bluuebunny/crossref_metadata_2025 huggingface dataset:
Thyrotoxic crisis presenting as status epilepticus
Authors: Safe A F , Griffiths K D , Maxwell R T
Published: December 2008

A 30 year old male patient with thyrotoxic crisis presenting as status epilepticus is reported. The aetiology, manifestations and management of this medical emergency are discussed. The importance of prompt, vigorous and comprehensive treatment of thyrotoxic crisis is emphasized. Rapid control of hyperthyroidism as well as other supportive measures are essential if the high fatality rate is to be reduced. Comprehensive management reduces mortality from 90% to 20%.
Leptospirosis presenting as a flaccid paraplegia
Authors: Mumford C , Dudley N , Terry H
Published: December 2008

A fatal case of leptospirosis in a 64 year old farm worker is described. The dramatic neurological presentation with a rapidly evolving flaccid paraplegia associated with biochemical evidence of renal and hepatic dysfunction is discussed. Attention is drawn to the wide range of neurological symptoms reported in leptospirosis, and to the possibility that this infectious disease may present neurologically.
Successful treatment with ketoconazole of Cushing's syndrome in pregnancy
Authors: Amado J A , Pesquera C , Gonzalez E M , Otero M , Freijanes J , Alvarez A
Published: December 2008

Patients with Cushing's syndrome rarely become pregnant. This is a high risk situation both for the fetus and the mother, if untreated. We report a patient with Cushing's syndrome due to adrenocortical adenoma who became pregnant and was successfully treated with ketoconazole during the last period of pregnancy.
Premature coronary artery disease and the Prader-Willi syndrome
Authors: Page S R , Nussey S S , Haywood G A , Jenkins J S
Published: December 2008

A 28 year old woman with the Prader-Willi syndrome developed chest pain and loss of anterior R wave amplitude on the electrocardiogram. Cardiac catheterization demonstrated a severe proximal stenosis of the left anterior descending artery with delayed antegrade flow together with antero-apical akinesia consistent with myocardial infarction. Physicians involved in the management of patients with the Prader-Willi syndrome should be aware of this association with premature coronary artery disease.
Myoglobinuria: the importance of reaching a firm diagnosis—a patient with defective fatty acid oxidation
Authors: Ellis C J , Dewhurst A G , Cooper M , Brenton D P , Dathan J R
Published: December 2008

A 52 year old man presented with myoglobinuria-induced acute renal failure requiring dialysis. Despite renal biopsy, the cause of the myoglobinuria was not established until he re-presented a year later with a milder episode. At this stage investigations, including a muscle biopsy, demonstrated a defect in fatty acid oxidation amenable to dietary and lifestyle advice. This report emphasizes the importance of reaching a definitive diagnosis in myoglobinuria.
Lovastatin-induced acute rhabdomyolysis
Authors: Kogan A D , Orenstein S
Published: December 2008

Severe rhabdomyolysis complicated by respiratory and renal failure developed three weeks after initiation of low dose lovastatin therapy in a 79 year old, non-immunocompromised patient. The concomitant use of gemfibrozil may increase the risk of this complication.
Rifampicin-induced upper gastrointestinal bleeding
Authors: Zargar S A , Thapa B R , Sahni A , Mehta S
Published: December 2008

Gastrointestinal disturbances like anorexia, nausea, vomiting, abdominal discomfort and diarrhoea are known adverse effects of rifampicin. We report an upper gastrointestinal bleeding due to haemorrhagic gastric erosions after ingestion of rifampicin for pulmonary tuberculosis. The cause and effect relationship between development of haemorrhagic gastric erosions and rifampicin administration was confirmed by rechallenge with rifampicin. To our knowledge no such adverse effect of rifampicin has been reported previously.
Recurrent thrombosis and anticardiolipin antibodies associated with adenocarcinoma of the lung
Authors: Shaukat M N , Hughes P
Published: December 2008

A case of adenocarcinoma of the lung, in which high titre anticardiolipin antibodies were associated with recurrent venous thromboses resistant to all forms of therapy, is described. It is suggested that such an autoimmune response may be a contributory factor in the para-neoplastic development of vascular thromboses.
Behavioural treatment of epilepsyBased on a lecture given to the European Medical Research Group on 20 November 1989.
Authors: Fenwick P B C
Published: December 2008

There is abundant evidence of the close interrelation between the induction and inhibition of seizure activity and the patient's thoughts, feelings and behaviour. The detailed knowledge that we now have of the epileptic focus and the way that it is connected to the surrounding cerebral mechanisms, makes it possible for many patients with focal epilepsy to establish a significant degree of seizure control by altering their thinking and behaviour.
Antiphospholipid antibodies and Mycoplasma pneumoniae infection
Authors: Snowden N , Wilson P B , Longson M , Pumphrey R S H
Published: December 2008

Anticardiolipin antibody levels were measured in 57 patients with Mycoplasma pneumoniae infection and 21 patients with other infections. Significantly more patients in the mycoplasma group had increased IgM and IgG anticardiolipin. Within the mycoplasma group significantly higher titres were found in patients with severe infection (assessed by need for hospital admission) and in patients with cold agglutinins. A tendency for particularly high titres to occur in patients with extra-pulmonary complications was identified.
The relationship between ‘normal’ fluid retention in women and idiopathic oedema
Authors: Denning D W , Dunnigan M G , Tillman J , Davis J A , Forrest C A
Published: December 2008

A sample of women attending a gynaecological outpatient clinic were examined for symptoms and objective signs of fluid retention. Patients completed a questionnaire on symptoms suggesting fluid retention and recorded daily weight and abdominal girth variation. Daily weight variation varied from 0–9 pounds (mode 2 pounds) with no discernable difference between premenstrual and intermenstrual variation. Daily girth variation varied from 0–6 inches (mode 1 inch). Symptoms of breast swelling were more common premenstrually, finger/hand and ankle swelling intermenstrually and abdominal swelling occurred with equal frequency in both periods. No correlation between symptoms and weight variation was seen although abdominal swelling and girth variation were associated (P < 0.04).

