bluuebunny/crossref_metadata_2025 huggingface dataset:
Carcinoid tumours
Authors: Janmohamed S , Bloom S R
Published: December 2008

The use of long-acting and potent somatostatin analogues is a major advance in the management of carcinoid tumours. In addition to providing effective symptom relief in malignant carcinoid syndrome, octreotide can also be used for diagnostic purposes. Despite its expense, octreotide is the current agent of choice for the treatment of this condition while analogues with different receptor specificities and pharmacokinetics hold promise for the future. Gastric carcinoids have aroused interest because of their experimental association with chronic hypergastrinaemia, a condition now commonplace because of the widespread use of H2-blockers and proton-pump inhibitors. This subject is reviewed. The slow evolution of many tumours demands prolonged follow-up and the active use of a variety of palliative interventions. These include measures such as hepatic and cardiac surgery, which might be deemed inappropriate for patients with other types of metastatic malignancy. Interferons may have a role when first-line treatments have failed. Chemotherapy is, generally, of limited value.
Boerhaave's syndrome
Authors: Janjua K J
Published: December 2008

Boerhaave's syndrome or spontaneous oesophageal perforation, is a potentially lethal and frequently elusive medical condition which presents not only a diagnostic but also a therapeutic challenge. It is insufficiently considered in diagnostic hypotheses, yet may be confirmed or excluded by simple methods such as an erect chest film and a contrast study of the oesophagus. Errors in diagnosis are usually caused by unawareness of its varied and atypical presentations or failure to consider its possibility in acute cardiothoracic and upper gastrointestinal conditions. Early aggressive surgical intervention in the form of open and wide mediastinal and chest drainage, with or without oesophageal repair, resection or exclusion, offers the patient the best chance of survival against this otherwise invariably fatal event. Nonoperative therapy consisting of antibiotics, nil oral regimen, nasogastric tube suction, pleural drainage, H2 receptor blockers and either a feeding enterostomy or total parenteral nutrition, may also be appropriate in selected patients. It is probable that the condition is more common than is generally supposed. All clinicians need to be aware of this lethal disease, its frequently unusual presentations and the importance of early diagnosis.
A six-year follow-up study of smoking habits and microvascular complications in young adults with type 1 diabetes
Authors: Sinha R N , Patrick A W , Richardson L , Wallymahmed M , MacFarlane I A
Published: December 2008

One hundred insulin-dependent diabetic patients (age < 45 years, 53 smokers) were followed for six years. The age, duration of diabetes and mean glycated haemoglobin levels, were comparable between the smokers and non-smokers. Microvascular complications (retinopathy and increased urine albumin excretion) were commoner and more severe in the smoking group at six years, particularly in heavy smokers. Of the 45 original smokers reviewed at six years, 12 (27%) had stopped, six of whom had developed microvascular complications. Only two of the ‘heavy’ initial smokers, likely to be at most risk, had stopped smoking, and three original non-smokers had started smoking.
Delayed cyanide poisoning following acetonitrile ingestion
Authors: Mueller M , Borland C
Published: December 2008

Acetonitrile (methyl cyanide) is a common industrial organic solvent but is a rare cause of poisoning. We report the first recorded UK case. Acetonitrile is slowly converted to cyanide, resulting in delayed toxicity. We describe a case of deliberate self-poisoning by a 39-year-old woman resulting in cyanide poisoning 11 hours later which was successfully treated by repeated boluses of sodium nitrite and thiosulphate. The half-life of conversion of acetonitrile was 40 hours and harmful blood cyanide levels persisted for over 24 hours after ingestion. Departments treating or advising in cases of poisoning need to be aware of the delayed toxicity of acetonitrile. Monitoring in an intensive care unit of cases of acetonitrile poisoning should continue for 24–48 hours.
The Mirizzi syndrome
Authors: Pemberton M , Wells A D
Published: December 2008

The Mirizzi syndrome is an unusual presentation of gallstones which occurs when a gallstone becomes impacted in either Hartmann's pouch of the gallbladder or the cystic duct, causing obstruction of the common hepatic duct by extrinsic compression. The diagnosis of this syndrome is of importance because surgery in its presence is associated with an increased incidence of bile duct injury. The pathology, clinical presentation and management of this syndrome are discussed, and several illustrative case reports presented.
Minimising delays to thrombolysis in patients developing acute myocardial infarction in hospital
Authors: Mumford A D , Banning A P
Published: December 2008

We investigated the clinical features and management of 50 patients presenting with acute myocardial infarction from the community and 50 patients presenting with cardiac symptoms who developed an infarct after being admitted to a general medical ward for observation. Nineteen of the 50 patients initially admitted to non-specialist wards were found retrospectively to have sustained an infarct prior to hospital admission. Of the remaining 31 admission in this group, 24 developed symptoms within 24 hours of admission, 26 presented with chest pain, while 21 had evidence of acute coronary ischaemia on the admission electrocardiograph. Of the 26 patients who presented with chest pain, 20 were treated with aspirin, 13 with intravenous nitrate and four with heparin. Median delay from onset of symptoms to thrombolysis with in-hospital patients was 120 minutes and for community patients 287 minutes. Interestingly, the greatest component of this delay in both groups was the time taken for patients to decide to seek assistance after developing acute symptoms. Patients at high risk of developing acute myocardial infarction within 24 hours of hospital admission may be identified by a history of chest pain and electrocardiographic evidence of acute coronary ischaemia at admission. Such patients may experience suboptimal treatment and delays to thrombolysis if admitted to nonspecialist wards, but this may be reduced by admitting all ‘high risk’ patients directly to a high dependency cardiac ward for the first 24 hours after presentation.
Nonsteroidal anti-inflammatory drug associated diaphragm disease
Authors: McGonigal A , Moffat D F , Lindop G B M , Gilchrist W J
Published: December 2008

