bluuebunny/crossref_metadata_2025 huggingface dataset:
Progressive hypokalaemia in elderly patients taking three thiazide potassium-sparing diuretic combinations for thirty-six months
Authors: Sawyer N , Gabriel R
Published: December 2008

Three different thiazide potassium-sparing diuretic combinations were given to elderly patients for heart failure. Eighty patients received their allocated combinations for 3 years and had 6-monthly measurements of plasma potassium. A further 84 were recruited for study but 29 died within 6 months and 55 had to be withdrawn from the trial. The triamterene-containing preparation was discontinued most frequently (6/44) because of hypokalaemia (plasma potassium less than 3.0 mmol/l); amiloride (5/44) and spironolactone (1/47). The median fall in plasma potassium over 3 years in those patients not withdrawn because of hypokalaemia was similar in each case (P greater than 0.05) and possibly failed to reach significance because of the withdrawal rate (9%). The trend was for a greater fall in those patients taking triamterene. The spironolactone-containing preparation may be the least unsatisfactory of the three.
Hypercalcaemia in a patient with non-secretory myeloma
Authors: Chew D , Playfer J R
Published: December 2008

A case of severe hypercalcaemia associated with a non-secretory multiple myeloma in the absence of skeletal deposits is described. The importance of considering this condition in the differential diagnosis of hypercalcaemia in the elderly is discussed.
Medical organisation and training in Switzerland
Authors: Zulian G B
Published: December 2008

This paper aims to report on a successful medical system in a very successful country, politically organized as a federal republic, which put 12 billion Swiss francs in its Health budget in 1980. It also reports on the training of Swiss physicians with special reference to internal medicine and emphasis on their independence. The benefit of close collaboration between the public and the private sector should appear obvious even if this situation might be jeopardized by too many new graduates for fewer patients.
Beryllium disease
Authors: Jones Williams W
Published: December 2008

The increasing use of beryllium in a variety of industries continues to be a hazard. New cases are still being reported to the UK Beryllium Case Registry, now numbering 60 in the period 1945-1988. The majority of cases follow inhalation which results in acute beryllium disease (chemical pneumonitis) or more commonly chronic beryllium disease--a granulomatous pneumonitis. Granulomatous skin nodules also occur following local implantation. The clinical and radiological features are briefly described with the emphasis on pathology and immunology. Laser microprobe mass spectrometry analysis of tissue sections is a major advance in diagnosis. Detection of beryllium distinguishes the granulomas of chronic beryllium disease from other diseases, in particular sarcoidosis. The role of beryllium lymphocyte transformation tests is discussed. Chronic beryllium disease is steroid dependent and local excision of skin lesions appears to be curative. There is no evidence that beryllium is carcinogenic.
Rickettsial infection presenting as culture-negative meningitis
Authors: Woo M L , Leung J W C , French G L
Published: December 2008

Meningitis is an unusual presentation of rickettsial infection. We report a patient who was confirmed by serology to have typhus fever (not scrub), but who presented with the typical findings of culture-negative bacterial meningitis. Neurological manifestations of different types of rickettsial infection are discussed.
‘Delivery’ of an anal angiofibroma
Authors: Kurzel R B , Enriquez S
Published: December 2008

A case is presented of an anal angiofibroma. This is the first report of this tumour in a pregnant patient. The tumour appeared to grow in size during the pregnancy.
Does cyclosporin A adversely affect Pneumocystis carinii infection?
Authors: McGonigle R J S , Beaman M , Stone J , Young J , Michael J , Adu D
Published: December 2008

Fourteen immunosuppressed patients with Pneumocystis carinii infection presented in two clusters that were separated by 2 years. The diagnosis in all cases was made early by alveolar lavage with cytology. The first group of seven patients was immunosuppressed with cyclophosphamide or azathioprine and prednisolone. All recovered with high dose co-trimoxazole. The second group of seven patients was on prednisolone and cyclosporin A. Despite identical treatment three patients died and a further two who survived lost their grafts from rejection. Our data suggest that cyclosporin A adversely affects the prognosis from Pneumocystis carinii infection and raises the question of prophylactic co-trimoxazole in these patients. The clustering of Pneumocystis carinii infection suggests the possibility of nosocomial transmission although in this study we were unable to implicate person-to-person spread of infection.
Clinical and laboratory responses to niceritrol in the treatment of hypercholesterolaemia
Authors: Curtis L D , Reckless J P D , Winder A F , Betteridge D J
Published: December 2008

Twenty-five hypercholesterolaemic patients from three centres in the UK were investigated in an open study of the efficacy and side effects of niceritrol. Five patients dropped out of the study at an early stage and had insufficient data for analysis. There were 13 males and 7 females (mean age 49.2 years, range 18-69). Fourteen patients had heterozygous familial hypercholesterolaemia, and six polygenic hypercholesterolaemia. Niceritrol was started at a dose of 750 mg/day and this was increased at weekly intervals over 4 weeks to the maximum tolerated dosage up to 3 g/day. This was then maintained for a further 8 weeks. There were statistically significant decreases in total plasma cholesterol, total triglyceride, LDL cholesterol and VLDL triglyceride; HDL cholesterol remained unchanged after 12 weeks of treatment (Wilcoxon matched pairs, signed ranks test). The 14 patients with familial hypercholesterolaemia showed a 13.9% fall in total cholesterol and a 19.8% fall in LDL cholesterol. All patients reported flushing and some had gastrointestinal symptoms but 19 would have been prepared to continue with the therapy at doses up to 3 g/day. Thus niceritrol has been found to be beneficial in the treatment of both familial and polygenic hypercholesterolaemia.
Spinal cord compression due to carcinoid metastasis
Authors: Gray J A , Nishikawa H , Jamous M A , Grahame-Smith D G
Published: December 2008

