bluuebunny/crossref_metadata_2025 huggingface dataset:
Homozygous variegate porphyria: an evolving clinical syndrome
Authors: Hift R J , Meissner P N , Todd G , Kirby P , Bilsland D , Collins P , Ferguson J , Moore M R
Published: December 2008

Variegate porphyria is one of the most frequently encountered genetic conditions in South Africa. It is inherited as an autosomal dominant disease and in excess of 300 heterozygous cases have been studied by the Cape Town unit. Despite this, the homozygous condition has not previously been encountered in South Africa. We report two cases of homozygous variegate porphyria, one of whom represents the first South African case. We delineate a syndrome principally characterized by growth retardation, developmental delay, epileptic seizures, photosensitivity and an abnormal porphyrin excretion pattern. In addition we describe, in one case, two features not previously reported: skin disease in areas unexposed to light and a severe sensory neuropathy which may account at least in part for the hand deformities of this disorder.
Bancroftian filarial pleural effusion
Authors: Aggarwal Jyotima , Kapila Kusum , Gaur Abhishek , Wali Jyoti Prakash
Published: December 2008

This paper describes a case of filarial pleural effusion, the fifth such to be reported. Microfilariae of Wuchereria bancrofti were detected in the pleural fluid on cytological examination. There was a prompt and complete response to treatment with diethylcarbamazine. There were, however, no symptoms and signs of tropical pulmonary eosinophilia nor any peripheral eosinophilia.
Cerebral infarction in association with Ecstasy abuse
Authors: Manchanda S , Connolly M J
Published: December 2008

A previously fit 35 year old man presented with a right hemiparesis and dysphasia 36 hours after abuse of Ecstasy (3,4-methylenedioxymethamphetamine). Computerized axial tomography scan demonstrated an extensive acute left cerebral infarction and carotid digital subtraction angiogram, 2 days after admission, revealed left middle cerebral artery occlusion. There were no other known risk factors and all other investigations were negative. The patient made a partial recovery. We propose an association between Ecstasy abuse and cerebral infarction.
Candida lusitaniae causing fatal meningitis
Authors: Sarma P S A , Durairaj P , Padhye A A
Published: December 2008

Fatal meningitis due to Candida lusitaniae in a 35 year old previously healthy man is described. C. lusitaniae is an opportunistic fungal pathogen reported infrequently in the English literature. This is the third case report of meningitis and the first fatal infection in an adult from Central India due to C. lusitaniae known to the authors.
Carcinoma of the breast at the site of migrated pacemaker generators
Authors: Bhandarkar D S , Bewu A D M , Taylor T V
Published: December 2008

We report two patients in whom breast malignancy developed in the proximity of 'migrated' pacemaker generators. These cases and the similar ones reported in the literature raise concerns whether this association is merely coincidental or whether the pacemaker generator is responsible for the occurrence in some inexplicable manner. We urge for a routine, careful examination in all patients with implanted pacemaker generators at follow-up visits. This would help in (a) timely detection of migration of the pacemaker generators and (b) earlier diagnosis of any mass developing close to the migrated generators.
Sudden cardiac death and the potential role of beta-adrenoceptor-blocking drugs
Authors: Rajman Iris , Kendall Martin J
Published: December 2008

Sudden cardiac death is a major health problem in the industrially developed countries. The risk of sudden cardiac death may be reduced by early detection of coronary heart disease, elimination of the risk factors, treatment of the ischaemia in patients known to have coronary heart disease and suppression of ventricular arrhythmias. Of all the therapeutic measures currently available to reduce the risk of sudden cardiac death, beta-adrenoceptor-blocking drugs (beta blockers) appear to be the most effective. In this paper their actions are reviewed and evidence for their efficacy is presented.
Spontaneous coronary artery dissection: a report of three cases and review of the literature
Authors: Kearney Peter , Singh Harsh , Hutter John , Khan Saleem , Lee Gary , Lucey James
Published: December 2008

We describe the clinical course of three patients who developed spontaneous coronary artery dissection. All patients were young women, one 9 weeks pregnant. All presented with chest pain; one died suddenly proving refractory to resuscitation, another developed unstable angina culminating in myocardial infarction, cardiogenic shock and death, and the third patient underwent coronary artery bypass grafting following diagnosis of a spontaneous coronary dissection of the left anterior descending artery at angiography. Pathological findings in the two fatal cases are reported.

This condition, although rare, is a prominent cause of ischaemic coronary events in young women, when it is frequently associated with pregnancy or the puerperium. Most patients die suddenly, but a clinical spectrum is seen including stable and unstable angina, myocardial infarction and cardiogenic shock. The left anterior descending artery is most frequently affected. The classical histological finding is that of a large haematoma occupying the outer third of the media resulting in complete compression of the true lumen.

The cause of spontaneous dissection remains unclear but theories of aetiology include a medial eosinophilic angiitis, pregnancy-induced degeneration of collagen in conjunction with the stresses of parturition, and rupture of the vasal vasorum.

