bluuebunny/crossref_metadata_2025 huggingface dataset:
Adults with spina bifida and/or hydrocephalus
Authors: Morgan D J R , Blackburn M , Bax M
Published: December 2008

Recent advances in medical technology enable many children with complex disabilities to survive into adulthood and to have certain expectations of life. One of these expectations is the continuity of specialist health care in an adult setting. This paper describes a new out-patient service which aims to provide optimum care, continuity and consistency of service for adults with spina bifida and/or hydrocephalus. The need for specialist health input into this service, in order to monitor the neurological, urological and psychosocial complications often associated with spina bifida and/or hydrocephalus is recognised. In one year (1992), 86 young adults with spina bifida and/or hydrocephalus attended for annual or more frequent assessment, either independently or with their families or carers. A variety of health and social problems were treated. In response to demand, a multi-disciplinary assessment unit, which includes the services of both medical and nursing specialists, occupational and physiotherapists, psychologists and access to specialist surgical opinions has recently opened at the Chelsea and Westminster Hospital. This new service attempts to meet some of the needs described in the outpatient audit. Adults with other disabilities are requesting to use this service. A longitudinal study to monitor quality, and outcome is indicated from this initial survey.
Survival in hypercalcaemic patients with cancer and co-existing primary hyperparathyroidism
Authors: Hutchesson A C J , Bundred N J , Ratcliffe W A
Published: December 2008

Hypercalcaemia associated with malignancy is generally thought to carry a poor prognosis. Of 47 consecutive patients with hypercalcaemia and malignancy, serum parathyroid hormone (PTH) was elevated in seven, consistent with co-existing hyperparathyroidism. Median survival from onset of hypercalcaemia in these seven patients was 817 days; compared to 33 days in the remaining 40 patients with hypercalcaemia of malignancy, in whom PTH was suppressed (p = 0.007). Among patients with hypercalcaemia of malignancy, plasma PTH-related protein (PTHrP) concentration showed no correlation with survival (r2 = 2.1%), but one patient with increased levels of both PTH and PTHrP survived only nine days after the onset of hypercalcaemia. A raised PTH had a positive predictive value of 86% for survival > 100 days, and of 71% for survival > 1 year. A raised plasma PTHrP predicted death within 100 days with a positive predictive value of 69%. We conclude that measurement of serum PTH is indicated in patients with hypercalcaemia and malignancy to identify the 15% with hyperparathyroidism, since this is associated with prolonged survival. In patients with hyperparathyroidism, assay of plasma PTHrP may indicate concurrent hypercalcaemia of malignancy, with an associated poor prognosis.
Endocarditis due to high-level gentamicin-resistant Enterococcus faecalis
Authors: Lee P Y C , Das S S
Published: December 2008

We report a case of aortic valve endocarditis caused by Enterococcus faecalis highly resistant to gentamicin, which failed to respond to conventional antibiotic combination therapy. Extensive in vitro testing was required to determine an appropriate antimicrobial regimen. Despite bacteriological resolution and cardiac surgery the patient died from complications of infective endocarditis.
The pathogenesis of chronic pancreatitis
Authors: Sidhu S S , Tandon R K
Published: December 2008

To date, there is no consensus on the evolution of chronic pancreatitis. Comfort’s initial proposal of acute pancreatitis progressing to chronic pancreatitis was discarded by protagonists of the ‘separate’ theory. Sarles thus stresses the de novo evolution of chronic pancreatitis-acinar protein hypersecretion associated with an imbalance of pancreatic stone promoting and inhibiting factors. However, the ‘necrosis-fibrosis sequence’ hypothesis of Kloppel and Mallet resurrects the probability of acute pancreatitis leading to chronic pancreatitis. Dimagno offers a unifying concept that the degree of acinar injury determines the natural history of pancreatitis. Uninhibited release of toxic free radicals could be a common end point for various aetiologies resulting in acute or chronic pancreatitis. The pathogenesis of chronic calcifying pancreatitis of the tropics is possibly no different from alcoholic chronic pancreatitis. Neurocrine and paracrine mechanisms have been offered to explain pain out of proportion to radiological and histological pancreatic abnormalities in minimal change chronic pancreatitis.
Pneumocystis carinii pneumonia presenting with pneumomediastinum in an HIV-positive patient
Authors: Moss S , Carey P B , Hind C R K
Published: December 2008

A 19-year-old man presented with community-acquired pneumonia, complicated by pneumomediastinum. Subsequently he was found to be HIV-positive, and to have Pneumocystis carinii pneumonia.
Effect of age upon the induction and maintenance of anticoagulation with warfarin
Authors: Gladman J R F , Dolan G
Published: December 2008