A case of cord compression secondary to the carcinoid syndrome is reported. The patient made an excellent response to surgical treatment, emphasizing that active management of this unusual complication should be considered.
Use of exercise Doppler for non-invasive haemodynamic optimization of dose and identification of poor responders to an oral anti-anginal agent. A double-blind dose-finding study of nisoldipine
Authors: Singer M , Trotman I F
Published: December 2008

Nisoldipine, a new dihydropyridine calcium antagonist, was examined for its dose-related haemodynamic effects using exercise-induced changes in aortic blood flow as measured by Doppler ultrasound. Following a two-week placebo run-in, 24 patients with stable angina pectoris were assigned double-blind to one of three groups receiving doses ranging from 2.5-20 mg/day over 8 weeks, given once or twice daily. Doppler studies identified the low dose group as responding less well at the placebo phase compared to the other two groups. There was an overall improvement in percentage change of peak velocity and stroke distance with exercise at all doses, with a dose of 5 mg/day giving optimal benefit in both variables (P less than 0.05) and no additional benefit being seen on twice-daily dosage. Six patients reporting increased chest pain exhibited a significantly worse rise in peak velocity and a fall in stroke distance to exercise (P less than 0.05) whilst on active drug compared to those who responded favourably. Doppler ultrasound can be of benefit in the haemodynamic assessment of new drugs, the recognition of non-responders and the optimization of therapeutic regimes.
Severe disseminated intravascular coagulation associated with massive ventricular mural thrombus following acute myocardial infarction
Authors: Solomon S A , Cotton D W K , Preston F E , Ramsay L E
Published: December 2008

We describe three patients who developed severe disseminated intravascular coagulation associated with large ventricular mural thrombi shortly after presenting with acute myocardial infarction. To our knowledge this association has not been reported before.
Familial breast cancer
Authors: Phipps R F , Perry P M
Published: December 2008

Familial breast cancer is important because of all the known risk factors associated with developing the disease. The one with the most predictability is a positive family history. It is also important because a family history causes anxiety in the families concerned, and young women will often ask their chance of developing the disease. This form of breast cancer accounts for 10% of causes and has factors that distinguish it from the sporadic variety. Relatives of familial breast cancer patients are not only at an increased risk of developing the disease (if female) but also of developing other tumours especially colonic.
Coeliac disease and pernicious anaemia
Authors: Ng J P , Green S T , Lam D C , Shahriari S
Published: December 2008

Despite the often reported autoimmune basis for coeliac disease and pernicious anaemia, there have been only occasional reports of the two conditions occurring together. We wish to report of such an association occurring in a 61 year old patient and comment on the diagnostic and prognostic implications.
Benign tumour of the ampulla of Vater presenting with portal hypertension
Authors: Aitken P , Erwin L , Fulton J D
Published: December 2008

Benign tumours of the ampulla of Vater are uncommon and usually present with obstructive jaundice. This is believed to be the first report of anicteric portal hypertension and hypersplenism caused by a benign ampullary tumour.
Hypopituitarism in the elderly in the presence of elevated thyroid stimulating hormone levels
Authors: Beringer T , McClements B , Weir I , Gilmore D , Kennedy L
Published: December 2008

Two cases of primary hypothyroidism with hypopituitarism in elderly patients are reported. The elevated levels of thyroid stimulating hormone led to delay in the recognition of accompanying pituitary failure. Elderly patients should not be commenced on thyroxine replacement therapy until the possibility of hypopituitarism and cortisol deficiency has been excluded.
Successful reversal of sleep apnoea syndrome following treatment for acromegaly, confirmed by polygraphic studies
Authors: Main G , Borsey D Q , Newton R W
Published: December 2008

A patient with acromegaly was shown to have obstructive sleep apnoea by polygraphic recordings. Following successful hypophysectomy, further recordings demonstrated resolution of obstructive sleep apnoea.
Spontaneous subcutaneous and mediastinal emphysema--a complication of lung function tests in Pneumocystis carinii pneumonia
Authors: Ramakrishnan S , MacLeod P M , Tyrell C J
Published: December 2008

A case is described of subcutaneous and mediastinal emphysema developing as a complication of lung function tests in an immunocompromised patient with presumed Pneumocystis carinii pneumonia.
Peritonitis due to perforated mesenteric fibroma–an hormonal aetiology?
Authors: Cole R P
Published: December 2008

Peritonitis is a very rare complication of mesenteric fibromatosis. A case is reported which occurred 6 days post-partum. It is suggested that such lesions are hormone-sensitive.
Acute inflammatory demyelinating polyradiculoneuropathy presenting as complete heart block and Stoke-Adams attacks
Authors: Wani B A , Misra M , Shah M , Mufti S
Published: December 2008

