bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiac tamponade complicating central venous catheter
Authors: Chamsi-Pasha H , Waldek S
Published: December 2008

Cardiac tamponade complicating central venous catheters is usually fatal. We present a 23 year old woman who developed cardiac tamponade 12 hours after the insertion of a subclavian line. Early recognition of this complication and urgent pericardiocentesis led to her survival.
Transthoracic image guided biopsy
Authors: Dick R
Published: December 2008

Transthoracic image guided biopsy is now firmly established in the armamentarium of diagnostic tests to establish the nature of a mass in the lung, pleura, mediastinum or chest wall. It may be performed under computed tomographic, ultrasonic or fluoroscopic control, and provided a fine needle technique is employed, morbidity is low. Worldwide reports show a 90% true positive yield and a false positive rate of less than 1%.
Recent observations on drugs and human fertility
Authors: Turner P
Published: December 2008

The transmembrane migration method has permitted quantification of the effect of drugs on human sperm motility. Calcium ionophores and calcium antagonists have paradoxical effects on motility depending on the stage of sperm maturity. Drugs with membrane stabilizing properties inhibit sperm motility. Propranolol, for example, has been shown to have contraceptive activity when administered intra-vaginally. Pharmacokinetic studies have shown that the systemic availability of vaginally administered propranolol is markedly greater than after oral administration. Seminal fluid concentrations of propranolol after oral administration are similar to those in plasma, but cervicovaginal mucus concentrations are much higher, and residence times much longer. The clinical consequences of these observations await elucidation.
Recurrent acute renal failure due to a rectal villous adenoma
Authors: Williams B , Pearson H J , Barrie W W , Walls J
Published: December 2008

A case is reported in which a rectal villous adenoma was complicated by severe fluid and electrolyte depletion producing recurrent renal failure. The pathophysiology of the depletion syndrome and its complications are discussed. Successful management by acute haemodialysis and early surgical resection of the tumour is described.
Problems with a renal replacement programme in a developing country
Authors: McLigeyo S O , Otieno L S , Kinuthia D M W , Ongeri S K , Mwongera F K , Wairagu S G
Published: December 2008

Since August 1984 patients with end-stage renal disease in Kenya have been started on haemodialysis with a view to renal transplantation. In a two year period (August 1984-August 1986) 77 patients mean age 29.6 years (49 males), have been dialysed. The mean duration on dialysis prior to death or transplantation was 2.9 months (range 1 day to 11 months). Fifty patients (65%) died while on dialysis, including 2 who had had unsuccessful transplantation. Fourteen patients were still on dialysis, 11 had discharged themselves to peripheral hospitals for conservative management, and 2 had had successful renal transplantation. The possible causes of this abysmal experience include admission of critically ill patients, shortage of trained staff, over-dependence on arteriovenous shunts for vascular access, lack of centralization of patient management, recurrent shortage of essential equipment and reagents and a slow pace of transplantation.
Long-term symptomatic relief of postprandial hypoglycaemia following gastric surgery with a somatostatin analogue
Authors: D’Cruz D P , Reynard J , Tatman A J , Kopelman P G
Published: December 2008

Somatostatin has been shown to be effective in the management of the dumping syndrome and there have been reports of the effective use of long acting somatostatin analogue in the management of this condition. However, there have been few reports of the prolonged use of a somatostatin analogue in the late dumping syndrome. We describe a patient in whom this management provided good long term symptomatic relief which was confirmed biochemically.
Milk protein allergy--a rare cause of pyrexia of unknown origin in an adult female
Authors: Dhar K L , Gupta B , Adlakha A , Choudhrie A V
Published: December 2008

Milk protein allergy is described in a young adult female patient who presented with fever and malabsorption syndrome. The patient fulfilled Goldman’s criteria for the diagnosis of milk protein allergy and responded to an elimination diet.
Extensive aortic valve ring abscess formation: a rare complication of Q fever endocarditis
Authors: Fort S , Fraser A G , Fox K A A
Published: December 2008

We report the successful management and 2 year follow up of a young patient with Q fever endocarditis on a congenitally bicuspid aortic valve complicated by extensive abscess formation in the aortic valve ring and interventricular septum. Aortic root abscess formation complicating Q fever endocarditis has been reported in only one previous patient. Serological tests may thus be indicated in patients with aortic abscesses.

Despite extensive aortic and intramyocardial abscess formation it proved possible to control the progression of disease by open drainage of the abscess and aortic valve replacement. Although the requirement for aortic root replacement was anticipated in this patient, it has not been required.
Portal hypertension and ascites in systemic mastocytosis
Authors: Narayanan M N , Liu Yin J A , Azzawi S , Warnes T W , Turck W P G
Published: December 2008