We aimed to examine the effect of age upon the control of anticoagulation with warfarin in ordinary clinical practice, using a retrospective examination of routine anticoagulation clinic records from the University Hospital, Nottingham. Considerable over-anticoagulation (international normalisation ratio (INR) > 6.0) during induction occurred in 54 (11%) of 495 patients and was more likely in older patients (p < 0.05). Lesser degrees of over-anticoagulation during induction (INR > 4.0) were also more common in older patients, occurring in 58% of those aged 75 or above. Loading doses of warfarin were not reduced in older patients. INR in the maintenance phase rose with age (p < 0.001) despite lower maintenance doses of warfarin (p < 0.001). An INR > 6.0 in the maintenance phase was noted in 24 (3%) of 739 patients and again was more likely in older patients (p < 0.05). Patients using ambulance transport to the clinic were older than those who did not (p < 0.01) and those aged over 75 had shorter intervals between clinic visits (p < 0.01). We conclude that doctors using warfarin therapy do not take sufficient account of the increased sensitivity of older people to warfarin. Hospital anticoagulant policies need implementation and evaluation.
The role of ultrasound in the diagnosis of ganglion cysts
Authors: Spence L D , Fitzgerald E
Published: December 2008

Ganglion cysts are usually diagnosed clinically. We report three cases in which diagnostic doubt existed and in which ultrasound enabled the correct diagnosis to be made.
Post-thymectomy collapse: an unusual case of acute adrenal insufficiency
Authors: Richardson J
Published: December 2008

A 54-year-old man who had an appearance strongly suggestive of Cushing’s syndrome, collapsed after the removal of a carcinoid tumour of the thymus. The clinical suspicion of acute adrenal insufficiency was supported by invasive haemodynamic data and the diagnosis was subsequently confirmed biochemically. These post-operative events were subsequently ignored and a further crisis was probably prevented by tumour recurrence (and hence resumption of adrenocorticotropic hormone (ACTH) production). The ectopic production of ACTH from a carcinoid tumour of the thymus is recognised but a report of acute adrenal insufficiency from its removal is probably unique.
The association of hereditary neuropathies and heritable skeletal disorders
Authors: Chattopadhyay A K , Kandler R H , Sharrack B
Published: December 2008

We describe two patients with associations of hereditary neuropathies and heritable skeletal disorders not previously reported. The first patient had Marfan’s syndrome and hereditary motor and sensory neuropathy Type 1. The second patient had Ehlers-Danlos syndrome, Klippel-Feil syndrome and tomaculous neuropathy.
Prophylactic use of fluconazole in neutropenic cancer patients
Authors: Yamaç K , Șenol E , Haznedar R
Published: December 2008

This study was carried out on 70 patients with haematological or solid malignancies who were receiving chemotherapy and/or radiotherapy. Forty-one patients were randomly assigned to receive fluconazole, 400 mg/day, while they were neutropenic. Systemic fungal infection developed in four of the 41 patients (9%) receiving prophylaxis in comparison to nine of 29 patients (31%) not receiving prophylaxis. The incidence of systemic fungal infection was significantly different between the groups receiving prophylaxis and those not receiving it (p < 0.05). Fluconazole was found to be effective for preventing systemic fungal infections in neutropenic patients with cancer.
Effects of captopril and enalapril on renal function in elderly patients with chronic heart failure
Authors: Haffner C A , Kendall M J , Struthers A D , Bridges A , Stott D J
Published: December 2008

OBJECTIVE: To compare the effects on renal function of captopril and enalapril in elderly patients with chronic heart failure. DESIGN: A multi-centre double-blind parallel-group comparison of the two angiotensin-converting enzyme (ACE) inhibitors, captopril (12.5 mg bid) and enalapril (2.5 mg bid). SUBJECTS: 80 elderly patients with chronic heart failure (41 in the captopril group, 39 in the enalapril group). MAIN OUTCOME MEASURES: The blood pressure and pulse rate response to the first dose of ACE inhibitor was assessed in all patients. Glomerular filtration rate (GFR) was measured radioisotopically by 99mTcDTPA or 51CrEDTA clearance after three and six months of each treatment. Subgroups were assessed for effective renal plasma flow (33 patients), exercise tolerance (25 patients) and by a symptom-oriented questionnaire (45 patients). RESULTS: No serious adverse effect on GFR was noticed. There was no significant difference between the two treatments in the mean baseline GFR or in changes from baseline at three and six months (captopril mean baseline GFR 49.6 ml min-1 1.76 m-2, enalapril 54.7 ml min-1 1.76 m-2; mean change (95% confidence interval) at three months captopril 12 ml min-1 (+3.0, +21.0), enalapril -2 ml min-1 (-13.0; +9.0); mean change at six months, captopril 3.7 ml min-1 (-6.7; +14.2), enalapril -6.0 ml min-1 (-21.0; +9.4). Significantly more patients given captopril had an improvement in GFR during the study period (26/31 compared with 20/31 enalapril-treated patients at three months, p = 0.0096, and 23/30 compared with 15/27 at six months, p = 0.021). There were no significant changes in effective renal plasma flow. Three patients treated with enalapril developed symptomatic hypotension within three days of starting treatment. Quality of life questionnaires revealed more gastrointestinal symptoms in the enalapril group (p = 0.039). CONCLUSIONS: Captopril seems marginally preferable to enalapril in the treatment of chronic heart failure in elderly patients.
Cutaneous scleroderma in association with carcinoid syndrome
Authors: Durward G , Blackford S , Roberts D , Jones M K
Published: December 2008

