bluuebunny/crossref_metadata_2025 huggingface dataset:
Continuous ambulatory peritoneal dialysis in the elderly: a seven-year experience
Authors: Hung K Y , Hsu W A , Tsai T J , Yen C J , Hou C H , Yen T S
Published: December 2008

This is a retrospective comparison of the status among the elderly (> or = 60 years, 23 patients) and younger patients (< 60 years, 31 cases) who initiated continuous ambulatory peritoneal dialysis (CAPD) between January 1986 and December 1992 at the National Taiwan University Hospital. The distribution of underlying renal diseases differed in the two groups with diabetes (56%) as the most common disease in the elderly, in contrast to glomerulonephritis (60%) in the younger patients. Haemodialysis intolerance and patient preference were the main reasons leading to the use of CAPD in both groups. Social rehabilitation status was poorer in the elderly group. The difference in cumulative risk of the first peritonitis episode and the technique failure rate were not statistically significant. The major causes of mortality were of vascular origin in both groups. In conclusion, similarities in the technique failure rate and the cumulative risk of peritonitis imply that CAPD is an acceptable alternative long-term dialysis therapy for geriatric patients.
Toxoplasma gondii--an unusual cause of myocarditis in old age
Authors: Chapman N , MacLennan W J , Rahilly M
Published: December 2008

We report the case of an 86-year-old man who was admitted with congestive cardiac failure and chronic renal failure. He was previously known to have a thoracic aortic aneurysm and chronic bronchitis. There was no history of myocardial infarction but his heart failure was assumed to be due to ischaemic heart disease. Despite treatment of the heart failure the patient died. At post-mortem he was found to have Toxoplasma gondii myocarditis.
Retinal vasculitis associated with Crohn’s disease
Authors: Garcia-Diaz M , Mira M , Nevado L , Galván A , Berenguer A , Bureo J C
Published: December 2008

Although systemic vasculitis can be a complication of inflammatory bowel disease at several locations (skin, eyes, brain, mesentery, and lung) the association of retinal vasculitis with Crohn’s disease is rare. We studied a 26-year-old woman with biopsy-demonstrated Crohn’s disease who developed a severe bilateral retinal arteritis and phlebitis, with acute loss of vision.
Symptomatic cardiomyopathy as a presentation in Whipple’s disease
Authors: de Takats P G , de Takats D L P , Iqbal T H , Watson R D S , Sheppard M N , Cooper B T
Published: December 2008

A patient presenting with congestive cardiac failure and anaemia underwent investigation which led to the diagnosis of Whipple’s disease, associated with dilated cardiomyopathy. Conventional antibiotic therapy for Whipple’s disease resulted in resolution of the traditional features of Whipple’s disease and a marked improvement in the patient’s heart failure.
Dysphagia in an HIV-positive man
Authors: Moss S , Valentine C B , Carey P B , Hind C R K
Published: December 2008

An HIV-positive man whose dysphagia was due to non-Hodgkin’s lymphoma. The differential diagnosis of this symptom in the context of HIV infection is summarised in box 3.
Respiratory failure in acute pancreatitis
Authors: Banerjee A K , Haggie S J , Jones R B , Basran G S
Published: December 2008

There are a number of important pulmonary complications of acute pancreatitis which make a significant contribution to the morbidity and mortality of the condition. The pathophysiology and management guidelines are given for each and approaches towards better treatment in the future are discussed.
Surgical cure of hypertension in a patient with brainstem capillary haemangioblastoma containing neuropeptide Y
Authors: Hedderwick S A , Bishop A E , Strong A J , Ritter J M
Published: December 2008

We describe a 29-year-old woman with persistent arterial hypertension which resolved following complete excision of a capillary haemangioblastoma from within the spinal cord at the cervico-medullary junction. Immunohistochemical staining was positive for neuropeptide Y in capillary walls and nerves in the tumour. This raises the possibility of an association between neuropeptide Y and the central control of blood pressure in man.
Communicating with young adults with cystic fibrosis
Authors: Webb A K
Published: December 2008

The care of the young adult with cystic fibrosis is complex, requiring a multidisciplinary input from different carers. Communication with and education of patients covers many areas; topics may include medical and personal problems, transplantation, survival, current scientific breakthroughs and the future. Communicating in these areas with knowledgeable young adults requires skill, tact and self-education upon the part of the cystic fibrosis team.
Radiotherapy and chemotherapy for inoperable non-small cell lung cancer
Authors: Bleasdale C , Jones B
Published: December 2008

Non-small cell lung cancer is a major cause of mortality and significant morbidity in the UK. The majority of patients are inoperable and the optimum management of these patients requires a multidisciplinary approach involving the cooperation of respiratory physicians, thoracic surgeons and clinical oncologists (radiotherapists). Treatment techniques are constantly being refined and new approaches developed.
The changing context of undergraduate medical education
Authors: Parsell G J , Bligh J
Published: December 2008