We report a case of systemic mastocytosis (SM) presenting as ascites and portal hypertension. The haematological picture at presentation was suggestive of chronic myelomonocytic leukaemia. Initial difficulties in making a diagnosis of SM were encountered as the cutaneous signs were atypical. The correct diagnosis was established only after tissue sections were appropriately stained for mast cells. The liver biopsy showed portal and sinusoidal mast cell infiltration, portal fibrosis and evidence of hepatic venous outflow obstruction. The disease progressed rapidly and recurrent massive ascites was a dominant problem. This case illustrates again the problems of making a diagnosis of SM especially when the clinical picture is atypical. Ascites as a presenting manifestation of SM has been reported previously in only six patients. Published cases of SM with portal hypertension or ascites or both are reviewed.
Babesiosis: under-reporting or case-clustering?
Authors: Clarke C S , Rogers E T , Egan E L
Published: December 2008

Babesiosis is a tick-borne protozoan disease which principally affects animals but occasionally affects humans. Cases have been reported from many parts of Europe with no evidence of case-clustering. We report the second case of babesiosis from a small area in the west of Ireland.
Neuroleptic malignant syndrome: another medical cause of acute abdomen
Authors: Lo T C N , Unwin M R , Dymock I W
Published: December 2008

We present a patient with neuroleptic malignant syndrome and intestinal pseudo-obstruction misdiagnosed as being secondary to septicaemia. The management of the patient is discussed with emphasis on the role of creatine kinase and liver function tests.
Hypercalcaemia associated with chronic viral hepatitis
Authors: Cadranel J F , Cadranel J , Buffet C , Ink O , Pelletier G , Bismuth E , Etienne J P
Published: December 2008

A patient with long lasting non-parathyroid hormone mediated hypercalcaemia occurring within the context of hepatitis B virus chronic hepatitis is reported. Hepatocellular carcinoma and bone malignancy were carefully excluded. The biological pattern associated hypercalcaemia with normal phosphataemia, low nephrogenic cAMP level and high level of tubular reabsorption of phosphate. The usual causes of hypercalcaemia were ruled out. Hypercalcaemia may represent a rare biological feature of some advanced liver disease. The underlying mechanisms remain to be elucidated.
Simple avulsion of onychogryphotic toenails: a justifiable treatment?
Authors: Greig J D , Anderson J H , Ireland A J , Anderson J R
Published: December 2008

Twenty-nine consecutive patients with onychogryphotic toenails in whom conservative treatment had failed, were entered into the study over a one year period and followed-up prospectively for a further year. All patients were treated by simple nail avulsion. The incidence of recurrence was 27 out of 29 patients (93%); only five of these were symptomatic (17%). Only two patients required further surgery. We conclude that simple avulsion of onychogryphotic toenails offers symptomatic relief in the majority of patients, particularly in this elderly population in whom the use of a tourniquet may be contraindicated.
Familial malignant retroperitoneal paraganglioma
Authors: Sebastian J P , Williams S E , Wells M , Peake M D
Published: December 2008

Paragangliomas are neuroendocrine tumours and those occurring in the head and neck have well recognized familial association. Retroperitoneal paragangliomas are uncommon and we present two cases of familial malignant retroperitoneal paraganglioma. Review of the literature revealed marked differences in the incidence and malignant potential of familial and non-familial paraganglioma. In contrast to the cases reported here, familial tumours are generally benign, though they may occur at multiple sites. Familial and non-familial paragangliomas may indeed be different disease entities.
The automatic implantable cardioverter/defibrillator for a life threatening arrhythmia in a case of post-partum cardiomyopathy
Authors: Bower M , Freeman L J , Rickards A F , Rowland E
Published: December 2008

We report the development of severe life threatening polymorphic ventricular tachycardia in a young woman shortly following her first pregnancy, who ultimately required the insertion of an automatic implantable cardioverter/defibrillator because of the failure of conventional antiarrhythmic therapy. Although only about 7 patients have received units in the UK to date, the experience in the USA, where up to 300 per month may be implanted, suggests that they will become a more common method of treatment in cases of life threatening arrhythmias.
Severe tissue destruction in the ear caused by alkaline button batteries
Authors: Premachandra D J , McRae D
Published: December 2008

Button batteries spontaneously leak corrosive electrolyte solution on exposure to moisture. Tissue in contact with such solution will undergo liquefaction necrosis. Three cases of skin, bone and tympanic membrane necrosis caused by a leaking button battery lodged in the external auditory meatus are described.
Thyroid function tests in amyloid goitre
Authors: Duhra P , Cassar J
Published: December 2008

We present two patients with amyloid goitre due to primary systemic amyloidosis which was confirmed at post-mortem. Both were clinically euthyroid but had hyperthyroxinaemia and other thyroid function tests suggestive of thyrotoxicosis.
Osteomyelitis complicating Streptococcus milleri endocarditis
Authors: Barham N J , Flint E J , Mifsud R P
Published: December 2008

A patient with osteomyelitis of the spine complicating bacterial endocarditis due to Streptococcus milleri is discussed. To our knowledge, this is the first time this organism has been associated with this complication.
Recurrent pneumothorax following abdominal paracentesis
Authors: Stafford P J
Published: December 2008

A 62 year old man presented with abdominal ascites, without pleural effusion, due to peritoneal mesothelioma. He had chronic obstructive airways disease and a past history of right upper lobectomy for tuberculosis. On two occasions abdominal paracentesis was followed within 72 hours by pneumothorax.

