bluuebunny/crossref_metadata_2025 huggingface dataset:
17α-Hydroxylase deficiency with persistence of müllerian ducts in a genotypic male and paradoxical aldosterone secretion
Authors: Panesar N S , Yeung V T F , Chan J C N , Shek C C , Nicholls M G , Cockram C S
Published: December 2008

We report a case of congenital adrenal hyperplasia due to 17 α-hydroxylase deficiency in a Chinese genotypic male patient. Despite the male genotype, normal female external genitalia were present and with the introduction of cyclical oestrogen therapy withdrawal bleeding occurred, confirming the presence of functional endometrial tissue. We believe this to be the first report of persistent Mullerian duct structures in a genotypic male with 17 alpha-hydroxylase deficiency. It could be explained by either impaired secretion or impaired action of anti-Mullerian hormone. Further, contrary to the usual finding of suppressed aldosterone secretion, this patient had measurable levels of plasma aldosterone.
Quality of life of hirsute women
Authors: Sonino Nicoletta , Fava Giovanni A , Mani Elisa , Belluardo Piera , Boscaro Marco
Published: December 2008

Hirsutism is recognized to cause profound distress in affected women, due to cosmetic and psychosexual implications. It was evaluated in the present study by methods found to be valid and reliable in psychosomatic research. Fifty women with hirsutism belonging to the spectrum of disorders from idiopathic hirsutism to polycystic ovary syndrome, after complete medical work-up, underwent the same psychometric evaluation as 50 healthy non-hirsute women, matched for sociodemographic variables. Hirsute women had a Ferriman and Gallwey score ranging from 8 to 19. Psychometric evaluation for quality of life was carried out by the following methods: (a) Kellner's Brief Problem List, a 12 item self-rating list of psychosocial problems; (b) Kellner's Symptom Rating Test (SRT), a 46 item self-rating scale that yields a total score of distress as well as six subscales (anxiety, depression, somatic symptoms, anger-hostility, cognitive and psychotic symptoms); and (c) Marks' Social Situations Questionnaire (SSQ), a 30 item self-rating scale concerned with social phobia. Patients with hirsutism displayed significantly higher social fears at the SSQ than controls (P < 0.01). They also showed more anxiety (P < 0.01) and psychotic symptoms (P < 0.01) at the SRT, whereas there were no significant differences in depression, somatization, anger-hostility and cognitive symptoms. These results suggest that the complex management of hirsute women, in addition to pharmacological and/or cosmetic measures, may require specific psychotherapy.
Age-related differences in simultaneous interarm blood pressure measurements
Authors: Fotherby Martin D , Panayiotou Barnabas , Potter John F
Published: December 2008

Simultaneous noninvasive blood pressure measurement were recorded bilaterally in 40 young and 40 elderly subjects. Overall interarm blood pressure (BP) differences for the elderly and young groups were similar, the absolute interarm differences being for systolic blood pressure (SBP) elderly: 4.2 mmHg (95% CI 3.1-5.3 mmHg); young 3.3 mmHg(2.6-4.1 mmHg); diastolic blood pressure (DBP) elderly 3.6 mmHg(2.8-4.4 mmHg), young 2.7 mmHg(2.0-3.3 mmHg). However, the range of interarm BP differences was wide. Four (10%) of the elderly had an interarm SBP difference > 10 mmHg compared to one (3%) of the young group. Interarm DBP differences > 8 mmHg were found in three (8%) of the elderly and in none of the young group. Although age does not affect mean interarm BP differences, clinically important interarm BP differences exist in both young and elderly subjects. Blood pressure should be measured in both arms of all patients at initial assessment to avoid potential problems with misclassification of blood pressure status.
Obesity, albuminuria and hypertension among Hong Kong Chinese with non-insulin-dependent diabetes mellitus (NIDDM)
Authors: Chan J C N , Cheung C K , Swaminathan R , Nicholls M G , Cockram C S
Published: December 2008

