bluuebunny/crossref_metadata_2025 huggingface dataset:
Gangrene of the anterior abdominal wall after orthotopic liver transplantation: invasive cutaneous candidiasis
Authors: Rela M , Heaton N D , Vougas V , Rolando N , Wade J , Portmann B , Williams Roger , Tan K C
Published: December 2008

Fungal infections following liver transplantation are not uncommon and may be life-threatening. Superficial candidal infections of the bronchus, oesophagus and urinary tract are the most common mode of presentation. Invasive cutaneous and subcutaneous candidiasis is, however, very rare. We report two patients with invasive cutaneous and subcutaneous candidiasis after orthotopic liver transplantation.
Psychosocial aspects of chronic pelvic pain, with special reference to sexual abuse. A study of 164 women
Authors: Fry R P W , Crisp A H , Beard R W , McGuigan S
Published: December 2008

Patients with chronic pelvic pain attending a tertiary referral centre show certain social, developmental and psychological characteristics. Specifically, they appear to have fewer children and to report more paternal overprotection, and a trend towards low maternal care compared to normals. They also show more depression, free-floating anxiety and somatic anxiety than such populations. The levels are similar to those found in other outpatient populations presenting with migraine or irritable bowel syndrome. Hostility levels are greater than those in normal subjects. Overall the present patient population reports the same degree of childhood sexual abuse as do many other female clinic and community sample populations. Sexual abuse is unlikely to be a specific aetiological factor in the development of chronic pelvic pain though it may yet be found to be important in subsets of the population.
Hypomagnesaemia and hypocalcaemia in a patient with ovarian carcinoma
Authors: Leese G P , Jung R T , Browning M C K
Published: December 2008

A patient with disseminated ovarian carcinoma presented with symptoms of hypocalcaemia secondary to hypomagnesaemia. The low serum magnesium (0.4 mmol/l) appeared to be due to renal leakage with no evidence of ureteric obstruction or hydronephrosis on intravenous urogram. Parathyroid hormone activity (serum levels and cAMP response) was normal, despite hypomagnesaemia. The patient's complaints resolved after magnesium and calcium supplementation. Hypomagnesaemia of malignancy is a rare but important complication, and is both poorly recognized and understood.
Right-sided endocarditis in the non-drug addict
Authors: Naidoo D P
Published: December 2008

Fifteen patients with right-sided infective endocarditis during a 5 year period (1985-1990) were retrospectively reviewed. Isolated tricuspid valve involvement occurred in nine patients.

Staphylococcus aureus was the causative organism in seven cases; four were culture negative. The diagnosis was established by two-dimensional echocardiography in 11 patients and at postmortem in the remaining four patients who succumbed shortly after admission. Fever, tachypnoea and pneumonia were universal features. A successful outcome ensued in eight patients with medical therapy alone and in two patients who were submitted to valve replacement. Five patients died, two from uncontrolled infection with repeated pulmonary emboli.

Right-sided infective endocarditis should be suspected in any pneumonic illness that complicates post-abortal infection or other inadequately treated sepsis. Two-dimensional echocardiography is important in diagnosis since cardiac signs are minimal at presentation.
Atypical presentations of pulmonary tuberculosis diagnosed by fibreoptic bronchoscopy
Authors: Jayasundera C I W , Attapattu Maya , Kumarasinghe M P
Published: December 2008

A total of 356 patients were subjected to fibreoptic bronchoscopy from September 1989 to June 1991 to exclude bronchial carcinoma. Bronchial biopsy, bronchial brush smears and bronchial wash were obtained. Bronchial wash was examined for acid fast bacilli (AFB) compatible with Mycobacterium tuberculosis. The total number diagnosed as pulmonary tuberculosis by fibreoptic bronchoscopy was 21(5.8%). The sputum smears were negative for AFB in all these patients. Previous studies have shown the importance of fibreoptic bronchoscopy in suspected cases of tuberculosis where the sputum smear is negative. This study is further evidence of the importance of routine examination of bronchial wash for AFB in all cases undergoing fibreoptic bronchoscopy to detect atypical cases of pulmonary tuberculosis.
Lymphocytic meningitis as the sole manifestation of Q fever
Authors: Schattner A , Kushnir M , Zhornicky T , Fenakel G
Published: December 2008

A young man who presented with a 3 week history of fever and severe headache accompanied by mild leukocytosis, was found to have lymphocytic meningitis due to Coxiella burnetti. Thus, Q fever can present as lymphocytic (aseptic) meningitis responsive to tetracycline with no evidence of pulmonary involvement.
Hairy leukaemic cell influx into the cerebrospinal fluid secondary to encephalomyelitis
Authors: Wierzbicki A S , Luxton R , McLean B N , Gilois C , Norman P M , Thompson E J
Published: December 2008

A case report of a 53 year old male with hairy cell leukaemia is presented in whom encephalomyelitis caused by toxoplasmosis resulted in an influx of hairy cells into the cerebrospinal fluid following disruption of the blood-brain barrier. These cells subsequently disappeared as the barrier reformed. It is suggested that the presence of hairy cells in the cerebrospinal fluid is a secondary self-limiting phenomenon.
Gastric phytobezoar: unusual association and resolution
Authors: Wyatt J P , Haddock G , Aitken R J
Published: December 2008