This previously unreported complication of abdominal paracentesis may be due to increased diaphragmatic excursion following the procedure and should be considered in patients with preexisting lung disease.
Late-onset drug fever associated with minocycline
Authors: Gorard D A
Published: December 2008

A patient presenting with a pyrexial illness and transiently deranged liver function tests is described. He had been taking minocycline for 12 months. The causal association with this drug was demonstrated by withholding and then rechallenging with minocycline. This report documents drug fever as an adverse reaction to minocycline, and its late onset is of added interest.
Persistent nephrogenic diabetes insipidus, tubular proteinuria, aminoaciduria, and parathyroid hormone resistance following longterm lithium administration
Authors: Neithercut W D , Spooner R J , Hendry A , Dagg J H
Published: December 2008

We report a patient who developed persistent nephrogenic diabetes insipidus associated with renal tubular acidosis, renal resistance to parathyroid hormone, aminoaciduria and proximal tubule pattern proteinuria in the presence of a reduced glomerular filtration rate (19–24 ml/min). A review of the previous reports of persistent nephrogenic diabetes insipidus revealed that in all patients the glomerular filtration rate had been less than 60 ml/min at presentation. Chronic renal failure may therefore predispose to the development of persistent nephrogenic diabetes insipidus in patients receiving lithium.
Venepuncture for calcium assays: should we still avoid the tourniquet?
Authors: McMullan A D , Burns J , Paterson C R
Published: December 2008

Blood was collected by venepuncture from nine healthy subjects over a ten minute period before applying a standard tourniquet, and over a ten minute period afterwards. Plasma ionised calcium was unaltered by the tourniquet, whereas total calcium, total protein and albumin in serum increased modestly. However, there was no effect on total calcium adjusted for albumin. Even without albumin adjustment the change in total calcium was negligible within one minute of the application of the tourniquet. We consider that in ordinary clinical practice, there is no need to perform venepuncture for calcium assays without a tourniquet.
Weight change, perceived health status and mortality in middle-aged British men
Authors: Wannamethee G , Shaper A G
Published: December 2008

The association between weight change over a 5-year period, the subsequent perception of health and the mortality during a 4-year follow-up period has been examined in a prospective study of 7735 middle-aged British men. There were 357 deaths from all causes. Self-assessment of health status was considered as a potential guide to whether weight loss was intended or involuntary. Irrespective of weight change those who reported poor or fair health had a more than two-fold increase in death rate compared to those who reported good or excellent health. Considerable weight gain (> 10%) was associated with high rates of cardiovascular disease regardless of health perception, although this was most marked in those who perceived poor or fair health. Moderate weight gain was of little importance except in those who regarded their health as poor or fair. Weight loss was associated with increased death rates from cancer regardless of health perception, although the rates were highest in those who perceived poor or fair health.

This study emphasizes that weight loss is a potentially serious symptom even in men who report good health. Assessment of weight change and of perception of health status are both of value and could be used in standard health enquiries to monitor health status in individuals and the community.
Post-traumatic external nasal neuralgia—an often missed cause of facial pain?
Authors: Golding-Wood D G , Brookes G B
Published: December 2008

Pain about the bridge of the nose is often a diagnostic dilemma. There is an important recognizable subgroup who may, as a consequence of involvement of the external nasal nerve in nasal injury, exhibit neuralgic pain after a latent interval. Temporary relief by anaesthesia can be achieved and cure is possible by division of the anterior ethmoidal nerve. This rare cause of facial pain is presented using two illustrative cases.
Helicobacter pylori in children
Authors: Sullivan P B , Thomas J E
Published: December 2008

The clinical manifestations of Helicobacter pylori (formerly Campylobacter pylori) infection in children overlap with those encountered in adults but there are some important differences. The aim of this review is to describe the range of manifestations of this infection in children, together with means of diagnosis and treatment.
Immune responsiveness in chronic fatigue syndrome
Authors: Milton J D , Clements G B , Edwards R H T
Published: December 2008

We have endeavoured to find immunological indications of chronic virus infection in patients with chronic fatigue syndrome (myalgic encephalomyelitis) and to investigate immune responsiveness to viruses in such patients in comparison with normal subjects and patients with muscular dystrophy. Levels of circulating IgM immune complexes were elevated (above the 95% normal control range) in 10 (17%) of 58 patients with chronic fatigue syndrome, which was not significantly different from the normal controls or from dystrophy controls (by Mann Whitney U test). Levels of IgG complexes were only increased in 10% of patients.

Lymphocyte proliferation in response to concanavalin A (Con A), assessed by increase in 3H-thymidine incorporation, did not differ between 14 patients and 18 normal subjects. The proliferative response to Coxsackie B virus antigen did not differ between chronic fatigue patients and normal subjects when expressed either as an increase in counts or as a stimulation index. Adjustment of the counts in relation to the proliferation response to Con A, as an indication of the overall proliferative response of the cell preparation, did not reveal any hidden difference. IgM antibodies to Coxsackie B viruses were not found in any of 20 patients and in 1 of 20 dystrophy controls. Significant levels of neutralizing antibodies to Coxsackie B viruses 1–5 were found in 6 out of 19 (32%) patients compared with 4 out of 17 (24%) dystrophy controls, which does not differ from currently expected normal incidence. Antibody titres to other respiratory viruses were also not notably different between the patient and control groups.