The results indicate that symptoms of mild fluid retention and of diurnal weight and abdominal girth variation are part of the everyday experience of our study population. There is no clear-cut separation between ‘normal’ and ‘abnormal’ fluid retention (idiopathic oedema, periodic oedema, fluid retention syndrome); the latter may be an exaggeration of normal fluid-retaining mechanisms common to most women or may represent a pathological state. An approach which evaluates individual risk factors and the severity of fluid retention in each patient is recommended.
Type I protein S deficiency and skin necrosis
Authors: Craig A , Taberner D A , Fisher A H , Foster D N , Mitra J
Published: December 2008

A kindred with Type I protein S deficiency is described in which the index case developed skin necrosis during induction of oral anticoagulant therapy for deep venous thrombosis. Two other family members with protein S deficiency have been detected, and demonstrate the clinical variability of this condition.
Tissue plasminogen activator in the treatment of superior vena caval thrombosis associated with parenteral nutrition
Authors: Barclay G R , Allen K , Pennington C R
Published: December 2008

Two patients, one of whom was pregnant, developed superior vena caval thrombosis while receiving central parenteral nutrition. They were successfully treated with recombinant tissue plasminogen activator (t-PA).
A clinical audit of thallium – technetium subtraction parathyroid scans
Authors: Samanta A , Wilson B , Iqbal J , Burden A C , Walls J , Cosgriff P
Published: December 2008

Eighty six consecutive thallium-technetium subtraction parathyroid scans performed over a three year period for hypercalcaemia have been evaluated. Twelve had chronic renal failure, 11 had hypercalcaemia due to non-hyperparathyroid causes and in 10 the imaging study was technically inadequate. The remaining 53 technically adequate studies performed for hypercalcaemia clinically thought to be possibly due to hyperparathyroidism have been analysed. Of 20 (38%) positive scans, 13 came to surgery (10 correctly localized parathyroid adenomas, 2 with multiple gland hyperplasia, and 1 papillary carcinoma of the thyroid). Of 33 (62%) negative scans, 9 had surgical exploration on the basis of strong clinical grounds and all had parathyroid adenomas.

Multiple biochemical parameters have been assessed in relation to a positive outcome on scan. The adjusted calcium-phosphate product and the ratio of the adjusted calcium-phosphate product to creatinine (Ca × P/Cr) were both significantly lower in the scan positive group (P < 0.01). The scan positive group had a significantly higher mean level of PTH (P < 0.001) and lower mean level of phosphate (P < 0.001). The present experience shows that parathyroid imaging is useful in localizing parathyroid adenomas in 50% of cases (10 out of 19). This figure is at the lower end of the range of previously published results.

It is less effective in demonstrating multiple gland hyperplasia. The decision as to whether to undertake surgical exploration when the scan is negative has been based successfully on clinical judgement. We feel that an analysis of this nature is important, as it gives insights into the practical relevance of parathyroid imaging in the context of routine clinical work.
Acquired von Willebrand's disease and hypothyroidism: report of a case presenting with menorrhagia
Authors: Blesing N E , Hambley H , McDonald G A
Published: December 2008

A 17 year old woman presented with severe anaemia due to menorrhagia. On investigation, she was shown to have abnormalities of her haemostatic mechanism consistent with von Willebrand's disease Type I, although there was no family history of this disorder. In addition, she was shown to have severe primary hypothyroidism. On correction of hypothyroidism with oral thyroxine, her coagulation defects returned to normal and menorrhagia ceased. This is consistent with acquired von Willebrand's disease secondary to hypothyroidism.
Multiple Salmonella enteritidis leg abscesses in a patient with systemic lupus erythematosus
Authors: Shamiss A , Thaler M , Nussinovitch N , Zissin R , Rosenthal T
Published: December 2008

We describe a 19 year old woman with systemic lupus erythematosus on corticosteroid therapy, who developed bilateral, multiple, gas-forming Salmonella enteritidis leg abscesses and osteomyelitis mimicking deep vein thrombosis. The infection was treated successfully by a combination of surgical drainage and intravenous ceftriaxone, followed by prolonged oral pefloxacin.