A 58 year old man underwent a laparotomy for intestinal obstruction, which proved to be due to intestinal pseudo-obstruction. Following a slow postoperative course, he was discovered to have a gastric phytobezoar. The association between bezoars and pseudo-obstruction has not been previously described, but might be expected. The gastric phytobezoar could not be fragmented mechanically, but it completely disappeared when enteral feeding was commenced. The possibility of a future role of enteral feeding in this situation is suggested.
Rigors in tuberculosis
Authors: Harvey Christopher , Eykyn Susannah , Davidson Craig
Published: December 2008

Rigors are not a recognized characteristic of miliary tuberculosis. We report two patients presenting with persistent rigors, thought to be suggestive of acute pyogenic infection, who were subsequently found to have miliary tuberculosis. In both cases, there was significant diagnostic delay. Miliary tuberculosis should therefore be included in the differential diagnosis of any patient presenting with unexplained rigors.
Spontaneous biloma in an elderly patient
Authors: Mason J C , Babbs C , Lee S H , Connolly M J
Published: December 2008

A previously well 84 year old man without prior history of abdominal trauma, instrumentation or surgery presented with localized biliary peritonitis (biloma). An associated bile duct stone was detected by abdominal ultrasound and endoscopic retrograde cholangiopancreatography and was successfully treated with systemic antibiotics and percutaneous and endoscopic stenting. The case is unusual in that the presentation was spontaneous.
The development of spontaneous colo-umbilical fistula
Authors: Pracyk John B , Pollard Stephen G , Calne Roy Y
Published: December 2008

A patient with colo-umbilical fistula is reported. This presentation is unique because it documents the development of a fistula from a colonic diverticulum. Sigmoid colectomy was undertaken successfully.
A study of plasma sodium levels in elderly people taking amiloride or triamterene in combination with hydrochlorothiazide
Authors: Fidler H M , Goldman J , Bielawska C A , Rai G S , Hoffbrand B I
Published: December 2008

This study was performed to compare the effect of one month's treatment with hydrochlorothiazide (25 mg) in combination with either amiloride (2.5 mg) or triamterene (50 mg) on plasma sodium levels in elderly people in institutional care. Fifty residents of NHS nursing or social service residential care established on diuretics for congestive cardiac failure and aged 64 years or over were recruited. Forty-one patients were included in the final data analysis. Patients on hydrochlorothiazide/amiloride had a significantly lower plasma sodium (137 vs 139 mmol/l, 95% confidence interval for difference between medians 0-2 mmol/l) than those on hydrochlorthiazide/triamterene (P = 0.01). In equivalent potassium-retaining doses, amiloride is associated with significantly lower plasma sodium levels than triamterene, when given in combination with hydrochlorothiazide in elderly patients with congestive cardiac failure. This finding adds weight to uncontrolled observations implicating thiazide/amiloride diuretic combinations in causing serious hyponatraemia. This danger, although uncommon, should perhaps influence prescribing habits in an at-risk population.
Recurrent infective endocarditis
Authors: Lossos Izidore S , Oren Ran
Published: December 2008

Infective endocarditis is a serious disease associated with high mortality. Patients surviving recurrent bouts of infective endocarditis are reported infrequently. We report on a non-drug abuser patient who experienced seven episodes of infective endocarditis--the largest number reported to our knowledge in a single non-drug abuser patient.
Intestinal prolapse through the vagina
Authors: Patankar R V , Scott S D , McGinn F P
Published: December 2008

We describe the case of a 68-year-old woman who presented with an acute onset spontaneous vaginal vault rupture and intestinal prolapse through the vagina. Results of a literature survey are presented and the causes of vaginal vault rupture are discussed.
Type IV renal tubular acidosis associated with Alport's syndrome
Authors: Tkácová Ruzena , Roland R , Böör A , Kovácová Anna , Lazúrová Ivica , Tkác I , Hildebrand T , Sefara P
Published: December 2008

A case of hereditary nephritis with mild reduction of renal function associated with renal tubular acidosis type IV is described. The patient was admitted with life-threatening hyperkalaemia. To our knowledge, type IV renal tubular acidosis has not been reported previously in association with Alport's syndrome in an adult patient.
Prognostic factors in Wegener's granulomatosis
Authors: Briedigkeit L , Kettritz R , Göbel U , Natusch R
Published: December 2008

We analysed data from 64 patients with Wegener's granulomatosis to determine predictor variables of outcome. The mean period of observation after the diagnosis had been established was 3.2 (range 0.1-11.2) years. At the time of diagnosis, 15 (23%) patients had only local symptoms. The disease was generalized to multiple organs in 49 (77%) patients. Renal biopsies were obtained in 33 patients; 13 (39%) had extracapillary glomerulonephritis, which was the most common renal lesion. All but three patients received immunosuppressive therapy. At time of follow-up, 17 (27%) patients were in complete, and 26 (40%) in partial remission. We employed a Kaplan Meier analysis to identify predictor variables of outcome. Renal involvement, initial creatinine concentration, serum albumin or total protein concentration, leukocyte count and erythrocyturia proved to be predictor variables. These variables may be of value in guiding the intensity of treatment in patients with Wegener's granulomatosis.
A pharmacokinetic interaction between cimetidine or ranitidine and lornoxicam
Authors: Ravic M , Salas-Herrera I , Johnston A , Turner P , Foley K , Rosenow D E
Published: December 2008

Cimetidine 400 mg twice daily significantly increased serum concentrations and reduced apparent oral clearance of lornoxicam 8 mg twice daily in 12 healthy volunteers. Ranitidine 150 mg twice daily produced no significant changes in lornoxicam pharmacokinetics.
Type IV renal tubular acidosis and spironolactone therapy in the elderly
Authors: O'Connell J E , Colledge N R
Published: December 2008