In conclusion we can find no evidence for a definable viral aetiology for the chronic fatigue syndrome, neither in terms of a persistent infection nor an altered ability to respond to virus.
Patent foramina ovale in elderly stroke patients
Authors: Vella M A , Sulke A N , Rodrigues C A , McNabb W R , Lewis R R
Published: December 2008

Fifty elderly patients who had suffered cerebrovascular incidents from no obvious cause and 33 age-matched controls were investigated for the presence of a patent foramen ovale by contrast 2-dimensional echocardiography at rest and after the Valsalva manoeuvre. Right-to-left shunting was found in only one patient and in none of the controls. This finding is in contradistinction to young adult stroke patients in whom the prevalence of a haemodynamically significant patent foramina ovale is high. Paradoxical embolism is an uncommon cause of stroke in the elderly.
Life-threatening hypercalcaemia in association with Addisonian crisis
Authors: Miell J , Wassif W , McGregor A , Butler J , Ross R
Published: December 2008

A 35 year old woman was admitted with acute radial artery occlusion necessitating two operations and thrombolytic therapy. Subsequently a diagnosis of primary hypothyroidism was made and she was commenced on thyroxine replacement therapy. Her condition, however, continued to deteriorate with the development of an Addisonian crisis heralded by, and complicated by, severe, life-threatening hypercalcaemia. This case highlights the importance of considering Addison's disease in any patient whose condition deteriorates after the introduction of thyroxine replacement, and illustrates the often forgotten association of hypercalcaemia and hypoadrenalism.
Fatal splenic sequestration crisis in adult sickle cell-beta thalassaemia
Authors: van Rhee F , Balsitis M , French E A
Published: December 2008

Fatal acute splenic sequestration crisis in an adult patient with sickle cell-beta+ thalassaemia is described. To our knowledge fatal splenic sequestration in adult sickle cell-beta thalassaemia has not been previously reported.
Rhabdomyolysis associated with cranial diabetes insipidus
Authors: Kung A W C , Pun K K , Lam K S L , Yeung R T T
Published: December 2008

Rhabdomyolysis has been reported to be associated with hyperosmolality in diabetic ketoacidosis and non-ketotic hyperosmolal state. Whether the rhabdomyolysis was due to hyperosmolality per se or whether hyperglycaemia also played a role is not clear. We hereby report a case of cranial diabetes insipidus with hypernatraemia and hyperosmolality complicated by rhabdomyolysis. None of the known risk factors, such as coma, hypokalaemia, hypophosphataemia, diabetic ketoacidosis or non-ketotic hyperosmolality, were present in this patient. We believe that severe hyperosmolality per se is an important predisposing factor for non-traumatic rhabdomyolysis, and serum muscle enzymes should be closely monitored in the management of patients with diabetes insipidus.
The diagnosis of femoral hernia
Authors: Corder Allan P
Published: December 2008

The accuracy of diagnosis of femoral hernia in referrals to a district general hospital over a period of 5 years has been studied and related to clinical outcome. A correct diagnosis was made in only 36 of 98 cases (60 urgent, 38 routine) before admission to hospital. A correct pre-operative diagnosis was ultimately made in 85 cases. Four patients, all urgent admissions with incarcerated bowel, died within 30 days of operation. In none of these cases was a correct diagnosis made before admission to hospital. The median length of post-operative stay of urgent admissions was 7 days (range 4-50) when a correct initial diagnosis was made and 10 days (range 4-50) when the initial diagnosis was incorrect (P = 0.07, Mann-Whitney test). When strangulated small bowel was found at operation, 70% of those with an incorrect initial diagnosis (n = 23) required resection, as compared with 20% of those with a correct initial diagnosis (n = 10, P = 0.014, χ2 with Yates' correction).

Femoral hernias are frequently incorrectly diagnosed before hospital admission and this is associated with worsened outcome in urgent cases.
Tumours of the accessory lobe of the parotid gland
Authors: Afify S. E. , Maynard J. D.
Published: December 2008

Three cases of tumour of the accessory lobe of the parotid gland are reported and the surgical aspects discussed. An approach through a routine parotidectomy incision is preferred to direct incision over the mass.
Elevated serum parathyroid hormone related protein and 1,25-dihydroxycholecalciferol in hypercalcaemia associated with adult T-cell leukaemia-lymphoma
Authors: Johnston S R D , Hammond P J
Published: December 2008

Hypercalcaemia occurs in up to 80% of patients with adult T-cell leukaemia-lymphoma (ATLL) associated with human T-cell leukaemia virus-1 infection. Elevated serum levels of 1,25-dihydroxycholecalciferol, implicated in the pathogenesis of hypercalcaemia in lymphoma, and of parathyroid hormone-related protein (PTHrP), which is associated with hypercalcaemia of several solid malignancies, were demonstrated in a patient with ATLL hypercalcaemia. Treatment with bisphosphonates reduced the serum calcium but had no significant effect on the serum PTHrP levels. This case supports recent in vitro evidence for enhanced PTHrP expression in ATLL tumour cells and suggests that more than one tumour cell product may be involved in the pathogenesis of ATLL hypercalcaemia.
Fatal haematemesis due to benign retrosternal goitre
Authors: Parker D R , el-Shaboury A H
Published: December 2008