A patient with acute inflammatory demyelinating polyradiculoneuropathy (AIDP, Guillain-Barré syndrome) whose presenting complaints were related to autonomic dysfunction in the form of parasympathetic and sympathetic overactivity is reported. Parasympathetic overactivity was severe enough to cause complete atrioventricular block (atropine-responsive) and Stoke-Adams attacks, for which a demand pacemaker was required. Limb weakness was apparent 48 hours later. To our knowledge no such presentation of AIDP has been previously recorded.
Intestinal obstruction secondary to a congenital pre-iliac hernia
Authors: Siriwardena A K
Published: December 2008

A previously undescribed type of congenital abdominal wall hernia is described. Presentation was with the symptoms and signs of subacute large bowel obstruction. The diagnosis was suggested by barium enema and confirmed at laparotomy.
Pizotifen in deafferentation pain
Authors: Ghose K
Published: December 2008

Deafferentation pain is known usually to be resistant to both narcotic and non-narcotic analgesics. Four cases of this condition are reported here in which benefit was obtained with pizotifen, a 5-hydroxytryptamine antagonist. Further controlled clinical studies are required to verify this observation.
Hypersplenism due to fungal infection of spleen in a successfully treated patient with Hodgkin’s disease
Authors: Raina V , Young P T , Foulis A K , Soukop M
Published: December 2008

A 58 year old woman, with dermatitis herpetiformis was found to have Hodgkin’s disease following the discovery of an abdominal mass and splenomegaly. Combination chemotherapy was given. Although the abdominal mass and systemic symptoms resolved, the splenomegaly did not and the patient developed severe prolonged anaemia and pancytopaenia. Splenectomy resulted in a complete reversal of the haematological abnormalities. Histopathological examination of the spleen revealed fungal granulomas of Candida albicans. No residual Hodgkin’s disease was found. The patient thus had hypersplenism due to fungal granulomas in the spleen. This form of presentation of fungal granuloma is very rare and resulted in delay in diagnosis and considerable morbidity to the patient.
Vascular injury after arterial catheterization
Authors: Groome J , Vohra R , Cuschieri R J , Gilmour D G
Published: December 2008

Twenty-three cases of arterial injury after 8,208 arterial catheterizations for diagnostic or therapeutic indications at Glasgow Royal Infirmary are reviewed. Clinical presentation included haematoma formation, development of an acutely ischaemic limb or a false aneurysm. Patients with valvular heart disease are identified as a high risk group. Nine cases were managed by simple suture of the puncture site whereas thrombectomy and vein patch closure was required in 12 patients. The incidence of late complications requiring vascular reconstruction was 9%. The early recognition of complications after arterial catheterization and prompt referral to a specialized vascular unit is essential if morbidity is to be avoided.
Parathyroid hormone and anaemia--an erythrocyte osmotic fragility study in primary and secondary hyperparathyroidism
Authors: Foulks C J , Mills G M , Wright L F
Published: December 2008

Parathyroid hormone (PTH) has been shown in vitro to enhance erythrocyte osmotic fragility (EOF) and has been incriminated as a factor in the anaemia seen in patients with primary hyperparathyroidism and in patients with renal disease and secondary hyperparathyroidism. Enhanced EOF has also been shown in patients with chronic renal failure but did not correlate with PTH levels. We studied a group of patients with primary hyperparathyroidism with and without anaemia, and patients with secondary hyperparathyroidism and anaemia. We found that EOF studies in these patients did not differ from normal control groups and that there was no relation between PTH, EOF, and haematocrit in either study group. We conclude that PTH over a range of concentrations seen in vivo does not affect erythrocyte osmotic fragility or cause anaemia.
Anthraquinone laxatives and human cancer: an association in one case
Authors: Patel P M , Selby P J , Deacon J , Chilvers C , McElwain T J
Published: December 2008

An 18 year old girl presented with a leiomyosarcoma of the small bowel with widespread dissemination. Despite short term remissions after chemotherapy and surgery she died of the disease 10 months later. A history of prolonged exposure to danthron (an anthraquinone laxative) in childhood was obtained. Anthraquinones are known to be mutagenic and may be carcinogenic in experimental systems but danthron is not a proven carcinogen in man. The association of danthron and a rare bowel cancer in one case cannot prove a causative link. However, collection of further data seems advisable.
The relevance of anatomy and morbid anatomy for medical practice and hence for postgraduate and continuing medical education of doctors
Authors: Crisp A H
Published: December 2008

A case is presented for the durability of anatomy including dissection of the cadaver and of morbid anatomy as elements in medical education and practice. It is these subjects, as consistently relevant over the centuries for medical practice as are communication skills, that are our hallmark as doctors. It is submitted that we should take stock very carefully of their relevance to us before it is too late easily to redress the balance, given the major trends of the last two decades.
Hepatomegaly with bull’s eye calcifications
Authors: Kreel L
Published: December 2008

A woman aged 35 years from the Philippines presented with epigastric discomfort associated with an epigastric mass. On examination the liver was markedly enlarged.
Artefacts associated with a cryoglobulin
Authors: Hambley H , Vetters J M
Published: December 2008