Spironolactone therapy is a well-known cause of hyperkalaemia, but in susceptible patient, it may also be associated with metabolic acidosis. We report a case of severe renal tubular acidosis (Type IV) with life-threatening hyperkalaemia caused by spironolactone, and discuss the mechanisms by which this may occur.
Public osteomyelitis caused by Staphylococcus simulans
Authors: Sturgess I , Martin F C , Eykyn S
Published: December 2008

A patient is described who developed pubic osteomyelitis caused by an uncommon pathogen, Staphylococcus simulans.
Successful use of a transjugular intrahepatic portosystemic stent shunt to control severe refractory oesophageal variceal haemorrhage in a poor risk patient
Authors: Beales I L P , Jackson J E , Rudolf M , Arnold J
Published: December 2008

This report describes a 44 year old man with a severe gastrointestinal haemorrhage from oesophageal varices. Bleeding could not be controlled with conservative therapy and sclerotherapy. He was successfully treated with a radiologically guided transjugular intrahepatic stent shunt at a time when his condition was too poor to attempt an open surgical procedure.
Anti-mitochondrial antibodies in patients with Graves' disease may not signify primary biliary cirrhosis
Authors: Perros P , Palmer J M , Yeaman S J , Kendall-Taylor P
Published: December 2008

Two patients with Graves' disease were incidentally found to have anti-mitochondrial antibodies by immunofluorescence in the absence of symptoms, clinical signs or biochemical evidence of liver dysfunction. Anti-mitochondrial antibody titres became undetectable in both patients on follow-up. Screening of the patients' sera by immunoblotting against the purified antigens of the M2 complex was negative. We conclude that in these cases, anti-mitochondrial antibodies detected by immunofluorescence were directed against antigens other than the primary biliary cirrhosis-associated M2 complex and therefore did not signify subclinical primary biliary cirrhosis.
Perforated typhoid enteritis in children
Authors: Gupta Vineeta , Gupta Sanjeev K , Shukla Vijay K , Gupta Saroj
Published: December 2008

A prospective study of 65 patients with perforated typhoid enteritis managed operatively over a 3 year period at a university hospital is presented. There were 45 males and 20 females with ages ranging from 5 to 15 years. Presenting symptoms were fever, abdominal pain, vomiting and either diarrhoea or constipation. All the patients were subjected to surgery and 56 (86%) underwent two-layer bowel closure after freshening of ulcer margins. The overall mortality rate in this study was 20% and was adversely influenced by the increasing duration of perforation, presence of shock and faecal peritonitis.

Early surgery after prompt and adequate resuscitation is life saving. However, prevention of typhoid fever by providing safe drinking water and better sanitary conditions appears to offer the best chance of decreasing the high rates of mortality and morbidity of this deadly disease.
Warfarin treatment and migraine
Authors: Suresh C G , Neal D , Coupe M O
Published: December 2008

A patient suffering from migraine, whose symptoms were abolished by warfarin therapy, is reported. Warfarin was prescribed for deep vein thrombosis and the frequency of the patient's headache improved remarkably during the anticoagulant therapy. Because of the unusual nature of the response to anticoagulant therapy, warfarin was reintroduced on a double blind (versus placebo) basis and once again abolished the headaches.
Pulmonary hypertension associated with non-cirrhotic portal hypertension in systemic lupus erythematosus
Authors: Woolf Desmond , Voigt Michael D , Jaskiewicz Kasimir , Kalla Azga A
Published: December 2008

A case of non-cirrhotic portal hypertension in a patient with systemic lupus erythematosus, the first of our knowledge, is described. Severe pulmonary hypertension was associated with the portal hypertension and with markers of active auto-immunity. Pulmonary hypertension has not previously been associated with non-cirrhotic portal hypertension. The coexistence of vasculopathy of the portal and pulmonary vascular beds in this patient with active autoimmunity supports the postulate that portal-pulmonary hypertension may be immunologically mediated.
Tracheoesophageal fistula as the presenting manifestation of Hodgkin's lymphoma
Authors: Alba David , Lobato Salvador Díaz , Alvarez-Sala Rodolfo , Villasante Carlos , Echevarría Celina
Published: December 2008

We present a patient with tracheoesophageal fistula as the initial manifestation of Hodgkin's disease with oesophageal involvement. To our knowledge, this has not been previously reported. The diagnosis of Hodgkin's lymphoma was made at autopsy.
The effect of different nitrate preparations on plasma heparin concentrations and the activated partial thromboplastin time
Authors: Brack Michael J , More Ranjit S , Hubner Peter J B , Gershlick Anthony H
Published: December 2008

There is evidence that intravenous nitrates which are frequently used in acute coronary syndromes may interfere with the anticoagulant effect of heparin. We compared the effect of two different nitrate preparations on the activated partial thromboplastin time (APTT), anti-thrombin III activity (AT III) and plasma heparin levels in patients (n = 50) undergoing routine percutaneous transluminal coronary angioplasty (PTCA) for stable angina. Patients were randomized to either: (1) intravenous heparin and nitroglycerin (GTN); or (2) intravenous heparin and isosorbide dinitrate. The APTT, plasma heparin concentration and AT III activity were measured before PTCA and at 2 and 4 hours after commencement of infusions. Both groups received identical doses of heparin. Group 1 patients received a constant dose of 16.6 micrograms/minute of GTN, and group 2 patients received 33.3 micrograms/minute of isosorbide dinitrate.