The development of a goitre in the retrosternal space may result in many different symptoms due to local compression. We describe a case in which such a goitre resulted in full-thickness ulceration of the oesophagus, which presented as a fatal haematemesis. We believe that such a complication has not been previously reported.
Massive haemorrhage due to ulcerative colitis presenting as melaena
Authors: Aristodemou Aristi , Ryder S , Jacyna M R
Published: December 2008

We present a patient with known ulcerative colitis who presented with massive lower gastrointestinal bleeding in the form of melaena. Extensive investigations indicated that the source of blood loss was only from the colon, was attributable to the colitis, and settled when the colitis was treated with steroids. Melaena may be due to blood loss from the colon.
Craniospinal intradural arachnoid cyst
Authors: Bhatia Sanjay , Thakur Rup Chand , Devi B Indira , Radotra B D , Kak V K
Published: December 2008

A patient with an uncommonly situated congenital intradural arachnoid cyst is reported. The cyst extended from the cervical spinal canal into the posterior cranial fossa and was posterolateral to the spinal cord. The patient's initial complaint was urinary hesitancy. The location of the cyst is unique and the presenting complaint rare.
Family therapy
Authors: Lieberman S
Published: December 2008

The discipline of family therapy, one of the psychotherapies, is defined and illustrated clinically in this article using case material. References are provided which allow further reading about family systems medicine.
Biliary tract invasion and obstruction by hepatocellular carcinoma: report of five cases
Authors: Lai S T , Lam K T , Lee K C
Published: December 2008

Major biliary tract obstruction caused by tumour invasion is a rare manifestation of hepatocellular carcinoma. The authors had the opportunity to diagnose and treat five such cases, three of whom had features of acute cholangitis. The prevalence of both hepatocellular carcinoma and recurrent pyogenic cholangitis is high in patients from the Far East. The former may first present under the guise of the latter. Gastroenterologists and surgeons should be aware of hepatocellular carcinoma when managing these patients who present with obstructive jaundice, gross hepatomegaly and cholangitis.
Significance of a low serum ferritin level in elderly in-patients
Authors: Joosten E , Dereymaeker L , Pelemans W , Hiele M
Published: December 2008

Iron deficiency, defined as a serum ferritin level less than or equal to 50 micrograms/l was found in 28 (11%) of 252 consecutive elderly in-patients (mean age 81 years). Sixteen among them were anaemic and only five had a microcytic anaemia. In a separate study, 15 anaemic and 13 non-anaemic iron-deficient elderly in-patients were investigated in order to evaluate the prevalence of gastrointestinal symptoms and lesions in both groups. In nine of the anaemic and seven of the non-anaemic patients a potential cause for the iron deficiency was established. Most anaemic and non-anaemic patients lacked the symptoms described as suggestive of underlying gastrointestinal pathology. Thus, a ferritin level less than or equal to 50 micrograms/l justifies a gastrointestinal investigation if the general condition allows for it as well in anaemic as in non-anaemic elderly hospitalized patients. Therefore, serum ferritin should be part of the routine biochemical investigation of elderly in-patients.
Pancreatitis associated with diclofenac
Authors: Khan Izhar H , Edward Neil
Published: December 2008

A 34 year old female developed acute pancreatitis after commencing diclofenac for a painful arthropathy. The possible role of prostaglandin inhibition in non-steroidal analgesic drug-induced pancreatitis is discussed and the suggestion is made that serum amylase should be measured in patients who develop abdominal pain, following ingestion of non-steroidal anti-inflammatory
Myositis due to cholesterol emboli
Authors: Robinson R J , Pemberton M , Goddard M J
Published: December 2008

Myositis due to spontaneous cholesterol embolization is uncommon and usually associated with cutaneous abnormalities at presentation. A case of myositis due to cholesterol emboli is reported. The patient presented with painful weak legs, and the diagnosis was confirmed by muscle biopsy.
Butterfat absorption—a valuable screening test in malabsorption
Authors: Harper G D , Wheeler D C , Wicks A C B
Published: December 2008

The diagnosis of intestinal malabsorption is difficult to make without the use of specific tests such as endoscopic retrograde cholangiopancreatography (ERCP) or duodenal biopsy which are invasive and potentially hazardous. Faecal fat estimation or C14 Triolein breath tests have limitations as screening tools are time consuming and expensive. The butterfat absorption test (BFAT) is, in contrast, a simple, quick and cheap test for fat malabsorption. We have assessed the performance of this test in a blinded retrospective study of all such procedures performed in a teaching hospital over an 8 year period.

One hundred and fourteen cases of suspected malabsorption had one or more butterfat tests. These were divided into absorbers and malabsorbers without knowledge of the butterfat test results.