A 70 year old man is described in whom the presence of a cryoglobulin caused a number of unusual laboratory features which were not recognized as being due to a cryoglobulin initially. Pseudoleucocytosis has been recognized in the past. However, the intracytoplasmic inclusion bodies have only rarely been described. The curious appearance of the ESR has not previously been described.
Bladder outflow obstruction induced by ipratropium bromide
Authors: Lozewicz S
Published: December 2008

Three cases are described in which bladder outflow obstruction was produced by ipratropium bromide, a widely used anticholinergic bronchodilator which has been regarded as virtually free from systemic side effects. Many patients treated with ipratropium bromide are elderly males in whom prostatic hypertrophy is common and in these circumstances, large doses should be used with caution.
The cost of chronic dialysis in multiple myeloma
Authors: Coward R A
Published: December 2008

The complications and costs of chronic dialysis in 4 patients with renal failure due to multiple myeloma are presented. In three patients the paraprotein responded to chemotherapy though without recovery of renal function. These three patients are alive after 18, 16 and 15 months of dialysis, the other dying after 7 months. Hospital admissions ranged from 26 to 74 days per year with infections accounting for 54 to 87% of admission days, 62.5% of which occurred during the first three months of dialysis treatment, with an incidence of 2.4 to 6.9 admissions episodes per year.

An in-house audit of our chronic dialysis patients indicated that treatment of myeloma patients is 5-33% more expensive. The extra cost in such high risk patients is mostly due to the greater number and longer duration of hospital admissions for infection. The other extra costs (in decreasing value) of blood products, antibiotics and chemotherapy are relatively small in comparison to in-patient treatment.
Abdominal pancreatic pseudocyst--an unusual cause of dysphagia
Authors: Propper D J , Robertson E M , Bayliss A P , Edward N
Published: December 2008

A 44 year old man with a long history of alcohol abuse developed progressive dysphagia. Radiological investigation revealed a pancreatic pseudocyst. Following percutaneous drainage the dysphagia resolved.
Visual hallucinations in the elderly associated with the use of levodopa
Authors: Banerjee A K , Falkai P G , Savidge M
Published: December 2008

Visual hallucinations are a well recognized unwanted effect of treatment with levodopa. Although many individual cases have been reported, there has only been one review previously published about this finding, and this did not discriminate age groups. We present five cases and briefly review the literature. It is important to enquire specifically about visual hallucinations in patients on levodopa therapy at follow up, as this otherwise potentially reversible side effect may be overlooked.
Riedel’s thyroiditis associated with hypothyroidism and hypoparathyroidism
Authors: Marín F , Araujo R , Páramo C , Lucas T , Salto L
Published: December 2008

Hypoparathyroidism secondary to Riedel’s thyroiditis is rare, only 2 previous cases having been reported. We present the case of a 36 year old woman with Riedel’s thyroiditis which developed into hypothyroidism and hypoparathyroidism.
Lack of efficacy of phenytoin in the syndrome of inappropriate anti-diuretic hormone secretion of neurological origin
Authors: Decaux G , Przedborski S , Soupart A
Published: December 2008

Phenytoin has been proposed in the management of patients with the syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) of neurological origin who fail to respond to water restriction.

We have conducted a prospective study in order to evaluate the role of phenytoin in the management of seven consecutive patients with SIADH of neurological origin which could not be controlled by limited water intake. Only one patient was successfully treated with chronic phenytoin regimen. This patient, like one previously reported, had suffered a basal skull fracture. It seems likely that in the majority of cases of SIADH of neurological origin phenytoin is ineffective on a long-term basis.
Small bowel obstruction: a review of 264 cases and suggestions for management
Authors: Deutsch A A , Eviatar E , Gutman H , Reiss R
Published: December 2008

Two hundred and sixty-four cases of acute small bowel obstruction were retrospectively reviewed for the purpose of defining factors which could point to the presence of strangulated bowel. History, physical signs and investigations, including body temperature, X-rays, white blood count, and serum amylase, were not significantly different in the simple and strangulated groups. Although an elevated urinary white blood count and a palpable mass were more common in the strangulated group, they were not sufficiently reliable for early diagnosis of strangulation.

In reviewing the literature, it is clear that all hernias with obstruction must undergo emergency surgery. Cases with intra-abdominal complete intestinal obstruction should also undergo emergency surgery. A more conservative attitude can only be taken when there is incomplete obstruction.
Algoneurodystrophy following herpes zoster
Authors: Foster O , Askaria A , Lanham J , Perry D
Published: December 2008

Algoneurodystrophy frequently follows an identifiable triggering event. It is not widely recognized that herpes zoster can precipitate algoneurodystrophy and three such cases are described here. In one, the affected dermatome did not correspond to the limb involved by the algoneurodystrophy.
Progression of hydrocephalus during corticosteroid therapy for neurosarcoidosis
Authors: Foley K T , Howell J D , Junck L
Published: December 2008

We describe a patient with sarcoid meningitis and hydrocephalus who improved rapidly after initiation of oral prednisone therapy, but who later decompensated acutely and required an emergency ventriculoperitoneal shunt. Hydrocephalus associated with neurosarcoidosis may progress despite steroid treatment, even when symptoms have improved. If hydrocephalus associated with neurosarcoidosis is treated with corticosteroids and without a shunt procedure we suggest that the corticosteroids should be continued at high doses for a prolonged period.
Toxic reaction to inhaled paint fumes
Authors: Atkinson L , Ince P , Smith N M , Taylor R
Published: December 2008