At 4 hours the median APTT ratio was significantly lower in group 1 compared with group 2 (2.6 versus 4.5) (P < 0.05) as was the plasma heparin concentration (0.18 U/ml versus 0.32 U/ml (P < 0.05). However, no significant difference in APTT ratios or plasma heparin concentrations were noted at any of the other sample times. AT III activity was not significantly different between the groups at any sample time. Within-group analysis showed significantly lower APTT ratio and heparin concentrations at 4 hours compared with the respective 2 hour values.

These results would suggest that there is a potential impairment of anticoagulation with low-dose intravenous nitroglycerin and to a lesser extent with low-dose isosorbide dinitrate. Early and frequent monitoring may therefore be appropriate when intravenous nitrates and heparin are used in combination.
Aortocaval fistula: a rare cause of paradoxical pulmonary embolism
Authors: Bridger J E
Published: December 2008

An 83 year old woman died suddenly from a paradoxical pulmonary embolus which had originated in an abdominal aortic aneurysm and embolised via an aortocaval fistula. This lesion should be considered in the differential diagnosis of embolic disease.
A case of narcotic bowel syndrome successfully treated with clonidine
Authors: Wong Voishim , Sobala George , Losowsky Monty
Published: December 2008

Patients with chronic abdominal pain without an organic basis present a difficult management problem. Some of these patients may be prescribed opiates initially which may result in requiring progressively higher doses for pain relief. In this clinical setting, the suspicion of narcotic bowel syndrome should be borne in mind. With appropriate treatment and counselling, further invasive investigations including laparotomy may be avoided and resolution of symptoms can be achieved with clonidine. This case report demonstrates such a typical clinical scenario and discusses the possible aetiology and pathophysiology of narcotic bowel syndrome as well as the role of clonidine in controlling opiate withdrawal symptoms.
Acute renal failure in patients with type 1 diabetes mellitus
Authors: Woodrow G , Brownjohn A M , Turney J H
Published: December 2008

Acute renal failure (ARF) is a serious condition which still carries a mortality of around 50%. People with diabetes may be at increased risk of developing ARF, either as a complication of diabetic ketoacidosis or hyperosmolar coma, increased incidence of cardiovascular disease, or due to increased susceptibility of the kidney to adverse effects in the presence of underlying diabetic renal disease. During the period 1956-1992, 1,661 cases of ARF have been treated at Leeds General Infirmary. Of these, we have identified 26 patients also having type 1 diabetes. ARF due to diabetic ketoacidosis is surprisingly uncommon (14 cases out of 23 patients whose notes were reviewed). All cases of ARF complicating ketoacidosis in the last decade have been associated with particularly severe illness requiring intensive care unit support, rather than otherwise 'uncomplicated' ketoacidosis.

We discuss the conditions that may result in ARF in patients with diabetes and the particular difficulties that may be encountered in management.
Multiple strokes after initiation of steroid therapy in giant cell arteritis
Authors: Collazos Julio , García-Moncó Carlos , Martín Aitor , Rodriguez Jose , Gómez Ma Angeles
Published: December 2008

We report the case of a 66 year old woman with clinical manifestations of giant-cell arteritis, positive temporal artery biopsy and excellent response to prednisone, who developed massive cerebral infarcts after 5 days of treatment. Computed tomographic and magnetic resonance imaging scans revealed multiple infarcts in areas irrigated by both the carotid and vertebrobasilar systems bilaterally. A four-vessel angiography performed 19 days later revealed only mild atheromatous disease. Anticardiolipin antibodies were negative and a transoesophageal echocardiogram was normal.

Stroke during the first 2 weeks of therapy in giant-cell arteritis, especially in the vertebrobasilar territory, has been previously reported. Anticoagulation during the first weeks of steroid treatment in these patients might be advisable.
Prolonged remission of hypercalcaemia due to parathyroid carcinoma with pamidronate
Authors: Newrick P G , Braatvedt G D , Webb A J , Sheffield E , Corrall R J M
Published: December 2008

Parathyroid carcinoma is rare and the associated hypercalcaemia is often resistant to all treatment. A case is described in which prolonged control of hypercalcaemia has been achieved by infrequent infusions of pamidronate despite continuing hypersecretion of parathyroid hormone.
Role of respiratory sleep disorders in the pathogenesis of nocturnal angina and arrhythmias
Authors: Liston R , Deegan P C , McCreery C , McNicholas W T
Published: December 2008

This report documents how respiratory sleep disorders can adversely effect ischaemic heart disease. Three male patients (aged 60-67 years) with proven ischaemic heart disease are described. They illustrate a spectrum of nocturnal cardiac dysfunction, two with nocturnal angina and one with nocturnal arrhythmias. Full sleep studies were performed in a dedicated sleep laboratory on all patients, and one patient had 48 hours of continuous Holter monitoring. Two patients were found to have obstructive sleep apnoea with apnoea/hypopnoea indices of 57 and 36 per hour, respectively, the former with nocturnal arrhythmias and the latter with nocturnal angina. In both cases, nasal continuous positive airways pressure successfully treated the sleep apnoea, with an associated improvement in nocturnal arrhythmias and angina. The third patient who presented with nocturnal angina, did not demonstrate obstructive sleep apnoea (apnoea/hypopnoea index = 7.2) but had significant oxygen desaturation during rapid eye movement (REM) sleep. This patient responded to a combination of nocturnal oxygen and protriptyline, an agent known to suppress REM sleep, and had no further nocturnal angina. All patients were considered to be an optimum cardiac medication and successful symptom resolution only occurred with the addition of specific therapy aimed at their sleep-related respiratory problem. We conclude that all patients with nocturnal angina or arrhythmias should have respiratory sleep abnormalities considered in their assessment.
Giant cell arteritis presenting as oculomotor nerve palsy with pupillary dilatation
Authors: Davies G E , Shakir R A
Published: December 2008