It has long been recognised that intensive efforts are needed to reform medical education in order to meet the future needs of populations worldwide. Pressure for changes to the organisation, content and delivery of both undergraduate and postgraduate medical education has greatly increased in the last two decades. The experience of innovative medical schools, the emergence of learner-centred teaching methods and the implications of health-care reforms in North America and Britain are major factors influencing calls for change. The pace of change has accelerated to such an extent in recent years that progress towards widespread reform appears to be more attainable than ever before. This article provides an overview of the changing context of health-care, some patterns of existing medical education and some strategies for change.
Kerosene poisoning in children in Iraq
Authors: Nagi N A , Abdulallah Z A
Published: December 2008

One hundred and three children with kerosene poisoning were studied. The majority of the patients were under five years of age and included a newborn baby. More patients were seen in spring and fewer in winter months. Most of the patients were children of poor families living in overcrowded conditions. Negligence and ignorance were the main causes of poisoning. Respiratory and central nervous systems were mainly involved. Chest X-ray abnormalities were frequently seen. The patients were treated symptomatically. Only one patient died, he had been in a coma on admission to the hospital. All other patients had rapid and complete recoveries.
Post-typhoid anhidrosis: a clinical curiosity
Authors: Raveenthiran V
Published: December 2008

A 19-year-old girl developed generalised anhidrosis following typhoid fever. Elaborate investigations disclosed nothing abnormal. A skin biopsy revealed the presence of atrophic as well as normal eccrine glands. This appears to be the third case of its kind in the English literature. It is postulated that typhoid fever might have damaged the efferent pathway of sweating.
Angiography and the aetiology of heart failure
Authors: Brookes C I , Hart P , Keogh B E , Cleland J G
Published: December 2008

The diagnosis of idiopathic dilated cardiomyopathy should not be made without first performing a coronary angiogram. If the cause of heart failure is unknown this should be stated rather than attributing the cause to dilated cardiomyopathy. Severe ventricular dysfunction may improve dramatically after revascularisation in some cases of coronary disease. Preservation of R waves on the surface electrocardiogram suggests the presence of hibernating myocardium but thallium scintigraphy or positron emission tomography scanning should be employed to investigate this further.
Polymyalgia rheumatica, temporal arteritis and malignancy
Authors: Speed C A , Haslock I
Published: December 2008

The use of steroid therapy in polymyalgia rheumatica and temporal arteritis is necessary and usually effective, but may mask coexisting disease. The importance of early consideration of other disorders in such patients is illustrated by three case histories.
Renal calculi in primary hyperaldosteronism
Authors: Kabadi U M
Published: December 2008

Increased urinary calcium (Ca++) excretion and the presence of negative Ca++ balance is well documented in primary hyperaldosteronism. However, renal calculi as a major manifestation of this disorder has not previously been described. This report describes a patient who presented with renal calculi in association with primary hyperaldosteronism. We believe that primary hyperaldosteronism was a major pathogenetic factor in the formation of renal calculi since the increased urinary excretion of Ca++ and uric acid noted at onset declined following a short-term spironolactone administration and remission from renal calculi has persisted following initial nephrolithotomy and continued spironolactone therapy, which also corrected hypertension and hypokalemia, a hallmark of this disorder.
Giant cell carcinoma of the lung
Authors: Aziz S A , Ahmad M , Shah A , Bhat G M , Lone A , Ahmad K , Bano H
Published: December 2008

A 50-year-old non-smoking, hypertensive female, presenting with superior vena caval compression, was found to have giant cell carcinoma of the lung. She received intensive combination chemotherapy. However she died in the following 36 hours, as a consequence of refractory hypotension.
An audit of ANCA in routine clinical practice
Authors: Edgar J D , McMillan S A , Bruce I N , Conlan S K
Published: December 2008

We have reviewed the medical records of 301/327 consecutive patients in whom anti-neutrophil cytoplasmic antibodies (ANCA) were detected by the Regional Immunology Laboratory in Northern Ireland between January 1988 and October 1991 (45 months). We have collected data for each patient regarding age, sex, smoking habit, area of residence, and details of any other autoantibody activity. Clinical diagnosis was established, with the number of organ systems involved and the evidence for that involvement (symptomatic, biochemical, radiological, and histological). Diagnoses were divided into four groups according to their recognised vasculitic features and these were related to the pattern of immunofluorescence and maximum ANCA titre detected. The most frequent diagnosis was rheumatoid arthritis (18.2% of patients) and the connective tissue disorders as a whole accounted for 27.9% of patients. ANCA were also detected in a wide range of clinical conditions which are not associated with vasculitis and these patients were an important source of ‘false-positives’. The positive predictive value (PPV) of ANCA of all patterns and titres for vasculitic conditions was 27%, however, the detection of a classical ANCA pattern at high titre (> or = 1:640) was associated with an increased PPV of 75%. The coexistence of an antinuclear antibody (ANA) reduces the PPV of both classical and perinuclear ANCA, although perinuclear ANCA with antimyeloperoxidase specificity had an improved PPV. We conclude that ANCA testing should not be used as the only screening investigation for vasculitis but should be included in a rational investigative scheme. The interpretation of a positive ANCA result must take into account the presence of other autoantibodies and the full range of non-vasculitic conditions when the clinical situation is not typical of vasculitis.
Dealing with the difficult patient
Authors: Smith S
Published: December 2008