An acute confusional state was observed to follow heavy exposure to polyurethane gloss paint fumes in a previously healthy 60 year old man. This state remitted over a 3-day period, but was followed by transient bone marrow suppression and evidence of liver cell damage. The corroborated absence of other toxins and the temporal association of exposure to paint fumes suggest that a volatile paint component was responsible. White spirit is the major volatile solvent in polyurethane gloss paint. Ingestion of related aliphatic hydrocarbons has been reported to cause nausea, drowsiness and hepatotoxicity, but these symptoms have not previously been documented following excessive inadvertent inhalation of paint fumes.
Rapidly progressive cardiac failure due to lymphomatous infiltration of the myocardium
Authors: Gouldesbrough D R , Carder P J
Published: December 2008

A case of myocardial infiltration by lymphoma causing rapidly progressive cardiac failure is described. The clinical and pathological features are detailed and the rarity of this mode of presentation of cardiac involvement by lymphoma is emphasized.
Perirenal and renal subcapsular haematoma as presenting symptoms of polyarteritis nodosa
Authors: Schlesinger M , Oren S , Fano M , Viskoper J R
Published: December 2008

Two young men, were hospitalized due to acute massive blood loss with left abdominal flank pain. In both cases renal angiography showed signs of a haemorrhagic event in the left kidney, perirenal in one and subcapsular in the other. Microaneurysms indicated a diagnosis of polyarteritis nodosa, supported by renal biopsy in one case. Renal haemorrhage is an infrequent presentation of polyarteritis nodosa. Furthermore, one patient suffered also from familial Mediterranean fever, and is the fifth reported case with this combination of diseases.
Elderly people taking non-steroidal anti-inflammatory drugs are unlikely to have excess renal impairment
Authors: Allred J , Wong W , Kafetz K
Published: December 2008

The importance of possible adverse effects on renal function of non-steroidal anti-inflammatory drugs has been widely discussed. Elderly people have been thought to be particularly at risk. We therefore studied simple indices of renal function and plasma potassium in 54 patients with a mean age of 85 years, 27 taking these drugs and 27 controls. Twenty five of our 54 patients were also taking diuretics. Non-steroidal anti-inflammatory drugs did not affect renal function or plasma potassium in these patients.
The use of myocutaneous flaps by general surgeons
Authors: Allan S M , Williams C R P , Heddle R M , Jackson D B , Collins R E C
Published: December 2008

This is a study of the use of myocutaneous flaps by general surgeons in a district general hospital over a 5 year period, and shows that such work can be satisfactorily performed by general surgeons.
Formed hallucination in the hemianopic field
Authors: Benson M T , Rennie I G
Published: December 2008

We present a case in which formed hallucinations were the sole presenting feature of an occipital infarct. The hallucinations occurred in the resulting hemianopic field. The localizing value of such phenomena is discussed.
Primary cerebral lymphoma presenting with cranial diabetes insipidus
Authors: Patrick A W , Campbell I W , Ashworth B , Gordon A
Published: December 2008

A 30 year old woman with an 8-year history of thirst and polyuria was found to have cranial diabetes insipidus. There were no neurological abnormalities at presentation but she subsequently developed diverse signs and died 26 months later. Autopsy revealed a diagnosis of diffuse primary cerebral lymphoma. Cranial diabetes insipidus with otherwise minimal abnormality of hypothalamic/pituitary function has not previously been reported as a presentation of this neoplasm.
Pulmonary vasculitis associated with cholangiocarcinoma of liver
Authors: Ong E L C , Evans S , Hanley S P
Published: December 2008

A 62 year old woman presented with an acute pulmonary vasculitis which responded to treatment with oral steroids. Investigations over one year revealed a cholangiocarcinoma of the liver. The association of vasculitis with neoplastic diseases remains a diagnostic challenge.
The ovarian remnant syndrome presenting with acute urinary retention
Authors: Bryce G M , Malone P
Published: December 2008

The case of a woman presenting with acute urinary retention, which, on investigation, proved to be due to the ovarian remnant syndrome, is reported. This syndrome is rare, with only 36 previously published cases. To our knowledge none has so far presented in this manner.
Pulmonary uptake in 67-gallium citrate scintigraphy-the ‘negative heart’ sign
Authors: Cooke S G , Davies E R , Goddard P R
Published: December 2008

Diffuse pulmonary uptake in 67-gallium citrate (67-Ga) scintigraphy occurs in a large number of neoplastic and inflammatory conditions. Discrimination between normal and abnormal 67-Ga uptake over the chest can be difficult and a simple visual method for identifying abnormal studies is described. A series of 39 gallium scintigrams was retrospectively reviewed by the authors and reported without knowledge of the patients’ clinical condition. Subsequent clinical follow up was obtained to establish the accuracy of the scintigram interpretation. Comparison of pulmonary uptake with that over the cardiac area is recommended as a simple and reliable method of confirming that the level of pulmonary activity is abnormal. In highly abnormal cases the cardiac area is seen as a ‘negative heart’ image due to the considerably increased activity in the lungs. This sign is best seen with abnormal diffuse uptake but is also seen with abnormal focal uptake. Care must be taken, as the sign may be masked, if uptake over the cardiac area itself is increased.
Is intravenous cholangiography an alternative to the routine per-operative cholangiogram?
Authors: Huddy S P J , Southam J A
Published: December 2008