This rare case of gas-producing S. enteritidis emphasizes the difficulty in diagnosing such complications in active systemic lupus erythematosus.
Acanthosis nigricans in obese women with the polycystic ovary syndrome: disease spectrum not distinct entity
Authors: Conway G S , Jacobs H S
Published: December 2008

Fasting and stimulated insulin concentrations in four patients with acanthosis nigricans and polycystic ovary syndrome were compared with four patients, matched for weight and ovarian morphology, without acanthosis. The median fasting serum insulin concentrations were 114.2 and 25.1 mU/l in the respective groups (P = 0.02). One additional patient was investigated before and after an 18% increase in weight which resulted in a 170% increase in fasting insulin concentrations and the development of acanthosis nigricans. These observations suggest that there is variation between individuals in the degree of obesity that results in the development of acanthosis and that obese patients with this skin condition represent the severe end of the spectrum of the polycystic ovary syndrome.
Analgesic nitrous oxide for alcohol withdrawal: a critical appraisal after 10 years' use
Authors: Gillman M A , Lichtigfeld F J
Published: December 2008

We describe a method of treating the mild to moderate alcohol withdrawal state which has been used successfully for 10 years in over 7,000 cases. It is now the standard therapy at the largest dedicated alcoholic rehabilitation centre in Southern Africa. The technique uses analgesic (subanaesthetic) concentrations of nitrous oxide, which in most cases is administered on a single occasion for 20 minutes only. This results in the most rapid detoxification presently available, such that within an hour of the commencement of therapy the patient is so improved that they can eat the next ward meal. Provided the correct equipment and simple training is used this non-anaesthetic treatment is completely free of any serious side effects and the patient is at all times conscious and cooperative. Apart from this the amounts of sedative medication, such as benzodiazepines, are drastically reduced during detoxification. Because of the rapidity of the therapeutic response this technique is useful also as a screening test for assessing those patients requiring intensive therapy for the alcohol withdrawal state. There is evidence of the usefulness of analgesic nitrous oxide therapy for treating other addictive withdrawal states including opioid and nicotine.
Retinal periphlebitis in ulcerative colitis
Authors: Kelly I M G , Frith P A , Hyman N M , Jewell D P
Published: December 2008

A man presented with unilateral visual blurring associated with bilateral retinal periphlebitis which was felt to be a complication of his biopsy-proven active ulcerative colitis. Retinal periphlebitis has been associated rarely with some forms of colitis but we can find no report of its occurrence in association with ulcerative colitis although other ocular inflammatory disorders are well recognized.
Extrinsic duodenal obstruction and halitosis
Authors: Stephenson B M , Rees B I
Published: December 2008

Two siblings with extrinsic duodenal obstruction caused by congenital peritoneal bands are reported. Attention is drawn to the unusual physical sign of halitosis as a presenting feature. It is suggested that this physical sign may be an indication for barium studies.
Medical training in the European Community
Authors: Crisp A H
Published: December 2008

The free movement of doctors within the European Community demands harmonization of standards of medical practice and carries major implications of an undergraduate and postgraduate educational kind. These have begun to be addressed by the first three Medical Directives and also by a series of reports produced by the Advisory Committee on Medical Training to the European Community. This Committee was established in 1975 in order to provide informed agreed advice to the Commission. Many tasks remain to be tackled. A system of mutual inspection of the examination processes and standards in Member States should be established. Control must be exercised over the numbers of doctors produced since educational resources, including numbers of patients available for study, are limited. Thus, excellent standards of medical practice can only be developed and maintained if the primacy of clinical skills derived from the study of patients is recognized as essential in this respect. In some Member States at the present time there are many unemployed and therefore presumably deskilled doctors.
Haemorrhagic pancreatitis—a cause of death in severe potassium permanganate poisoning
Authors: Middleton S J , Jacyna M , McClaren D , Robinson R , Thomas H C
Published: December 2008

Severe potassium permanganate poisoning (more than 10 g of potassium permanganate) is invariably associated with massive systemic upset and death. Multiple organ damage has been recognized as an inevitable consequence of such an overdose, although pancreatitis has not been previously reported. Death due to cardiovascular collapse and profound hypotension is a common end point in those who reach hospital, but the pathogenesis is uncertain. We report a case of haemorrhagic pancreatitis following an overdose of potassium permanganate and suggest that this complication may be an unrecognized factor contributing to the extremely high mortality rate associated with this condition.
Body packing—a case report and review of the literature
Authors: Stewart A , Heaton N D , Hogbin B
Published: December 2008

Drug smuggling by internal bodily concealment is a growing international problem. The management of a patient who swallowed packages containing heroin is described. The medical management, indications for surgery and the ethical dilemmas of treating patients with drugs concealed within the gastrointestinal tract are discussed.
Is serum gamma-glutamyl transferase a good marker of alcohol intake in stroke patients?
Authors: Peck K , Shinton R , Beevers G
Published: December 2008

Serial serum gamma-glutamyl transferase (GGT) levels were estimated in 23 consecutive patients admitted to hospital with a diagnosis of acute stroke. The proportion of patients with elevated GGT levels in the initial, 36-hour and 72-hour samples was 13%, 30% and 24% respectively, suggesting a transient rise following a stroke. Patients with a history of diabetes mellitus had an initial serum GGT level 21 IU/l (95% confidence interval 6 to 37) higher than non-diabetics.