Dealing with difficult patients can represent a significant burden in the life of doctors. It is more productive, however, to view this burden as a product of the interaction between doctor and patient, for which both have a responsibility, rather than attributing any problems encountered to shortcomings of the patient alone. There is a significant risk in such situations of potentially harmful over-medicalisation. It behoves doctors, therefore, to try to prevent such problems becoming established, or make some attempt to rectify matters if they have already become so. Much is known about the factors that contribute to successful and unsuccessful clinical transactions. The awareness of what doctors bring both as professionals and as individual people to this interaction, will count as much as the practical clinical efforts made towards helping patients.
Unrestricted availability of a plasma paracetamol assay service resulting in an increased number of inappropriate requests
Authors: Chan T Y , Critchley J A , Ho C S , Chan A Y
Published: December 2008

Previously, prior approval from the on-call chemical pathologist was required in our hospital for plasma paracetamol measurements. However, since May 1992, there have been no restrictions on ordering this assay. We have assessed the consequences of this policy change by comparing the number and appropriateness of requests for plasma paracetamol measurements in Chinese patients admitted to our hospital with acute poisoning over two six-month periods (July-December) in 1991 and 1993. Requests were considered appropriate if paracetamol ingestion was suspected or unknown drugs were ingested. The number of patients having plasma paracetamol concentrations assayed increased from 51 in 1991 to 141 in 1993 (176%). The corresponding increase in the number of Chinese patients admitted to two of our eight general wards with poisoning was estimated to be 93%. The proportion of ‘appropriate’ plasma paracetamol measurements dropped from 55% in 1991 to 21% in 1993. Eight patients had plasma paracetamol concentrations above the recommended treatment line; they were all from the group in whom the requests were appropriate. Three of the 135 patients in the group with ‘inappropriate’ requests were found to have slightly elevated but far from toxic plasma paracetamol concentrations. Unrestricted availability of plasma paracetamol measurements resulted in an increase in the number of inappropriate requests.
Giant retroperitoneal hemangiopericytoma
Authors: Chan S C , Lee C M , Ng Y B , Tsai C H
Published: December 2008

Hemangiopericytomas are rare vascular tumours that are derived from pericytes. Retroperitoneal hemangiopericytomas are usually bulky but clinically silent when diagnosed because of their slow rate of growth. A 49-year-old man, who presented with only vague symptoms of abdominal fullness for several months, was found on computed tomography to have a huge well-defined mass with areas of low attenuation and well-enhanced septa. The tumour was successfully resected and was confirmed to be a malignant retroperitoneal hemangiopericytoma. It measured 30 cm in the greatest dimension. We are prompted to present this case as it is believed to be the largest tumour reported to date.
Carcinoid syndrome due to a malignant somatostatinoma
Authors: Ozbakir O , Keleştimur F , Oztürk F , Sözüer E , Unal A , Patiroğlu T E , Güven K
Published: December 2008

Somatostatinoma is one of the rarest tumours of the endocrine pancreas. Cardinal manifestations of a somatostatinoma include gallstones, mild diabetes mellitus, steatorrhoea, diarrhoea and dyspepsia. Like any other pancreatic islet cell carcinoma, a somatostatinoma may also produce several different hormones such as adrenocorticotropic hormone, calcitonin, vasoactive intestinal polypeptide, pancreatic polypeptide, gastrin, insulin, and glucagon. In many cases, the clinical picture is dominated by the effect of these other hormones. We present a patient with somatostatinoma in which an immunocytochemical study of the specimens from pancreas and liver showed a weak positive reaction for gastrin besides a strong positive reaction for somatostatin. Interestingly, this patient also showed the signs of carcinoid syndrome which was successfully treated with octreotide.
Primary actinomycotic lung abscess
Authors: Mohan A , Chattopadhyay T K , Sharma S K , Dinda A K , Sharma R
Published: December 2008

A case of recurrent massive haemoptysis in whom primary actinomycotic lung abscess was diagnosed following right pneumonectomy is reported.
Martorell’s ulcer
Authors: Shutler S D , Baragwanath P , Harding K G
Published: December 2008

This paper reports a rare form of ulceration of the lower leg and, as a result of subsequent investigations and literature review, readdresses a recent debate regarding the legitimate classification of these ulcers as a separate disease entity.
Medullary carcinoma of the thyroid metastatic to breast
Authors: Kiely N , Williams N , Wilson G , Williams R J
Published: December 2008

Medullary carcinoma of the thyroid commonly spreads to the lymphatics and later on in the disease process, to distant sites such as lung, liver and bone. Spread to the breast is rare (only two previous reported cases) and presents a major diagnostic dilemma. We report a case of metastatic medullary carcinoma of the thyroid which presented as a primary breast nodule with ipsilateral axillary lymphadenopathy. Clearly it was important to distinguish this tumour from a breast primary as each are managed differently. Both cytological and radiological investigations were inconclusive but excision biopsy was diagnostic.
Bacterial meningitis after MMR immunisation
Authors: Riordan F A , Sills J A , Thomson A P , Hart C A
Published: December 2008