Ultrasonography, although an accurate method of detecting stones within the gall bladder, is unreliable for the detection of bile duct stones for which per-operative cholangiography remains the standard investigation. Fifty seven patients undergoing elective cholecystectomy had both a pre-operative intravenous cholangiogram and per-operative cholangiography. The pre-operative investigation is shown to be at least as effective in the detection of common bile duct stones and only missed a duct stone in one patient. The substitution of pre-operative intravenous cholangiography for routine per-operative cholangiography would result in a significant reduction in operating time, may provide advance knowledge on the biliary anatomy and would allow advance planning of the likely procedure. It is suggested that pre-operative intravenous cholangiography, carried out on the day of admission, should be considered as a preferred alternative investigation to per-operative cholangiography.
Audit of mortality in upper gastrointestinal bleeding
Authors: Katschinski B D , Logan R F A , Davies J , Langman M J S
Published: December 2008

The outcome in 1017 patients with haematemesis and malaena referred to two major hospitals in Nottingham within a 2-year period has been prospectively evaluated. Ninety one (9%) patients died during the time period under consideration and all but four were found to have been over 60 years of age. There were 13 (14%) deaths following rebleeding, of whom 5 (5%) could have been potentially avoided by alterations in management. Some improvement of mortality might result from intensive-care facilities with better management of transfusions and earlier detection of rebleeding allowing earlier endoscopy or surgery. The majority of patients (81%), however, died from concomitant disease which was exacerbated by gastrointestinal haemorrhage or bleeding developed in patients with an already existing end-stage disease. These results show that a reduction of mortality in patients with gastrointestinal bleeding is hampered by the high number of poor-risk patients. The rise in the proportion of elderly patients with this disorder seems to continue.
Spontaneous fracture of the ulna complicating tuberculous osteomyelitis
Authors: Seddon D J , Thanabalasingham T , Weinberg J
Published: December 2008

A 63 year old Asian woman presented with tuberculous osteomyelitis of the right ulna and a large subcutaneous cold abscess. During the course of her treatment the midshaft of the ulna sustained a spontaneous transverse fracture. Aspects of her case are reviewed.
Bilateral adrenal phaeochromocytomas associated with unilateral renal artery stenosis
Authors: Burns A P , O’Connell P R , Murnaghan D J , Brady M P
Published: December 2008

A 21 year old male was discovered to be severely hypertensive. He was found to have bilateral adrenal phaeochromocytomas and a single renal artery stenosis. More than 40 cases of coexisting renal artery stenosis and phaeochromocytomas have been reported. The aetiology of renal artery stenosis in association with phaeochromocytoma maybe multifactorial and the radiographic appearances are not always clear-cut.

Renin levels in this patient were elevated prior to the removal of the phaeochromocytomas but the renal vein renin ratio did not suggest that the renal artery stenosis contributed significantly to his hypertension. The patient’s hypertension resolved following successful removal of the phaeochromocytomas despite persistence of the renal artery stenosis. Thus, though renin levels may be misleading in these cases, renal vein renin ratios may still be helpful in deciding on patient management.
Dissociation between the secretion and renal action of endogenous atrial natriuretic peptide in the syndrome of inappropriate antidiuresis
Authors: Eadington D W , Cowan F M
Published: December 2008

A patient is described with the syndrome of inappropriate antidiuresis (SIAD) and renal sodium retention secondary to a lymphoma. The basal atrial natriuretic peptide (ANP) level and the ANP response to volume expansion were normal (age adjusted) but the natriuretic effect of ANP was attenuated by an unidentified factor. The case emphasizes the dominance of circulating volume over plasma tonicity in the regulation of ANP secretion.
Battered wives—measures by the social and medical services
Authors: Bergman B , Brismar B
Published: December 2008

The social files and medical records of 98 acutely battered wives who attended a surgical emergency department were studied. Although all women had been hospitalized during the decade preceding the present incident, wife battering was documented in the records in only 18%. The majority of the women (73%) were also known to the social services, but battering was documented in less than half of the cases in the social service files. The measures taken by the social services to help the battered women consisted mainly of economic support and psychotherapy. The cooperation between the medical and social services and the police in cases of wife battering was very limited or non-existent.