The diagnosis must be considered when a patient presents with a suggestive clinical profile. Urgent angiography should be undertaken to establish the diagnosis and consideration given to the need for coronary artery bypass grafting, which has been successfully employed in a number of patients. The uneventful long-term survival of cases treated conservatively has been reported.
A patient with coexisting narcolepsy and morbid jealousy showing favourable response to fluoxetine
Authors: Wing Yun-Kwok , Lee Sing , Chiu Helen F K , Ho Crover K W , Chen Char-Nie
Published: December 2008

A 37 year old Chinese man suffered from coexisting narcolepsy and morbid jealousy which were precipitated by head injury 5 years previously. Fluoxetine 20 mg/day reduced his narcoleptic symptoms and morbid jealousy but not his sleepiness. On defaulting treatment, the patient's symptoms and marital problem recurred. A common central serotonin disturbance might be involved in mediating the sleep disorder and associated psychopathology.
Orbital complications of sinusitis: avoid delays in diagnosis
Authors: Davis J P , Stearns M P
Published: December 2008

Orbital cellulitis and abscess formation are uncommon complications of sinusitis. Early diagnosis and treatment are important to prevent blindness and intracranial complications. We present four consecutive cases referred over 2 years which demonstrate how diagnostic delays may occur and suggest a protocol to avoid similar delays.
Atraumatic gluteal compartment syndrome
Authors: Hynes J E , Jackson A
Published: December 2008

A case of atraumatic gluteal compartment syndrome complicated by sciatic nerve palsy and acute rhabdomyolysis is presented. A presumed diagnosis of deep venous thrombosis led to a delay in diagnosis. Gluteal compartment syndrome should be considered in the differential diagnosis of the swollen leg.
Giardiasis of the stomach
Authors: Berney D M , Rampton D , van der Walt J D
Published: December 2008

A patient with giardiasis in an inflamed gastric antral biopsy specimen is reported. Helicobacter pylori were not identified and no other cause of the gastritis was apparent. This condition may be more common than has been previously supposed and may be linked to bile reflux or hypochlorhydria.
The association of thrombocytopaenia and Lyme disease
Authors: Ballard Harold S , Bottino Gino , Bottino Joseph
Published: December 2008

The association of asymptomatic thrombocytopaenia in six patients with acute Lyme disease is described. Recovery from thrombocytopaenia occurred shortly following antibiotic therapy. Patients residing in endemic areas for Lyme disease who present with flu-like symptoms and laboratory findings of thrombocytopaenia should prompt suspicion of acute Lyme disease. Appropriate clinical studies should be undertaken to confirm the diagnosis.
An acquired-pseudo Bernard Soulier syndrome occurring with autoimmune chronic active hepatitis and anti-cardiolipin antibody
Authors: Beales Ian L P
Published: December 2008

A case of autoimmune chronic active hepatitis with unusual extrahepatic manifestations is described. The patient exhibited marked thrombocytopenia and platelet aggregation dysfunction and morphological changes suggesting an acquired Bernard Soulier-type syndrome. This has not previously been described in association with chronic active hepatitis. The patient also demonstrated significant titres of anti-cardiolipin antibodies. This is also a new finding in association with both the liver and platelet diseases. The platelet aggregation deficit was transferable in the patient's serum rather than being intrinsic to the platelets. The three previously reported cases of acquired Bernard Soulier are reviewed and possible mechanisms for the platelet dysfunction are discussed.
Subcutaneous apomorphine infusion in Parkinson's disease: does it have a role?
Authors: Muhiddin Khulood A , Roche Mary T , Pearce Vaughan R
Published: December 2008

Apomorphine is a potent dopamine agonist at both D1 and D2 receptors and has been used successfully for treating the 'on/off' phenomenon in Parkinson's disease. We report our experience with apomorphine in treating the 'on/off' phenomenon in L-dopa responsive idiopathic Parkinson's disease. Thirteen such patients were commenced on apomorphine infusions. Their mean age was 69 (range 53-80) years and the mean duration of the disease was 15 (range 6-28) years. The clinical response to apomorphine was good in four patients, fair in two, unchanged in five and worse in two. Activities of daily living improved in six, were unchanged in five and worse in two. When the response was poor or showed no change, apomorphine was discontinued. In addition, apomorphine was also discontinued in three patients who had had a fair/good response but suffered side effects of hallucinations, delusions and psychosis, lack of cooperation or found the pump inconvenient. Apomorphine was continued in only three patients out of 13.
Impaired glucose tolerance and diabetes mellitus in a suburban Sri Lankan community
Authors: Fernando Devaka J S , Siribaddana Sisira , de Silva Deepthika
Published: December 2008

The prevalence of impaired glucose tolerance and diabetes mellitus was studied in a suburban Sri Lankan community using 1985 WHO criteria. Oral 75 g glucose tolerance tests were performed on 633 subjects aged 30-64 years. The age-standardized prevalence rates for diabetes mellitus were 5.02 (95% CI 3.59-6.43) and impaired glucose tolerance 5.27 (95% CI 3.74-6.78). A total of 21% of diabetic patients were not known to have diabetes and were diagnosed for the first time during the survey. Obesity was more common (P < 0.05) in diabetic patients (21%) when compared to non-diabetic subjects (10.5%). Diabetes mellitus is a common health problem in Sri Lanka, and there is a need for developing national policies for its prevention and control.
Anti-neutrophil cytoplasmic antibody-associated paraneoplastic vasculitis
Authors: Navarro J F , Quereda C , Rivera M , Navarro F J , Ortuño J
Published: December 2008