We conclude that GGT levels after a stroke may reflect a history of diabetes and cerebral damage as well as the usual more established causes. Physicians, therefore, should be wary of attributing all unexplained high GGT levels in stroke patients to alcohol.
Reactivation of latent melioidosis
Authors: Johnson A B , Ali N
Published: December 2008

Reports of melioidosis in residents of European countries are rare. We describe a case of reactivation of latent melioidosis in a United Kingdom resident. The case demonstrates the lack of clinical response to chemotherapy despite proven in vitro sensitivity of the organism to the drugs used. It is important to consider melioidosis as a cause of septicaemic illness in patients who have travelled to, or been resident in South-East Asia.
Spreading sepsis by cystoscopy
Authors: Bavetta S , Olsha O , Fenely J
Published: December 2008

A healthy 54 year old man was investigated for haematuria. In spite of a proven urinary tract infection a cystoscopy was carried out with no antibiotic therapy. As a result he developed systemic infection leading to two independent, and potentially fatal, complications: vertebral osteomyelitis and a mycotic false aneurysm.
Carotid artery stenoses and thrombosis secondary to cavernous sinus thromboses in Fusobacterium necrophorum meningitis
Authors: Jones T H , Bergvall V , Bradshaw J P P
Published: December 2008

We report the case of a young man with Fusobacterium necrophorum meningitis who developed bilateral carotid artery stenosis associated with thrombosis of the cavernous sinuses. Intraluminal clot was present in the region of the stenoses for which he was anticoagulated. The clinical presentation, problems with diagnosis, the use of anticoagulation and the need for prolonged treatment with metronidazole are discussed.
Intermittent hypercalcaemia and vitamin D sensitivity in Hodgkin's disease
Authors: Karmali R , Barker S , Hewison M , Fraher L , Katz D R , O'Riordan J L H
Published: December 2008

A patient with Hodgkin's disease spontaneously developed steroid-responsive hypercalcaemia during two consecutive summers. Administration of 3000 U/day of vitamin D, while he was normocalcaemic, caused a sharp increase in serum 1,25(OH)2D3 (from 59 pg/ml to 142 pg/ml) and subsequently hypercalcaemia while serum 25(OH)D3 rose moderately within the normal range (from 2.8 ng/ml to 10 ng/ml). During a spontaneous episode of hypercalcaemia which was accompanied by increased circulating 1,25(OH)2D3 concentrations, administration of hydrocortisone decreased serum 1,25(OH)2D3 rapidly (from 115 pg/ml to 62 pg/ml) and eventually led to normocalcaemia while serum 25(OH)D3 remained unchanged. Thus the disturbances of mineral metabolism found in this patient with Hodgkin's disease are very similar to those previously described in sarcoidosis.
A case of POEMS syndrome associated with essential thrombocythaemia and dermal mastocytosis
Authors: Jackson A , Burton I E
Published: December 2008

We describe a case of POEMS syndrome presenting with the recognized features of polyneuropathy, organomegaly, endocrine abnormalities, monoclonal protein, skin changes and anasarca. The patient was found to have both a solitary sclerotic plasmacytoma of the pelvis and evidence of Castleman's disease of lymph nodes. A number of unusual and unique features are also documented. Histological examination of affected skin demonstrated changes similar to urticaria pigmentosa including local oedema and mast cell infiltration. There was marked thrombocythaemia which has been seen in only one previous case and in addition the patient developed diffuse vascular calcification in the absence of recognized aetiological factors. Radiotherapy of the pelvic lesion and chemotherapy to control the myeloproliferative disorder gave rise to significant improvement in neuropathy. Control of anasarca required steroid therapy in addition to diuretics. The significance of these observations is discussed in relation to previous reports.
Endobronchial tuberculosis—is corticosteroid treatment useful? A report of 8 cases and review of the literature
Authors: Chan H S , Sun A , Hoheisel G B
Published: December 2008

Eight patients with endobronchial tuberculosis diagnosed on bronchoscopy were treated with antituberculosis drugs and a course of prednisone. The progress of the endobronchial lesions was assessed on repeated examinations. The course of the disease was variable and the endobronchial narrowing improved in two patients only. Hypersensitivity reactions associated with initiation of antituberculosis treatment may constitute a special group where corticosteroid is indicated. In other situations, the usefulness of corticosteroid for treatment of endobronchial tuberculosis is not well documented.
Danazol in non-splenectomized patients with refractory idiopathic thrombocytopenic purpura
Authors: Edelmann D Z , Knobel B , Virag I , Meytes D
Published: December 2008

Seven non-splenectomized patients with chronic refractory idiopathic thrombocytopenic purpura were treated with danazol 800 mg daily. All were glucocorticoid failures and four were refractory to all additional previous therapy. Five patients benefited from danazol and in two sustained normal platelet counts, for over 44 and 51 months, were observed. We conclude that danazol is useful for long term management of otherwise refractory idiopathic thrombocytopenic purpura. The advantage of danazol over splenectomy as a first line treatment in steroid failure is suggested.
Concomitant euthyroid Graves' ophthalmopathy and isolated ocular myasthenia gravis
Authors: Raef H , Ladinsky M , Arem R
Published: December 2008

A 44 year old diabetic woman presented with diplopia and bilateral ptosis and mild exophthalmos. The patient was clinically euthyroid, the baseline thyroid function tests were normal, but the thyroid stimulating hormone response to thyrotrophin releasing hormone was flat. Computed tomographic scan and magnetic resonance imaging of the orbits showed left medial and inferior rectus muscle thickening, more prominent on the left side, consistent with Graves' disease. The tensilon stimulation test resulted in resolution of the ptosis and partial improvement of the ophthalmoplegia. The single fibre electromyography was consistent with a defect in neuromuscular transmission. However, forced duction test was normal and anti-acetylcholine receptor antibodies were undetectable. Significant improvement of the extraocular muscle function and resolution of the right ptosis had resulted from anticholinesterase therapy.