Two children developed bacterial meningitis within five days of measles-mumps-rubella (MMR) immunisation. Diagnosis was delayed because symptoms were attributed to the vaccine, although both had a raised C-reactive protein. Fever or rash within five days of MMR vaccination are unlikely to be due to the vaccine and a raised C-reactive protein suggests bacterial infection.
Neuropathic urinary retention in the absence of neurological signs
Authors: Sylvester P A , McLoughlin J , Sibley G N , Dorman P J , Kabala J , Ormerod I E
Published: December 2008

We present two cases of painless urinary retention secondary to central intervertebral disc prolapse. In neither case were there signs or symptoms suggesting an underlying neurological insult. Both patients voided spontaneously following neurosurgical intervention. The classical features of acute cauda equina compression may be absent in patients with central lumbar disc protrusion. Painless urinary retention may be the only physical sign.
Diagnostic and management problems in a complex case of connective tissue disease
Authors: Yeap S S , Deighton C M , Powell R J , Read R C , Finch R G
Published: December 2008

A 28-year-old Nigerian woman presented with persistent pyrexia, marked pruritis, eosinophilia, myalgias, flitting arthralgias, serositis and massive splenomegaly. Intensive investigation for an infective or neoplastic aetiology proved negative. Empirical treatment for helminthic infections and tuberculosis was unhelpful. Although there were no specific clues to suggest an underlying connective tissue disease, a trial of steriods and azathioprine was introduced, with no obvious response. Her condition deteriorated to a point where it was decided that intravenous immunosuppressive therapy was needed and subsequently, her condition improved remarkably. This patient illustrates the problems in the diagnosis and management of complex disorders, particularly when classical tests for connective tissue diseases are absent. Also, we would like to report that marked pruritis can be associated with connective tissue disease.
Massive reversible pulmonary cysts in a patient with AIDS
Authors: Collazos J , Martínez E , Mayo J , Miguélez J L
Published: December 2008

We report the case of a patient with AIDS who presented with bilateral, massive pulmonary cystic disease and pneumothorax presumably caused by Pneumocystis carinii which responded to treatment with cotrimoxazole. Follow-up with sequential chest X-rays and computed tomography scans showed a progressive improvement in the lung cysts which had resolved almost completely 11 months later. Several theories have been proposed to explain the cavitary lesions in this infection. The course observed in our patient suggests that a non-destructive mechanism was responsible for his lung cysts.
Clinical guidelines and their implementation
Authors: Forrest D , Hoskins A , Hussey R
Published: December 2008

Within the UK there has been increasing interest in the development and implementation of guidelines, as the emphasis on clinical effectiveness is gathering momentum. This paper outlines some of the practical issues encountered in developing and implementing guidelines, based on experiences within Liverpool. Developing local guidelines can be a lengthy process, but that process is not a waste of time if it means there is more likely to be compliance in the end. Dissemination of guidelines alone is not enough; it needs to be combined with an appropriate implementation strategy. There is a danger of primary care being overloaded with new guidelines; there needs to be a timed strategy for their introduction. More imaginative thought needs to be put into the marketing of new ideas in order to change practice. We need to encourage the ethos amongst healthcare professionals of expecting to have to constantly update knowledge and practice.
Incidental mucinous cystadenocarcinoma of the appendix
Authors: Lee J , Gardiner K R , Wilson B G
Published: December 2008

The incidental finding of a rare appendiceal tumour in a previously healthy male patient is described. He presented as an emergency with a self-inflicted abdominal stab injury. At laparotomy, there was no visceral damage but the appendix was hugely distended and appendectomy was performed. Subsequent histological examination of the appendix revealed a low-grade mucinous cystadenocarcinoma. A right hemicolectomy was performed two months later which demonstrated no residual tumour.
Local anaesthesia for major general surgical procedures. A review of 116 cases over 12 years
Authors: Dennison A , Oakley N , Appleton D , Paraskevopoulos J , Kerrigan D , Cole J , Thomas W E
Published: December 2008

Between 1980 and 1992, 116 patients had either a simple mastectomy (32) or intra-abdominal procedures (84) under local anaesthesia (0.5-1% lignocaine with 1:200 000 adrenaline). A wide variety of general surgical procedures were feasible using only supplementary intravenous sedation (54%). Complications were uncommon and related to surgical procedure (three incorrect diagnoses, three procedures impossible) rather than the anaesthetic technique. There were no anaesthetic toxicity or postoperative problems. Local anaesthesia is extremely safe and facilitates larger surgical procedures than is generally appreciated.
The risk of severe salicylate poisoning following the ingestion of topical medicaments or aspirin
Authors: Chan T Y
Published: December 2008

Apart from isolated reports of severe salicylate poisoning after ingesting an unusually large amount of a medicinal oil, there are no published data on the threat arising from attempted suicide with topical medicaments containing methyl salicylate or wintergreen oil compared with aspirin tablets. In this retrospective study, the admission plasma salicylate concentrations and clinical presentations were compared in 80 subjects who had taken aspirin tablets (n = 42) or topical medicaments (n = 38). The proportions of subjects being symptomatic were similar in the two groups. Although the admission plasma salicylate concentrations were generally higher in subjects who had ingested aspirin tablets, the two highest readings (4.3 and 3.5 mmol/1) belonged to two of the subjects who had taken topical medicaments. Because of its liquid, concentrated form and lipid solubility, methyl salicylate poses the threat of severe, rapid-onset salicylate poisoning. The toxic potential of topical medicaments containing methyl salicylate or wintergreen oil should be fully appreciated by both physicians and the general public.
Concealed post-infarction left ventricular rupture--a diagnostic dilemma
Authors: Khogali S S , Bonser R S , Beattie J M
Published: December 2008

