
Authors: Wood W E A
Published: December 2008

Thyroid-stimulating hormone (TSH) levels obtained one month after the cessation of anti-thyroid drug treatment were assessed retrospectively for possible use in predicting outcome in 50 patients with a clinical diagnosis of Graves’ disease. Thirty-four patients remained in remission at the end of the follow-up period and 16 patients relapsed. Although a TSH level of < 1.2 mU/1 did not discriminate between the two groups, none of the 24 patients who had TSH levels of > 1.2 mU/1 relapsed during the follow-up period, making early discharge from the thyroid clinic possible for these patients.
Severe theophylline poisoning: charcoal haemoperfusion or haemodialysis?
Authors: Higgins R M , Hearing S , Goldsmith D J A , Keevil B , Venning M C , Ackrill P
Published: December 2008

Theophylline poisoning with a blood level of 183 mg/l in a 38-year-old man was treated with activated charcoal by mouth, but despite this the blood level of theophylline rose and there was circulatory collapse with rhabdomyolysis, acute renal failure and hyperthermia. Treatment with charcoal haemoperfusion and simultaneous haemodialysis was given, followed by continuous arteriovenous haemodialysis (CAVHD). Mean extraction rates of theophylline were 26% during CAVHD, and 86% during combined dialysis and charcoal haemoperfusion. During combined treatment, the mean extraction rate of haemodialysis was 62%, compared with 48% for charcoal haemoperfusion. In summary, activated charcoal given by mouth may be unable to prevent a rise in blood levels and the development of complications after substantial theophylline overdose. If theophylline is to be removed from the blood, a combination of charcoal haemoperfusion and haemodialysis will give the best clearance, but haemodialysis alone may be effective.
Poisoning due to an over-the-counter hypnotic, Sleep-Qik (hyoscine, cyproheptadine, valerian)
Authors: Chan T Y K , Tang C H , Critchley J A J H
Published: December 2008

The clinical features and risk of hepatotoxicity of ‘Sleep-Qik’ (valerian dry extract 75 mg, hyoscine hydrobromide 0.25 mg, cyproheptadine hydrochloride 2 mg) were determined in 23 patients treated in our hospital between 1988 and 1991. The main clinical problems were central nervous system depression and anticholinergic poisoning. There was no clinical evidence of acute hepatitis in the 23 patients after taking an average of 2.5 g of valerian (range 0.5 to 12 g). There was no evidence of subclinical liver damage in 12 patients who had routine liver function tests performed approximately 6-12 hours after ingestion. Delayed onset of severe liver damage was excluded in 10 patients in whom a telephone follow-up was possible. However, subclinical liver dysfunction in the acute stage (onset after 12-24 hours) and in the intervening period after discharge from hospital could not be excluded. To establish the risk of hepatotoxicity in long-term users and in those taking an overdosage of valerian, a much larger study of longer duration with serial liver function tests is clearly needed.
Iatrogenic Cushing’s syndrome due to nasal betamethasone: a problem not to be sniffed at!
Authors: Nutting C M , Page S R
Published: December 2008

Nasal steroid drops for the treatment of allergic rhinitis can cause iatrogenic Cushing’s syndrome and care should be taken with their use in clinical practice.
Central pontine myelinolysis following orthotopic liver transplant: association with cyclosporine toxicity
Authors: Kabeer M H , Filo R S , Milgrom M L , Pescovitz M D , Leapman S B , Lumeng L , Jindal R M
Published: December 2008

Central pontine myelinolysis can occur after orthotopic liver transplantation leading to high mortality and serious morbidity. In our case, central pontine myelinolysis was associated with wide fluctuations in cyclosporine levels during an episode of hypocholesterolaemia, which may have precipitated central pontine myelinolysis.
Hypopituitarism in primary haemochromatosis; recovery after iron depletion
Authors: Gama R , Smith M J , Wright J , Marks V
Published: December 2008

We report a case of primary haemochromatosis complicated by anterior hypopituitarism which recovered after aggressive venesection therapy. Reversal of anterior hypopituitarism in haemochromatosis following iron depletion has not been previously described.
Malignant transformation in a fatal case of giant cell tumour of the sacrum
Authors: Crew J P , Flannery M , Manners B , Coates C J
Published: December 2008

Most giant cell tumours can be treated by local surgery and only rarely are they life threatening. We report a case of a giant cell tumour of the sacrum causing irresectable and fatal small bowel obstruction following malignant transformation of the tumour. The role of radiotherapy in this transformation is discussed.
Amyloid goitre and hypothyroidism secondary to cystic fibrosis
Authors: Alvarez-Sala R , Prados C , Sastre Marcos J , García Río F , Vicandi B , de Ramón A , Villamor J
Published: December 2008