These findings and the clinical response to therapy were consistent with concomitant euthyroid Graves' ophthalmopathy and ocular myasthenia gravis. Coexistent isolated ocular myasthenia gravis and Graves' ophthalmopathy is rare and should be considered in patients with findings of ocular myasthenia and extraocular muscle dysfunction.
Peritoneal mesothelioma
Authors: Anderson J H , Stewart C J R , Hansell D T , Anderson J R
Published: December 2008

We report two patients who presented with small bowel obstruction secondary to peritoneal mesothelioma. The difficulties in establishing this diagnosis at an early stage are illustrated. Recent advances in the management of peritoneal mesothelioma are reviewed.
Typhoid hepatitis
Authors: Khosla S N
Published: December 2008

Liver involvement in typhoid fever is uncommon. Typhoid hepatitis is now being recognized as a definite entity. Over a period of 4 years, we have observed 10 cases (4.8%) of typhoid hepatitis out of 210 cases of typhoid fever. Jaundice, anaemia, hepatomegaly and abnormal biochemical tests were present in all cases. Liver biopsy was done in 8 cases and was found to be abnormal in 5. Two of the 10 cases of typhoid hepatitis died.

Recognition of typhoid hepatitis is important since it has to be differentiated from other common ailments in the tropics such as viral, malarial or amoebic hepatitis. Early institution of specific therapy in cases of typhoid hepatitis carries a good prognosis.
Withdrawal of maintenance digoxin from institutionalized elderly
Authors: Macarthur C
Published: December 2008

Chronic use of digitalis is common amongst the institutionalized elderly. Associated with digitalis use is the potential for toxicity and/or adverse reactions. In this study maintenance digoxin was withdrawn from 14 elderly nursing home residents in sinus rhythm. Subjects were followed over 18 months for evidence of dysrhythmia or heart failure. One resident had an episode of supraventricular tachycardia which required digoxin to be restarted. One resident developed left heart failure, treated with oral diuretic. For 12 of the 14 residents, withdrawal of maintenance digoxin was achieved without deleterious effect. This study suggests that maintenance digoxin may be withdrawn safely in elderly nursing home residents in sinus rhythm and without history of atrial dysrhythmia.
Histiocytic cytophagic panniculitis
Authors: Hilton D A , O'Malley B P , Durrant S T S
Published: December 2008

A 33 year old man developed fever, malaise, jaundice, pancytopenia, coagulation abnormalities, hepatomegaly, pleural effusions and a subcutaneous lump. Biopsies revealed a lobular panniculitis with the presence of cytophagic histiocytes; erythrophagocytosis was also demonstrated in the liver and bone marrow. Despite the use of chemotherapy (CHOP) his clinical condition deteriorated and he died 5 months after presentation. This illness is consistent with the recently described syndrome of histiocytic cytophagic panniculitis.
Cognitive impairment associated with beta-blockade in the elderly
Authors: Rogers T K , Bowman C E
Published: December 2008

We report the cases of three elderly patients presenting with insidious mental impairment whilst receiving both lipophilic and hydrophilic beta-adrenoceptor blocking agents (propranolol and atenolol respectively). In each case marked improvement occurred on drug withdrawal. Two of our cases probably had early senile dementia of the Alzheimer's type and continued to exhibit signs of mild mental impairment, but the third was restored to normal functioning. We found no evidence of impaired perfusion to suggest a vascular basis for the effect or of depression. We believe that beta-blockade may cause or exacerbate mental impairment in the elderly.
Impact of endoscopic duodenal biopsy on the detection of small intestinal villous atrophy
Authors: Saverymuttu S H , Sabbat J , Burke M , Maxwell J D
Published: December 2008

Coeliac disease is underdiagnosed partly because of insufficient recognition of more subtle presentations and partly because of the relative difficulty of jejunal biopsy. We have compared new case detection of small intestinal villous atrophy in the 5 years following changing to endoscopic multiple biopsy with our preceding 9 year experience utilizing jejunal capsule suction biopsy. The detection rate for small intestinal disease doubled while the number of patients investigated by small bowel biopsy increased threefold. We recommend that endoscopic duodenal biopsy replace jejunal biopsy for routine diagnostic purposes.
Strangulated femoral hernia: the persisting clinical trap
Authors: Heys S D , Brittenden J
Published: December 2008

Five cases of strangulated femoral hernia, all with a delay in establishing the diagnosis, are reported here. These cases illustrate the continuing difficulties experienced, both in primary care and hospital practice, in making this diagnosis despite the clinical awareness of this condition.
Caroli's disease misdiagnosed as hydatid liver cysts
Authors: Akoglu M , Davidson B R
Published: December 2008

A 27 year old woman who presented with upper abdominal pain was found on ultrasonography to have multiple liver cysts consistent with hydatid disease. Three years previously she had undergone evacuation of multiple infected liver cysts thought to be due to hydatid disease. Computed tomographic scanning supported the diagnosis of hydatid disease affecting the right lobe of the liver. At laparotomy the right lobe contained multiple cysts which were removed by right lobectomy. Histology revealed congenital dilatation of the intrahepatic bile ducts with fibrosis (Caroli's disease) but no evidence of hydatid disease.
Acute rhabdomyolysis associated with atypical Guillain-Barré syndrome
Authors: Scott A J , Duncan R , Henderson L , Jamal G A , Kennedy P G E
Published: December 2008