We describe a patient with post-infarction left ventricular rupture exhibiting several atypical features. A successful outcome was achieved after serendipitous surgery.
Abdominal pain in a young girl
Authors: Handa R , Chirukpalli R , Agarwal S , Mukhopadhyaya S , Gupta R , Sood R , Meena H S , Wali J P
Published: December 2008

A 14-year-old girl was admitted to our hospital with peri-umbilical pain associated with obstipation and vomiting. Plain erect X-rays of the abdomen revealed multiple air fluid levels. A supine X-ray is shown in this figure.
Four years of problem-based learning: a student’s perspective
Authors: von Doebeln G
Published: December 2008

After four years as a student in a medical school using problem-based learning I still find it an excellent way to learn. Group work has developed my personal skills and abilities. Learning how to obtain knowledge on my own has given me independence and confidence. Motivation to study has been encouraged by early clinical experience. Training in critical thinking has been further enhanced by in-depth studies. Medical education at the University of Linkoping has developed over the years and a contributing factor has been students’ involvement in designing the medical training. There are benefits and disadvantages with problem-based learning, but on the whole it is an enjoyable and fruitful experience.
Making medical recruitment practices fair
Authors: Maddock S
Published: December 2008

The fact that in the past each medical student was assured of a post when qualified has led many in medicine to believe that selection for recruitment is merely a formality based on qualification and accreditation. Consequently little thought has gone into developing detailed person or post selection criteria. As a result most recruitment panel members are unclear on what basis to discriminate between equally qualified candidates and invariably plump for ‘the face that fits’. This practice discriminates against women, black doctors and those white men not quite acceptable in manner, dress or attitudes. In this article, advice is offered on the development of equality strategies for public sector organisations and on the implementation of fair practices.
Aerosol delivery systems for bronchial asthma
Authors: Ariyananda P L , Agnew J E , Clarke S W
Published: December 2008

Many different inhalation devices are now available for the treatment of asthma. Pressures towards the elimination of chlorofluorocarbon propellants are driving forward development of new devices-as are obvious commercial pressures, including the increased availability of generic formulations. We still, however, often cannot tell exactly where within the lung we want to target a particular medication, be it a bronchodilator or a steroid. The basic processes of aerosol deposition are readily comprehensible. Nevertheless, even under carefully supervised inhalation conditions, one can only roughly estimate where the medication is deposited. We can, however, hope to give our patients good guidance on how to make the best use of a metered-dose inhaler or a jet nebuliser. From the array of available devices, we will increasingly be able to select the most comfortable and convenient for the patient-and therefore most likely to encourage good compliance.
Ectopic ACTH syndrome: redefinition and case report
Authors: Jolobe O M
Published: December 2008

A case is reported which supports the principle that ACTH precursors best characterise so-called ectopic ACTH-syndrome, which should therefore more accurately be referred to as ectopic ACTH-precursor syndrome.
Postural hypotension in a patient with acute myelitis
Authors: Kalita J , Misra U K
Published: December 2008

A case of acute transverse myelitis with severe postural hypotension is described.
Adrenal incidentaloma: subclinical Cushing’s syndrome
Authors: Newell-Price J , Grossman A
Published: December 2008

Adrenal incidentalomas present a significant differential diagnostic challenge. All patients with an incidentally discovered adrenal lesion should be carefully considered and re-evaluated to exclude extra-adrenal malignancy. Tumours with hypersecretory syndromes require excision, whilst those tumours more than 6 cm in size, particularly if they exhibit other features of malignancy on computed tomography (CT), magnetic resonance imaging (MRI) or scintigraphy, should also be excised. In all cases screening for phaeochromocytomas should be performed, and in the context of hypertension and spontaneous hypokalaemia, a primary aldosterone-secreting tumour requires exclusion. However, the natural history and treatment regimens for those individuals demonstrating ‘subclinical Cushing’s syndrome’ is far from clear. Size, as determined by CT or MR scanning, does not in itself reliably distinguish benign from malignant disease. Scintigraphy may be a useful adjunct, with discordant patterns suggesting malignant disease. Fine needle aspiration should not routinely be used but may be useful in cases of doubt about other extra adrenal malignancy.
Satellite-delivered continuing medical education in Europe
Authors: Geraghty J G , Young H L
Published: December 2008

There is increasing recognition of the need for continuing medical education in the medical profession. There are now many ways of delivering medical education including conferences, books, journals amongst others. This paper describes a novel method of delivering medical education using satellite transmission. This medium allows live medical education programmes to be broadcast to over 150 receiver sites in Europe. It also enables two-way live satellite links to be made between countries during the broadcast. EuroTransMed has an editorial board, in much the same way as a journal, which is representative of the differing medical societies in Europe. As the barriers between the various countries fall, EuroTransMed is an ideal medium to promote high quality, easily accessible, continuing medical education at a pan-European level.
Minoxidil, hypercoagulability and thromboembolic disease of the lung
Authors: Keohane S G , Edmunds M , Holton J , Swales J D
Published: December 2008