A case of scleroderma in a woman with carcinoid syndrome is described and the similarities between our case and those in the literature are reviewed. The carcinoid tumours were all of midgut origin and liver metastases were present. All subsequently developed fibrotic heart disease and none had clinical features or autoantibodies suggestive of systemic sclerosis. The association between carcinoid syndrome and particular features of scleroderma is likely to be more than fortuitous.
Fungating carcinoma of the stomach: en bloc multiple organ resection and abdominal wall reconstruction
Authors: Chu K M , Lai D T M , Stern H S , Sheldon D M
Published: December 2008

A patient with carcinoma of the stomach invading multiple adjacent organs and fungating through the anterior abdominal wall was treated by en bloc multiple organ resection and abdominal wall reconstruction. The patient is alive and well at the time of writing, six months after the operation. The rationale for embarking on multiple organ resection for gastric cancer is discussed. However, such an aggressive surgical approach should only be applied to carefully selected patients who are medically fit and have no evidence of widespread systemic metastases.
Antituberculosis treatment-induced hepatotoxicity: role of predictive factors
Authors: Singh J , Arora A , Garg P K , Thakur V S , Pande J N , Tandon R K
Published: December 2008

Antituberculosis drug-induced hepatotoxicity is quite common. However, factors predicting its development are still controversial. The objective of the present study was to evaluate the role of certain factors (age and sex of the patient, alcoholism, chronic liver disease, hepatitis B virus carrier status, acetylator status, nutritional status and antituberculosis treatment (ATT) regimen) in predicting the development of ATT-induced hepatitis. In a case-control study, 60 consecutive patients with evidence of ATT-induced hepatitis were studied to assess the possible association of the above-mentioned factors with ATT-induced hepatitis. Body mass index was found to be significantly lower in ATT-induced hepatitis patients (17.2 +/- 2.7) than in controls (19.5 +/- 3.3) (p < 0.05). Pyrazinamide was used in addition to isoniazid and rifampicin in a significantly higher percentage of patients in the ATT-induced hepatitis group (70%) as compared with those in the control group (42%). No significant differences were observed between the two groups with regard to the rest of the parameters.
Drug treatment of toxoplasmic encephalitis in acquired immunodeficiency syndrome
Authors: Winstanley P
Published: December 2008

Toxoplasma gondii is a ubiquitous parasite, which causes several serious diseases. Until the AIDS pandemic, toxoplasmic encephalitis was largely confined to the pharmacologically immune-suppressed and to cases of congenital transmission. T gondii is now one of the more commonly encountered opportunistic pathogens of advanced AIDS.
Central pontine myelinolysis: clinical and MRI correlates
Authors: Martin P J , Young C A
Published: December 2008

Central pontine myelinolysis (CPM) is a rare condition characterised by spastic tetraparesis, pseudobulbar palsy and the ‘locked-in syndrome’. It is frequently fatal. We report a patient who developed CPM secondary to profound hyponatraemia and who recovered with no disability. Serial magnetic resonance imaging (MRI) demonstrated characteristic abnormalities within the pons at the onset of the disease, whereas computerised tomography was normal. Clinical improvement was followed six months later by progressive resolution of the MRI changes, with almost complete resolution after 18 months. Clinical and MRI findings correlate early in the course of CPM but clinical recovery predates MRI improvement by several months.
Stents in the oesophagus
Authors: Murphy G J
Published: December 2008

The use of self-expanding metal stents can markedly improve the care of patients with inoperable oesophageal malignancy. The stents can be easily introduced without the need for general anaesthesia. They have fewer complications during insertion than rigid stents and fewer complications than laser therapy. With these stents lumens of up to 2.5 cm are easily obtainable. The article considers the type of patient who may be suitable for stenting, the technique of insertion, benefits and complications of their use.
Cardioversion of atrial fibrillation
Authors: Lip GYH
Published: December 2008

Cardioversion to sinus rhythm should be considered for all patients in atrial fibrillation in order to improve cardiac performance and perhaps to reduce the long-term risk of thromboembolic complications. Different methods of cardioversion, whether electrical or pharmacological, exist and there is often uncertainty about performing the procedure. In particular, there is often confusion about the use of anti-arrhythmic drugs and the suitable length of anticoagulant therapy required pre- and post-cardioversion. This review discusses the current understanding of electrical and pharmacological cardioversion of atrial fibrillation, the clinical effects and the role of prophylactic anti-arrhythmic and anticoagulant therapy in this procedure.
The quest for a more acceptable bowel preparation: comparison of a polyethylene glycol/electrolyte solution and a mannitol/Picolax mixture for colonoscopy
Authors: Saunders B P , Masaki T , Fukumoto M , Halligan S , Williams C B
Published: December 2008