It is concluded that support given to battered women by the formal sources of aid is insufficient. The documentation of the cases is poor, there is a lack of practical measures and the cooperation between the authorities is limited. This study indicates that the social and medical services underestimate the importance of informal help sources like women's groups or shelters which often are the most valued resources by the battered women themselves. With improved cooperation between authorities and between formal and informal sources of aid the battered wives could be helped more effectively.
Neuroleptic malignant syndrome: a case for electroconvulsive therapy
Authors: Harland C C , O'Leary M M , Winters R , Owens J , Hayes B , Melikian V
Published: December 2008

A case of prolonged and refractory neuroleptic malignant syndrome was treated successfully with electroconvulsive therapy. Neuroleptic malignant syndrome and its treatment are reviewed.
Recurrent transient thyrotoxicosis in multinodular goitre
Authors: Arem R
Published: December 2008

A patient initially presented with an autonomously functioning right thyroid nodule and transient hyperthyroidism which lasted for a few months. Several months after resolution of thyrotoxicosis, the patient had a recurrent episode of hyperthyroidism and was found to have a left hot nodule. The right hyperfunctioning nodule had become cold on scintigraphy, and its aspiration revealed haemorrhagic fluid suggesting haemorrhagic infarction as the mechanism of resolution of the first episode of hyperthyroidism. Again following resolution of the second episode of hyperthyroidism, the left hot nodule also became hypofunctioning on scintigraphy indicating that the spontaneous restoration to euthyroidism was secondary to infarction.

Recurrent hyperthyroidism and resolution due to nodular infarction in a patient with a nodular goitre may mimic the more common causes of transient thyrotoxicosis and should be considered in the differential diagnosis of goitrous hyperthyroidism.
Acquired immunodeficiency, malabsorption and lymphoma
Authors: Fischel B , Burke M , Sasson E , Felner S
Published: December 2008

A 66 year old female with a long history of recurrent pulmonary infection presented with a full-blown malabsorption syndrome. She was found to be suffering from acquired immunodeficiency. She later developed non-Hodgkin's lymphoma of the cervical lymph nodes. The possible relationships between immunodeficiency, malabsorption and lymphoma are discussed.
Pasteurella pneumotropica: meningitis following a dog bite
Authors: Minton E J
Published: December 2008

A 38 year old man developed meningitis following a dog bite. Pasteurella pneumotropica, usually an animal pathogen, was isolated from the cerebrospinal fluid. The patient made a complete recovery after antibiotic therapy. The relevant literature is reviewed.
Near fatal puerperal fever due to Mycoplasma hominis
Authors: Young M J , Cox R A
Published: December 2008

We describe a case of severe septicaemia caused by Mycoplasma hominis in a 23 year old patient following childbirth. She developed disseminated intravascular coagulation and acute respiratory distress syndrome which have not hitherto been described in association with septicaemia due to this organism. Investigation and treatment leading to full recovery is outlined.
Subungual amelanotic melanoma: a diagnostic pitfall
Authors: Winslet M , Tejan J
Published: December 2008

A 35 year old female presented with a persistent amelanotic lesion of the nail bed of the left great toe for 1 year, associated with destruction of the overlying nail. Incision biopsy revealed a nodular malignant melanoma and the toe was amputated. There is no sign of recurrence at 18 month follow-up. As prognosis is related to local disease extent, any persistent nail bed lesion should be biopsied to exclude the possibility of malignant melanoma.
Palmar-plantar erythema associated with combination chemotherapy
Authors: Pagliuca A , Kaczmarski R , Mufti G J
Published: December 2008

We report three cases of a distinctive palmar-plantar erythema associated with the treatment of non-Hodgkin's lymphoma and acute myeloid leukaemia. The rash is characterized by a painful, sharply demarcated, intense erythema of the palms and/or soles followed by bulla formation, desquamation and healing. The eruption is self limiting in nature and did not adversely affect prognosis. Treatment need be neither altered nor stopped; only symptomatic measures are required.
Carcinoma of the breast associated with polyethylene strip augmentation
Authors: Roberts J P , Taylor I
Published: December 2008

A case of adenocarcinoma of breast associated with polyethylene prosthesis is presented. The problems with diagnosis and relationship between prosthetic implants and breast carcinoma are discussed.
Occupational cancer: interaction with life style factors
Authors: Roe F J C
Published: December 2008

It is argued that as the major occupational cancer risks become matters of historical interest, research epidemiologists working in the field should broaden their approaches to encompass life style factors. In the investigation of possible low-cancer risks, it no longer makes any sense to confine their data-collecting activities solely to exposure to dusts and chemicals at work and to regard exposure to chemicals at home, in the garden or during leisure activities simply as possible confounding variables. Furthermore it is becoming more and more meaningless to undertake any epidemiological investigation aimed at detecting or defining a low level of cancer risk without taking into account what and how much, for example, people eat, drink and smoke. Possible exposure to chemicals at work is increasingly becoming a source for confounding variables in relation to life-style-associated cancer risks, as distinct from life-style being a source of confounding variables in epidemiological studies of occupation-associated cancer risks.
Physical and intellectual recovery following prolonged hypoxic coma
Authors: Falk R H
Published: December 2008

Prolonged coma resulting from hypoxic brain injury is usually associated with a dismal chance of return to independent existence. In this report a case is described of a 60 year old man who recovered and returned to work as a university professor after being in a vegetative state at least 8 weeks after a prolonged cerebral hypoxic event.
Spontaneous haemarthrosis following thrombolytic therapy for myocardial infarction
Authors: Oldroyd K G , Hornung R S , Jones A M , Andrews N P , Dawes P T , Carson P H M
Published: December 2008

Two cases of haemarthrosis following thrombolytic therapy for acute myocardial infarction are described. Both patients had active pre-existing inflammatory disease in the affected joints at the time of presentation. This complication of thrombolytic therapy has not been previously reported.
Acute lymphadenopathy complicating quinidine therapy
Authors: Lau C P , Wong K L , Wong C K , Leung W H
Published: December 2008