Acute complete oculomotor palsy with headache is a classical presentation of an extrinsic compression most commonly due to a posterior communicating artery aneurysm. We present a patient with such a presentation but with histologically proven giant cell arteritis. This possibility should be considered especially in the elderly to avoid complications and the need for angiography.
Gastric telangiectasis: a rare cause of severe blood loss in CREST syndrome
Authors: el-Omar M M , Jenkins A P , Hollowood K , Banerjee A K , Thompson R P H
Published: December 2008

A 46 year old woman presented with the CREST variety of systemic sclerosis and occult gastrointestinal bleeding due to vascular malformations of her stomach. Partial gastrectomy cured her anaemia. In systemic sclerosis, visceral angiography should be performed early when initial investigations have been negative.
Omeprazole in the treatment of asthmatics with nocturnal symptoms and gastro-oesophageal reflux: a placebo-controlled cross-over study
Authors: Ford G A , Oliver P S , Prior J S , Butland R J A , Wilkinson S P
Published: December 2008

Eleven adult patients with nocturnal asthma, and gastro-oesophageal reflux documented by endoscopy or ambulatory oesophageal pH monitoring completed a double-blind cross-over study (4 week treatment, one week run-in and cross-over periods) comparing the effects of omeprazole 20 mg daily and placebo on asthma control assessed by symptoms, peak expiratory flow rate and bronchodilator usage. Omeprazole treatment did not improve asthma symptoms during the day or night, or peak expiratory flow rate readings. There was no difference in bronchodilator inhaler usage during omeprazole therapy.

Treatment of gastro-oesophageal reflux with omeprazole in patients with nocturnal asthma and gastro-oesophageal reflux does not improve asthma symptoms or peak expiratory flow rate. This suggests that gastro-oesophageal reflux does not exacerbate bronchoconstriction in nocturnal asthma.
Views of hospital staff on the management of hypertension
Authors: Hutchinson P J A , Trill A S , Turner P , Jackson S H D
Published: December 2008

A questionnaire concerning the detection and management of hypertension was presented to 265 hospital doctors, 114 medical students and 59 student nurses. Of these 75% were completed. Although only 76% thought that routine measurement was necessary in outpatients, 92% of respondents thought that blood pressure (BP) should be measured routinely in all in-patients. A total of 17% of all doctors and 11% of physicians indicated that they would not use drug treatment until the diastolic BP exceeded 105 mmHg. Thirty-four per cent of respondents still use diastolic phase IV and 84% felt that BP should be measured 2-4 times before deciding on treatment but the posture of the patient (lying, sitting or standing) during recording was inconsistent. Seventy-seven per cent of respondents indicated that they recorded BP to the nearest 5 mmHg and 4% to the nearest 10 mmHg. Despite the literature on the subject, there are still widely differing opinions amongst medical staff on how to record BP and at what level it should be treated.
Cardiac tamponade after thrombolysis
Authors: Heymann T D , Culling W
Published: December 2008

Thrombolysis has been very effective in reducing the morbidity and mortality from acute myocardial infarction. Serious adverse events are not uncommon, however. We describe a case in which a haemopericardium and tamponade developed in a patient with a history of recurrent idiopathic pericarditis and to whom streptokinase had been administered following a suspected myocardial infarction. The case highlights the need for caution in the administration of thrombolytics to patients with a documented history of pericarditis.
Invasive pulmonary aspergillosis: a rare presentation of non-Hodgkin's lymphoma
Authors: Garcia-Gonzalez Miguel , Sanroman Antonio L , Arribas Rosario , Torres Gustavo , Cuesta Carmen , Moreira Victor F
Published: December 2008

We describe a patient with rapidly progressive pneumonia and a high level of serum lactate dehydrogenase, in whom postmortem study revealed the presence of a diffuse, small and large-cell multicentric non-Hodgkin's lymphoma, together with an invasive pulmonary aspergillosis. Aspergillosis is rare as a presenting feature of a lymphoproliferative disease; only one previous case has been reported to the best of our knowledge. Invasive aspergillosis and lymphoma should be considered in patients presenting with pneumonia and high level of lactate dehydrogenase.
Malignant astrocytoma of the cervico-medullary junction masquerading as Guillain-Barré syndrome
Authors: Beards S C , Robertson L J , Jackson A , Lipman J
Published: December 2008

Brainstem gliomas are rare primary brain tumours which most commonly occur in the midbrain and pons. Malignant gliomas and tumours at the cervico-medullary junction are particularly unusual. The diagnosis of tumours at this site is particularly difficult using computed tomographic (CT) scanning owing to artifacts around the base of the skull. Intrinsic tumours of the cervico-medullary junction may lead to a dissociated motor deficit and the onset of symptoms can be rapid. We describe a patient in whom an isolated ascending motor deficit in association with a raised cerebrospinal fluid protein and a normal CT scan led to an erroneous diagnosis of Guillain-Barré syndrome. The patient was treated on the intensive care unit for an 8-week period before further investigation demonstrated a malignant glioma of the cervico-medullary junction. We recommend confirmation of the diagnosis of polyradiculopathy by nerve conduction studies wherever possible.
Perforation of leiomyoma of stomach
Authors: Merrett N D , Gartell P C
Published: December 2008