A total of 412 Hong Kong Chinese diabetic patients were studied on at least two occasions 8-16 weeks apart. Although 28% were insulin-treated, only 3.6% had insulin-dependent diabetes (IDDM). In the remaining 397 patients with non-insulin-dependent diabetes (NIDDM), the mean (s.d.) body mass index (BMI) was 24.4 +/- 3.2 kg/m2 in females and 24.2 +/- 3.2 kg/m2 in males. Obesity was present in 17% of males (BMI > 27 kg/m2) and 40% of females (BMI > 25 kg/m2). Established hypertension was present in 49%. Abnormal albuminuria, defined as a mean urinary albumin/creatinine (UA/Cr) ratio greater than 5.4 mg/mmol based on two random spot urine samples, was present in 47%. On stepwise multiple regression analysis, UA/Cr ratio (R2 = 0.34, F = 65.4, P < 0.001) showed significant associations with systolic blood pressure (standardized regression coefficient beta = 0.40, P < 0.001), plasma creatinine concentration (beta = 0.27, P < 0.001) and glycosylated haemoglobin (beta = 0.20, P < 0.001). While the prevalence of hypertension increased with increasing severity of proteinuria, 40% of normoalbuminuric patients had hypertension. Among patients diagnosed before the age of 35 (n = 67), 52% were insulin-treated although only 10% were insulin-dependent. Among these NIDDM patients of young onset (n = 59), obesity was present in 25% of males and 56% of females. Overall, 18% of these patients had a blood pressure greater than 140/90 mmHg and 27% had abnormal albuminuria. In Hong Kong Chinese, diabetes mellitus is predominantly non-insulin-dependent even in the young. Obesity is more prevalent among females. Abnormal albuminuria is relatively common and is closely associated with hypertension and glycaemic control. In the light of increasing prevalence of diabetes among overseas Chinese, our findings may have important implications in the management of Chinese diabetic patients.
Asymptomatic acute pyelonephritis as a cause of acute renal failure in the elderly
Authors: Woodrow G , Patel S , Berman P , Morgan A G , Burden R P
Published: December 2008

Urinary tract infections in the elderly are common, often asymptomatic and usually benign. We report three patients who presented with acute renal failure due to acute pyelonephritis in the absence of clinical findings of infection or urinary tract obstruction. Blood and urine cultures grew Escherichia coli in two of the patients and in two patients renal biopsy confirmed acute pyogenic pyelonephritis. Antimicrobial therapy and haemodialysis led to improvement, though one patient subsequently died from an unrelated cause.

We suggest that acute bacterial pyelonephritis should be considered as a cause of acute renal failure in the elderly. Clinical features of infection may be absent despite bacteraemia. Prompt diagnosis and intervention may avoid chronic renal failure in a group that has a less favourable outcome with long-term dialysis.
Corticosteroid therapy and intercurrent illness: the need for continuing patient education
Authors: Peacey S R , Pope R M , Naik K S , Hardern R D , Page M D , Belchetz P E
Published: December 2008

In patients receiving long-term therapeutic or replacement corticosteroids, delayed or inappropriate adjustment of steroid dosage during intercurrent illness may be fatal. We used a questionnaire to assess current levels of patient knowledge, awareness of the need for action during intercurrent illness and the frequency with which steroid warning cards and Medic Alert pendants were carried, in 61 patients on long-term replacement corticosteroids and in 40 patients receiving long-term therapeutic corticosteroids.

Only 67 of the 101 patients taking corticosteroids were carrying a steroid warning card. Eleven of the 21 Medic Alert owners wore their pendants. Only 18 of the 41 patients in the therapeutic group and 41 of the 60 patients in the replacement group would take appropriate action during an intercurrent illness (P < 0.001).

Lack of patient knowledge in this important area emphasizes the need for continuing and effective education of these groups of patients during follow-up. An information sheet detailing the exact changes to be made during intercurrent illness may help reinforce verbal advice.
Complex neuromuscular disorder in a patient with chronic myeloid leukaemia
Authors: Bergin Peter S , Gale Andrew N
Published: December 2008

We report a 44 year old man who developed external ophthalmoplegia and predominantly respiratory, truncal and bulbar weakness with brisk reflexes, histological evidence of an inflammatory myopathy and a high titre of acetylcholine receptor antibodies, one month after starting hydroxyurea and allopurinol for chronic myeloid leukaemia. The temporal relationship suggests a possible association between this patient's unusual neuromuscular disorder and either the chronic myeloid leukaemia or its treatment.
Asynchronous ovarian torsion--the case for prophylactic oophoropexy
Authors: Grunewald B , Keating J , Brown S
Published: December 2008

The case of an 11 year old girl who suffered torsion of the left ovary 8 months following right oophorectomy for a similar event is presented. The left ovary was saved by immediate surgical intervention. The value of prophylactic oophoropexy in unilateral ovarian torsion is discussed.
Invasive aspergillosis in two patients with acute lymphoblastic leukaemia in complete remission
Authors: Turner Marc L , Russell Lesley , Milne Leslie J R , Parker Alistair C
Published: December 2008

Invasive aspergillosis is a disease of the immunosuppressed patient. We describe two patients with acute lymphoblastic leukaemia who attained complete remission, with partial or complete bone marrow recovery, but who went on to develop fatal invasive aspergillosis contemporaneous with recovery of neutrophil counts. Quantitative recovery of peripheral blood neutrophil counts does not guarantee control of Aspergillus infection, perhaps due to functional neutrophil deficiencies post-chemotherapy, and specific defensive strategies adopted by the organism itself.
A feminizing adrenocortical carcinoma presenting with gynaecomastia
Authors: Lanigan D , Choa R G , Evans J
Published: December 2008

A case is presented in which gynaecomastia was the sole initial presenting symptom of a feminizing adrenocortical carcinoma. This rare pathological lesion is discussed.
Intraperitoneal haemorrhage from anterior abdominal wall varices
Authors: Hunt J B , Appleyard M , Thursz M , Carey P D , Guillou P J , Thomas H C
Published: December 2008