We present a case of anaemia and intestinal obstruction in a 78-year-old woman taking nonsteroidal anti-inflammatory drugs who was found to have diaphragm disease at laparotomy.
Elevated levels of serum creatine kinase induced by hyponatraemia
Authors: Goldenberg I , Jonas M , Thaler M , Grossman E
Published: December 2008

Elevated serum creatine kinase levels are one of the major criteria for the diagnosis of myocardial injury. Noncardiac causes such as muscular and brain damage may also be associated with elevated serum creatine kinase levels. Hyponatremia may induce increased serum creatine kinase in association with rhabdomyolysis or with hypothyroidism. A patient is described where three episodes of hyponatraemia not associated with rhabdomyolysis or hypothyroidism induced transient elevations of serum creatine kinase levels. The association between hyponatraemia and elevated creatine kinase levels should be emphasized to prevent erroneous diagnosis of myocardial injury.
Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas
Authors: Williams N M A , Watkin D F L
Published: December 2008

Intraperitoneal free gas seen radiologically as air under the diaphragm nearly always indicates a perforated abdominal viscus that requires surgical intervention. Rarely, however, the presence of a pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. Such a situation is termed spontaneous or nonsurgical pneumoperitoneum. In this review, we explore the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. An appreciation of the condition and its likely aetiological factors should improve awareness and possibly reduce the imperative to perform an emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.
Basal cell carcinoma
Authors: Lear J T , Smith A G
Published: December 2008

Basal cell carcinoma is the commonest malignancy in Caucasians with incidence rates of 300 per 100,000 reported in the USA. Rates are increasing at over 10% per year leading to a lifetime risk of 30%. Although mortality is low, the disease is responsible for considerable morbidity and places a substantial burden on health service provision in the UK. Furthermore, lesions may recur and patients often develop multiple tumours giving major implications for treatment and follow-up. Four main types of basal cell carcinoma are seen: nodulo-ulcerative; pigmented; morpheaform and superficial. Diagnosis is by histological evaluation although many tumours have a characteristic clinical appearance. The differential diagnosis is large. Identified risk factors include male gender, skin type 1, red/blonde hair and increasing age. Patients with basal cell carcinoma are more likely to develop malignant melanoma and squamous cell carcinoma but it is still unclear whether there is a link with internal malignancy. The main treatment modalities are surgery and radiotherapy. Each has advantages and disadvantages. The choice of treatment depends on many factors. Principles of treatment include identification of high-risk patients to enable early detection, complete removal of the lesion, and careful follow-up to detect recurrence or new lesions. Approximately 10% of tumours recur, depending on site, size and treatment modality. Metastatic basal cell carcinoma and the association of ultraviolet radiation to basal cell carcinoma risk are reviewed.
Management options for solitary thyroid nodules in an endemic goitrous area
Authors: Sarda A K , Gupta A , Jain P K , Prasad S
Published: December 2008

An analysis of management of 546 cases of solitary thyroid nodules in an endemic area is presented. None of the evaluating procedures could effectively isolate benign from malignant disease. Of 508 cases considered clinically to be benign, 42 harboured malignancy on histological examination whereas of the 38 cases suspected clinically to be malignant, 21 were histologically benign. 131I-Thyroid scanning also lacked sensitivity in identifying malignant nodules since the prevalence of malignancy in cases which were ‘cold’ (44/316) was not significantly different from that amongst the ‘uniform’ cases (15/142). Fine-needle aspiration cytology, although the most sensitive and specific evaluating modality, did not decrease the number of operations for solitary thyroid nodules nor did it increase the incidence of malignancy amongst the operated cases, because of its limitations in differentiating benign from malignant follicular neoplasms. The conditions under which surgery was advocated are described.
Microbiologically proven bacterial infections in AIDS
Authors: Kirkpatrick B L , Glover S C , Reeves D S , MacGowan A P
Published: December 2008

We have reviewed the incidence, type and site of microbiologically proven bacterial infection occurring in 52 patients with the acquired immunodeficiency syndrome (AIDS) who presented to Southmead Hospital, Bristol between 1990 and 1994. A total of 30 (58%) patients had significant bacterial isolates. The majority of infections were community acquired. Overall, more infections were caused by Gram-negative organisms but Gram-positive organisms predominated in bacteraemia. Mycobacterium avium intracellulare (MAI) caused infection in the largest number of patients, followed by Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas sp, and Campylobacter sp. When individual episodes of infection were considered, after MAI, Haemophilus influenzae, Streptococcus pneumoniae and Pseudomonas sp were the organisms most frequently isolated; often these same organisms caused recurrent chest infection. Bacterial infections in AIDS patients are common and although they generally respond well to antimicrobial chemotherapy there is a high recurrence rate, particularly in the respiratory tract, which is the commonest site of infection.
Regression of cardiac involvement by malignant melanoma following lomustine chemotherapy
Authors: Carpenter M R , Vassallo M , Peat I M , Scriven A J I
Published: December 2008