Eighty-nine consecutive patients attending for day-case colonoscopy were randomly allocated either polyethylene glycol/balanced electrolyte (PEG) mixture (n = 45) or a mannitol/Picolax mixture (n = 44). Both preparations were administered in two fractions. Patients recorded their experience of the preparation on a questionnaire and one of two experienced endoscopists (unaware of the type of preparation given) assessed the result of bowel cleansing. Carbon dioxide insufflation was used for all examinations. Good/excellent bowel cleansing occurred in significantly more patients given PEG, 43 (96%), than those allocated mannitol/Picolax, 34 (77%), p = 0.01. More patients receiving mannitol/Picolax were able to complete the preparation in full than patients receiving PEG (38 vs 27, p = 0.01). More patients found the taste of mannitol/Picolax pleasant compared to PEG (46% vs 20%). Both preparations had a similar side-effect profile. Of those patients tested, 13% receiving mannitol/Picolax had a postural drop in blood pressure and blood parameters suggestive of mild dehydration. A fractionated administration of PEG as a bowel preparation for day-case colonoscopy is well tolerated and superior as a cleansing agent to a mannitol/Picolax combination. Provided carbon dioxide is used as the insufflating agent, mannitol/Picolax is an acceptable alternative in fit, young patients intolerant of PEG.
Liver abscess and disseminated intravascular coagulation in tuberculosis
Authors: Nampoory M R , Halim M M , Sreedharan R , al-Sweih N A , Gupta R K , Constandi J N , Johny K V
Published: December 2008

We report the case of a 55-year-old man with chronic renal failure, and a history of prolonged fever and jaundice. Radiological studies revealed a multiloculated irregular liver abscess. Mycobacterium tuberculosis was isolated from the abscess on smear and culture of aspirated pus. Haematological studies revealed the presence of disseminated intravascular coagulation. A detailed search failed to identify any reason for this other than the tuberculous infection. The treatment of tuberculous liver abscess and pathogenesis of disseminated intravascular coagulation in tuberculosis are discussed.
Iatrogenic profound hypoalphalipoproteinaemia: an unrecognised cause of very low HDL cholesterol
Authors: Murphy M J , Duncan A , Vallance B D , Packard C J , O’Reilly D S
Published: December 2008

A significant reduction in plasma high density lipoprotein (HDL) cholesterol is a recognised consequence of treatment with probucol. By contrast, fibrate therapy in general has the opposite effect. We report two cases where the combination of probucol and a fibrate led to profoundly reduced plasma levels of HDL cholesterol associated with very low levels of apolipoprotein A-I (apoA-I). In the first, bezafibrate was added to probucol, and in the second, probucol added to a combination of simvastatin and fenofibrate. In both cases, plasma levels of HDL and apoA-I returned towards normal after discontinuation of one or both drugs, indicating that the reduction was reversible.
Renal dysfunction associated with liver transplantation
Authors: Jindal R M , Popescu I
Published: December 2008

It has been known for some time that a variety of liver diseases affect kidney function, but renal dysfunction associated with orthotopic liver transplantation has received scant attention. Although the mechanisms mediating these abnormalities are incompletely defined, advances in the understanding of renal pathophysiology after liver transplantation have made it possible to develop new treatment strategies. Aggressive and early intervention to diagnose and treat renal complications associated with liver transplantation should be the goal for transplant centres.
The management of acute myocardial infarction
Authors: Saltissi S , Mushahwar S S
Published: December 2008

Greater understanding of the underlying pathophysiology of acute myocardial infarction (AMI) has led to more aggressive management and lower mortality, both in-hospital and long term. AMI results mainly from thrombotic occlusion of the infarct-related coronary artery. The ensuing necrosis evolves over a 6-12 h period providing a time window for interventions designed to reduce eventual infarct size. The most appropriate interventions are those which restore coronary artery patency and hence myocardial blood flow as soon as possible. Occasionally, disruption of the occluding thrombus and compression of the underlying atheromatous lesion is best achieved by direct percutaneous transluminal coronary angioplasty. For the vast majority however, revascularisation by drug therapy is more appropriate. As soon as possible, all patients without contraindications should be offered oral aspirin and intravenous thrombolysis, usually with streptokinase but occasionally with tissue plasminogen activator. Patients in whom these agents are contraindicated should be considered for intravenous beta-blockade using atenolol or metoprolol to reduce myocardial demand and hence infarct size. Patients with large infarcts, impaired ventricular function, left ventricular failure or hypertension should be considered for early angiotensin-converting enzyme inhibitor therapy. Other agents may be valuable symptomatically, but have no proven role in reducing infarct size or mortality. After the first 24 h, the main aims of management are to assess the likelihood of later ischaemic events or death (risk stratification) and hence to choose appropriate long term secondary prophylaxis.
The prevalence of drivers in acute geriatric wards
Authors: Morgan R , Turnbull C J , King D
Published: December 2008

An audit of 150 patients on five acute geriatric wards found that 28 (19%) still drove. Forty-three (28%) used to drive but had given up, whilst 79 (53%) (76 of whom were female) had never driven. Former drivers gave the main reason for stopping as cost. No driver could recall being advised about driving by a doctor. Twenty-two drivers (79%) had a significant clinical condition that could affect driving, ranging from blackouts to arthritis. It is recommended that all elderly patients should be asked if they drive and any clinical conditions they might have that would adversely affect their driving be sought. Appropriate advice should be given by doctors to their elderly patients in order to safeguard them and the public from road traffic accidents.
Endoscopic balloon dilatation of duodenal strictures in Crohn’s disease
Authors: Kelly S M , Hunter J O
Published: December 2008