Although cystic fibrosis (CF) is still the most frequently fatal childhood disease, many adults now survive into their third and fourth decades. Uncommon complications of chronic diseases, such as amyloidosis, while infrequent, may now appear during the course of CF in adulthood. We present a case of a patient with CF who was diagnosed with hypothyroidism due to amyloid deposits in the thyroid.
Primary duodenal carcinoma
Authors: Adedeji O A , Trescoli-Serrano C , Garcia-Zarco M
Published: December 2008

Eight cases of primary duodenal carcinoma in a district general hospital are presented. The cases highlight the advanced state of the disease at presentation, the difficulty in diagnosis, and its poor prognosis. Duodenal carcinoma occurs in both sexes worldwide with no predisposing factors in the majority of cases. There is an increased risk in patients with familial adenomatous polyposis and adenomas of the duodenum. Duodenal carcinoma occurs about 22 years from the diagnosis of familial adenomatous polyposis in about 2% of patients, forming over 50% of upper gastrointestinal cancers occurring in these patients. Carcinomatous changes occur in 30 to 60% of duodenal villous adenomas and much less in tubulo-villous and tubular adenomas. These categories of patients should be screened and adequately followed up. Aggressive and radical surgery, even in the presence of locally advanced disease and lymph node involvement, gives a better outcome. When curative surgery is not possible, chemotherapy must accompany palliation with or without radiotherapy. Pre-operative chemotherapy may facilitate a curative radical resection. The general five-year survival is 17-33% but some centres have achieved a five-year survival of 40-60% with aggressive management of these patients.
Covert bronchogenic cyst as a cause of life-threatening cardiopulmonary impairment
Authors: Mather E A , Hogg J I C , Miller A R O
Published: December 2008

We present a case in which a covert bronchogenic cyst resulted in two hospital admissions within three years, the second of which was characterised by life-threatening cardiopulmonary compromise requiring sustained support on the intensive therapy unit.
Gastrointestinal haemorrhage associated with free-base (crack) cocaine
Authors: Fennell D A , Gandhi S S , Prichard B N C
Published: December 2008

We report a case of a crack user presenting with chronic gastrointestinal haemorrhage due to deep gastric ulceration; the putative aetiology being predictable from this agent’s pharmacology.
The economic and quality-of-life benefits of Helicobacter pylori eradication in chronic duodenal ulcer disease--a community-based study
Authors: Phull P S , Ryder S D , Halliday D , Price A B , Levi A J , Jacyna M R
Published: December 2008

A policy of Helicobacter pylori eradication in patients with duodenal ulceration on long-term acid-suppressing therapy was evaluated in a prospective study amongst a general practice population, with particular reference to economic and quality-of-life benefits. One hundred and sixty-eight patients on long-term acid-suppressing therapy had chronic duodenal ulcer disease of whom 88 were eligible for the study; 45 patients attended for review, with 42 testing positive for H pylori (as assessed by 13C-urea breath test). The median duration of acid-suppressing therapy was six years (maximum 15 years); 47.6% of the patients were using additional antacids and 80.9% still experienced epigastric discomfort. Two-thirds (28/42) of the patients eradicated H pylori. Successful eradication was associated with a highly significant reduction in all symptoms. At 12 months follow-up, heartburn had decreased from 28.7% to 7.1%, epigastric discomfort from 75% to 3.6%, nausea from 32.1% to 0% and wind from 50% to 0%. Of the patients that eradicated H pylori 96.4% reported an improvement in their general health compared to none of those that remained H pylori positive. Successful H pylori eradication therapy scored higher on satisfaction ratings than long-term acid-suppressing therapy. Eradication of H pylori resulted in 27/28 patients being able to discontinue acid-suppressing therapy, representing a 5.8% reduction in the use of such drugs per year in the local general practice population. A policy of H pylori eradication in chronic duodenal ulcer disease reduces the use of long-term acid-suppression therapy in general practice. This has important financial implications as well as offering considerable symptomatic benefits to the patients and improving their quality of life.
Popliteal vein thrombosis associated with femoral osteochondroma and popliteal artery pseudoaneurysm
Authors: Scott E M , White F J , Jennings P E
Published: December 2008

Deep vein thrombosis is a common condition thought to be caused by impaired venous blood flow or hypercoagulable blood states. However, often no predisposing cause can be found. We describe a deep vein thrombosis formed in association with femoral osteochondroma and popliteal artery pseudoaneurysm. It is an interesting combination that has only been described once before.
Pellagra complicating Crohn’s disease
Authors: Zaki I , Millard L
Published: December 2008

We report a 53-year-old patient with clinical features of pellagra as a complication of Crohn’s disease. His symptoms improved rapidly on taking oral nicotinic acid and vitamin B complex. We suggest the paucity of reported cases of pellagra in Crohn’s disease is a reflection of poor recognition of this complication.
The older driver--a review
Authors: Morgan R , King D
Published: December 2008