Cardiac involvement by malignant melanoma is usually a premorbid event. We present a case of presumed cardiac involvement by malignant melanoma with regression following chemotherapy as demonstrated by transoesophageal echocardiography.
Mesenteric revascularisation for acute-on-chronic intestinal ischaemia
Authors: Holdsworth R J , Raza Z , Naidu S , McCollum P T
Published: December 2008

Eleven patients (eight women) underwent urgent revascularisation for acute-on-chronic mesenteric ischaemia. Four patients had dual vessel and seven single vessel reconstructions. Two patients underwent simultaneous bowel resection and one patient has had three separate grafts to the superior mesenteric artery. There were two peri-operative deaths and three have died in the late follow-up period after 18, 24 and 36 months. The remainder have survived for between five and 63 months. Revascularisation for acute-on-chronic mesenteric ischaemia has been shown to be technically possible and of substantial benefit to patients who would otherwise be treated as terminal cases.
Warfarin potentiation with bezafibrate
Authors: Beringer Timothy R O
Published: December 2008

Two cases are described in which lack of awareness of the potentiation of bezafibrate on warfarin was of clinical importance.
Localised carcinoma of the prostate: a paradigm of uncertainty
Authors: Sandhu S S , Kaisary A V
Published: December 2008

The incidence and prevalence of prostate cancer is increasing. A number of aetiological factors including age, race, family history and diet have been implicated. The majority of patients present with disease which is amenable only to palliation. Digital rectal examination, serum prostate-specific antigen and transrectal ultrasound can lead to a prostatic biopsy. Transrectal ultrasound, magnetic resonance imaging, bone scan and a chest X-ray are used for staging. The management of localised cancer is shrouded in uncertainty. Three options exist, watchful waiting, radiotherapy, and radical total prostatectomy. The published data are inadequate for a valid comparison of these, and none has been shown to offer an advantage. Surgery, and to a lesser degree radiotherapy, have a significant morbidity. It is hoped that through better understanding our management of this disease will improve.
Inhalation of chlorine gas
Authors: Williams J G
Published: December 2008

The clinical features of acute chlorine gas inhalation, and its management are reviewed. Current medical views on the chronic effects of an acute overwhelming exposure on lung function (reactive airways dysfunction syndrome), and the more controversial field of lung disease secondary to repeated inhalations of lower concentrations of chlorine gas are discussed.
Soft tissue tumours
Authors: Hayes A J , Thomas J M
Published: December 2008

Any soft tissue swelling beneath the deep fascia should be considered a sarcoma until proven otherwise. As the most important factor in the primary treatment of these cancers is the adequacy of the primary surgical resection, it is vital to diagnose these malignant tumours pre-operatively.

The modern treatment of soft tissue sarcomas may involve all modalities, but the most important aspect of treatment of a primary localised sarcoma is wide excisional surgery preserving limb function. Radiotherapy is a vital adjunct in high-grade tumours, or in tumours whose resectability is limited either by size or anatomical proximity to vital structures. Apart from a few chemosensitive sarcomas, the role of chemotherapy is limited to treatment of metastatic disease where documented response rates are no greater than 30%. As 50% of patients with high-grade sarcomas will die from metastatic disease, improvements in survival rates will only come from improvements in response to systemic therapy. No controlled trials have shown any survival benefit for adjuvant chemotherapy, although a recent meta-analysis of published data has shown a trend to increased survival at two years. Multicentre randomised trials are ongoing.

The prognosis of these lesions is highly variable, but is intimately related to the anatomical site (i.e., resectability), and also the grade and size of the tumour.
Improving management of duodenal ulcer disease
Authors: Bateson M C , Diffey B L
Published: December 2008

Audit of treatment of duodenal ulcer disease has allowed management to improve and keep abreast of rapid advances in care. Eradication of Helicobacter pylori was assessed by 14C urea breath test one to two months after anti-Helicobacter therapy. The old triple therapy regime of bismuth, tetracycline and metronidazole for two weeks was found to be toxic and of low effectiveness (82%). Regimes with lansoprazole for one month and antibiotics for one week gave 90–98% success rates. The best success has been with regimes containing both clarithromycin and a nitro-imidazole. There was complete success in 98% of 109 patients given quadruple therapy with lansoprazole 30 mg daily for one month plus tetracycline 500 mg twice daily, clarithromycin 250 mg twice daily and metronidazole 400 mg twice daily for one week.
The views of medical students and junior doctors on pre-graduate clinical teaching
Authors: Ward B , Moody G , Mayberry J F
Published: December 2008