A 68 year old man presented with a systemic necrotizing vasculitis and elevated levels of anti-neutrophil cytoplasmic antibody (ANCA) which responded to treatment with steroids and cyclophosphamide, with a decrease in the titre of ANCA until its disappearance. Four months later he presented with weakness, loss of weight, aphonia and dysphagia. A computerized tomography scan showed a solid mass in the anterior mediastinum, and histological studies revealed an undifferentiated adenocarcinoma. Vasculitis improved although the malignancy progressed and ANCA was persistently negative. Our case demonstrates an association between ANCA and paraneoplastic vasculitis.
Clinical contact preceding suicide
Authors: Obafunwa J O , Busuttil A
Published: December 2008

Of the 400 consecutive completed suicides investigated over a 5-year period, 114 (28.5%) who had consulted a doctor in the week preceding death were specifically reviewed and compared with those who did not. The study comprised an analysis of the medical history, the scene of death and a complete autopsy with histological and toxicological examination and the identification of features which occurred more frequently in this group when compared with other suicides not contacting their doctors.

Suicide-associated factors include psychiatric illness (58.8%), deteriorating health (16.7%), and a loss of spouse (7.0%); all these features were manifested by this group of suicides more frequently than by those who made no clinical contact (P < 0.001). A pre-indication of suicidal intention was made by 45% of these patients. This feature, as with previous attempts, occurred more commonly in patients who consulted a doctor (P < 0.001).

Drug overdose was the most common suicidal method chosen (50.9%) and anti-depressants predominated (35%); 78% of those who overdosed ingested prescribed drugs. Poisoning was more common in this group (P < 0.001).

Half of the victims committed suicide within 24 hours following consultation; of these, 51% overdosed on drugs with 61% of them ingesting their prescribed drugs. Of these 114 cases, the final consultation in 43% was to collect more drugs. All suicidal threats should be taken seriously, and particular care should be taken in prescribing and dispensing medication which may be fatal in overdose.
Improvement in glucose tolerance and beta-cell function in a patient with vitamin D deficiency during treatment with vitamin D
Authors: Kumar S , Davies M , Zakaria Y , Mawer E B , Gordon C , Olukoga A O , Boulton A J M
Published: December 2008

Glucose metabolism was studied in a patient with vitamin D deficiency during its treatment with small doses of vitamin D. A continuous infusion of glucose test was performed to assess glucose tolerance and insulin sensitivity and beta-cell function were derived by mathematical modelling. Fasting glucose was 5.6 mmol/l and achieved glucose after the infusion was 10.4 mmol/l confirming diabetes.

The test was repeated 0.5, 1, 3 and 5 months after starting treatment. Serum calcium increased glucose intolerance from 1.76 to 2.0, 2.08, 1.96 and 2.0 mmol/l, respectively; vitamin D reached supraphysiological levels initially and returned to normal levels, and parathyroid hormone levels were normalized. Her weight did not change during treatment. Glucose tolerance improved during treatment and achieved glucose was 9.4, 8.6, 9.2 and 9.0 mmol/l at 0.5, 1, 3 and 5 months, respectively; insulin sensitivity did not change. Beta-cell function improved from 101% at diagnosis to 126%, 147%, 173% and 198% at 0.5, 1, 3 and 5 months, respectively.

Improvement in beta-cell function and consequently in glucose tolerance is likely to have been due to correction of hypocalcaemia, vitamin D deficiency and secondary hyperparathyroidism.
Malakoplakia of bone presenting as a pathological fracture
Authors: Tyagi Nirmala , Sherwani Rana , Sadiq S A , Maheshwari Veena , Abbas M , Tyagi S P
Published: December 2008

A male aged 54 years presented with a pathological fracture of the right femur at the subtrochanteric level. The fracture site showed a lytic lesion with expansion of the bone, considered to be a metastasis. On histology, however, the area turned out to be malakoplakia of bone. The patient responded well to antibiotics and sulphonamides along with skeletal traction. This appears to be the fourth reported case of malakoplakia of bone.
Association between serum uric acid and some cardiovascular risk factors in a Chinese population
Authors: Woo J , Swaminathan R , Cockram C , Lau E , Chan A
Published: December 2008

The association between serum uric acid concentration and some cardiovascular risk factors was examined in a working Hong Kong Chinese population (mean age 38 years), consisting of 910 men and 603 women. There was no significant age-related rise in serum uric acid concentration. Positive associations were found between serum uric acid concentration and body mass index, waist hip ratio, systolic and diastolic blood pressure, urea, creatinine, protein, glucose (fasting and 2 hours after 75 g oral glucose load), 2 hour insulin, triglycerides, and apolipoprotein B in men. Similar, but fewer, associations were seen in women, with the addition of a positive association with age. In both sexes, serum uric acid was negatively associated with high-density lipoprotein cholesterol. These findings complement the well-known clinical association between gout and cardiovascular and metabolic diseases, such as hypertension, hyperlipidaemia and diabetes mellitus, and suggest that serum uric acid may be a marker for the presence of an adverse cardiovascular risk factor profile.
Side effects with amiodarone therapy
Authors: Shukla R , Jowett N I , Thompson D R , Pohl J E F
Published: December 2008

Amiodarone hydrochloride is increasingly being used in the treatment of ventricular and supraventricular arrhythmias. Although a highly effective anti-arrhythmic agent, its use is restricted by the high incidence of side effects. To elucidate the value of monitoring serum level of both the parent drug and its active metabolite in predicting the occurrence of side effects, the investigators examined 109 patients from a register of patients treated with amiodarone for the prevalence of known side effects of the drug. The register contained over 90% of patients treated with amiodarone at the Leicester General Hospital during the period of the study.