There are differences between elderly drivers and younger drivers in that the elderly are more likely to have cognitive, motor and sensoriperceptual deficits affecting their driving performance. The elderly driver is more likely to have a chronic illness and to be on medication, that might adversely affect driving. The elderly driver requires more study and help either by retraining or provision of adaptations to vehicles. Fitness to drive is of clinical importance to doctors in most specialities and recent studies would suggest that doctors need to be more aware of the current guidelines on driving and be prepared to offer advice.
Hyperkalaemia in diabetes: prevalence and associations
Authors: Jarman P R , Kehely A M , Mather H M
Published: December 2008

Hyperkalaemia is associated with diabetes, but there are no recent reports of its prevalence and associations. Serum potassium concentrations were measured in all 1764 patients attending a diabetic clinic over a 12-month period and found to be > 5.0 mmol/l in 270 (15%), and > 5.4 mmol/l in 67 (4%). There was no other evident cause of hyperkalaemia in 41 of these 67 patients. These data serve to highlight the risk of dangerous hyperkalaemia in diabetic patients, particularly with concurrent administration of angiotensin-converting-enzyme inhibitors and potassium-sparing diuretics.
Rapidly progressive glomerulonephritis complicating acute rheumatic fever
Authors: Akasheh M S , al-Lozi M , Affarah H B , Hajjiri F K , al-Jitawi S
Published: December 2008

A case of acute rheumatic fever and glomerulonephritis following streptococcal throat infection is presented. The coincidence of rheumatic fever and post-streptococcal glomerulonephritis is uncommon, but well recognised. This case is of additional interest since the nephritis was crescentic.
Pure white cell aplasia and health food products
Authors: Forsyth P D , Davies J M
Published: December 2008

The safety of ‘health’ foods and complementary medicine products is increasingly questioned. We report a case of pure white cell aplasia developing in a patient who took a variety of such products leading to an excessive intake of zinc. Recovery was complete following the withdrawal of her ‘medications’. The aetiology of the pure white cell aplasia is discussed with respect to the ingredients of the products ingested.
Discussing cardiopulmonary resuscitation with patients and relatives
Authors: Stewart K
Published: December 2008

This paper aims to give clear guidance for doctors working in the UK about their responsibilities when discussing cardiopulmonary resuscitation with patients and their relatives. The ethical and legal framework for making decisions is outlined and the commonly encountered dilemmas are discussed.
The management of central post-stroke pain
Authors: Bowsher D
Published: December 2008

Central post-stroke pain (CPSP) used to be known as ‘thalamic syndrome’. Early post-mortem studies showed that many cases had extrathalamic lesions, and modern imaging methods have confirmed and extended these findings. CPSP affects between 2 and 6% of stroke patients, ie, there is an annual incidence in the UK of between 2000 and 6000. Most patients with CPSP appear to be younger than the general stroke population, and usually to have relatively mild motor affliction; thus they may live for many years, giving a prevalence perhaps as high as 20,000. True CPSP, characterised by a partial or total deficit for thermal and/or sharpness sensations, is best treated initially with adrenergically active antidepressants. If these do not work, mexiletine may be added in suitable cases. Recent studies suggest that stimulation of the motor cortex or spinal cord by implanted electrodes may help patients resistant to medical treatment. Positive relaxation, as an adjuvant therapy, should be used in nearly all cases. Considerable or even total relief can be achieved in almost two thirds of patients. There is evidence that the sooner antidepressant treatment is begun, the more likely the patient is to respond; time should not be wasted trying conventional analgesics, which rarely have any significant effect.
The effect of nilvadipine on bloodflow in the dorsal pedis artery in type 2 diabetic patients--a study using duplex Doppler ultrasonography
Authors: Sone H , Okuda Y , Mizutani M , Kawakami Y , Bannai C , Yamashita K
Published: December 2008

The effects of nilvadipine on the peripheral circulation in the lower extremities using a duplex system of two-dimensional colour and pulse Doppler ultrasonography were studied in 32 patients with type 2 diabetes mellitus and mild essential hypertension. The patients (19 men and 13 women) were randomly divided into treatment and control groups. The anatomical cross-sectional area and blood flow index of the dorsal pedis artery were determined by colour and pulse Doppler ultrasonography before and 60 min after administration of 4 mg nilvadipine or placebo. Pulse rate and blood pressure were measured simultaneously. There were no significant changes in pulse rate or blood pressure after administration of either drug. Both cross-sectional areas (from 4.3 +/- 0.4 to 5.2 +/- 0.5 mm2, p < 0.05) and blood flow index (from 40.3 +/- 4.3 to 58.8 +/- 9.0, p < 0.05) were significantly increased in the treatment group, whereas there were no significant changes in either measurement in the control group. The findings showed that a single administration of nilvadipine increases blood flow in the dorsal pedis arteries of diabetic patients.
Spontaneous regression of pulmonary mucormycosis
Authors: Abraham P , Govil S , Srivastava V M , Ganesh A
Published: December 2008

A case of pulmonary mucormycosis with spontaneous resolution is presented. The patient had no known underlying predisposing disease.
Medical examinations for pilots
Authors: Nicholson P J
Published: December 2008