A total of 277 third and fourth year medical students and 304 house officers and senior house officers were asked to prioritise the content and methods of clinical teaching. Response rates were poor, but similar to that in market surveys. Bedside teaching and medical clerking were considered the most valuable methods of teaching and training in practical procedures such as venepunctures and urinary catheterisation was seen as valuable. The design of new curricula in medical education will need to accommodate the views of its clients.
Large airway obstruction by a chronic dissecting aortic aneurysm in the Marfan syndrome
Authors: Hargreaves M R , Gilbert T J , Pillai R , Hart G
Published: December 2008

We describe a patient with the Marfan syndrome who presented with an acute aortic dissection. She underwent composite graft replacement of the aortic root. She returned two years later with dyspnoea and stridor due to tracheal compression by a large chronic dissection of the thoracic aorta. Marfan patients are at risk of chronic dissection involving the remaining distal aorta and require regular noninvasive assessment following surgery.
Cerebellar degeneration following neuroleptic malignant syndrome
Authors: Lal V , Sardana V , Thussu A , Sawhney I M S , Prabhakar S
Published: December 2008

A 55-year-old woman with a history of bipolar affective disorder developed hyperpyrexia, rigidity and depressed consciousness (neuroleptic malignant syndrome) after commencing neuroleptic therapy. On regaining consciousness, she was mute and had signs suggesting pancerebellar involvement. Hyperpyrexia, which is a cardinal feature of neuroleptic malignant syndrome, may have caused cerebellar damage. Neuroleptic malignant syndrome needs both early recognition and prompt treatment to obviate devastating complications.
Perforated diverticulitis following extra-abdominal surgery
Authors: Gaya A M , Chisholm E M , Scott H J , Donaldson D R
Published: December 2008

The peritonitis of perforated diverticular disease is a life-threatening condition. We report three cases where it occurred following unrelated extra-abdominal surgery and where surgical intervention proved to be the correct course of management. All cases were treated with a Hartmann's procedure; this is probably the safest option for purulent peritonitis in patients who are a high operative risk and have recently undergone major surgery.
Late reversal reaction after 10 years of adequately treated leprosy
Authors: Thacker A K , Kumar P , Mukhija R D , Sharma S P
Published: December 2008

Differentiation between a relapse or late reversal reaction following completion of regular drug therapy in patients with leprosy is often difficult, though it has definite therapeutic implications. The present case documents a late reversal reaction occurring an unusually long time after the completion of multi-drug therapy.
Neuroleptic malignant syndrome in the acquired immunodeficiency syndrome
Authors: Hernández J L , Palacios-Araus L , Echevarría S , Herrán A , Campo J F , Riancho J A
Published: December 2008

Patients infected by the human immunodeficiency virus are predisposed to many infectious and noninfectious complications and often receive a variety of drugs. Furthermore, they seem to have a particular susceptibility to idiosyncratic adverse drug reactions. It is therefore surprising that only a few cases of the neuroleptic malignant syndrome have been described in patients with the acquired immunodeficiency syndrome. A high index of suspicion is required to diagnose the neuroleptic malignant syndrome in these patients, as its usual manifestations, including fever and altered consciousness, are frequently attributed to an underlying infection.
Setting up a heart emergency centre
Authors: Virk S J S , Edmunds E , Perry R A
Published: December 2008

We describe the setting up of a ‘heart emergency centre’ linked to a pre-existing coronary care unit. The ‘heart emergency centre’ offers a new and efficient way of providing a fast and effective system for the assessment and management of patients with cardiac emergencies. This set-up can result in significant improvements in ‘door to needle’ time for thrombolysis, which has been shown to be beneficial both in terms of morbidity and mortality following myocardial infarction.
Assessment of disease activity in systemic vasculitis
Authors: Tse W Y , Cockwell P , Savage C O S
Published: December 2008

The systemic vasculitides are a group of inflammatory disorders characterised by relapses and remission. Before the introduction of immunosuppressive drugs, mortality was unacceptably high. Immunosuppressive therapy has had a therapeutic impact, but at the cost of increased risk of infection and other adverse effects. Differentiating infection from active disease can be difficult, and the inappropriate prescription of immunosuppressive drugs can be fatal. Hence disease indices which can aid physicians to identify the active phase of disease and enable early treatment, will be valuable in the management of this group of disorders.
Recent developments in assessing medical students
Authors: Fowell S L , Bligh J G
Published: December 2008

Most medical schools in the UK are revising their undergraduate courses in response to the recommendations published by the General Medical Council Education Committee in Tomorrow's doctors. However, achievement of the objectives of curricular change is attendant on revision of the assessment process. This paper reviews traditional and more recently developed methods for assessment of medical education in the light of the General Medical Council's recommendations which relate specifically to summative assessment of the core curriculum. The importance of reliability and validity is highlighted, and the case for criterion-referenced assessment is examined.
Imported infections in east Birmingham children
Authors: Riordan F A I , Tarlow M J
Published: December 2008

This 15-month prospective study of admissions to a children's ward found imported infections in 58 children (1.3% of admissions), aged between two months and 15 years. Most had visited the Indian subcontinent 14 (1-341) days earlier. Few had taken preventative measures. The commonest infection was malaria (n = 23).
Coexistence of hereditary angioedema and Turner's syndrome
Authors: Fletcher A , Weetman A P
Published: December 2008