We report a patient with atypical Guillain-Barré syndrome associated with acute rhabdomyolysis. Rhabdomyolysis may be the cause of elevation of creatine kinase sometimes seen in patients with Guillain-Barré syndrome.
A case of resolving idiopathic hypoparathyroidism
Authors: Ostlere L , Reeve J
Published: December 2008

A 72 year old man developed idiopathic hypoparathyroidism. The condition spontaneously resolved which, to our knowledge, has not been previously described. Causes of fluctuating hypocalcaemia are outlined and their possible relevance to our patient discussed.
Bilateral cilio-retinal artery occlusion in classic migraine
Authors: Hykin P G , Gartry D , Brazier D J , Graham E
Published: December 2008

A case of bilateral cilio-retinal artery occlusion in a patient with classic migraine is described. It is unlikely that this hitherto unreported occurrence represents altered tone in the dense adrenergic innervation to the posterior ciliary circulation. We advise the continued use of beta-adrenergic blockers as prophylaxis in ocular migraine.
Alopecia totalis and vitiligo in common variable immunodeficiency
Authors: Spickett G , Prentice A G , Wallington T , Webster A D B , Chapel H
Published: December 2008

Three cases of severe and irreversible alopecia occurring in patients with common variable immunodeficiency are described. In all three cases, hair loss developed after the diagnosis of immune deficiency; one of the patients also had extensive vitiligo. A fourth patient had vitiligo in the absence of alopecia. No change in the alopecia or vitiligo was noted in any patient as a result of immunoglobulin replacement therapy.
Disseminated gonococcal infection associated with deficiency of the second component of complement
Authors: McWhinney P H M , Langhorne P , Love W C , Whaley K
Published: December 2008

A case of C2 deficiency presenting with disseminated gonococcal infection is described. The predisposition of C2-deficient individuals to infection in addition to the commoner problem of immune complex diseases is noted. Attention is drawn to the absence of documented cases of gonococcal infection associated with C2 deficiency. No other homozygous C2 deficient family members were identified. Lifelong penicillin prophylaxis was recommended for the patient.
Virilization in a postmenopausal woman due to ovarian stromal hyperthecosis
Authors: Goldman J M , Kapadia L J
Published: December 2008

Virilization in women is occasionally caused by ovarian stromal hyperthecosis. Although three cases of post-menopausal women with hyperthecosis have been reported, the history in two of them strongly suggests a premenopausal origin. We describe a 64 year old woman with postmenopausal virilization due to bilateral ovarian stromal hyperthecosis.
Is the routine measurement of ionized calcium worthwhile in patients with cancer?
Authors: Riancho J A , Arjona R , Sanz J , Olmos J M , Valle R , Barceló J R , González-Macías J
Published: December 2008

This study was undertaken to analyse the relationship between total calcium (TCa) and ionized calcium (ICa) in patients with cancer, and to assess the clinical value of routine measurements of ICa in these patients. Serum TCa, ICa, albumin, proteins and creatinine were measured in 188 adult patients with solid malignant tumours. Most of them were out-patients, the Karnofsky score being 80 or above in 67%. The correlation coefficient between ICa and TCa was 0.85 (P < 0.001) and did not improve after correcting TCa for protein concentration with several published formulae. Although TCa measurements had a global diagnostic accuracy (percent of patients correctly classified) of 90%, they failed to identify a substantial proportion of patients with increased levels of ICa (57% for uncorrected TCa, and 27–57% for protein-corrected TCa). However, the finding of slightly increased ICa levels did not seem to predict the development of frank hypercalcaemia and did not impair the prognosis. According to these results, the routine measurement of ICa in unselected patients with cancer has no clinical usefulness.
Giant lymph node hyperplasia (Castleman's disease): a clinical study of eight patients
Authors: Baruch Y , Ben-Arie Y , Kerner H , Lorber M , Best L-A , Gershoni-Baruch R
Published: December 2008

We report on 8 patients with giant lymph node hyperplasia (GLNH), diagnosed over a 10-year period. The age of the patients at diagnosis, the clinical presentation and the histological subtype varied, indicating that GNLH is a heterogeneous condition. One case was associated with liver cirrhosis, and in another patient bacterial endocarditis was diagnosed post mortem. Our study shows that GLNH is localized and benign in the young, and diffuse and aggressive in the elderly. It is concluded that GLNH should be separated into 3 clinical entities—namely, localized, systemic and reactive GLNH—defined by their clinical presentation and course, and correlated or not correlated with the histological findings.
Spontaneous external biliary fistula uncomplicated by gallstones
Authors: Birch B R P , Cox S J
Published: December 2008

External biliary fistulae are rare. Only 65 cases have been reported in the literature and in each instance gallstones were a complicating factor. We report in this paper the first case of spontaneous external (cholecystocutaneous) biliary fistula uncomplicated by gallstones.
Ablation of recurrent primary liver cancer using 131I-lipiodol
Authors: Novell R , Hilson A , Hobbs K
Published: December 2008