High altitude is an environment that is alien to man. Stressors associated with the mechanics of flight include motion and acceleration forces applied in three vectors and in degrees that are foreign to the human vestibular apparatus. Furthermore, the work patterns of a pilot can interfere with lifestyle and circadian rhythms. Therefore medical fitness is an important consideration in determining an individual’s suitability to exercise a pilot’s licence. The medical standards applied depend on the type of aircraft flown and the duties expected of a pilot. There are three broad categories of pilot. In ascending order of stringency of medical standards these are the private pilot, the professional pilot and the military pilot.
Anorexia nervosa--diagnosis, aetiology, and treatment
Authors: Hartman D
Published: December 2008

The aetiology, assessment and treatment of anorexia nervosa are reviewed in the light of the classical accounts of Morton, Lasègue and Gull. The core symptoms are deliberate weight loss, disturbed body image and amenorrhoea, and complications may include cardiac failure, electrolyte disturbances, hypothermia and osteoporosis. Common clinical findings are described. Disturbed brain serotonin activity is implicated in the aetiology of anorexia nervosa, but there is little support for the use of pharmacological treatments. Psychological theories of aetiology are discussed with reference to Bruch, Crisp, Palazzoli and Minuchin: the common theme is the reaction of the patient and her family to the physical and social changes of puberty. Individual and/or family psychotherapy is seen as central to the treatment of anorexia nervosa, and the relevant clinical research is reviewed. The roles of general practitioners, general psychiatrists and eating disorder specialists are discussed in the light of recent consensus treatment guidelines.
The effects of octreotide in a patient with Nelson’s syndrome
Authors: Kelestimur F , Utas C , Ozbakir O , Selçuklu A , Kandemir O , Ozcan N
Published: December 2008

We have administered octreotide, 100 micrograms tid, to a 27-year-old man with Nelson’s syndrome. After seven days of therapy, adrenocorticotropin levels fell to 54% of initial values, and some shrinkage of the tumour was observed. This study indicates that octreotide therapy may have a role in the treatment of Nelson’s syndrome.
A reader’s guide to the evaluation of prognostic studies
Authors: van Walraven C , Hébert P C
Published: December 2008

In this article, we review guidelines which may be used to evaluate studies documenting prognosis. We describe a clinical problem involving the prognosis of a patient in an intensive care unit. An approach to the literature search is then outlined. The results of the literature search are described and criteria for the appraisal of articles describing prognosis and prognostic factors are discussed using one article as an example.
Bleeding in a patient taking Lorenzo’s oil: evidence for a vascular defect
Authors: Chai B C , Etches W S , Stewart M W , Siminoski K
Published: December 2008

We describe a man with adrenoleukodystrophy receiving Lorenzo’s oil (glycerol trioleate and glycerol trierucate) who developed purpura, petechiae, and bleeding. Bleeding time was markedly increased (>20 min), although he had only borderline thrombocytopenia (120 x 10(9)/1) and conventional platelet aggregation studies were normal (except for a borderline response to low concentration collagen), as were results using a new technique employing immobilised von Willebrand factor. Together these results suggest that bleeding in this man resulted from a defect in vascular wall function or in the interaction of platelets with the endothelium.
Coronary flow reserve and oesophageal dysfunction in syndrome X
Authors: Chauhan A , Mullins P A , Gill R , Taylor G , Petch M C , Schofield P M
Published: December 2008

The relative prevalence of abnormalities of coronary flow reserve and oesophageal function was ascertained in 32 syndrome X patients with typical angina chest pain, a positive exercise test, and normal coronary arteries. Coronary flow reserve in response to a hyperaemic dose of papaverine was measured using an intracoronary Doppler catheter positioned in the left anterior descending coronary artery. An abnormal coronary flow reserve was defined as being < 3.0. Patients were investigated for oesophageal dysfunction by manometry and 24-hour pH monitoring. Thirteen patients had an impaired coronary flow reserve (group 1) and 19 patients had a normal flow reserve (group 2). Eight of the 13 group 1 patients (62%) and 13 of the 19 group 2 patients (68%, p = NS) had evidence of oesophageal dysfunction on either manometry or pH studies. Therefore, a total of 26 (81%) syndrome X patients had either an abnormality of coronary flow reserve or oesophageal dysfunction suggesting that chest pain in these patients may be due to myocardial ischaemia or oesophageal dysfunction, thus confirming the heterogeneous nature of this syndrome. The prevalence of oesophageal abnormalities was independent of any abnormalities of coronary flow reserve.
Your child is brain dead
Authors: Blair A W , Steer C R
Published: December 2008