A 34-year-old woman presented to the out-patient clinic with angioedema and type II hereditary angioedema was confirmed immunologically. She also volunteered she had never had a menstrual period and physical examination identified several features of Turner's syndrome. A mosaic karyotype with XY and XO was found on chromosomal analysis and gonadectomy was performed in view of the high risk of gonadoblastoma. After commencing oestrogen at physiological replacement doses, the patient experienced a marked deterioration in both the severity and frequency of angioedema attacks. Coexistence of hereditary angioedema and Turner's syndrome has not previously been reported and this case highlights the detrimental C1 inhibitor level lowering effect of oestrogen in hereditary angioedema.
Isolated angiitis of central nervous system with pleocytosis in the cerebrospinal fluid
Authors: Ferraz H B , Rolim J A B , Neves A C , Augusto L A F , Andrade F , Rodrigues J F , Stavale J N
Published: December 2008

We report the case of a 32-year-old woman with isolated angiitis of the central nervous system. This case shows that high levels of pleocytosis may not rule out isolated angiitis of the central nervous system if this diagnosis can be considered on clinical grounds.
Anabolic steroid induced hypogonadism treated with human chorionic gonadotropin
Authors: Gill G V
Published: December 2008

A case is presented of a young competitive body-builder who abused anabolic steroid drugs and developed profound symptomatic hypogonadotrophic hypogonadism. With the help of prescribed testosterone (Sustanon) he stopped taking anabolic drugs, and later stopped Sustanon also. Hypogonadism returned, but was successfully treated with weekly injections of human chorionic gonadotropin for three months. Testicular function remained normal thereafter on no treatment. The use of human chorionic gonadotropin should be considered in prolonged hypogonadotrophic hypogonadism due to anabolic steroid abuse.
Unravelling the helix—a physician's guide to spiral computed tomography
Authors: Kearney S E , Garvey C J
Published: December 2008

The introduction of spiral technology to computed tomography (CT) scanners in the late 1980s has revolutionised the field of CT. Spiral CT offers definite practical benefits over conventional scanners and has expanded the role of CT through the development of new scanning techniques. CT scanning now rivals magnetic resonance imaging in many areas of investigation, and for some situations is the clear investigation of choice. This review is aimed at those clinicians who have access to spiral scanning services but wish to have a greater understanding of the technique and its clinical applications. The concept of spiral CT, and the differences between spiral and conventional scanning are discussed. The various clinical applications of the technique are illustrated.
Disorders of the sleep–wake cycle in adults
Authors: Sedgwick P M
Published: December 2008

Adults have an intrinsic body clock which regulates a complex series of rhythms including sleep and wakefulness, fatigue and cognitive ability. This endogenous clock naturally runs more slowly than the solar day and is entrained to a 24-h rhythm primarily by the alternation of light and darkness. Jet lag, shift-work sleep disorder, and some of the chronic insomnias are caused by a temporal discrepancy of the body clock relative to the surrounding environment and social network. The underlying mechanisms and general management are described. Both bright light and melatonin therapy have potential in the management of these disorders. Traditionally, bright light therapy has been used to alleviate the depression associated with seasonal affective disorder. Melatonin has received much ill-formed publicity, it being claimed that it is a panacea and an ‘antiageing’ treatment. Both of these treatment approaches are reviewed.
Assessment of respiratory muscle function and strength
Authors: Syabbalo N
Published: December 2008

Measurement of respiratory muscle strength is useful in order to detect respiratory muscle weakness and to quantify its severity. In patients with severe respiratory muscle weakness, vital capacity is reduced but is a non-specific and relatively insensitive measure. Conventionally, inspiratory and expiratory muscle strength has been assessed by maximal inspiratory and expiratory mouth pressures sustained for 1 s (PImax and PEmax) during maximal static manoeuvre against a closed shutter. However, PImax and PEmax are volitional tests, and are poorly reproducible with an average coefficient of variation of 25%. The sniff manoeuvre is natural and probably easier to perform. Sniff pressure, and sniff transdiaphragmatic pressure are more reproducible and useful measure of diaphragmatic strength. Nevertheless, the sniff manoeuvre is also volition-dependent, and submaximal efforts are most likely to occur in patients who are ill or breathless. Non-volitional tests include measurements of twitch oesophageal, gastric and transdiaphragmatic pressure during bilateral electrical and magnetic phrenic nerve stimulation. Electrical phrenic nerve stimulation is technically difficult and is also uncomfortable and painful. Magnetic phrenic nerve stimulation is less painful and transdiaphragmatic pressure is reproducible in normal subjects. It is a relatively easy test that has the potential to become a widely adopted method for the assessment of diaphragm strength. The development of a technique to measure diaphragmatic sound (phonomyogram) during magnetic phrenic nerve stimulation opens the way for noninvasive assessment of diaphragmatic function.
Phosphate diabetes in patients with chronic fatigue syndrome
Authors: De Lorenzo F , Hargreaves J , Kakkar V V
Published: December 2008