A case of recurrent hepatocellular carcinoma following resection is reported. The patient received 2 treatments of 131I-lipiodol administered via the hepatic artery at angiography. Good localization in tumour tissue was observed on subsequent computed tomographic scans and no adverse effects were seen after either treatment. After the first treatment 2 nodules of recurrent tumour were resected and proved to be totally necrotic. The patient remains well 9 months later with a persistently elevated serum alphafetoprotein but no evidence of residual tumour. It is suggested that 131I-lipiodol may be the treatment of choice for small tumours in elderly high-risk patients.
Hypoglycaemia associated with anorexia nervosa
Authors: Fonseca V , Ball S , Marks V , Havard C W H
Published: December 2008

A 41 year old woman with severe emaciation due to longstanding anorexia nervosa presented with recurrent hypoglycaemia. During an episode of hypoglycaemia, serum insulin and C peptide were undetectable and plasma beta hydroxybutyrate, free fatty acids and lactate were inappropriately low. Response to intravenous glucagon was poor. Muscle enzymes were grossly elevated until she gained weight. Hypoglycaemia was abolished by weight gain.
Pulmonary embolism: a cause of acute confusion in the elderly
Authors: Shaw J E , Belfield P W
Published: December 2008

Large numbers of elderly patients are admitted to hospital with an acute confusional state. In many of these, the underlying cause is easily found, but in a proportion, correct diagnosis is very difficult. Two cases of acute confusion due to hypoxia are presented, in which the diagnosis of pulmonary embolic disease was made late. The importance of considering this in all patients presenting with acute confusion and the value of blood gas analysis is discussed.
Transient hyperphosphatasaemia in association with acute infection in adults
Authors: Parker S G
Published: December 2008

The causes of raised serum alkaline phosphatase were determined prospectively in a consecutive series of 2884 acute medical admissions. Diagnoses were established by pre-defined clinico-pathological criteria. Two hundred and four patients had hyperphosphatasaemia. Liver and bone disease accounted for only 98 (48%) of the established diagnoses. The diagnosis was not established in 31 (15%). Transient hyperphosphatasaemia occurred in 66 (32.4%) cases. In 25 of these patients (12% of the total) an acute infection was the sole illness identified. In this infected group, the isoenzyme type was predominantly hepatic, although jaundice occurred in only 3 patients. Discriminant analysis revealed that this group was characterized by haematological and biochemical features of an acute phase response.

Transient hyperphosphatasaemia is commonly found in acutely ill medical inpatients and is frequently associated with acute extrahepatic infection.
Hypernatraemia in an adult in-patient population
Authors: Long C A , Marin P , Bayer A J , Shetty H G M , Pathy M S J
Published: December 2008

We report a retrospective study of hypernatraemia (serum sodium concentration > 150 mmol/l) in an adult in-patient population of a health district during one year. The incidence was 0.3% with at least 60% of cases developing after hospital admission, mainly in elderly patients. Dehydration appeared to be the major cause, with the use of diuretics, depressed conscious level or febrile illness implicated in a majority. Most patients had more than one contributory factor and iatrogenic causes were common. Associated illnesses were often severe and the in-hospital mortality was high (54%) regardless of age. Hypernatraemia in hospitalized patients should be largely avoidable and there is a need for greater awareness of the importance of active maintenance of hydration in susceptible patients.
How reliable is the electrocardiogram in detecting left ventricular hypertrophy in hypertension?
Authors: Vijan S G , Manning G , Millar-Craig M W
Published: December 2008

This paper assesses the sensitivity and specificity of the electrocardiogram in detecting left ventricular hypertrophy in 75 hypertensive patients. Each patient underwent a 12 lead electrocardiogram and echocardiogram. Left ventricular mass index, using echocardiogram, was calculated according to the Penn convention and left ventricular hypertrophy was assessed by standard electrocardiographic criteria.

The electrocardiogram was found to be very specific but insensitive in the detection of left ventricular hypertrophy as compared with the echocardiogram. Other non-voltage dependent markers appeared to have similar reliability.

We conclude that the electrocardiogram may be unreliable in the detection of left ventricular hypertrophy in hypertensive patients. Accurate assessment of left ventricular hypertrophy, in these patients should be by echocardiography.
Bradyarrhythmias in acute myocardial infarction: should thrombolysis lower the decision threshold for temporary pacing?
Authors: Lim C W , Bennie M J , Lim R
Published: December 2008

Both acute myocardial infarction and reperfusion therapy with thrombolytic agents may be associated with bradyarrhythmias, and there may be a case for ‘prophylactic’ insertion of a temporary pacing wire in selected patients. We describe 4 patients in whom clinical decisions had to be made concerning the appropriateness and timing of temporary pacing, and discuss the implications for modern guidelines on the indications for pacing in such a setting.
Interaction of ketoprofen and frusemide in man
Authors: Wa T C L K , Lawson M , Jackson S H D , Hitoglou-Makedou A , Turner P
Published: December 2008

The effects of ketoprofen on frusemide-induced diuresis, natriuresis and renin release were studied in 12 healthy male volunteers. Each received frusemide 40 mg once daily with either ketoprofen 100 mg twice daily or placebo for two periods of 5 days separated by a treatment-free period according to a randomized, double-blind, cross-over study design. Ketoprofen significantly reduced frusemide-induced diuresis on Day 1 but not on Day 5 of treatment. The natriuresis induced by frusemide on Day 1 or Day 5 of treatment did not differ significantly whether ketoprofen or placebo was administered, although the mean urinary sodium excretion values were consistently lower following ketoprofen. Ketoprofen did not affect the kaliuretic response to frusemide on Day 1 or Day 5 of treatment. The increase in plasma renin activity after frusemide was inhibited by ketoprofen on both Day 1 and Day 5. These results suggest that ketoprofen reduces the diuresis and renin release induced by frusemide, but that the reduction in diuretic response may become less important after their repeated coadministration.
Occult tuberculous postpneumonectomy space empyema four years after lung resection
Authors: Rogiers Ph , Verschakelen J , Knockaert D , Vanneste S
Published: December 2008