The findings suggest cutaneous side effects and abnormal thyroid function tests (without overt gland dysfunction) are more likely to occur with increasing duration of treatment and cumulative dosage. However, neither the serum amiodarone level nor the serum metabolite level had any predictive power for the occurrence of side effects.

In view of this finding, it is recommended that close attention be paid to the continued clinical monitoring of side effects and that there is utility in measuring the serum amiodarone level in each patient to avoid the prescription of unnecessarily high doses. This is necessary not only to lessen the occurrence of cumulative dose-related side effects, but also because the variable but very long half-life of the drug leads to difficulties in relating spot drug levels to long-term effects.
Localized eosinophilic gastroenteritis with necrotizing granulomas presenting as acute abdomen
Authors: Fraile G , Rodríguez-García J L , Beni-Pérez R , Redondo C
Published: December 2008

Eosinophilic gastroenteritis is a condition of unknown aetiology that has been frequently reported involving the stomach and bowel. The colon is rarely cited as a site for the condition. We report a patient suffering from allergic symptoms (asthma, atopic dermatitis, elevated serum IgE levels) who presented with colonic perforation due to eosinophilic colitis with necrotizing granulomas.
Human pythiosis in Thailand
Authors: Imwidthaya P
Published: December 2008

Pythium insidiosum is a protoctista and causes diseases in plants and animals. In Thailand it can cause a unique human infection of three types.

The first type is a subcutaneous lesion in thalassaemic patients, with the pathological findings of a granulomatous reaction, diffuse infiltration, and oedema of the vessel walls. The patients responded to a saturated solution of potassium iodide. The second type is chronic inflammation and occlusion of blood vessels mainly in the lower extremities which results in gangrene or aneurysm formation. This type of infection is only found in thalassaemic patients and leads to amputation of the affected extremities or resection of the involved arteries. The third type is keratitis. This type of infection may or may not be associated with thalassaemia. The clinical signs and symptoms do not differentiate it from other types of myocotic keratitis. The patients end up with keratoplasty, evisceration or enucleation.

Thailand is an agricultural country, and there are plenty of swampy areas and several plants to support the life cycle of Pythium. Moreover, many people suffer from thalassaemia, and there is no drug available for Pythium. Pythiosis plays an important role in medicine in Thailand.
Severe dysphagia associated with major tranquillizer treatment
Authors: Hughes T A T , Shone G , Lindsay G , Wiles C M
Published: December 2008

A 56 year old patient with psychiatric complications of systemic lupus erythematosus developed severe dysphagia complicated by weight loss and aspiration. Following investigation it was concluded that the addition of haloperidol to her treatment was the major precipitating cause and withdrawal of the drug was followed by an objective improvement in swallowing. Patients taking major transquillizers may be at increased risk of severe dysphagia; regular observation of swallowing is suggested as a useful addition to the clinical examination of these patients.
The association of systemic lupus erythematosus and myasthenia gravis
Authors: Vaiopoulos G , Sfikakis P P , Kapsimali V , Boki K , Panayiotidis P , Aessopos A , Tsokos G C , Kaklamanis P
Published: December 2008

Two women with the rare association of systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are reported. The first patient developed SLE (arthritis, severe thymectomy for MG. The second patient developed SLE (oral ulcers, arthritis, serositis, leukopenia, high titres of anti-DNA and anti-nuclear antibodies) 4 years prior to the clinical and serological onset of MG. Lymphocyte subsets and in vitro proliferative responses of peripheral blood mononuclear cells to mitogens were normal in both patients. A review of the literature revealed 26 additional patients with definite SLE coexisting with MG. Besides the theoretical interest of this association, the differential diagnosis of fatigue in patients with SLE should always include the possibility of MG.
A virilized patient with congenital hemihypertrophy
Authors: Mark S , Clark O H , Kaplan R A
Published: December 2008

An 18 year old woman with congenital hemihypertrophy of her left side, presented with the rapid onset of virilism, hypertension and a cushingoid appearance. A computed tomographic examination revealed adrenal and hepatic masses. Adrenocortical carcinoma was confirmed by surgical pathology. Hemihypertrophy is linked to a variety of benign and malignant disorders that usually appear during childhood. These disorders include adrenocortical carcinoma and hepatoblastoma. We bring this case to clinical attention to increase awareness that adult patients with congenital hemihypertrophy are still at a significant risk of developing neoplasms.
Bilateral foot drop, weight loss and rectal bleeding as an acute presentation of Crohn's disease
Authors: Gariballa S E , Gunasekera N P
Published: December 2008

We report a 71 year old lady who presented with weight loss, rectal bleeding and bilateral foot drop having been previously fit and well. Clinical examination, laboratory investigation and postmortem examination confirmed the diagnosis of active Crohn's disease and acute peripheral neuropathy. The clinical course of this patient suggests that the peripheral neuropathy might have resulted from the common pathogenesis for Crohn's disease.
Haemodynamic and oxygen transport response during exchange transfusion for severe falciparum malaria
Authors: Beards S C , Joynt G M , Lipman J
Published: December 2008