Phosphate depletion is associated with neuromuscular dysfunction due to changes in mitochondrial respiration that result in a defect of intracellular oxidative metabolism. Phosphate diabetes causes phosphate depletion due to abnormal renal re-absorption of phosphate be the proximal renal tubule. Most of the symptoms presented by patients with phosphate diabetes such as myalgia, fatigue and mild depression, are also common in patients with chronic fatigue syndrome, but this differential diagnosis has not been considered. We investigated the possible association between chronic fatigue syndrome and phosphate diabetes in 87 patients who fulfilled the criteria for chronic fatigue syndrome. Control subjects were 37 volunteers, who explicitly denied fatigue and chronic illness on a screening questionnaire. Re-absorption of phosphate by the proximal renal tubule, phosphate clearance and renal threshold phosphate concentration were the main outcome measures in both groups. Of the 87 patients with chronic fatigue syndrome, nine also fulfilled the diagnostic criteria for phosphate diabetes.

In conclusion, we report a previously undefined relationship between chronic fatigue syndrome and phosphate diabetes. Phosphate diabetes should be considered in differential diagnosis with chronic fatigue syndrome; further studies are needed to investigate the incidence of phosphate diabetes in patients with chronic fatigue syndrome and the possible beneficial effect of vitamin D and oral phosphate supplements.
Cure of hyperparathyroidism in pregnancy by sternotomy and removal of a mediastinal parathyroid adenoma
Authors: Rooney D P , Traub A I , Russell C F J , Hadden D R
Published: December 2008

Primary hyperparathyroidism is rarely reported during pregnancy but can cause significant maternal and neonatal morbidity. We report a case of hyperparathyroidism during pregnancy requiring a median sternotomy for resection of a mediastinal parathyroid adenoma. Surgery resulted in normalisation of serum calcium, resolution of symptoms, and prevented neonatal hypocalcaemia.
Aldosterone excess: a rare non-nephrophathic cause of hypertension in type I diabetes
Authors: Chan N N , Feher M D
Published: December 2008

The aetiology of hypertension in type 1 diabetes is commonly due to the presence of diabetic nephrology. A rare case of hypertension in a patient with type 1 diabetes and no proteinuria is reported, where the investigation of borderline hypokalaemia allowed us to make a diagnosis of hyperaldosteronism due to bilateral adrenocortical hyperplasia. Secondary causes of hypertension should always be considered in all diabetic patients, particularly in the absence of clinical proteinuria.
Fever, hepatosplenomegaly and pancytopenia in a patient living in the Mediterranean region
Authors: Büyükaşik Y , Ileri N S , Haznedaroğlu İ C , Demiroğlu H , Dündar S
Published: December 2008

A 24 year old woman living in the Mediterranean region of Turkey present with a three-month history of weight loss and irregular fever that was peaking at 40 degrees C with shivering. No definite aetiology could be identified in a local hospital. A bacterial infection had been suspected, but antibiotic therapy, at first with sulbactam-ampicillin and later with azithromycin, had no influence on the fever. Physical examination revealed an emaciated patient with fever (39 degrees C), pallor, and hepatosplenomegaly (spleen 9 cm and liver 5 cm palpable below the costal margin). No peripheral lymphadenopathy was present. The laboratory examinations are summarised in the table. Notably, a prominent increase of macrophages containing intracellular micro-organisms (figures 1 and 2) was seen in the bone marrow smears. The same micro-organisms were also identified within the Kupffer cells in liver biopsy.
Genetic and environmental factors affecting bone mineral density in large families
Authors: Yeap S S , Beaumont M , Bennett A , Keating N A , White D A , Hosking D J
Published: December 2008

This study assessed whether relatives with low bone mineral density (BMD) could be identified in five large families using historical, biochemical, and genetic markers for osteoporosis. Fifty of 65 relatives had their bone density and bone turnover markers measured, together with an assessment of their risk factors for osteoporosis. Only 33% (5/15) of siblings, 50% (6/12) of children and 43% (10/23) of nephews and nieces had entirely normal BMD. There was no difference in life-style risk factors for osteoporosis, history of previous fractures or body mass index between normal subjects and those with osteopenia or osteoporosis. Osteopenic individuals had a significantly higher than normal osteocalcin value. Within families, there was no clear association between BMD and any of the genetic markers (vitamin D receptor gene polymorphisms, COL 1A1 and COL 1A2 polymorphisms of the collagen gene), either alone or in combination. The addition of genetic markers to the other risk factors for low BMD did not improve the prediction of BMD. In conclusion, we suggest that the presence of osteoporosis in a first degree relative should be one of the clinical indications for bone density measurement as the individuals at risk would not be picked up by other methods.
Time delay to thrombolytic therapy—a Sri Lankan perspective
Authors: Constantine G R , Thenabadu P N
Published: December 2008

Reducing the time delay in initiating thrombolytic therapy in acute myocardial infarction is critical in maximising the functional and survival benefit. We analysed 120 consecutive admissions for thrombolytic therapy to the Coronary Care Unit. The total delay was divided into prehospital, in-hospital and Coronary Care Unit stages, and the median delays were found to be 130, 70, and 15 minutes, respectively. The delay was significantly longer in patients who sought prehospital medical advice, and when the diagnosis was not made at the emergency treatment unit. Educating at-risk groups and modifying the admission system may help to minimise these delays, while the establishment of an emergency ambulance service with well-trained crew would also improve the prognosis after acute myocardial infarction in Sri Lanka.
Induction training, career counselling, and performance review: views of junior medical staff
Authors: Williams J G , Cheung W Y
Published: December 2008