A patient is described with quinidine-induced acute lymphadenopathy syndrome proven by rechallenge of the drug. Serum markers for systemic lupus were negative.
Raised dopamine metabolites in a case of malignant paraganglioma
Authors: Florkowski C M , Fairlamb D J , Freeth M G , Taylor S A , Taylor A , Weinkove C , Jacobs A G
Published: December 2008

This paper describes the case of a malignant retroperitoneal paraganglioma with extensive metastases. The patient presented with a supraclavicular mass and an absence of hypertension. Exclusively raised dopamine metabolites were detected which may be a marker of a malignant process and account for the lack of hypertension.
An evaluation of combining thiopentone and etomidate for the induction of anaesthesia
Authors: Slater R M , Pollard B J , Young T M , Hunt L P
Published: December 2008

The characteristics of three combinations of thiopentone and etomidate [in the ratios of thiopentone (mg):etomidate (mg) of 5:1, 13:1 and 25:1] have been compared with the individual agents alone for the induction of anaesthesia. The incidence of pain on injection and abnormal movements was less with the combination containing the highest ratio of thiopentone to etomidate, when compared to etomidate alone. The mixtures did not otherwise confer any advantages over the individual agents.
Acquired von Willebrand disease associated with free lambda light chain monoclonal gammopathy, normal bleeding time and response to prednisone
Authors: Stewart A K , Glynn M F X
Published: December 2008

We report a case of acquired von Willebrand's syndrome with severe gastrointestinal bleeding and associated free monoclonal lambda light chains. The patient had a rapid sustained clinical and laboratory response to the administration of prednisone. Of note in this patient was the occurrence of angiodysplasia which has previously been reported in association with acquired von Willebrand's syndrome. No inhibitors of VWF:Ag, VWF:RCoF, or factor VIII:C were detected by mixing studies and the bleeding time was normal. Very few high molecular weight von Willebrand multimers were present prior to prednisone; however, the pattern reverted to a normal distribution following treatment.

In appropriate patients with acquired von Willebrand's syndrome and monoclonal para-proteins, a trial of prednisone may be indicated.
An unusual case of adrenal cortical carcinoma
Authors: Mufti G R , Farrell J
Published: December 2008

We describe a case of non-functioning adrenal cortical carcinoma, which recurred 16 years after surgical adrenalectomy. In addition, the patient was successfully treated for two anatomically separate and histologically different, primary malignant tumours. This case highlights the importance of lifelong follow-up after apparently curative surgical excision of an adrenal tumour.
An audit of the usage of operating theatre time in a peripheral teaching surgical unit
Authors: Haiart D C , Paul A B , Griffiths J M T
Published: December 2008

A recent report by the National Audit Office found that only 50% to 60% of weekday operating time was being used. This report was examined by the Committee of Public Accounts and much of the blame for underutilization of operating theatres was attributed to poor working practices among surgeons. We investigated theatre utilization in our hospital and found underutilization on the same scale as the National Audit Office. Twenty-five per cent of theatre sessions were not allocated for use, 23% of general surgical lists were cancelled and, of the lists which did take place, a further 23% of theatre time was not utilized. The single largest cause of underutilization was understaffing. To increase theatre utilization higher levels of staffing and expenditure are needed rather than changes in the working practices of surgeons.
Multiple sclerosis associated with water intoxication
Authors: D'Costa D F , Weston P , Millac P A
Published: December 2008

We present a case of well documented multiple sclerosis which presented with the syndrome of inappropriate antidiuretic hormone secretion, following an exacerbation of the disease. This is a poorly documented association.
Large bowel obstruction due to an impacted barolith—a delayed complication of a barium study
Authors: Saunders M P
Published: December 2008

Complications of barium sulphate studies abound in the literature but there are very few recorded instances of large bowel obstruction due to inspissated barium and faeces forming a ‘barolith’. A patient who suffered this complication is reported.
A critical look at nursing observations
Authors: Burroughs J , Hoffbrand B I
Published: December 2008

Our experience has suggested that not only do nurses on hospital wards waste time making too many unnecessary clinical observations, but that it is very difficult to persuade them to modify the pattern of their practice.

We therefore conducted a survey by questionnaire among trained nurses in one health district of their everyday ward practice and attitudes to clinical observations. This showed that whilst a majority of nurses questioned believe in the importance of routine observations for patient care, there is a lack of consistency in the criteria and communication procedures used that must seriously limit the value of the information obtained by the individual nurse.

We believe that uncritical faith in routine observations is a barrier to rationalizing procedures to optimize efficient use of the professional skills of ward nurses in this regard. There is need for more thought to be given to the problem and in particular it is important that doctors play a more active role in decision making.
Anicteric hepatitis and uveitis in a worker exposed to trichloroethylene
Authors: Schattner A , Malnick S D H
Published: December 2008

A previously healthy woman developed acute anicteric hepatitis which slowly resolved, though bilateral anterior uveitis then appeared. No other cause than an occupational exposure to trichloroethylene was found, and rechallenge by resuming work has led to a transient increase in serum alkaline phosphatase. Both manifestations may constitute a rare systemic reaction to trichloroethylene.