We found the butterfat test to have a sensitivity of 88% and a specificity of 94% using a cut-off of 20 light-scattering intensity units to discriminate normal from abnormal tests. At this level, predictive values are 91% for a positive result and 92% for a negative. These results are similar to those reported with the C14 Triolein breath test and adjusted faecal fats.

We conclude that the butterfat test is a simple, cheap and effective screening test in the diagnosis of malabsorption.
Hyperosmolar non-ketotic diabetic coma and rhabdomyolysis
Authors: Trump Dorothy , O'Hanlon Shaun , Rinsler Michael , Sharp Patrick
Published: December 2008

Rhabdomyolysis is a rare but potentially fatal complication of hyperosmolar states. We report a case of severe hyperosmolar non-ketotic diabetic coma causing rhabdomyolysis in a young man. Despite very high levels of creatine kinase there was no detectable myoglobinuria. Creatine kinase estimation should be a standard investigation in all patients presenting with a hyperosmolar state.
Streptokinase and facial haematoma
Authors: Jervis P , Mason J D T , Jones N S
Published: December 2008

We report two cases of facial haematoma following streptokinase therapy. This is an important complication as it can have fatal consequences. Early recognition and close monitoring are essential as emergency intervention may be required.
Stents in the biliary tree
Authors: Rowlands P C
Published: December 2008

Biliary stenting has become established as a valuable method of palliation in malignant biliary strictures. The development of percutaneous and endoscopic techniques is described and illustrative cases are shown. The role of percutaneous vs endoscopic procedures is examined.
A model for rational introduction of new and expensive medicines
Authors: Bell E , McCartney C
Published: December 2008

The reported impact of human monoclonal IgM antibody (HA1A) on the mortality rate from Gram-negative bacteraemia aroused considerable interest in its use in Glasgow Royal Infirmary. However, the commercial preparation of HA1A was extremely expensive. With this in mind, the Infirmary’s Drugs and Therapeutics Committee introduced a system whereby the commercial preparation of HA1A could be introduced in a controlled fashion, thereby establishing a model which would encourage targeting the prescription of new, highly expensive treatments to appropriate patients. This model provides the clinician with a set of objective criteria to be met before prescribing such a preparation, thus preventing unnecessary increases in the hospital drug budget and justifying using expensive resources.
Lower limb intra-arterial thrombolysis
Authors: Golledge J , Galland R B
Published: December 2008

In the UK, approximately 5000 patients present annually with acute lower limb ischaemia. The aetiology is usually thromboembolic disease, other causes include aortic dissection and arterial trauma. Over the past two decades thrombosis has replaced embolism as the principal cause of acute ischaemia, and now accounts for approximately 59% of cases. As a consequence, intra-arterial thrombolysis is being increasingly used as first-line treatment for this condition.
Crescentic glomerulonephritis and eosinophilic interstitial infiltrates in a patient with hypereosinophilic syndrome
Authors: Richardson P , Dickinson G , Nash S , Hoffman L , Steingart R , Germain M
Published: December 2008

Crescentic glomerulonephritis with immune complex deposition and acute eosinophilic interstitial nephritis developed in a patient with the hypereosinophilic syndrome. Acute renal failure ensued but was rapidly reversed by high-dose oral prednisone. Confounding factors and unusual findings are described with a review of recent literature. This mode of presentation has not previously been reported.
Factors associated with high risk of marginal hyperthermia in elderly patients living in an institution
Authors: Vassallo M , Gera K N , Allen S
Published: December 2008

The elderly, the very young, and the sick are known to be adversely affected by high environmental temperatures. In a retrospective open case-note review of 872 patients in a large institution during a hot summer we identified characteristics in the elderly that increase the risk of marginal hyperthermia. Women were more likely to be affected than men (25.6% vs 16.9%). We found an age-related increase in marginal hyperthermia, 15.7% of those below 60 years developed a hyperthermia compared to 18.9% in those between 70-79 years (non-significant), 28.3% in those between 80-89 years (p = 0.01) and 50% in those above 90 years (p < 0.01). There was also a direct relationship between the incidence of hyperthermia and the ambient temperature (29% in the warmer wards, compared to 17.2% in cooler ones; p < 0.01) and with the level of dependence (42.3% of the bedridden group, p < 0.01, and 20.4% of the semi-dependent, p < 0.01, compared to 11.1% of the mobile group). These factors were more significant as predictors of risk than the diagnosis. Identifying high risk patients early and taking appropriate measures to avoid hyperthermia and dehydration is important to try to decrease mortality during heatwaves.
Antiphospholipid syndrome in a patient with rapidly progressive fibrosing alveolitis
Authors: Kelion A D , Cockcroft J R , Ritter J M
Published: December 2008

The antiphospholipid syndrome is a thrombotic disorder which can occur in a primary form or more classically in systemic lupus erythematosus. An association between cryptogenic fibrosing alveolitis and the antiphospholipid syndrome has not previously been reported. We describe a patient with severe cryptogenic fibrosing alveolitis who developed pulmonary embolism and myocardial infarction in the presence of antiphospholipid antibody. The case also illustrates that worsening respiratory function may represent superimposition of one lung pathology on another, and may not simply be a deterioration of the pre-existing disease.
Is this patient fit for thoracotomy and resection of lung tissue?
Authors: Thomas S D , Berry P D , Russell G N
Published: December 2008