Surveys of senior house officers and registrars were undertaken by postal questionnaire to ascertain views on the need for and content of induction training, career counselling, and performance review. The questionnaire was sent out in May 1990 and repeated in May 1996, after measures had been taken to improve induction training, and assessment and appraisal of trainees. In 1990 there was a clear wish to receive information on career prospects, research and education opportunities, and clinical audit, but more ambivalence regarding information or training in communication, discharge policies, standards, and encoding procedures. There was also a firm view that career counselling could be improved and formal goal setting and performance appraisal interviews would be welcomed. In 1996 there was disappointingly little change in the views expressed by the junior medical staff, though there was a significant increase in confidence in the role of the consultant in career counselling.
Oesophageal perforation: a dangerous but potentially curable condition
Authors: Mahmoud S , Prudham R , Sidra G , Solomon S
Published: December 2008

A series of three cases of oesophageal perforation are described. All three presented differently and the X-ray findings were different in the three patients.
An analysis of discharge drug prescribing amongst elderly patients with renal impairment
Authors: Wong N A C S , Jones H W
Published: December 2008

Renal impairment is common amongst elderly patients and increases the risk of drug toxicity. Analysis of the discharge summaries of patients discharged from the geratology wards of an Oxfordshire hospital, showed that renal impairment was not referred to in 42% of patients with calculated creatinine clearances of 10–20 ml/min. A fifth of these patients, and 67% of patients with calculated creatinine clearances < 10 ml/min, had discharge drug prescriptions that contradicted the British National Formulary guidelines for prescribing in the presence of renal impairment. There should be increased awareness that, in elderly patients, normal serum creatinine concentrations do not exclude renal impairment and that several commonly prescribed drugs require dose adjustments or should be avoided in the presence of renal insufficiency.
Patterns of injury associated with automobile airbag use
Authors: Mohamed A A , Banerjee A
Published: December 2008

The wide use of automobile airbags has undoubtedly reduced the mortality and the incidence of serious injuries from motor vehicle accidents. However, automobile airbags appear to be associated with a variety of injuries including fatal injuries, ocular injuries, upper limb and chest injuries. Further improvements in airbag design together with education of the general public in their use should help reduce airbag-related injuries.
Ursodeoxycholic acid therapy for primary biliary cirrhosis. A 10-year British single-centre population-based audit of efficacy and survival
Authors: Bateson M C , Gedling P
Published: December 2008

The effect of ursodeoxycholic acid treatment on survival in primary biliary cirrhosis was studied in 40 patients with symptomatic disease. Two patients developed early exacerbation of symptoms and stopped therapy in days; they are both alive 4 and 4½ years later. The other 38 patients have continued on treatment for up to 10 years. Results were compared with 12 other similar cases previously seen but not given specific therapy. Kaplan-Meier analysis showed that ursodeoxycholic acid treatment was associated with better survival (p <0.05) after the first two years of therapy. Predictors of favourable outcome included histological stage I disease. In 26 patients with primary biliary cirrhosis stage II, III or IV, therapy showed a trend to improved survival, but this was still significantly worse than the general population. Prognosis was not different between these different advanced stages. Symptoms improved in 28 out of 40 patients on ursodeoxycholic acid, but 50% had a recurrence by two years.
Familial cavernous angiomas masquerading as multiple sclerosis
Authors: Dougan C F , Coulthard A , Cartlidge N E F , Burn D J
Published: December 2008

We report here two cases of cavernous angioma, in the proband and her father, with quite different clinical presentations. The proband presented with a brainstem syndrome, mimicking multiple sclerosis, while the father had a history of mild epilepsy. Both patients were managed conservatively. The cases also demonstrate the utility of magnetic resonance imaging in the diagnosis of cavernous angioma.
Hyponatraemia: biochemical and clinical perspectives
Authors: Gill G , Leese G
Published: December 2008

Hyponatraemia is a common bio-chemical abnormality, occurring in about 15% of hospital inpatients. It is often associated with severe illness and relatively poor outcome. Pathophysiologically, hyponatraemia may be spurious, dilutional, depletional or redistributional. Particularly difficult causes and concepts of hyponatraemia are the syndrome of inappropriate antidiuresis and the sick cell syndrome, which are discussed here in detail. Therapy should always be targeted at the underlying disease process. ‘Hyponatraemic symptoms’ are of doubtful importance, and may be more related to water overload and/or the causative disease, than to hyponatraemia per se. Artificial elevation of plasma sodium by saline infusion carries the risk of induction of osmotic demyelination (central pontine myelinolysis).
Thyroid disease in pregnancy
Authors: Drake W M , Wood D F
Published: December 2008

This review article provides a broad overview of thyroid disease and pregnancy.
Short-course ceftriaxone therapy in spontaneous bacterial peritonitis
Authors: Javid G , Khan B A , Khan B A , Shah A H , Gulzar G M , Khan M A
Published: December 2008