One to two per cent of admissions to Paediatric Intensive Care Units eventually fulfil the criteria for brain death, implying the need for very difficult decisions. Brain death is defined as irreversible loss of function of the whole brain. The diagnostic criteria caused a great deal of anxiety but are now the subject of a consensus approach. When the situation can be anticipated it is of immense value for the professional staff to develop a good working relationship with the parents to help and support them through the phase of impending disaster and facing the issue when the time actually comes. However, it is vital to help parents to make their own decision regarding continuation or otherwise of life support and they should be supported in whichever decision they take. They must be absolutely convinced that the child is brain dead and this territory may have to be covered again and again in discussion, questions must be answered factually, and time allowed for reflection. Stage management of the process of ‘switching off’ is vital and the parents’ wishes may vary widely from one family to another. They must be warned what is likely to happen and provided with appropriate privacy and support for expression of their grief. The question of asking for post-mortem permission has to be handled sensitively and long-term support for the parents must be offered. Education of undergraduate and postgraduate doctors in this area is now receiving more attention with skills being increased by video teaching and role play. It should not be overlooked that the professional staff attending such patients sometimes require counselling and support themselves.
Intestinal permeability and orocaecal transit time in elderly patients with Parkinson’s disease
Authors: Davies K N , King D , Billington D , Barrett J A
Published: December 2008

The aetiology of weight loss in patients with Parkinson’s disease is likely to be multifactorial. We studied 15 patients with Parkinson’s disease and 15 age- and sex-matched controls and looked for evidence of malabsorption due to small bowel bacterial overgrowth or alteration of intestinal permeability. There was a marked increase in orocaecal transit time in the patients with Parkinson’s disease, although lactulose hydrogen breath testing did not show evidence of small bowel bacterial contamination. Intestinal permeability measured by the differential sugar absorption test was also deranged. There was reduced absorption of mannitol in patients with Parkinson’s disease while lactulose absorption was similar in both groups, suggesting decreased non-mediated uptake across the enterocyte brush border membrane in patients with Parkinson’s disease.
Hirsutism in the United Arab Emirates: a hospital study
Authors: Gatee O B , Al Attia H M , Salama I A
Published: December 2008

In a study of 102 women (Arabs and Asians) with hirsutism, polycystic ovary syndrome was diagnosed in 93 patients (91%) including 26 cases with hirsutism and regular menstrual periods. In more than half of the cases the diagnosis was made on the basis of transabdominal ultrasonography, which was the single test with the highest yield. Luteinising hormone hyperresponsiveness to gonadotropin-releasing hormone was positive in only seven of 50 patients tested. Late onset congenital adrenal hyperplasia due to 21-hydroxylase deficiency was identified in two cases, thus forming a prevalence of 8% in those who underwent adrenocorticotropin stimulation. In one case, polycystic ovary syndrome was an associated condition. In this study of a population of women with hirsutism and regular menses, the majority had polycystic ovaries. It is suggested that the term ‘idiopathic or racial’ hirsutism should not be applied unless a thorough evaluation has failed to reveal a diagnosable underlying disorder.
Late presentation of a solitary metastasis of renal cell carcinoma as an obstructive duodenal mass
Authors: Toh S K , Hale J E
Published: December 2008

We present a rare case of late solitary metastasis of renal cell carcinoma presenting with duodenal obstruction. Metastatectomy resulted in relief of symptoms and may improve long-term survival.
Sarcoidosis
Authors: Peckham D G , Spiteri M A
Published: December 2008

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology. The condition commonly affects young adults and frequently presents with bilateral hilar lymphadenopathy with or without pulmonary infiltration, ocular or cutaneous lesions. The clinical presentation can be extremely varied depending upon the organs affected. The diagnosis is firmly established when recognised clinical and radiographic findings are supported by histological evidence of discrete non-necrotising epithelioid cell granulomata in one or more organs. Sarcoidosis is usually self-limiting with spontaneous resolution, although in a few patients there is a progressive downhill course, culminating in irreversible fibrosis and severe impairment of organ function.
The development of healthcare services for diabetic prisoners
Authors: MacFarlane I A
Published: December 2008

The conditions experienced by people in custody in the UK have received considerable attention recently and there has been considerable debate concerning the standards of healthcare in British prisons. The Prison Health Care Service works under great pressure and difficulties and doctors have to deal with a large and ever-changing population, often with mental and physical disorders, who are frequently manipulative. This article highlights problems encountered in delivering diabetes care in prisons. Prisoners may self-induce diabetic ketoacidosis by refusing insulin injections, in order to be transferred to an outside hospital. On the other hand, prison staff may mis-interpret the symptoms of poorly controlled diabetes as ‘acting up’ by prisoners and inappropriate treatment can be given. If structured diabetes care is provided in prison, however, with close liaison between the Prison Staff and the local Diabetes Care Team, the basics of modern diabetes management can be provided. Good diabetic metabolic control can be achieved in the majority of patients, probably due to the rigid dietary regime, no alcohol and compliance with treatment. Imprisonment can ensure screening for diabetic complications and reassessment of treatment regimens. The British Diabetic Association guidelines for the provision of diabetes care in British prisons are outlined in this article.
Nesidioblastosis-associated hypoglycaemia presenting with prominent cardiac manifestations
Authors: Galizia A C , Fava S , Foale R
Published: December 2008