Minoxidil is a potent antihypertensive agent used in the treatment of resistant hypertension. A case is presented which illustrates a probably fatal interaction between minoxidil and a coagulation disorder.
Acute pancreatitis due to zinc phosphide ingestion
Authors: Sarma P S , Narula J
Published: December 2008

The case of a young woman is described who suffered from acute pancreatitis related to the ingestion of zinc phosphide. This unusual complication was successfully managed with conservative treatment.
Thoracic spondylosis presenting with spastic paraparesis
Authors: Chana J S , Afshar F
Published: December 2008

Spondylotic change of the spine is common in the cervical and lumbar regions and may present with compression of the spinal cord and nerve roots. Myelopathy due to degenerative disease in the thoracic spine is exceptional. Only a few cases have been reported in the literature and these reports have described disease in the lower four thoracic segments. We report a case of paraparesis caused by degenerative disease in the upper thoracic spine which has not previously been described.
The evaluation and management of subclinical pituitary disease
Authors: Soule S G , Jacobs H S
Published: December 2008

The advent of sophisticated and sensitive radiologic techniques has undoubtedly improved the evaluation of patients with established endocrine disease. An inevitable consequence of the increased sensitivity and widespread availability of modern imaging is, however, the discovery of apparently asymptomatic mass lesions in endocrine tissues. The clinician is then required to determine the appropriate degree of often uncomfortable and costly investigation in a patient with no overt disease. This article attempts to provide guidelines for the management of the ‘pituitary incidentaloma’, a pituitary mass lesion evident on a computed tomography or magnetic resonance imaging scan performed for a reason other than the evaluation of the pituitary gland.
Nocturnal and respiratory disturbances in Steele-Richardson-Olszewski syndrome (progressive supranuclear palsy)
Authors: De Bruin V S , Machado C , Howard R S , Hirsch N P , Lees A J
Published: December 2008

Respiratory and sleep disturbances may be important causes of morbidity in Steele-Richardson-Olszewski syndrome but the frequency and character of nocturnal abnormalities remains uncertain. A prospective study of 11 patients with Steele-Richardson-Olszewski syndrome and age-matched control subjects was undertaken using clinical assessments, a structured sleep questionnaire, spirometry, static maximum inspiratory and expiratory pressures and nocturnal oximetry. The mean age of the Steele-Richardson-Olszewski syndrome patients was 63.2 (52-70) years and mean disease duration was 4.0 (2-6) years. There was moderate to severe motor disability in nine and mild to moderate dementia in eight. In the patients with Steele-Richardson-Olszewski syndrome the following abnormalities contributed to sleep disturbances significantly more frequently than in normal controls: depression, dysphagia, frequent nocturnal awakenings (usually associated with urinary frequency), immobility in bed, difficulty with transfers, impaired dressing and feeding. There was profound impairment of voluntary respiratory control whilst automatic and limbic control were well maintained. Nocturnal respiratory abnormalities were not present even in the most severely disabled. In Steele-Richardson-Olszewski syndrome sleep abnormalities are common; they relate to the cognitive, pseudobulbar and extrapyramidal disturbances and may therefore be amenable to symptomatic control.
Gallstone ileus--beware the silent second stone
Authors: Davies J B , Sedman P C , Benson E A
Published: December 2008

Gallstone ileus remains a rare but important cause of small bowel obstruction. We report a case of recurrent gallstone ileus, presumably caused by an unidentified second stone resident within the gallbladder at the time of the initial laparotomy. This raises important questions about the traditional surgical management of this interesting condition.
Transitional cell carcinoma of the bladder in an HIV-infected patient
Authors: Al Soub H
Published: December 2008

A case of transitional cell carcinoma of the urinary bladder in a patient infected with the human immunodeficiency virus is reported. The tumour was very large, occupying most of the bladder, however cystoscopic removal of the tumour was successful with no recurrence after one year. This association has never reported before. The possible contribution of human immunodeficiency virus infection to its occurrence is discussed.
Spindle cell stromal tumour of the rectum treated by restorative resection
Authors: Harrison J D , Musgrove C , Kirby R M
Published: December 2008

Stromal tumours of the rectum and anal canal are rare, representing 0.02-0.03% of malignant neoplasms in the region. Current advice in their management is treatment by abdomino-perineal resection. We report a case of malignant spindle cell stromal tumour in which adequate clearance was obtained whilst preserving the anal sphincter, using a posterior parasacral approach.
Chronic pancreatitis: diagnosis and treatment
Authors: Sidhu S , Tandon R K
Published: December 2008