Endoscopic balloon dilatation of oesophageal and colonic strictures is now widely performed. Duodenal strictures due to Crohn’s disease represent a difficult clinical problem as surgical intervention is a major undertaking and recurrences are common. We describe endoscopic balloon dilatation in three patients with obstructive symptoms from duodenal strictures due to Crohn’s disease. The procedure appeared safe, was well tolerated and resulted in an excellent symptomatic response. This method is particularly suitable for short duodenal strictures and avoids the need for surgical intervention in this difficult group of patients.
Systemic lupus erythematosus presenting as effuso-constrictive pericarditis
Authors: McMechan S R , McClements B M , McKeown P P , Webb S W , Adgey A A
Published: December 2008

We describe a 62-year-old woman in whom systemic lupus erythematosus presented as life-threatening effuso-constrictive pericarditis. Surgical drainage of the pericardium was required and the patient made a satisfactory recovery. At six-months follow-up, while taking hydroxychloroquine and a non-steroidal anti-inflammatory agent, she remains well.
Developing comprehensive stroke services: an evidence-based approach
Authors: Langhorne P
Published: December 2008

The recent interest in the development of services for stroke patients reflects an increasing optimism about stroke management and the recognition that properly organised care can improve outcomes after stroke. A comprehensive stroke service should provide early assessment and investigation of stroke disease in both in-patient and out-patient settings, acute care for stroke in-patients to manage their medical and surgical problems, and rehabilitation for patients with persisting functional problems. Other components may include out-patient, day hospital or domiciliary rehabilitation facilities and continuing care and support facilities for patients discharged from hospital. This article discusses the evidence to support different components of a comprehensive stroke service and emphasises the need for flexible approaches to different local conditions.
Venepuncture: the medicolegal hazards
Authors: McConnell A A , Mackay G M
Published: December 2008

Venepuncture is commonly regarded as a trivial procedure allocated to the most junior medical staff. The result of this policy is that junior doctors are required to perform a minimally invasive procedure on consenting patients without any structured venepuncture training or assessment. Consequently, inexperienced doctors may perform multiple and sometimes unnecessary, venepunctures, which could damage essential venous access, eg, in the diabetic or renal patient. We review the medicolegal position and suggest that structured venepuncture training is essential and argue that unskilled treatment may be regarded by the Courts as demonstrating the mens rea of assault in the form of recklessness.
HIV medicine: drug side effects and interactions
Authors: Bates C M
Published: December 2008

The drugs used in HIV medicine often have toxic side effects; additionally, the risk of drug interactions is high because of the frequent necessity to prescribe multiple drugs. This article covers common or important drug side effects and interactions.
Massive haemorrhage due to colitis secondary to nonsteroidal anti-inflammatory drugs
Authors: Sacanella E , Muñoz F , Cardellach F , Estruch R , Miró O , Urbano-Márquez A
Published: December 2008

A case of massive haemorrhage due to colitis induced by nonsteroidal anti-inflammatory drugs in a 74-year-old man is reported.
Cerebral venous thrombosis
Authors: Martin P J , Enevoldson T P
Published: December 2008

Cerebral venous thrombosis is a treatable and under-recognised cause of a benign intracranial hypertension syndrome, and may also cause focal signs, seizures, and depression of consciousness.
Guidelines for the management of thrombophilia. Department of Haematology, The Royal London Hospital, Whitechapel, London, UK
Authors: Cavenagh J D , Colvin B T
Published: December 2008

Although there are numerous risk factors for venous thromboembolic disease, the term ‘thrombophilia’ refers only to those familial or acquired disorders of the haemostatic system that result in an increased risk of thrombosis. The inherited thrombophilias include antithrombin III deficiency, resistance to activated protein C (factor V Leiden), protein C and protein S deficiencies as well as some rare forms of dysfibrinogenaemia. It is possible that other inherited conditions might also predispose to thrombosis. In contrast, when using the above definition, the antiphospholipid syndrome is the only genuine acquired thrombophilic state. Patients who have thromboembolic disease at a young age with no provoking event or who have a positive family history or whose thrombosis involves an unusual site should be investigated for thrombophilia. The management of a patient identified as having a laboratory abnormality associated with thrombophilia will depend on a variety of factors such as the patient’s individual and family thrombotic history, the site of the thrombosis and the presence of other prothrombotic risk factors. The use of prophylactic anticoagulation during pregnancy and the puerperium requires particularly careful consideration in thrombophilic women. As more becomes known about the thrombophilias it will become possible to formulate more exact guidelines as to the management of these conditions.
Subclinical thyroid disease
Authors: Elte J W , Mudde A H , Nieuwenhuijzen Kruseman A C
Published: December 2008

Thyroid disease can roughly be divided into functional and anatomical disorders. Subclinical disease is by definition not accompanied by symptoms or signs and usually goes unrecognized for the bearer (and the observer). In this communication an overview will be given of existing literature and some own results concerning subclinical hypothyroidism, subclinical thyrotoxicosis and thyroid incidentalomas. Apart from definitions, data on prevalence, clinical effects, prognostic significance and the need for and response to therapy will be discussed.
Pulmonary embolism--the role of thrombolytic therapy in its management
Authors: More R S , Chauhan A
Published: December 2008