We present a case of nesidioblastosis presenting with hyperinsulinaemic hypoglycaemia and electrocardiographic abnormalities.
Primary coronary angioplasty in acute myocardial infarction
Authors: Grech E D , Ramsdale D R
Published: December 2008

It is well established that recanalisation of the infarct-related artery is of great benefit in the early hours after acute myocardial infarction. This can be achieved by the use of thrombolytic agents and/or by percutaneous transluminal coronary angioplasty (PTCA). This article reviews data on the role of primary PTCA and summarises current opinion on its use.
The distribution of antibodies to streptokinase
Authors: Lynch M , Pentecost B L , Littler W A , Stockley R A
Published: December 2008

To determine the distribution of antibodies to streptokinase that might be anticipated in patients requiring treatment with streptokinase, specific anti-streptokinase antibody titres were determined in a group of subjects from the general population and in a group of patients presenting with acute myocardial infarction. Enzyme-linked immunosorbent assays were developed to measure specific anti-streptokinase IgG and subclass IgG1 in 95 subjects from the general population and in 160 patients presenting with acute myocardial infarction. Low titres of IgG1 were found in both the general population (median = 5; range: 0-490) and in the myocardial infarction group (median = 7; range: 0-2000). A minority of subjects in both groups had high titres. The findings suggest that low titres of antibody are widespread in the population. The minority of subjects in both groups who had high titres may explain the infrequent type III immune reactions encountered with streptokinase.
Gerstmann’s syndrome
Authors: Sukumar S , Ferguson G C
Published: December 2008

Although Gerstmann’s syndrome has been well documented since it was characterised in the latter half of last century, there has not been much literature on it in the last few years. We present a classical case in a patient who was admitted into hospital for an unrelated problem. We conclude that clinical examination still has a valuable role in neurology, despite the availability of excellent imaging techniques.
Asymptomatic primary hyperparathyroidism
Authors: Birkenhäger J C , Bouillon R
Published: December 2008

The prevalence of hypercalcaemia in the adult population is probably between 0.6 and 1.1%, sufferers being predominantly women over 50 years of age. Most apparently asymptomatic hypercalcaemic patients are found to have primary hyperparathyroidism, and may in fact show some symptoms of the condition (lowered bone mineral density, cardiovascular disease and/or neuropsychiatric symptoms). The criteria for surgical intervention in these cases are discussed in the light of the high success rate of parathyroidectomy in experienced hands and the lack of effective alternative treatments.
Training in anaesthesia: the US perspective
Authors: Strang T I , Ball D R
Published: December 2008

In the light of the recent Calman Report and the Royal College of Anaesthetists document ‘Specialist training in anaesthesia, supervision and assessment’, there is currently much debate concerning the future of anaesthesia training in the UK. We present a description of anaesthesia training in the US for discussion and comparison. US residency training is short and seamless. It is highly structured, but retains a capacity for specialisation. It may offer ideas for the future direction of training in the UK.
Klippel-Trenaunay syndrome
Authors: Jolobe O M
Published: December 2008

The Klippel-Trenaunay syndrome, typically characterised by the triad of cutaneous haemangioma, venous varicosities, and limb hypertrophy, may also have a formes frustes presentation, with absence of the cutaneous naevus. A case is reported in a 75-year-old woman with a presumptive diagnosis of renovascular hypertension.
Changes in haemodynamic parameters following Tai Chi Chuan and aerobic exercise in patients recovering from acute myocardial infarction
Authors: Channer K S , Barrow D , Barrow R , Osborne M , Ives G
Published: December 2008

In this study, 126 patients (90 males, average age 56 years, range 39-80) were randomised to Wu Chian-Ch’uan style Tai Chi (38), aerobic exercise (41) or a non-exercise support group (47) following acute myocardial infarction. Patients attended twice weekly for three weeks then weekly for a further five weeks. Heart rate and blood pressure were recorded before and after each session. Over the 11 sessions of exercise there was a negative trend in diastolic blood pressure only in the Tai Chi group (Rs = 0.79, p < 0.01). Significant trends in systolic blood pressure occurred in both exercise groups (Rs = 0.64 and 0.63, both p < 0.05). Only four (8%) patients completed the support group eight-week programme which was less than the number completing Tai Chi (82%; p < 0.001) and aerobic exercise groups (73%; p < 0.001).
Coronary subclavian steal syndrome following coronary by-pass surgery
Authors: Kneale B J , Irvine A T , Coltart D J
Published: December 2008

The coronary steal syndrome is an uncommon but well recognised occurrence following coronary artery by-pass surgery using the internal mammary artery. We report a case of coronary steal successfully treated with percutaneous transluminal angioplasty of a subclavian stenosis.
Cytomegalovirus causing acute colonic pseudo-obstruction in a renal transplant recipient
Authors: Shrestha B M , Darby C , Fergusson C , Lord R , Salaman J R , Moore R H
Published: December 2008