Three-dimensional magnetic resonance cholangiopancreatography is currently the most exciting new imaging technique for chronic pancreatitis. Endoscopy-assisted duodenal intubation during the secretin-cholecystokinin test reduces intubation time in difficult cases. The NBT-para-amino benzoic acid test has been refined to enhance its discriminant power. The cholesteryl-[C13]octanoate breath test and the faecal elastase test are newer highly sensitive and specific tubeless tests. Pain in chronic pancreatitis continues to be a vexing therapeutic issue. Enzyme treatment continues despite criticism. Neurotensin is the new suspected mediator of the feedback mechanism, which is downregulated by enzyme therapy. Steroid ganglion block is an exciting therapeutic tool for pain relief. Endoscopic pancreatic sphincterotomy, Dormia basketing and pancreatic stenting in conjunction with extracorporeal shock wave lithotripsy should be performed early in chronic pancreatitis to prevent parenchymal atrophy with ensuing exocrine and endocrine pancreatic dysfunction. The modified Puestow’s procedure preserves endocrine and exocrine pancreatic functions besides relieving pain. Closed loop insulin infusion allows superior management of pancreatic diabetes following near total pancreatectomy. The standardised incidence rate of pancreatic cancer is 16.5 in patients with alcoholic chronic pancreatitis and 100 for tropical chronic pancreatitis. Aggressive treatment protocols combining neo-adjuvant chemoradiation and intra-operative radiation with surgery are being used to improve the prognosis in this dismal complication of chronic pancreatitis.
Influenza vaccination in the elderly
Authors: Morgan R , King D
Published: December 2008

There is overwhelming evidence for the clinical efficacy of the influenza vaccine, especially in the elderly with chronic disease, reducing mortality and hospital admissions. There is also evidence to suggest that the influenza vaccine may be beneficial in the healthy elderly. There is some evidence to suggest that the antibody response in the elderly to the vaccine may decrease with increasing age, although there are several confounding factors that have not been taken into account in many of these studies. That aside, even if antibody response is not as good as that in younger people, the evidence that vaccination saves lives and reduces morbidity in the elderly means that the vaccination should be offered to elderly patients at high risk and perhaps even to the elderly healthy population. Although vaccination of an elderly at-risk patient does not necessarily mean that that particular patient will mount an appropriate antibody response, a significant number of elderly patients will respond appropriately. Serious side-effects from vaccination are extremely rare and the more common side-effects are mild and self-limiting. Increasing the number of elderly people receiving the influenza vaccination will not only result in cost savings for the National Health Service in terms of reduced hospitalisation but, more significantly, the elderly will benefit in terms of reduced morbidity and mortality.
Digoxin toxicity presenting as encephalopathy
Authors: Greenaway J R , Abuaisha B , Bramble M G
Published: December 2008

We describe two cases of digoxin toxicity presenting with clinical and electroencephalographic evidence of encephalopathy without other features of digoxin toxicity.
Intracranial imaging
Authors: Gibson M , Cook G , Al-Kutoubi A
Published: December 2008

This article concentrates on the imaging of intracranial structures and outlines some basic imaging strategies for common clinical presentations.
Enteral nutrition and the critically ill
Authors: Shikora S A , Ogawa A M
Published: December 2008

Critically ill patients invariably require nutritional intervention. Traditionally, enteral nutrition has not been widely employed in this patient population. This is due in part to the success of present-day parenteral nutrition, and to difficulties encountered with enteral feeding. Recent evidence has demonstrated that enteral is preferable to parenteral nutrition in terms of cost, complications, gut mucosal maintenance, and metabolic and immune function. Enterally administered nutritional support can and should be utilised as the preferred route of nourishment for the critically ill. The appropriate choice of access and formula, as well as a rational strategy for implementation, should improve the likelihood of success. This article describes the unique features of critical illness as they pertain to nutritional support, the benefits of enteral nutrition, and the obstacles to success, and offers suggestions which may improve the ability to provide nutrients adequately via the intestinal tract.
Leucocytoclastic vasculitis in a patient with azathioprine hypersensitivity
Authors: Beckett C G , Hill P , Hine K R
Published: December 2008

We report the case of a 77-year-old man admitted nine days after being commenced on azathioprine with symptoms initially thought to be secondary to sepsis but in fact due to azathioprine hypersensitivity. He developed histologically proven cutaneous leucocytoclastic vasculitis following the re-introduction of azathioprine. We review the literature concerning adverse reactions to azathioprine and the problems of making the diagnosis as well as highlighting azathioprine as a novel cause of leucocytoclastic vasculitis.
Colorectal liver metastases
Authors: Burke D , Allen-Mersh T G
Published: December 2008

Each year in the UK, between 12-14,000 people develop liver metastases from colorectal cancer. These metastases will contribute to the death of the patient in about 80% of cases. Treatments aimed at these tumours are best administered when the tumour is small. Current investigative methods allow tumours as small as 0.5 mm to be detected, and should be offered to all colorectal cancer patients at risk of developing liver metastases. Surgery remains the only curative treatment for these tumours, but, unfortunately, only 20% of those who have tumour excision will survive five years. In those patients unsuitable for surgery, chemotherapy with fluoropyrimidines produces the best tumour response. This may be administered systemically or regionally, via a catheter placed within the hepatic artery. The latter approach reduces systemic toxicity, but may produce hepatotoxicity. The results of other forms of systemic chemotherapy currently undergoing clinical trials are awaited. The vast majority of patients will benefit from suitable palliative treatment delivered either locally or systemically. With the wide range of treatments now available for liver metastases, these patients are best assessed in a unit with a special interest in the problem.
Narcolepsy-cataplexy and loss of sphincter control
Authors: Vgontzas A N , Sollenberger S E , Kales A , Bixler E O , Vela-Bueno A
Published: December 2008