We describe the haemodynamic and oxygen transport response in a patient undergoing exchange transfusion for severe falciparum malaria. We found that exchange transfusion produced a significant increase in left ventricular stroke work index, systemic oxygen delivery and oxygen consumption. This potentially beneficial effect of exchange transfusion has not been reported previously.
Possible role of Helicobacter pylori serology in reducing endoscopy workload
Authors: Tham T C K , McLaughlin N , Hughes D F , Ferguson M , Crosbie J J , Madden M , Namnyak S , O'Connor F A
Published: December 2008

We validated a commercial enzyme-linked immunosorbent assay (ELISA), Helico-G, in diagnosing H. pylori in 129 patients (mean age 50 years, range 15-86). We analysed the results of endoscopy against serology to see whether there was a possibility of adopting the strategy of not endoscoping dyspeptic subjects under the age of 45. H. pylori infection was considered present if either histology and/or culture were positive. The ELISA had a sensitivity of 88%, specificity of 72%, positive predictive value of 85%, negative predictive value of 77% and accuracy of 82% in detecting H. pylori. In a subgroup of 52 subjects aged 45 or less (mean age 35 years, range 15-45), 17 out of 25 patients with positive endoscopic findings were H. pylori seropositive while 16 out of 27 patients had normal endoscopic findings. Eighteen out of the 52 patients (35%) were H. pylori seronegative and normal endoscopically except for five patients (10%) who had mild to moderate oesophagitis and two who had non-erosive gastritis (4%). All patients with duodenal ulcer disease (7) were seropositive giving predictive values of positive and negative serology for a diagnosis of duodenal ulcer disease as 28% and 100%, respectively.

Therefore adopting a strategy of endoscoping subjects under the age of 45 only if they were H. pylori seropositive would have saved 35% of endoscopies in this age group but missed oesophagitis in 10%. Negative serology would tend to exclude duodenal ulcer disease while positive serology discriminates poorly for it. Serology may be a useful adjunct in screening to reduce endoscopy workload provided that patients with gastro-oesophageal reflux symptoms are excluded.
Living wills: would sick people change their minds?
Authors: Potter J M , Stewart D , Duncan G
Published: December 2008

Patients admitted acutely to a geriatric medical unit were interviewed on admission about their opinions on cardiopulmonary resuscitation (CPR). They underwent a general examination and their mental health was documented by completing the geriatric depression scale. Those who did not wish CPR in the event of a cardiac arrest were questioned again on recovery.

Of 216 patients admitted, only three objected to answering the questions and after the other exclusion criteria were applied, 100 patients were included in the study. A total of 92% of patients wished CPR in the event of a cardiac arrest. The 8% who did not wish CPR contained more people scoring high on the geriatric depression scale. After recovery, three of that eight had changed their minds and wished CPR if required.

Patients who are acutely unwell may make decisions that are influenced by their condition at this point in time and it is important to recognize that these decisions may not be maintained. In this study, consultant geriatricians did not reflect their patients' desires in making decisions about who should receive CPR if required.
Corticosteroids: do they damage the cardiovascular system?
Authors: Maxwell Simon R J , Moots Robert J , Kendall Martin J
Published: December 2008

Since their introduction for the treatment of rheumatoid arthritis, corticosteroids have become widely used as effective agents in the control of inflammatory diseases. Although there have been undoubted benefits upon mortality in diseases such as systemic lupus erythematosus, many patients survive only to suffer a high incidence of premature atherosclerosis. There is also evidence of increased rates of vascular mortality in other corticosteroid-treated diseases, such as rheumatoid arthritis, reversible airways obstruction and transplant recipients. Possible mechanisms of damage include elevated blood pressure, impaired glucose tolerance, dyslipidaemia, and imbalances in thrombosis and fibrinolysis. This paper reviews the clinical evidence supporting the contention that there is an excess cardiovascular mortality in steroid-treated patients and the underlying mechanisms, and points to further areas of research.
Effect on central obesity and associated disturbances of low-energy, fruit- and vegetable-enriched prudent diet in north Indians
Authors: Singh Ram B , Niaz Mohammed A , Ghosh Saraswati
Published: December 2008

The effects of fruit and vegetables in conjunction with low-energy diet as adjuncts to a prudent diet were compared for 6 months in a randomized, single blind trial in the management of 202 group A and 204 group B patients with acute myocardial infarction. Dietary intakes were obtained based on weighing of fruit, vegetable and legume intake and weekly diet diaries. After 6 months of follow-up, mean body weight, waist/hip ratio and glucose intolerance fell significantly in patients in group A compared with those in group B. Body weight declined by 5.3 kg in group A versus 2.2 kg in group B (95% confidence interval of difference (CI) 1.28-4.92), waist/hip ratio decreased by 0.05 in group A and 0.02 in group B (95% CI 0.01-0.10), and glucose intolerance decreased by 0.85 mmol/l in group A versus 0.19 mmol/l in group B (95% CI 0.19-1.21). There was a significant net decrease in serum triglycerides (0.18 mmol/l), systolic and diastolic blood pressures (7.9/4.7 mmHg), and a net increase in high-density lipoprotein cholesterol (0.10 mmol/l). Underlying these changes, group A patients had 393 g/day net increase in the consumption of fruit and vegetables and 1,160 kJ/day net decrease in energy intake compared to these changes in groups. Those who made greater changes in diet also had greater improvements in central obesity, glucose intolerance and in other associated disturbances.
Arterial thrombosis in the nephrotic syndrome
Authors: Fahal Ibrahim H , McClelland Peter , Hay Charles C R , Bell Gordon M
Published: December 2008