A female patient presented with pyrexia and features of large intestinal obstruction, 10 weeks posttransplantation, with biopsy-proven colitis caused by cytomegalovirus (CMV) and positive CMV antigenaemia and IgM tests. The symptoms resolved after treatment with ganciclovir, nasogastric aspiration and intravenous fluid replacement.
Schmidt’s syndrome associated with sarcoidosis
Authors: Watson J P , Lewis R A
Published: December 2008

We present a case of Schmidt’s syndrome (autoimmune Addison’s disease and hypothyroidism) associated with sarcoidosis. There have been only four previous reports of Schmidt’s syndrome with sarcoidosis, and a possible fifth with negative autoantibodies. We have been able to find only four other reports of adrenal failure (without hypothyroidism) in sarcoidosis. It is important to be aware of the potential for masking the diagnosis of Addison’s disease by steroid treatment.
Imaging the spine
Authors: Gibson M , al-Kutoubi A
Published: December 2008

This article on neuroradiology concerns the imaging of the spine. The imaging modalities are discussed, and some basic imaging strategies are outlined.
Reverse sequestration in a case of sickle crisis
Authors: Lee E S , Chu P C
Published: December 2008

A patient with homozygous sickle cell disease presented with sickle crisis complicated by hepatic and pulmonary sequestration and required intensive therapy. During the recovery phrase she developed a rapid rise of haemoglobin concentration, unrelated to blood transfusion, followed by hypertension, congestive cardiac failure and catastrophic intracerebral haemorrhage. This serious haemodynamic disturbance was considered to be caused by a reversal of the sequestration process. Careful monitoring of a sickle cell patient’s blood pressure, blood counts, haematocrits, haemoglobin S level and plasma viscosity, even after the end of a sequestration crisis, is recommended.
Training for visiting registrars: experience in East Anglia, UK
Authors: Jenkins P F , Biggs J S
Published: December 2008

A questionnaire was sent to 24 visiting registrars in East Anglia to obtain information on their perceptions of their training experiences. The results suggest that the needs of overseas doctors and the requirements of training authorities would benefit from organisational changes aimed at improving selection and training programmes. Formal training programmes are needed, tailored to an individual’s requirement, with identification of educational supervisors for each trainee. An improved system of introduction to the National Health Service is also required.
Excessive libido in a woman with rabies
Authors: Dutta J K
Published: December 2008

Rabies is endemic in India in both wildlife and humans. Human rabies kills 25,000 to 30,000 persons every year. Several types of sexual manifestations including excessive libido may develop in cases of human rabies. A laboratory proven case of rabies in an Indian woman who manifested excessive libido is presented below. She later developed hydrophobia and died.
Percutaneous endoscopic gastrostomy
Authors: Hussain A , Woolfrey S , Massey J , Geddes A , Cox J
Published: December 2008

Percutaneous endoscopic gastrostomy (PEG) is now the technique of choice for patients requiring long-term enteral feeding. It is a good method for feeding patients with neurological dysphagia and can safely be kept in situ for long periods. PEG feeding requires a multidisciplinary approach, involving doctors, nurses, pharmacists, speech therapists, dieticians and carers. The insertion of a PEG, which requires two operators and two endoscopy nurses, is described in full. Feeding can commence after a few hours. Various types of feed and feed-ing patterns are described and their relative merits discussed. Although psychological problems may occur following PEG insertion, the procedure is usually well accepted by patients.
Diagnosis and management of chronic persistent dry cough
Authors: Chung K F , Lalloo U G
Published: December 2008

Cough is one of the commonest symptoms of lung disease and is a frequent problem encountered in general practice as well as in hospital practice. A wide range of disease processes may present with cough and definitive treatment depends on making an accurate diagnosis of the cause. A diagnostic work-up for patients with persistent dry cough is presented. The most common associated conditions are post-viral cough, asthma, rhinosinusitis (post-nasal drip or ‘nasal catarrh’) and gastro-oesophageal reflux. Treatment with angiotensin-converting enzyme inhibitors can also lead to a persistent dry cough. Specific treatment of the cause should control the cough, but this may not occur in all cases and in a sizeable proportion of patients, no associated cause can be found. An increased sensitivity of the cough reflex can be observed in patients with persistent dry cough. Symptomatic relief must be considered when the cough interferes with the patient’s health and sleep but the most effective antitussive opiates cause sedation and may be addictive. Treatment of persistent dry cough remains a challenge in some patients and there is still scope for improvement in its diagnosis and effective therapy.
Cushing’s syndrome due to autonomous macronodular adrenal hyperplasia: long-term follow-up after unilateral adrenalectomy
Authors: Boronat Mauro , Lucas Tomás , Barceló Balbino , Alameda Carmen , Hotait Hassan , Estrada Javier
Published: December 2008

This report describes a case of Cushing’s syndrome due to autonomous macronodular adrenocortical hyperplasia in which unilateral resection of the right adrenal resolved the Cushing’s syndrome.
Papillary thyroid carcinoma associated with ulcerative colitis
Authors: Evgenikos N , Stephen J G
Published: December 2008