We describe a patient in whom a tuberculous postpneumonectomy empyema developed 4 years after resection for lung cancer. The clinical presentation was dominated by non-specific constitutional symptoms, without any chest complaints. A computed tomographic scan of the chest suggested inflammation in the postpneumonectomy space. Ultimately Mycobacterium tuberculosis was cultured from material aspirated by needle thoracocentesis.

To our knowledge this is the first report of a tuberculous postpneumonectomy empyema complicating resection for cancer.
Gynaecomastia and extragonadal symptoms leading to diagnosis delay of germ cell tumours in young men
Authors: Cantwell B M J , Richardson P G G , Campbell S J
Published: December 2008

We report two young men with gynaecomastia in whom the underlying causative metastatic germ cell malignancies were not diagnosed for prolonged time periods. Despite the fact that cancer is an uncommon cause of gynaecomastia, doctors should consider germ cell malignancy, even in the absence of testicular symptoms or signs, in previously healthy young men with recent gynaecomastia or other unusual symptoms or signs. Serum beta human chorionic gonadotrophin and other germ cell malignancy markers (alpha fetoprotein and lactic dehydrogenase) should always be assayed. If a testicular primary site is not clinically apparent, there should be early recourse to scrotal ultrasonography.
Evisceration and other complications of abdominal drains
Authors: Loh A , Jones P A
Published: December 2008

Drainage following major abdominal surgery remains controversial. A case of small bowel evisceration through a Wallis drain site after an abdomino-perineal excision of rectum is reported as a complication of abdominal drainage.
Clustering of colorectal neoplasia: characteristics of coexisting adenomas in patients with severely dysplastic polyps or invasive (malignant) polyps as compared to patients with benign adenomas or carcinomas
Authors: Pines A , Bat L , Shemesh E , Rosenblum J , Horowitz A , Levo Y , Bubis J J
Published: December 2008

This study compared the size, histology and morphology of coexisting neoplastic polyps found in colonoscopy, and evaluated the clustering of these polyps in patients with either colorectal carcinoma, cancerous polyps or benign adenomas. Patients were divided by their most malignant form of neoplasia: Group A included 58 patients with early invasive cancerous polyps, and Group B included 73 patients with in situ carcinoma within an adenoma. Group C consisted of 335 patients with benign adenomas, and Group D had 289 patients with colorectal carcinoma. There were no significant differences between the four groups regarding sex, age and ethnicity. The cancerous polyps were significantly larger than the benign polyps. There were significantly (P less than 0.01) more patients with multiple (greater than or equal to 5) colonic lesions in Groups A or B than in Groups C or D. Coexisting polyps were much closer to the index growth, and demonstrated more severe dysplastic changes in the case of cancerous polyps than those associated with benign polyps or cancer. Based on our data we speculate that cancerous polyps are not merely a middle link in adenoma-carcinoma sequence, but rather mark a subset of patients who are especially prone to develop neoplastic changes in their colonic mucosa. These patients should be included in a more strict colonoscopic surveillance programme.
Pedunculated left ventricular thrombus—report of two cases
Authors: John R M , Sturridge M F , Swanton R H
Published: December 2008

In two patients presenting with myocardial infarction, one with a subendocardial infarction and the second patient with a classic Q wave infarction, pedunculated left ventricular thrombi were detected in the course of subsequent routine cardiac catheterization. Both patients underwent successful surgical thrombectomy.
Infection in exacerbations of asthma: views of different groups of practitioners
Authors: Connolly C K , Murthy N K , Prescott R J , Alcock R M
Published: December 2008

A questionnaire designed to elucidate views on the frequency of infection in asthma and its management was circulated to general practitioners, general physicians, paediatricians and respiratory physicians in the north of England. On the whole, general practitioners agreed with the general physicians and paediatricians with respiratory physicians. The generalists, and to a lesser extent the specialists, tended to overestimate the risk of bacterial infection, which was perceived to be a particular risk following viral infection in intrinsic asthma. This resulted in more frequent prescription of antibiotics than is justified by the published evidence. There was a tendency for frequent prescribers of antibiotics to withhold corticosteroids. If prescribing habits are to be altered, education will have to be directed at those responsible for acute admissions to hospital as well as at general practitioners.
Spontaneous hyphaema as a result of systemic anticoagulation in previously abnormal eyes
Authors: Holden R
Published: December 2008

Spontaneous hyphaema in patients on systemic anticoagulants has been described in normal eyes and also in eyes with certain intraocular lenses following cataract surgery. These cases are rare and in all the reported cases the hyphaemas resolved without sequelae. Four cases are reported here of spontaneous hyphaemas in previously abnormal eyes of patients on anticoagulants. Three of these patients suffered considerable pain as a result of this. The reasons for this are discussed and early ophthalmic referral recommended if a hyphaema is suspected in these situations.