In massive pulmonary embolism where there may be evidence of right ventricular dysfunction and acute pulmonary hypertension, anticoagulation therapy alone may prove inadequate. In such situations use of thrombolytic agents produces an improvement in haemodynamics compared to anticoagulants alone, although studies to date have been too small to address the issue of mortality benefit. It would appear that all age groups gain benefit from the use of thrombolytics. Studies that have compared thrombolytic agents and anticoagulants are discussed. In addition, the issues of the choice of thrombolytic agent and the different modes of delivery of therapy are addressed.
Do accident and emergency senior house officers know the British guidelines on the management of acute asthma?
Authors: Ulahannan T , Hardern R D , Hamer D W
Published: December 2008

Avoidable deaths from asthma continue, even in hospital. Since the management of acute severe asthma is often initiated in the Accident and Emergency department, it is crucial that staff there have adequate knowledge. An anonymous questionnaire, containing items based on chart 6 of the UK guidelines, was completed by 66 Accident and Emergency Senior House Officers from the Yorkshire region. The study aim was to establish these doctors’ levels of knowledge about the recommended management of acute asthma in Accident and Emergency. The median score was 10 (out of a possible 24) and the interquartile range 8-13. Further efforts are required to implement these guidelines so that the best patient outcomes can be achieved.
Iris metastasis: an unusual cause of anterior uveitis
Authors: Chua C H , Westlake W , Rich W
Published: December 2008

We report a case of anterior uveitis due to iris metastasis in a patient with known carcinomatosis.
Metformin treatment in NIDDM patients with mild renal impairment
Authors: Connolly V , Kesson C M
Published: December 2008

Metformin is contraindicated in patients with renal failure because of the risk of lactic acidosis. This study assessed the complications of metformin treatment in patients with non-insulin-dependent diabetes mellitis with normal and raised serum creatinine. Subjects using metformin with serum creatinine above the upper reference range (120 mu mol/l) were identified (n = 17) from a hospital diabetes register; those with abnormal liver function, cardiac failure, peripheral vascular disease or recent severe illness were excluded. Reference plasma lactate levels were established, mean 1.742 mu mol/l (SD 0.819) using age-matched non-diabetic subjects. Age-matched patients treated with metformin with normal serum creatinine levels formed the control group (n = 24). Details of gastrointestinal disturbance were recorded, and plasma lactic acid and vitamin B12 levels measured. The median total daily dose of metformin in both groups was 1700 mg. The mean plasma lactate in subjects with serum creatinine 80-120 mu mol/l (2.640 mmol/l (SD 1.434) p < 0.02) was higher than non-diabetic control levels while diabetic subjects with serum creatinine 120-160 mumol/l had a mean of 2.272 mmol/l (SD 0.763) p < 0.05. There was no significant difference between the two groups taking metformin, nor any significant difference in the reporting of gastrointestinal symptoms between the groups on metformin (11.76% vs 12.5%). Plasma lactic acid levels are higher in diabetic subjects taking metformin compared with healthy volunteers but, within the diabetic groups, the small elevation of serum creatinine was not associated with higher plasma lactate levels.
Telling relatives that a family member has died suddenly
Authors: Marrow J
Published: December 2008

Persons dying suddenly are very likely to be taken to the nearest Accident and Emergency Department. The task of informing and counselling bereaved relatives therefore frequently falls to the staff of these Departments. Adequate preparation is important in allowing such situations to be dealt with in a sensitive and appropriate manner. Advice on coping with different aspects of sudden death is given and some common reactions discussed. Special problems are also considered (eg, the death of a child, criminal violence, communication difficulties). Aftercare must also not be forgotten and staff should receive training in the care of the bereaved.
Retroperitoneal fungal abscess presenting as superior mesenteric artery syndrome
Authors: Siddiqui M N , Ahmad T , Jaffary A
Published: December 2008

We report a patient two years post-cholecystectomy for gallstone pancreatitis presenting with superior mesenteric artery syndrome due to a retroperitoneal fungal abscess.
Gastric cancer
Authors: McCulloch P
Published: December 2008

We are gaining a clearer insight into the causes and mechanisms of gastric carcinogenesis, and may be able to reduce the incidence in the future by Helicobacter pylori eradication, perhaps in conjunction with nutritional supplements. The work required to establish this kind of prevention programme still has a long way to go. Surveillance and early detection are a key area, and current hopes rest with an increasingly low threshold for gastroscopy together with improved awareness in both patients and general practitioners. Identification of a high-risk group for surveillance would be a major advance, and may become possible due to advances in molecular biology. In terms of treatment, surgery remains the mainstay, but for useful analysis of its’ efficacy, uniform and detailed pathological staging is vital. Pre-operative assessment has improved greatly in recent years, resulting in fewer nontherapeutic laparotomies, thanks to a combination of improved imaging techniques and laparoscopy. Limited endoscopic surgery is now feasible for very early disease. The extent of radical surgery remains controversial: a strong argument can be made for concentrating this kind of surgery in the hands of a limited number of specialist units who will have the numbers and the expertise to answer the outstanding questions. Chemotherapy has yet to prove its value, but there are hopes that the newest regimes may do this. Treatment results in the West remain unsatisfactory, but they have improved in the last two decades, and should be capable of considerable further improvement.
Cancer of the oesophagus
Authors: Hennessy T P
Published: December 2008