A case is reported of papillary thyroid adenocarcinoma with cervical lymph node metastases in a young man who had presented earlier with severe total ulcerative colitis. The aetiological factors in the pathogenesis of papillary thyroid carcinoma are briefly reviewed and an association between this neoplasm and ulcerative colitis is suggested.
New treatments for patients with type 2 diabetes mellitus
Authors: Wolffenbuttel B H , Graal M B
Published: December 2008

In subjects with type 2 diabetes, both defects of insulin secretion and insulin resistance contribute to the development of hyperglycaemia. The major goals of treatment are to optimise blood glucose control, and normalise the associated lipid disturbances and elevated blood pressure. Pharmacologic treatment is often necessary. This paper discusses new forms of oral treatment for subjects with type 2 diabetes. These include a new sulphonylurea compound glimepiride (Amaryl), which binds to a different protein of the putative sulphonylurea receptor than glibenclamide, and seems to have a lower risk of hypoglycaemia. A new class of drugs with insulin secretory capacity, of which repaglinide (NovoNorm) is the leading compound, is now in phase III clinical trials. Alpha-glucosidase inhibitors reversibly inhibit alpha-glucosidase enzymes in the small intestine, which delays cleavage of oligo- and disaccharides to monosaccharides. This leads to a delayed and reduced blood glucose rise after a meal. Two compounds are in development or have been marketed, ie, miglitol and acarbose (Glucobay). Another new class of drugs is the thiazolidine-diones, which seem to work by enhancing insulin action. The ‘insulin sensitising’ effects of the leading compounds, troglitazone and BRL 49653C, do not involve any effect on insulin secretion. These drugs also seem to beneficially influence serum cholesterol and triglyceride levels. Oral antihyperglycaemic agents can be used only during a limited period of time in most patients, after which the diabetic state ‘worsens’ and insulin therapy has to be started. In this light, two new forms of treatment which require subcutaneous injections are also discussed: the synthetic human amylin analogue AC137 (pramlintide) and glucagon-like peptide-1 (7-36)-amide, a strong glucose-dependent stimulator of insulin secretion. It remains to be seen whether these compounds can be developed further for clinical use in patients with diabetes.
Breast cancer
Authors: Sainsbury R
Published: December 2008

The management of patients with breast cancer has been changing over the last few years and this article highlights some areas of particular interest. The changes have been brought about against a background of an increasing disease incidence coupled with increasing political aspirations from patients and their relatives. This paper focuses on organisational aspects of breast cancer care, screening, induction and high-dose chemotherapy, clinical trials, genetics, training of surgical and nonsurgical oncologists and future prospects.
Cerebral venous thrombosis and chronic active hepatitis as part of the antiphospholipid syndrome
Authors: Kesler Anat , Pomeranz Itamar S , Huberman Moshe , Novis Ben , Kott Edna
Published: December 2008

A case of antiphospholipid syndrome, presenting as sinus vein thrombosis together with chronic active hepatitis, is reported in a 35-year-old woman.
Improving the early diagnosis of acute myocardial infarction
Authors: Banerjee A
Published: December 2008

The diagnosis of early myocardial infarction, especially in association with atypical clinical presentations, can be difficult to establish. Continued observation of high-risk patients, with multiple serial electrocardiographs and the use of other diagnostic modalities as available, is essential to prevent the inadvertent premature discharge of patients with evolving myocardial infarcts from the accident and emergency department.
The role of cigarettes and nicotine in the onset and treatment of ulcerative colitis
Authors: Birtwistle J
Published: December 2008

Epidemiological evidence suggests that ulcerative colitis is a disease of nonsmokers, while Crohn’s disease is a disease of smokers. The relative risk of developing ulcerative colitis is not only greater in nonsmokers, in addition there appears to be a rebound effect in smokers who quit, with the heaviest (ex-)smokers increasing their relative risk of the disease the most. This factor poses an ethical dilemma for health professionals giving advice on stopping smoking, which may thus have a serious detrimental effect on the health of some patients. Nicotine is believed to be the pharmacological ingredient of tobacco that is responsible for this beneficial effect and several clinical trials using nicotine have demonstrated it to be an effective therapeutic agent in the treatment of ulcerative colitis. Although the aetiology of ulcerative colitis is unclear, current research using nicotine-based products has produced some interesting clues, together with the possibility of some form of therapeutic treatment based on nicotine administration.
Nonvalvular myocardial involvement in metastatic carcinoid disease
Authors: Davis G , Birbeck K , Roberts D , Naqvi N
Published: December 2008

A patient with the unusual post mortem finding of myocardial metastatic carcinoid tumour without classical valvular or endocardial carcinoid disease is described. This rare occurrence may represent an aggressive type of carcinoid tumour, with metastatic disease occurring before the development of classical fibrous valvular and endocardial pathology.