Forty patients with spontaneous bacterial peritonitis, three of whom had complicating acute hepatitis syndrome, eight late-onset hepatic failure, and 29 with cirrhosis, were treated with ceftriaxone 2 g intravenously once daily for 5 days. Ascitic fluid culture was positive in 28 patients, with Escherichia coli and Klebsiella as common isolates. All the bacteria isolated were sensitive to ceftriaxone except Enterococcus faecalis, which was isolated in a cirrhotic patient. All culture-positive patients sensitive to ceftriaxone showed bacteriological cure and 26 (65%) patients showed cytological cure after 48 hours of treatment. A total of 95% were cured of their infection after 5 days of treatment. Twelve (30%) patients died during hospitalisation after documented cure of their spontaneous bacterial peritonitis (renal failure, gastrointestinal bleed and cerebral oedema were the primary causes of death). Infection-related mortality due to Pseudomonas septicaemia was seen in one cirrhotic patient.
Myasthenic syndrome of snake envenomation: a clinical and neurophysiological study
Authors: Sanmuganathan P S
Published: December 2008

In this prospective study, 65 consecutive patients with neurological manifestations after snake envenomation, were examined in order to describe the natural history of the reversible nature of muscle weakness. Snake envenoming led to a completely reversible muscle paralysis involving the external ocular muscles with sparing of the pupils, muscles of mastication, facial muscles, palatal muscles, neck and proximal limb muscles. The deep tendon reflexes were preserved with no sensory abnormalities. The muscular weakness usually set in within an hour of envenomation and lasted up to 10 days, with fatigability lasting for 12 days. Respiratory muscle paralysis led to ventilatory failure needing ventilation in severely envenomed patients. Motor and sensory nerve conduction were normal with normal resting compound motor action potentials on electromyography. Repetitive nerve stimulation gave rise to a decremental response during high frequency stimulation. The edrophonium test gave negative results. These manifestations are due to abnormalities of neuromuscular transmission and are not typical of myasthenia gravis. As the exact pathophysiology of venom-related neurotoxicity is not known, it is suggested that the neurological manifestations of snake envenoming be designated a myasthenic syndrome. Further studies to isolate the neurotoxin and its mechanism and exact site of blocking at the neuromuscular junction would pave the way for the development of a novel long-acting neuromuscular blocking agent.
Localised upper airway obstruction in a patient with acquired immunodeficiency syndrome
Authors: D'Arsigny C L , Ford S , O'Donnell D E
Published: December 2008

We describe a case of rapidly progressive upper airway obstruction due to tracheal Pseudomonas abscesses in a patient with acquired immunodeficiency syndrome. The case highlights the aggressive nature of Pseudomonas infections and the difficulty of eradicating this organism in patients infected with the human immunodeficiency virus.
Systemic multifocal fibrosclerosis
Authors: Johal S S , Manjunath S , Allen C , Trash D B
Published: December 2008

We describe a case of hydronephrosis as a result of retroperitoneal fibrosis in a patient who had previous sclerosing lobulitis of the breast. To the best of our knowledge this is the first reported association between these two conditions in the english literature. We presume these conditions are linked and unify them under the general heading of systemic multifocal fibrosclerosis.
Blurred vision and high blood pressure in a young woman
Authors: Flanagan D E H , Cole C , Crick M D P , Kerr D
Published: December 2008

A 41-year-old woman presented with a short history of blurred vision. She had a 6-year history of refractory hypertension which had been treated with a variety of drug regimens. She was found to have bilateral branch retinal vein occlusion. Retinal vein occlusion is a recognised complication of hypertension but simultaneous involvement of both eyes is extremely rare. Following this episode, blood pressure control has improved without change in drug therapy, suggesting that treatment compliance may partly explain the previous difficulties.
Copper, zinc, and magnesium levels in non-insulin dependent diabetes mellitus
Authors: Zargar A H , Shah N A , Masoodi S R , Laway B A , Dar F A , Khan A R , Sofi F A , Wani A I
Published: December 2008

A relationship has been reported between trace elements and diabetes mellitus. This study evaluated the role of such a relationship in 83 patients with non-insulin dependent diabetes mellitus (40 men and 43 women), with a mean duration of diabetes of 3.9 +/- 3.6 years. Patients with nephropathy were excluded. Thirty healthy non-diabetic subjects were studied for comparative analysis. Subjects were subdivided into obese and non-obese. Diabetic subjects were also subdivided into controlled and uncontrolled groups; control was based on fasting blood glucose and serum fructosamine levels. Plasma copper, zinc and magnesium levels were analysed using a GBC 902 double beam atomic absorption spectrophotometer. Plasma zinc and magnesium levels were comparable between diabetic and non-diabetic subjects, while copper levels were significantly elevated (p < 0.01) in diabetic patients. Age, sex, duration and control of diabetes did not influence copper, zinc, or magnesium concentrations. We conclude that zinc and magnesium levels are not altered in diabetes mellitus, but the increased copper levels found in diabetics in our study may merit further investigation of the relationship between copper and non-insulin dependent diabetes mellitus.