A case of perforation of gastric leiomyoma is reported, a presentation not previously described.
Subarachnoid haemorrhage: a cause of left bundle branch block?
Authors: Dubrey S , Huehns T Y , Brooks A P
Published: December 2008

We describe what we believe to be the first reported case of documented de novo left bundlebranch block in association with acute subarachnoid haemorrhage.
Dexamethasone-suppressible feminizing adrenal adenoma
Authors: Paja M , Díez S , Lucas T , Ojeda A , Salto L , Estrada J
Published: December 2008

A 39 year old man presented with gynaecomastia, loss of libido and high blood pressure. Hormone studies revealed elevated plasma levels of oestradiol and its precursors, which increased in response to adrenocorticotrophic hormone and were reduced to normal levels with dexamethasone. Computed tomography disclosed a left adrenal mass and surgery was performed. The removed tumour weighed 84 g and the histological diagnosis was of adenoma. Nine years after surgery, he is asymptomatic, without hypertension, and radiological and or hormonal evidence of recurrence. We discuss the hormone profile in this case and the dynamics of steroid production by the tumour which, in contrast to the classical concept of tumour autonomy, showed dependence of oestradiol secretion on endogenous adrenocorticotrophic hormone.
Twenty-four hour ambulatory blood pressure and heart rate in a patient with a predominantly adrenaline secreting phaeochromocytoma
Authors: Gallen I W , Taylor R S , Salzmann M B , Tooke J E
Published: December 2008

In this report, we present the symptoms, biochemical investigations, 24 hour ambulatory blood pressure and heart rate recordings in a patient before and following removal of a predominantly adrenaline-secreting phaeochromocytoma. The symptoms were of episodic shaking, faintness, nausea, palpitations, sweating and panic, chest and neck pain with headache, and are consistent with previous reports. Ambulatory blood pressure recording demonstrated that mean daily blood pressure was normal, with normal diurnal variation, and two episodes of severe hypertension and bradycardia coincident with symptoms (MAP 150 mmHg and HR 49 beats/minute, MAP 178 mmHg and HR 29 beats/minute, respectively), not reported in predominantly adrenaline-secreting phaeochromocytoma.
Life-threatening, localized angio-oedema associated with streptokinase
Authors: Cooper John P , Quarry Daniel P , Beale Derek J , Chappell A Guy
Published: December 2008

We report what we believe to be the first documented case of localized angio-oedema of the upper airway secondary to streptokinase.
Angiographic comparison of coronary artery disease between Asians and Caucasians
Authors: Dhawan J , Bray C L
Published: December 2008

Asians in the United Kingdom surpass the already high mortality from coronary artery disease seen in Caucasians. In the present study, the angiographic features of consecutive series of 87 Caucasians, 83 British Asian and 30 Asian patients in India with coronary artery disease were assessed. Blood samples at fasting and after ingestion of 75 g of dextrose were taken to assess the extent of diabetes. Fasting blood samples were also taken for measurement of cholesterol, high-density lipoprotein cholesterol and triglyceride. Coronary angiograms were scored by two independent observers who were blinded to the patients' ethnic origin.

The Asians were younger than the Caucasians, but did not differ in their body mass index, systolic or diastolic blood pressure or in cigarette consumption. Lipids were similar apart from Indian Asians having lower cholesterol than British Asians, and Caucasians having lower triglyceride than Asians. There were more diabetics in Asians than in Caucasians. Asians in Britain wait longer than Caucasians and Asians in India from onset of angina to undergoing coronary angiography.

The presence of triple vessel disease was not significantly different (P = 0.19) in the three groups, that is, 38%, 43% and 27% in Caucasians, British Asians and Indian Asians, respectively. The geometric mean coronary score was 26.3 (C.I. 22.6-30.6), 25.3 (C.I. 21.8-29.4), and 25.2 (C.I. 19.6-32.5) in Caucasians, British Asians and Indian Asians, respectively. This difference was not significant (P = 0.92).

Total number of lesions more than three were similar, that is, in 25% Caucasian, 41% British Asian and 40% Indian Asian patients (P < 0.10). British Asians had less proximal disease (P = 0.0002), and Indian Asians less distal disease (P = 0.003) compared to Caucasians. Non-discrete (long) lesions were more prevalent in Asians than Caucasians (P = 0.0005) The total number of lesions more than three in diabetic Asians was significantly more than in the non-diabetic, 71% versus 31% in British Asians (P = 0.002) and 90% versus 15% in Indian Asians (P= 0.0001). The relationship between diabetes and long lesions in both British and Indian Asians was highly significant (P < 0.00001 and P < 0.001, respectively).