Oesophageal cancer is the fourth most common tumour in developing countries, comprising mainly squamous cell tumours, although the incidence of adenocarcinoma has increased enormously over the last decades. Surgical resection has long been acknowledged as the mainstay of treatment, and developments in surgical technique are reviewed. The roles of radiotherapy and chemotherapy in the management of oesophageal cancer remain unclear, especially as the majority of studies to date have been uncontrolled trials. We present an analysis of 601 patients who underwent resection for carcinoma of the oesophagus between 1970 and 1994 in the Department of Clinical Surgery, St James’s Hospital, Dublin. The analysis shows clearly that, while peri-operative mortality continues to improve, conventional surgery offers little prospect of cure in the majority of cases. We have therefore embarked upon a prospective controlled trial of neoadjuvant chemoradiotherapy followed by surgery versus surgery alone in patients with adenocarcinoma or squamous cell tumours of the oesophagus. Preliminary results indicate that multi-modality treatment may have a valuable role to play in the treatment of carcinoma of the oesophagus.
Pre-operative computed tomography in abdominal aortic aneurysms
Authors: Fitzgerald E J , Spence L D
Published: December 2008

Major additional pathology, in the abdomen or directly related to the aneurysm itself, which influenced surgical management was demonstrated in 39 (34.5%) of 113 patients with suspected abdominal aortic aneurysm who had undergone pre-operative assessment with computed tomography (CT). Major additional pathology within the abdomen was shown in 11 (9.7%) and related to the aneurysm itself in 26 (23%). Therefore, CT has a significant impact on operative management of such patients and should be routine in the pre-operative evaluation of abdominal aortic aneurysms. The current roles of CT angiography and magnetic resonance angiography are discussed.
Primary Sjögren’s syndrome, ulcerative colitis and selective IgA deficiency
Authors: Steuer A , McCrea D J , Colaco C B
Published: December 2008

A 24-year-old man with primary Sjögren’s syndrome presented with xerophthalmia, xerostomia, and marked parotid swelling. He had a previous history of selective IgA deficiency and ulcerative colitis treated with sulphasalazine. Immunosuppression and withdrawal of sulphasalazine resulted in rapid resolution of the parotitis and disappearance of autoantibodies. A possible role for sulphasalazine in the induction of autoimmunity in this case is discussed.
Investigation of patients with polycythaemia
Authors: Pearson T C , Messinezy M
Published: December 2008

Polycythaemia may complicate or be the presenting feature of a wide variety of different pathologies. Early diagnosis and treatment of primary polycythaemia will significantly reduce the morbidity and mortality associated with this condition. Patients with a raised packed cell volume are divided into those with a raised red cell mass (absolute polycythaemia), and those with a red cell mass within their normal range (apparent polycythaemia). A standard investigative approach of an absolute polycythaemia enables patients with primary and secondary polycythaemia to be identified, leaving a group termed idiopathic erythrocytosis. There are a number of physiological situations and pathological events associated with idiopathic erythrocytosis and apparent polycythaemia. Careful follow-up of both groups of these patients is essential to identify possible causative mechanisms.
Apneustic breathing provoked by limbic influences
Authors: Stewart J , Howard R S , Rudd A G , Woolf C , Russell R W
Published: December 2008

We describe a 64-year-old man with cerebrovascular disease who had an acute stroke characterised by pseudobulbar palsy, facial weakness, and pyramidal signs. He developed frequent emotional outbursts followed by periods of apneusis. Between these episodes he breathed with a regular and unvarying rate and tidal volume. Autopsy showed extensive cortical, subcortical and pontine infarction. The respiratory pattern indicated a dissociation between voluntary and automatic pathways. The descending limbic pathways were preserved but an abnormal pattern of automatic breathing (ie, apneusis) occurred because of the presence of bilateral pontine infarction.
Cystic lymphangioma of the pancreas
Authors: Daltrey I R , Johnson C D
Published: December 2008

Cystic lymphangioma of the pancreas is a rare condition. A 14-year-old girl presented with a cystic abdominal mass and abdominal pain. She was initially treated by biopsy and cyst drainage, and subsequently with partial excision of the cystic mass. The mass, which was a cystic lymphangioma involving the pancreas, recurred after each operation. Persisting symptoms led to a pylorus-preserving pancreatectomy and hepaticojejunostomy. Total excision is the only effective method of treating this benign tumour. The patient remains symptom free 2 1/2 years after pancreatectomy.
A new immunosuppressant: tacrolimus
Authors: James D G
Published: December 2008

Tacrolimus is the new name for the Japanese immunosuppressant drug FK506. It blocks interleukin 2 transcription thereby inhibiting the CD4 Th-1 lymphocyte response to foreign antigens. It also selectively inhibits cytokine secretion of IL3, IL4 and interferon-gamma. It is metabolised by the cytochrome P-450 enzyme system. The results of two trials indicate that it is similar to cyclosporin in efficacy and toxicity.
The sleepwalking/night terrors syndrome in adults
Authors: Crisp A H
Published: December 2008

A third of a million adults in the UK sleepwalk while a million suffer from night terrors. In both conditions the individual is unaware of the fullness of their surroundings and is totally focussed in their concern or activity. Doctors are only likely to become involved if the individual comes to harm or seeks help or if other people are inconvenienced or threatened. The constitutional basis of the disorder is beyond doubt, although the actual expression may be related to stressful life-events resulting from an individual’s personality, relationships and circumstances. Treatment may include the provision of a secure environment, counselling, and the use of benzodiazepines and serotonin re-uptake inhibitors.
The elderly and their medication: understanding and compliance in a family practice
Authors: Blenkiron P
Published: December 2008