Thrombosis is a frequent cause of morbidity and mortality in patients with the nephrotic syndrome. Venous thrombotic complications are well recognized but arterial complications are rare. Thrombosis is multifactorial, and has been attributed to a hypercoaguable state due to alterations in blood levels of the various factors involved in the coagulation and fibrinolytic systems, alterations in platelet function, venous stasis, haemoconcentration, increased blood viscosity and possibly the administration of steroids. Thrombosis in general and arterial thrombosis in particular is a significant and potentially serious problem in nephrotic patients. Awareness of the condition and its pathogenesis is needed. Assessment for the risk factors is required to allow appropriate prophylactic measures to be taken.
Hypoparathyroidism with extensive intracranial calcification: a case report
Authors: Goel A , Bhatnagar M K , Vashishta A , Verma N P S
Published: December 2008

We present a case of hypoparathyroidism, demonstrating extensive intracranial calcification, not only in basal ganglia, but also outside the extrapyramidal system. The patient presented with an unexplained epileptifors disorder, accompanied by extrapyramidal dysfunction in the form of choreoathetosis and hemiballismus. Hemiballismus is reported for the first time to our knowledge in association with hypoparathyroidism.
High-dose intravenous gammaglobulin therapy for acquired von Willebrand disease
Authors: Van Genderen Perry J J , Papatsonis Dimitri N M , Michiels Jan J , Wielenga Jenne J , Stibbe Jeanne , Huikeshoven Frans J M
Published: December 2008

Patients with acquired von Willebrand disease may present with severe bleeding, which is usually difficult to manage. Adequate haemostasis in acquired von Willebrand disease may be achieved with the infusion of factor VIII/von Willebrand factor concentrates or with the administration of desmopressin. We report a case of acquired von Willebrand disease with severe postoperative bleeding, responding poorly to classical von Willebrand factor replacement therapy but successfully treated with high-dose intravenous gammaglobulins. This new treatment mode of acquired von Willebrand disease is discussed in the light of a critical analysis of the literature.
The painless soft tissue mass in childhood--tumour or not?
Authors: Boothroyd A E , Carty H
Published: December 2008

Soft tissue malignancies are uncommon in adults and even rarer in children. Twelve children presented to the radiology department over a three-year period with a clinical diagnosis of a malignant lower limb mass. This diagnosis was usually based on the presence of a firm, painless mass. However, imaging revealed a heterogeneous group of benign pathologies: haemangioma (two cases), haematoma (two cases), aneurysm (two cases), and one case each of infection, myositis ossificans, Baker’s cyst, lipoma, muscle rupture, and venous malformation. During the same period there was only one malignant soft tissue neoplasm. A variety of imaging techniques were used but ultrasound combined with colour flow Doppler was the single most helpful modality. The radiological diagnosis were confirmed by biopsy, surgery or clinical follow-up.
Pancreatic ketoacidosis: ketonemia associated with acute pancreatitis
Authors: Kabadi U M
Published: December 2008

Ketonaemia is well documented as a consequence of prolonged starvation, acute alcoholism, and uncontrolled diabetes mellitus. However, its occurrence in acute pancreatitis has not been described. In this report, three patients who manifested ketoacidosis at the time of presentation of acute pancreatitis are described. In none of these patients could ketoacidosis be attributed to any of the well known pathogenetic factors such as ethanol, diabetes mellitus or prolonged starvation. In one patient, both the serum ketone titres and increased anion gap persisted for several days during the recovery period, despite appropriate therapy (including restriction of oral intake or nasogastric suction, intravenous fluids, and analgesic administration), before declining in parallel with a decrease in serum lipase levels, and became undetectable following near normalisation of serum lipase. Therefore, we believe that pancreatic ketosis or ketoacidosis may be a distinct syndrome with ketogenesis being promoted and maintained by extremely high circulating pancreatic lipase concentrations.
Cerebral achromatopsia as a presentation of Trousseau’s syndrome
Authors: Orrell R W , James-Galton M , Stevens J M , Rossor M N
Published: December 2008

A 67-year-old man developed a sudden onset of achromatopsia. Magnetic resonance imaging showed occipital lobe infarction. Repeated episodes of neurological deficit referable to the posterior circulation initially suggested an embolic source, but subsequently proved to be due to a coagulopathy related to a carcinoma of the bladder. This has implications for the management of patients presenting with achromatopsia, and progressive or recurrent neurological episodes, and in particular the use of anticoagulation in this situation.
Anomalous splenic artery aneurysm: demonstration on CT scanning and angiography
Authors: Sidhu P S , Khaw K T , Belli A M
Published: December 2008

An asymptomatic 35-year-old female was found to have a congenital aneurysm of an anomalous splenic artery arising from the superior mesenteric artery on routine investigation for infertility. Demonstration on CT and angiography is presented and the pathogenesis, natural history, management, and implications during pregnancy are discussed.
Acute myelomonocytic leukaemia complicated by an acute aortic thrombosis
Authors: Leong K W , Bosco J J , Shaik I B
Published: December 2008