Thus severity and extent of coronary disease is no different in Asians as compared to Caucasians. Diabetes is perhaps responsible for the more diffuse disease seen in Asians.
Defrosting insulin: a case report
Authors: Dubrey S , Huehns T Y , Simpson R
Published: December 2008

We report a case where a patient used microwave radiation to thaw his frozen insulin resulting in marked deterioration in his diabetic control. The consequences of this action were examined using high-performance liquid chromatography.
Leiomyosarcoma in leiomyomatosis of the small intestine
Authors: El-Omar Magdi , Davies Jason , Gupta Sandeep , Ross Harvey , Thompson Richard
Published: December 2008

Multiple leiomyomata of the small intestine are rare. We report one such case where a leiomyosarcoma had arisen from a leiomyoma in the small intestine 8 years after presentation. The possible origin of the leiomyomata is discussed and it is concluded that small intestinal leiomyomatosis should be regarded as a premalignant condition.
Salt, hypertension and renal disease: comparative medicine, models and real diseases
Authors: Michell A R
Published: December 2008

Dogs are well established as experimental animals for the study of both renal disease and hypertension, but most work is based on surgical or pharmacological models and relatively little on spontaneous diseases. This review argues for the latter as an underexploited aspect of comparative medicine. The most important feature of canine hypertension may not be the ease with which models can be produced but the fact that dogs are actually rather resistant to hypertension, and perhaps to its effects, even when they have chronic renal failure. The importance of natural models of chronic renal failure is strengthened by the evidence that self-sustaining progression is a consequence of extreme nephron loss, that is, a late event, rather than the dominant feature of the course of the disease.

The role of salt in hypertension is discussed and emphasis given to the importance of understanding the physiological basis of nutritional requirement and recognizing that it is unlikely to exceed 0.6 mmol/kg/day for most healthy adult mammals except during pregnancy or lactation. Such a perspective is essential to the evaluation of experiments, whether in animals or humans, in order to avoid arbitrary definitions of 'high' or 'low' sodium intake, and the serious misinterpretations of data which result. An age-related rise in arterial pressure may well be a warning of excess salt intake, rather than a normal occurrence. Problems of defining hypertension in the face of variability of arterial pressure are also discussed.
Treatment of methyl bromide poisoning with haemodialysis
Authors: Moosa M R , Jansen J , Edelstein C L
Published: December 2008

Acute accidental methyl bromide poisoning was treated with haemodialysis. The treatment was successful in removing bromide from the blood but the patient persists with severe neuropsychiatric sequelae. To the best of our knowledge haemodialysis has not been used previously for the treatment of organic bromide poisoning.
A small cell bronchogenic carcinoma associated with tumoral hypophosphataemia and inappropriate antidiuresis
Authors: Robin N , Gill G , van Heyningen C , Fraser W
Published: December 2008

A patient is described with small cell carcinoma of the lung, associated with profound hypophosphataemia and hyponatraemia. Increased phosphate excretion and inappropriately high urine osmolality were observed. The abnormalities are consistent with tumoral hypophosphataemia and inappropriate antidiuresis. These tumour-related metabolic abnormalities have only been described once before with this malignancy.
Pseudobulbar palsy associated with trismus
Authors: Lai M M , Howard R S
Published: December 2008

A 60 year old patient presented with an acute pseudobulbar palsy associated with trismus. A computed tomography scan revealed low attenuation areas consistent with infarction affecting the genu of the internal capsules bilaterally. Trismus has not previously been described as the presenting feature of a pseudobulbar palsy.
Severe hypophosphataemia in anorexia nervosa
Authors: Cariem A K , Lemmer E R , Adams M G , Winter T A , O'Keefe S J D
Published: December 2008

In addition to well-described acid-base and electrolyte disturbances, anorexia nervosa may be complicated by severe hypophosphataemia. We report a case of anorexia nervosa complicated by life-threatening hypophosphataemia manifesting as generalized muscle weakness and bulbar muscle dysfunction, resulting in an aspiration pneumonia and cardiorespiratory arrest.
Genetic analysis in a female manifesting haemophilia B
Authors: Palmer S , Standen G R , Yates P , Oakhill A
Published: December 2008

A 5 year old female child presented with a psoas haematoma as the first manifestation of haemophilia B. Molecular genetic studies were performed to investigate the inheritance of the disorder and the mechanisms by which females may express the haemophilia B phenotype are discussed.
Toxic megacolon complicating chemotherapy for acute myeloid leukaemia
Authors: Wodziński M A , Snowden J A , Reilly J T
Published: December 2008

A 43 year old woman in remission from acute myeloid leukaemia developed abdominal pain, severe melaena, diarrhoea and gram-negative septicaemia whilst severely pancytopenic following consolidation chemotherapy. Subsequently, serial abdominal X-rays showed a progressive toxic megacolon. Conservative management was attempted but, because of radiological evidence of increasing colonic dilatation and incipient perforation, an emergency defunctioning colostomy was performed. The patient recovered and 2 months later the caecostomy was reversed and a right hemicolectomy performed.