Central to risk assessment for lung resection is the fact that surgery offers the only chance of long-term survival and cure in non-small carcinoma of the lung. The challenge is, therefore, to offer surgery to as many patients as possible, whilst avoiding the risk of death from postoperative respiratory failure. Risk assessment is based on careful evaluation of the patient’s existing cardiac and respiratory disease. The use of a cardiac risk index, such as that described by Detsky, will ensure that cardiac risk factors are recognised and, where possible, ameliorated prior to surgery. Pre-existing respiratory disease may be assessed by arterial blood gas analysis, exercise testing, whole and regional lung function tests. Criteria based on these tests have been proposed to aid patient selection prior to lung resection. However, these criteria take no account of the beneficial influence on outcome of modern anaesthesia and postoperative care. The elimination of postoperative pain, along with techniques such as minitracheostomy and incentive spirometry have allowed surgery to be offered to many patients who would have been deemed unsuitable by standard criteria. Patients with potentially resectable lung cancer must never be arbitrarily excluded from surgery on the basis of any single criteria or test. Referral for assessment by an experienced team consisting of a thoracic physician, surgeon and anaesthetist will maximise the number of patients offered surgery for this otherwise incurable disease.
Telling your patient he/she has multiple sclerosis
Authors: Ford H L , Johnson M H
Published: December 2008

It is difficult to tell a person that s/he has multiple sclerosis. The diagnosis is based on clinical findings and often cannot be made on first meeting. In many cases investigations do not help. When the diagnosis is made, the patient should be fully informed in the majority of cases. Guidelines have been developed for imparting the diagnosis. Early diagnosis will become increasingly important with the development of new treatments for multiple sclerosis.
The use of rheumatoid factors in clinical practice
Authors: Thomas M J , Adebajo A , Chapel H M , Webley M
Published: December 2008

Rheumatoid factor is a commonly requested test in the investigation of joint problems. Although the test has been found to be both sensitive and specific for rheumatoid arthritis in patients attending Rheumatology Clinics, when the test is applied to general hospital or community populations it performs poorly. Thus the setting in which rheumatoid factor tests are requested and awareness of the test’s limitations are critical for appropriate use and interpretation of results. We studied 295 consecutive requests for testing at four centres. The majority were performed for the investigation of joint problems but only 6% of these were positive, suggesting unselective requesting. Half of the results were used to make diagnoses and influence management. However, significant numbers of clinicians felt that the test result had either excluded or confirmed a diagnosis of rheumatoid arthritis suggesting that results were being over-interpreted and that clinical decisions made on this basis may have been inappropriate. We conclude that in this setting rheumatoid factor testing is of limited value and generates misleading information.
What should I do about my patient’s gall stones?
Authors: Dennison A R , Azoulay D , Oakley N , Baer H , Paraskevopoulos J A , Maddern G J
Published: December 2008

The problem of benign biliary disease is one that causes significant morbidity and social economic strain in the western world. The classical treatment, cholecystectomy, has been challenged by various medical and surgical techniques in a seemingly random nature. The development of the treatment of gall stone disease is reviewed by analysis of published studies over the last 20 years. The advantages and disadvantages are discussed as an overview and summary of the current management of gall stone disease in the light of our knowledge of its malignant potential.
Enterococcal endocarditis after extracorporeal shock wave lithotripsy for nephrolithiasis
Authors: Zimhony O , Goland S , Malnick S D , Singer D , Geltner D
Published: December 2008

We report a case of enterococcal endocarditis following extracorporeal shock wave lithotripsy (ESWL) for ureteral stone. Although endocarditis following ESWL is very rare, transient bacteraemia occurs during ESWL. This case is a reminder that enterococcal endocarditis may follow innovative genitourinary procedures without appropriate prophylaxis.
Pneumonitis complicating selective intra-arterial chemotherapy for locally advanced breast carcinoma
Authors: McLean A D , Doughty J C , Reid A W , McCarter D H , Kane E , McArdle C S
Published: December 2008

We describe a case of pneumonitis in a patient receiving selective intra-arterial chemotherapy for locally advanced breast cancer.
A reader’s guide to the evaluation of screening studies
Authors: Earle C , Hebert P C
Published: December 2008

In this article we will review how a reader should evaluate a screening study. A clinical problem involving screening mammography is presented. We then outline criteria to determine whether screening is appropriate for a given condition. A search for relevant articles is described followed by an outline of the steps used to appraise a screening study critically. An applicable study is examined in detail for such things as the quality of randomisation and outcomes measured. The results of this study are then applied to a patient considered for screening.
Counselling for an HIV test
Authors: Moss S , Williams O E , Hind C R
Published: December 2008