Acute aortic thrombosis is a rare condition, occurring mainly as a result of trauma or atherosclerosis and occasionally secondary to hypercoagulable states. We report a patient with relapsed acute myeloid leukaemia who developed an unusual complication, acute aortic thrombosis.
Are blood tests of value in the primary assessment and resuscitation of patients in the A&E department?
Authors: Pennycook A
Published: December 2008

Over a three month period an audit of the use of emergency blood tests was carried out in the accident and emergency (A&E) department at Southampton General Hospital. Few blood tests were found to be useful in the primary assessment and treatment of patients by the attending doctors. Only cross-matching of blood, an amylase level and an arterial blood gases were felt to be consistently of clinical benefit in the acute management of the patient. The reasons for inappropriate investigations and possible solutions are discussed. Significant cost savings can be made, allowing for better targeting of resources.
Descending necrotising mediastinitis
Authors: Alsoub H , Chacko K C
Published: December 2008

Descending necrotising mediastinitis is a rare but serious complication of oropharyngeal infections with high mortality. Diagnosis is frequently delayed, contributing to this high mortality, but awareness of such a complication and early diagnosis using computed tomographic scanning leads to prompt surgical drainage, proper antibiotic therapy, and survival.
Prostate disease: management options for the primary healthcare team. Report of a working party of the British Prostate Group
Authors: Chisholm G D , Carne S J , Fitzpatrick J M , George N J , Gingell J C , Keen J W , Kirby R S , Kirk D , O’Donoghue E P N , Peeling W B , Shearer R J , Williams G B
Published: December 2008

The prostate gland has attracted a remarkable increase in interest in the past few years. The two most common diseases of this gland, benign prostatic hyperplasia and carcinoma of the prostate, have been brought into greater prominence by new diagnostic methods, public interest, and a wider choice of surgical and non-surgical treatments. Uncertainty about the significance of these changes has occurred because of the rapidity of change, the profusion of statements, opinions and promotions, and the relatively little guidance available from the profession. Ten urologists and two general practitioners have reviewed the relevant evidence about these two prostate diseases and the newer diagnostic methods; their conclusions are summarised here. Management options and guidance on clinical practice are also discussed. Because of a number of unresolved diagnostic and management issues, detailed requirements for practice guidelines have not been specified.
Bacteraemia with Cedecea neteri in a patient with systemic lupus erythematosus
Authors: Aguilera A , Pascual J , Loza E , Lopez J , Garcia G , Liaño F , Quereda C , Ortuño J
Published: December 2008

We describe a case of Cedecea neteri bacteraemia in a patient with systemic lupus erythematosus during an acute severe exacerbation of the disease, which led to her death.
Fractional excretion of potassium in normal subjects and in patients with hypokalaemia
Authors: Elisaf M , Siamopoulos K C
Published: December 2008

The aim of our study was the determination of fractional excretion of potassium (FEK+) in both normal subjects and hypokalaemic patients. Three hundred and twelve normal subjects aged 21-69 years and 84 hypokalaemic patients aged 36-72 years were studied. The mean FEK+ in normal subjects was 8% (range 4-16%). FEK+ was positively correlated with serum potassium (r = 0.74, p < 0.0001) and inversely with serum creatinine (r = -0.51, p < 0.001). The mean FEK+ in patients with hypokalaemia of external origin was 2.8% (range 1.5-6.4%). On the contrary, the mean FEK+ in hypokalaemic patients in whom renal potassium loss was the main aetiologic factor for the pathogenesis of hypokalaemia was 15% (range 9.5-24%).
High dependency units in the UK: variable size, variable character, few in number
Authors: Thompson F J , Singer M
Published: December 2008

An exploratory descriptive survey was conducted to determine the size and character of high dependency units (HDUs) in the UK. A telephone survey and subsequent postal questionnaire was sent to the 39 general HDUs in the UK determined by a recent survey from the Royal College of Anaesthetists; replies were received from 28. Most HDUs (82%, n = 23) were geographically distinct from the intensive care unit and varied in size from three to 13 beds, although only 64% (n = 18) reported that all beds were currently open. Nurse: patient ratios were at least 1:3. Fifty per cent of units had one or more designated consultants in charge, although only 11% (n = 3) had specifically designated consultant sessions. Junior medical cover was provided mainly by the on-call speciality term. Twenty units acted as a step-down facility for discharged intensive care unit patients and 21 offered a step-up facility for patients from general wards. Provision of facilities and levels of monitoring varied between these units. Few HDUs exist in the UK and they are variable in size and in the facilities and monitoring procedures which they provide. Future studies are urgently required to determine cost-effectiveness and outcome benefit of this intermediate care facility.
Secretory symptoms from metastatic adrenal cortical carcinoma responding to octreotide
Authors: Pandha H S , Harrington K , Saini S , Lynn J , Peters M , Waxman J
Published: December 2008

The prognosis of patients with metastatic adrenal cortical carcinoma is poor, and their disabling symptoms are usually unresponsive to conventional therapy. A patient with Cushing’s syndrome secondary to a secretory adrenal cortical carcinoma was treated with octreotide, endocrine therapy and chemotherapy having failed. Treatment led to a dramatic relief of her symptoms with a fall in corticosteroid secretion. Somatostatin analogue therapy for this tumour should be encouraged in view of the lack of alternative palliative treatment.
Methotrexate-induced pericarditis and pericardial effusion; first reported case
Authors: Forbat L N , Hancock B W , Gershlick A H
Published: December 2008