This first described case of toxic megacolon following leukaemia treatment is compared with three previously described cases following cytotoxic chemotherapy for other conditions.
Bacterial meningitis in the first three months of life
Authors: Riordan F A I , Thomson A P J , Sills J A , Hart C A
Published: December 2008

A retrospective study of infants with bacterial meningitis admitted to our hospital during 1949-52, highlighted the lack of ‘classical’ signs of meningitis in these infants. We carried out a similar review of 44 infants aged less than three months, admitted during 1982-91. We also determined the causative organisms and their antibiotic sensitivities. Symptoms and signs were similar in the two series. Forty infants in the later series were either febrile, irritable or had seizures on the day of admission. Overall mortality fell from 30% to 11%. Between 1982 and 1991 Group B Streptocococcus and Neisseria meningitidis were the commonest causes of meningitis. All organisms, except one, were sensitive to ampicillin and/or cefotaxime. Bacterial meningitis should be suspected in young infants who are febrile, irritable or having seizures. Initial treatment with ampicillin and cefotaxime is appropriate.
Renal failure due to cholesterol embolisation
Authors: Khan M A , Hattersley J , Furness P N , Walls J , Feehally J , Harris K P H
Published: December 2008

Five cases of cholesterol crystal embolisation resulting in impaired renal function are reported and their investigation and management discussed.
Immunotherapy in the management of sepsis
Authors: Fagan E A , Singer M
Published: December 2008

The pathophysiological effects of severe sepsis, septic shock and related syndromes result from tissues damaged by the uncontrolled production of the mediators of inflammation. Early deaths are related primarily to the acute effects of the systemic inflammatory response. Later deaths are related more closely to the consequences of multiple organ dysfunction. Monoclonal antibodies and other immunotherapies have been developed against bacterial products, cytokines and other mediators involved in this systemic inflammatory response. Immunotherapies may improve outcome in the critically ill with sepsis if used early and as part of the therapeutic regimen of antimicrobial agents and intensive care support.
Effect of Helicobacter pylori eradication on peptic ulcer healing
Authors: O’Connor H J , Kanduru C , Bhutta A S , Meehan J M , Feeley K M , Cunnane K
Published: December 2008

In a prospective study designed to assess the effect of Helicobacter pylori eradication on peptic ulcer healing, 85 consecutive patients with H. pylori-positive peptic ulcer disease were treated with a triple therapy regimen consisting of colloidal bismuth subcitrate 120 mg four times daily for 28 days, with metronidazole 400 mg three times daily and tetracycline 500 mg three times daily for the first seven days of treatment. H. pylori status was assessed by CLO test and histology at least four weeks after completing therapy. Of 75 patients (88%) H. pylori-negative after therapy, 69 (92%) had healed ulcers compared with only five of 10 patients (50%) who remained H. pylori-positive (p = 0.003). Cigarette smoking had no significant effect on ulcer healing. Our results suggest that H. pylori eradication may accelerate ulcer healing and provide further evidence that an effective helicobactericidal regimen is the treatment of choice in H. pylori-positive peptic ulcer.
Improving the interpretation of electrocardiographs in an accident and emergency department
Authors: White T , Woodmansey P , Ferguson D G , Channer K S
Published: December 2008

In this study we have examined the ability of senior house officers in the Accident and Emergency (A&E) Department to interpret electrocardiographs (ECGs) and tested the value of a single seminar and guidelines on interpretation. We prospectively audited ECG interpretation taken from notes over a two-month period and repeated this audit following a single seminar by a consultant cardiologist and after the issue of guidelines. A formal test of interpretation of a set of 20 ECGs by senior house officers in A&E was also carried out. 245 case notes were reviewed and in one third the ECG was interpreted incorrectly by senior house officers in A&E but incorrect clinical management followed in only 3.2% of cases. Following the intervention, 242 case notes were reviewed and serious misinterpretations were halved as was the number of patients mismanaged as a result (1.7%). In conclusion, formal training in ECG interpretation can reduce serious errors.
Early diagnosis of Parkinson’s disease
Authors: Bakheit A M O
Published: December 2008

Early diagnosis of Parkinson’s disease is often difficult. The insidious onset of the disease, its slow progression and the lack of laboratory tests to confirm the diagnosis contribute to this difficulty. Nevertheless, early diagnosis can be greatly facilitated by the systematic application of diagnostic clinical criteria and the selective use of radiological and laboratory tests.
A large volume spacer significantly reduces the effect of inhaled steroids on bone formation
Authors: Meeran K , Burrin J M , Noonan K A , Price C P , Ind P W
Published: December 2008

Inhaled steroids are increasingly advocated as first line treatment for mild asthma. Some studies suggest that inhaled steroids suppress bone formation as reflected by a fall in plasma osteocalcin. Spacers have been shown to increase the proportion of inhaled aerosol that is deposited in the lungs and to reduce the amount swallowed. We measured plasma osteocalcin levels to determine the effect on bone formation of inhaled beclomethasone dipropionate (BDP) with and without a 750 ml spacer in a double-blind, randomised, placebo-controlled, cross-over study. Twenty-six healthy male volunteers took BDP 500 micrograms (two puffs of Becloforte) together with two puffs of placebo, inhaled twice daily for seven days. One inhaler was taken directly while the other was inhaled through a 750 ml spacer. After a two week washout period, the inhalers were exchanged so that BDP was taken by the alternate route for a further seven days. Fasting plasma osteocalcin levels were measured at 09.00 h before and at the end of each week. After a week of BDP taken directly (without a spacer), osteocalcin levels fell from 11.8 (SEM 0.6) ng/ml to 9.5 (SEM 0.5) ng/ml (p < 0.001). After a week of BDP taken through a spacer, osteocalcin levels fell from 12.1 (SEM 0.5) ng/ml to 11.1 (SEM 0.5) ng/ml (p < 0.001). The fall in osteocalcin when a spacer was used was significantly less than when BDP was taken directly (p < 0.005). This is likely to be because the systemic effects on bone are caused by swallowed rather than inhaled BDP, and this is limited by the use of a spacer. Spacers should be more widely prescribed with inhaled steroids. Further prospective studies are indicated to evaluate whether spacers protect bone mass.