Doctors may feel uncomfortable with the prospect of discussing a human immunodeficiency virus (HIV) antibody test with their patient. This is in part because they do not enquire about high risk activity as part of a medical history. With increasing medical and public awareness of both the clinical manifestations and social implications of HIV infection, it is important that all doctors receive guidance on how to deal with these issues. Counselling is not the usual term used to describe obtaining informed consent. In the general medical setting, tests for hepatitis B and syphilis are routinely carried out without specific consent even though results of these tests may have profound effects on both the patient and their sexual partners. However society and ethical considerations have made HIV testing different. HIV testing will inevitably become more widespread, and thus become a more routine part of patient investigation and management.
A reader’s guide to the evaluation of causation
Authors: Podrebarac T , Tugwell P , Hébert P C
Published: December 2008

In this article, we review the criteria used to establish a causal association. A literature search strategy will be outlined. We present a clinical scenario that was formulated to examine the evidence for nonsteroidal anti-inflammatory drugs as a possible cause of gastrointestinal ulceration and bleeding. Several of the studies identified in the literature search were critically appraised and the criteria needed to confirm a causal link were then applied. These guidelines may be employed to not only demonstrate the aetiology of a disease but have wider applicability in terms of determining whether a medication may be causing certain adverse events.
Reflux oesophagitis and Helicobacter pylori infection in elderly patients
Authors: Liston R , Pitt M A , Banerjee A K
Published: December 2008

Helicobacter pylori is associated with gastritis, peptic ulcers and gastric malignancies. Little attention has been paid to the possibility that it may also have a role in the pathogenesis of reflux oesophagitis. This is especially true in elderly patients who have life-long infection and provide an ideal group to study the mucosal changes associated with the organism. The aim of this study was to determine if H pylori is associated with reflux oesophagitis in elderly patients. Consecutive gastroscopy patients were recruited. Multiple biopsies were taken from oesophagus, stomach, antrum and duodenum for histology and rapid urease tests. Patients also had IgG ELISA antibodies and 13C-urea breath tests performed. Patients with macroscopic or microscopic evidence of reflux oesophagitis were compared to patients with macroscopically normal upper gastrointestinal tracts and no microscopic evidence of reflux. A total of 114 patients were recruited, average age 78.9 years (+/- 5.4). There were 37 refluxers and 33 non-refluxers. We found no evidence for an association between the presence of H pylori and reflux oesophagitis in elderly patients. The high prevalence of H pylori in patients with reflux oesophagitis can be explained by the presence of incidental gastritis.
Acute airway obstruction by laryngeal haematomas in acute immune thrombocytopenic purpura
Authors: Aiken T C , Collin R C
Published: December 2008

We report the case of a 79-year-old woman with acute immune thrombocytopenic purpura who spontaneously developed laryngeal haematomas which produced acute upper airway obstruction.
Coronary artery stents
Authors: Stewart A J , Coltart D J
Published: December 2008

The use of coronary stents to treat the acute complications of percutaneous transluminal coronary angioplasty and to reduce the restenosis rate following this procedure is reviewed.
Elevated serum prostate-specific antigen and pancreatic carcinoma
Authors: Ranganath L R , Lewis G A , Nobbs B T , Goddard P F , Rangedera D C
Published: December 2008

We report a case of elevated serum prostate-specific antigen-like immunoreactivity in a man with a disseminated pancreatic carcinoma.
The seroprevalence of hepatitis B, hepatitis C and human immunodeficiency virus infections in paediatric oncology patients in Turkey
Authors: Berberoğlu S
Published: December 2008

One hundred and two newly diagnosed children with malignancy followed up at the Pediatric Oncology Department of Ankara Oncology Hospital were investigated for hepatitis B, hepatitis C and human immunodeficiency virus markers. The ages ranged between seven months and 17 years with a median of 10 years; 62 were male. Twenty-four patients had Hodgkin’s disease, 11 had non-Hodgkin’s lymphoma and 67 patients had other solid tumours. Four patients had positive HBs-Ag, 15 developed immunity against hepatitis B and had anti-HBs antibodies. One patient had a previous infection with positive anti-HBc. Hepatitis C virus antibodies were positive in only one patient. HIV serology was negative in all patients. These results show the high prevalence of hepatitis B virus infection in paediatric oncology patients. In countries where hepatitis B is endemic, strict screening of blood donors, usage of disposable equipment and vaccination of patients is recommended. Although the incidence of hepatitis C and human immunodeficiency virus infections are rising, infection with hepatitis B is still by far the most common.
Renal lymphoma: an unusual cause of extrahepatic biliary obstruction
Authors: Abbas Z , Johnston D A , Murray F E
Published: December 2008

This report describes a case of lymphoma arising in a kidney subjected to previous pyelolithotomy, lithotripsies and percutaneous nephrolithotomy. The tumour had invaded the pancreas and duodenum, resulting in extrahepatic biliary and gastric outlet obstructions. Fine-needle apiration cytology guided by computed tomography failed to suggest the diagnosis which was confirmed only on laparotomy and open biopsy. Drainage procedures were performed to relieve the obstructions. To our knowledge this is the first case report of renal lymphoma presenting with extrahepatic biliary obstruction.
Coital emergencies
Authors: Banerjee A
Published: December 2008

The act of heterosexual coitus is associated with morbidity due to a variety of conditions as well as with a small risk of sudden death. Awareness of the presentation of coital emergencies is essential to allow appropriate medical management and sexual counselling.