We report a case of methotrexate-induced pericarditis and pericardial effusion in a 22-year-old pregnant woman. These complications have not previously been described as isolated phenomena associated with methotrexate therapy.
Neurosarcoidosis masquerading as glioma of the optic chiasm in a child
Authors: Ng K L , McDermott N , Romanowski C A J , Jackson A
Published: December 2008

We present a case of sarcoidosis in a 14-year-old girl who presented with a short history of visual disturbance. Computed tomography and magnetic resonance imaging (MRI) demonstrated enlargement of the optic chiasm and prechiasmic optic nerves. Post-contrast MRI showed marginal enhancement of the affected areas of the optic pathways. A diagnosis of optic nerve glioma and arachnoid gliomatosis was made; surgical confirmation was not sought due to the risk to vision associated with biopsy. A rapid clinical deterioration led to repeat MRI which demonstrated extensive enhancing soft tissue throughout the basal cisterns with extension into the brain. Biopsy confirmed a diagnosis of sarcoidosis.
Asking relatives for permission for a post mortem examination
Authors: Sherwood S J , Start R D
Published: December 2008

This article discusses the possible aims, benefits, and also the content, format and timing of training in one specific aspect of clinical practice; how to request permission for post mortems.
The US residency programme--lessons for pre-registration house officer education in the UK?
Authors: Salter R
Published: December 2008

The 1994 NACT Wyeth-Ayerst Travelling Fellowship provided the opportunity to compare the education and welfare of pre-registration house officers in the UK with their nearest counterpart in the US residency system. Investment in all aspects of learning was impressive, as was the retention of the central role of the patient in education. Adequate clinical exposure must take into account both the changing pattern of care delivery and the need to limit junior doctors’ hours of work. Service containment is difficult to achieve. The self-educating potential of junior medical staff should be maximised and a post analogous to ‘Chief Resident’ in the US could be considered. Explicit educational aims and objectives must be stated so that meaningful assessment can be carried out and feedback provided. Adequate support systems are essential and an earlier start to the working day is encouraged.
Mixed meningitis: association of Acinetobacter calcoaceticus var lwoffi and Streptococcus faecium
Authors: Sarma P S A , Mohanty S
Published: December 2008

We describe mixed bacterial meningitis in a young man due to Acinetobacter calcoaceticus var lwoffi and Streptococcus faecium. The combination of A calcoaceticus var lwoffi and S faecium as aetiology of mixed bacterial meningitis has not been previously reported. The patient recovered completely without neurologic sequelae on chloramphenicol and penicillin.
Colonic stricture in a boy with cystic fibrosis
Authors: Ong P S , Oades P J , Bush A , Brereton R J
Published: December 2008

Many problems may arise within the gastrointestinal tract of patients with cystic fibrosis. We report a new cause of subacute intestinal obstruction due to a fibrotic stricture of the ascending colon in a child with cystic fibrosis. Treatment was with a right hemicolectomy. There has been no recurrence after nine months follow-up. Recent similar cases suggest that this new pathology is linked to the use of enteric-coated high-strength pancreatin microspheres.
Gallstone ileus: a new role for abdominal computed tomography
Authors: Seal E C J , Creagh M F , Finch P J
Published: December 2008

This case report illustrates the difficulties in making the clinical diagnosis of gallstone ileus. In addition to an unusual clinical picture, the changes normally expected on abdominal X-ray in gallstone ileus were subtle and missed in our patient. The diagnosis was made using abdominal computerised tomography (CT). We recommend the early use of abdominal CT scanning in the investigation of clinical bowel obstruction, especially in the elderly, where gallstone ileus is a more common condition.
Problem-based learning in medicine: an introduction
Authors: Bligh J
Published: December 2008

Problem-based learning is an innovative and challenging approach to medical education--innovative because it is a new way of using clinical material to help students learn, and challenging because it requires the medical teacher to use facilitating and supporting skills rather than didactic, directive ones. For the student, problem-based learning emphasises the application of knowledge and skills to the solution of problems rather than the recall of facts. It is an approach much favoured by curriculum planners in new and more progressive medical schools. This paper describes the educational basis of problem-based learning and gives an example of how it operates in undergraduate medical education.
Congestive cardiomyopathy and endobronchial granulomas as manifestations of Churg-Strauss syndrome
Authors: Alvarez-Sala R , Prados C , Armada E , Del Arco A , Villamor J
Published: December 2008

Churg-Strauss syndrome is a systemic vasculitis. Its most frequent complications are heart diseases and asthma. Usually, cardiological manifestations are pericarditis, cardiac failure and myocardial infarction. Endobronchial granulomas identified by bronchoscopy are unusual. We present the case of a man with congestive cardiomyopathy and endobronchial granulomas macroscopically visible at bronchoscopy. After a review of medical literature, we found one case of congestive cardiomyopathy and no cases of endobronchial granulomas observed by bronchoscopy associated with Churg-Strauss syndrome.
Abdominal pain: do not forget Thorotrast!
Authors: Weber E , Laarbaui F , Michel L , Donckier J
Published: December 2008

The use of Thorotrast (25% thorium dioxide), a radiologic contrast agent used up until the mid-1950s, was associated with a wide range of malignancies, mainly of hepatic origin. We report a case of Thorotrast-induced hepatocarcinoma in an 82-year-old woman.