We describe the case of a 34-year-old man who presented intermittent faecal incontinence as a manifestation of cataplexy. The patient’s sleep history was positive for the full narcoleptic tetrad (sleep attacks, cataplexy, sleep paralysis and hypnagogic hallucinations) while extensive neuropsychiatric work up was negative for any neurologic or psychiatric illness. Repeat polysomnograms (including a polysomnogram with a full seizure montage) were positive for pathologic sleepiness, but there was no evidence of a seizure disorder. The course of the patient’s symptomatology and the favourable response of his symptoms to stimulants and imipramine support the theory that his intermittent loss of sphincter control is part of his narcolepsy-cataplexy.
The management of diabetes in pregnancy
Authors: Hadden D R
Published: December 2008

The aim of the diabetes specialist is to provide a service to the pregnant diabetic woman so that she will present to her obstetrician with such well-controlled plasma glucose levels that her pregnancy will proceed without any diabetes-related problem, and she will be delivered of a normal baby, of normal size, at the normal full-term gestation, by the normal route. There are some problems in achieving this aim. The exact definition of hyperglycaemia in pregnancy is still a matter of dispute. Screening methods to identify the problem differ widely. Many centres have developed joint diabetes/antenatal clinics, but there are practical problems with such an approach. Pre-pregnancy counselling, and discussion of contraceptive measures is an important task for the diabetologist and requires up-to-date knowledge. Control of plasma glucose requires alteration of insulin doses as pregnancy proceeds. Mothers with retinal, renal or cardiac problems will need special care. The medical problems which develop, and the management of blood glucose during labour and delivery, mean that the diabetes team must be very adjacent to the obstetric service, and a centralised approach offers many advantages. The postpartum state, and the long-term outcome for both mother and baby, remain both an interest and a responsibility for the obstetric physician.
Non-invasive ventilation
Authors: Spence D
Published: December 2008

Nasal intermittent positive pressure ventilation is an effective treatment for nocturnal hypoventilation secondary to chest wall deformity or respiratory muscle weakness. Physicians should be aware that, in these groups of patients, disabling breathlessness can be alleviated and established cor pulmonale reversed by the technique.
Syncope: driving advice is frequently overlooked
Authors: MacMahon M , O’Neill D , Kenny R A
Published: December 2008

Consecutive referrals to a syncope clinic were asked about the frequency of enquiries about driving status by referring general practitioners and/or hospital specialists. Although 40% were drivers, only 13% of patients had been previously asked about driving, and 12% of drivers had experienced symptoms whilst driving. This represents an important oversight on the part of referring doctors.
Cutaneous and pharyngeal diphtheria imported from the Indian subcontinent
Authors: Hart P E , Lee P Y , Macallan D C , Wansbrough-Jones M H
Published: December 2008

We report the case of a 32-year-old woman who presented upon returning from India with cutaneous ulcers on the feet and pharyngitis. Microbiological testing showed the causative organism to be a toxigenic strain of Corynebacterium diphtheriae. She was treated successfully with penicillin and diphtheria antitoxin. This case emphasises the importance of maintaining a high index of suspicion for such rare but significant infectious diseases.
An unusual cutaneous manifestation of ulcerative colitis: thrombotic skin gangrene
Authors: Singh S , Noshirwani K
Published: December 2008

Ulcerative colitis has a number of associated skin lesions. We report the case of a patient with active ulcerative disease presenting with rapidly progressive necrotic skin lesions, identified as thrombotic and requiring skin grafting. Thrombotic cutaneous gangrene is a rare but potentially serious manifestation of uncontrolled ulcerative colitis.
The homeless
Authors: Abdul-Hamid W , Cooney C
Published: December 2008

The medical literature on homeless people tends to concentrate on their biographic characteristics or clinical problems without enough attention being given to the social and environmental contexts which they have to survive. This article summarises the literature on the role of social factors in the causation and outcome of health problems of the homeless and emphasises the importance of addressing the social context in effecting intervention. Services that deal with the social needs of the homeless will be more successful in meeting their needs and reducing their distress.
Mixed pulmonary infection with Nocardia, Candida, methicillin-resistant Staphylococcus aureus, and group D Streptococcus species
Authors: Vassallo J , Galizia A C , Cuschieri P
Published: December 2008

A 67-year-old man on prednisolone and azathioprine for ulcerative colitis, developed severe pneumonia due to Nocardia otitidis caviarum, methicillin-resistant Staphylococcus aureus, a group D Streptococcus and Candida albicans. The patient responded well to aggressive antimicrobial therapy.
Polyarteritis nodosa and drug abuse: is there a connection?
Authors: Samuels N , Shemesh O , Yinnon A M , Fisher D , Abraham A S
Published: December 2008

Drug abuse has been controversially linked to polyarteritis nodosa. A 28-year-old man with a history of drug abuse with inhaled heroin presented with an enigmatic illness consisting of refractory fever, bilateral pleural effusions, migratory polyarthritis, and a leukaemoid reaction. An abdominal angiography confirmed the diagnosis of polyarteritis nodosa, and treatment with both prednisone and cyclophosphamide resulted in significant clinical and laboratory improvement.