Eighty patients aged 75 years and over were interviewed in the surgery or at home to assess their level of knowledge, degree of compliance, and problems with their medicines. Regular medication was prescribed to 59 patients, who took a total of 206 drugs. The correct purpose of medication was stated in 72% of cases, the dosage regimen recalled accurately for 75%, and the correct name given for 64% of drugs. The elderly rated their compliance as ‘good’ (never miss doses) for 77% of drugs prescribed. This correlated poorly for individual patients with the level of correct compliance as assessed on computer records of repeat prescriptions, which nevertheless was accurate for 80% of medicines taken. A significant difficulty for the elderly was the removal of tops from medicine containers, occurring in 18 cases (31% patients), including half of those taking analgesics or nonsteroidal anti-inflammatory drugs. The widespread, legally enforced, use of child-resistant containers for the elderly frequently seems inappropriate. Further improvements in comprehension and compliance may occur with regular explanation and rationalisation of medication by the family doctor, when visiting the elderly at home.
Clinicolaboratory profile of 33 Arabs with systemic lupus erythematosus
Authors: al-Attia H M
Published: December 2008

A clinical and laboratory survey of systemic lupus erythematosus was conducted in 33 Arab patients in the UAE. Arthropathy (91%) followed by renal involvement (54%) and haematological disorders (45.5%) were the major clinical manifestations. Discoid rash (3%) was the least common. Apart from headaches, other neuropsychiatric symptoms were uncommon or not encountered. A number of distinctive clinical subsets of lupus was also observed. An unusually high prevalence of dsDNA antibodies was detected in the study (97%), compared with a prevalence of 89.5% of ANF. There was a relative paucity of anti-Ro (18.5%), La (7.5%) and RNP (11%) antibodies, but a high rate of anti-Sm(33%). The occurrence of the latter in patients with central nervous system and renal disease was insignificant. C3-Hypocomplementaemia occurred in 38.5% of the patients and a positive VDRL and Coomb’s test in 9% and 24%, respectively. This study provides additional information on the characterization of systemic lupus erythematosus in various populations.
Intravenous leiomyomatosis complicated by Budd—Chiari syndrome
Authors: Kuenen B C , Slee P H T J , Seldenrijk C A , Wagenaar S S
Published: December 2008

A 76-year-old woman with intravenous leiomyomatosis complicated by Budd-Chiari syndrome is described.
A patient with Graves' disease, thrombocytopenia and chronic hepatitis B
Authors: Szeto C C , Chow C C , Ko G T C , Li K Y , Yeung V T F , Cockram C S
Published: December 2008

A 22-year-old Chinese man, a HBsAg carrier, presented with relapse of thyrotoxic Graves' disease complicated by thrombocytopenia and hepatitis. Platelet count and liver enzymes gradually improved following successful treatment of the thyrotoxicosis with radioactive iodine. Possible pathogenetic links and therapeutic implications are discussed.
Diffuse histoplasmosis in a patient with sarcoidosis
Authors: Badesha P S , Saklayen M G , Hillman N
Published: December 2008

A case is presented of a woman with a long history of sarcoidosis who developed diffuse histoplasmosis. Although association between these two entities has been described before, there are only a few case reports of histoplasmosis among sarcoid patients. Diagnosis was finally established by bone marrow biopsy which saved the patient's life.
Paget's disease of bone
Authors: Ooi C G , Fraser W D
Published: December 2008

Paget's disease of bone is a relatively common condition in the UK affecting up to 5% of the population over the age of 55 years with particularly high prevalence in the North West of England. The majority of those affected are asymptomatic. Its precise cause remains unknown, and until recently, choice of treatment of this sometimes painful and debilitating disease has been limited. In this article, we review various aspects of this disease, concentrating particularly on recent advances in our understanding of its aetiology and its treatment.
Does erythropoietin accelerate malignant transformation in multiple myeloma?
Authors: Olujohungbe A , Handa S , Holmes J
Published: December 2008

Growth factors or humoral agents can support haemopoiesis in various bone marrow disorders. They have the ability to act on multiple cell lineages and in myeloid cells, and the potential to act on the neoplastic equivalent of normal cells. Anaemia is a common feature of multiple myeloma seen in at least two-thirds of patients at presentation. Erythropoietin is increasingly being used with variable effect for the treatment of this anaemia, especially in cases associated with renal failure and in patients in whom blood transfusion may be undesirable or contraindicated. We describe a patient treated with recombinant erythropoietin who developed fulminating malignant transformation. The demonstration of erythropoietin receptors on a human myeloma cell line and the occurrence of the rare complication of plasma cell leukaemia in our patient stresses the need for caution and invites detailed clinical and laboratory studies before its general use.
Drug-induced antisynthetase syndrome
Authors: Thickett D R , Millar A B
Published: December 2008

We present a case of antisynthetase syndrome whose predominant feature was fibrosing alveolitis and which may have been drug-induced. This responded well to steroids and cyclophosphamide.