Patients with oesophageal varices frequently present with gastrointestinal haemorrhage but bleeding from varices at other sites is rare. We present a patient with hepatitis C-induced cirrhosis and partial portal vein occlusion who developed spontaneous haemorrhage from anterior abdominal wall varices into the rectus abdominus muscle and peritoneal cavity.
Anterior pituitary function after adrenalectomy in patients with Cushing's syndrome
Authors: Marazuela M , Cuerda C , Lucas T , Vicente A , Blanco C , Estrada J
Published: December 2008

We assessed anterior pituitary function in five patients with Cushing's syndrome before and after the removal of cortisol-secreting adrenal adenomas. Before surgery, all patients lacked response of growth hormone to hypoglycaemia, four had low responses of thyrotrophin to thyrotrophin releasing hormone, three had hypogonadism and two had low prolactin reserve. After successful removal of the adrenal adenoma, all patients developed postoperative hypoadrenocorticism and recovered all impaired anterior pituitary hormones within a period of 3 months. Our results point to a direct inhibiting action of glucocorticoids at the pituitary level as the explanation for the impaired anterior pituitary function. Moreover, direct gonadal suppression by glucocorticoids may be an additional mechanism of hypogonadism in some patients.
Severe metabolic acidosis complicating massive ibuprofen overdose
Authors: Downie Andrew , Ali Amza , Bell Derek
Published: December 2008

We report the progress of a patient who presented following the ingestion of ibuprofen in overdose. He survived despite developing an extremely severe metabolic acidosis.
Systemic lambda light-chain deposition presenting with predominant cardiac involvement
Authors: Garton M J , Walton S , Ewen S W B
Published: December 2008

An 82 year old woman with suspected Bence Jones myeloma developed intractable fluid retention presumed secondary to cardiac failure. In addition she experienced angina pectoris, and required permanent cardiac pacing for symptomatic sinus bradycardia. Postmortem studies revealed prominent myocardial and renal deposits of lambda light-chains which were Congo Red negative, and had a non-fibrillar ultrastructure. Non-amyloidotic light-chain deposition is uncommon, and a rare cause of cardiac disease. Previous work regarding possible pathogenetic mechanisms, clinical and laboratory features and treatment is reviewed.
Parathyroid hormone-related protein as a tumour marker in humoral hypercalcaemia associated with occult malignancy
Authors: Hutchesson A C J , Dunne F , Bundred N J , Gee H , Ratcliffe W A
Published: December 2008

The tumour-derived factor PTH-related protein (PTHRP) is the primary humoral factor responsible for hypercalcaemia in patients with solid tumours. In a woman presenting with anaemia and hypercalcaemia, the finding of raised plasma PTHRP and undetectable serum PTH concentrations led to further investigations and the subsequent identification of a uterine tumour. No evidence of tumour spread was found at operation, and removal of the tumour resulted in normalization of both serum calcium and plasma PTHRP. Expression of PTHRP by the tumour was shown by immunohistochemistry and in situ hybridization. We conclude that the identification of an occult tumour in a patient with hypercalcaemia and raised plasma PTHRP provides evidence of the diagnostic utility of PTHRP immunoassays in the investigation of patients with hypercalcaemia and suspected malignancy.
Salivary gland involvement as initial presentation of Wegener's disease
Authors: Vanhauwaert Bert G , Roskams Tania A , Vanneste Stefan B , Knockaert Daniel C
Published: December 2008

We describe a case of Wegener's disease with massive painful bilateral submandibular gland enlargement as the presenting symptom. The diagnosis was based on histologically documented nasal mucosa involvement, focal necrotizing glomerulonephritis, episcleritis and anti-neutrophil cytoplasmic antibody.
Comparison of clock drawing with Mini Mental State Examination as a screening test in elderly acute hospital admissions
Authors: Death John , Douglas Adam , Kenny Rose Anne
Published: December 2008

Clock drawing is a quick, easy to remember test that is well received by patients. It is a good screening test for Alzheimer's disease in the outpatient setting. We evaluated its usefulness compared with the standard Mini Mental State Examination (MMSE) in elderly acute medical and surgical hospital admissions. Within 48 hours of admission, 117 patients over 70 years old were administered the MMSE and asked to draw a clock. Using the MMSE as the standard, clock drawing had a sensitivity of 77% and a specificity of 87%. Patients with discrepant scores were then further evaluated. The findings suggest that normal clock drawing ability reasonably excludes cognitive impairment or other causes of an abnormal MMSE in elderly acute medical and surgical hospital admissions, where cognitive impairment is common and frequently missed.
Liver/spleen scintigraphy for diagnosis of splenic infarction in cirrhotic patients
Authors: Chin J K T , McCormick P A , Hilson A J W , Burroughs A K , McIntyre N
Published: December 2008

Splenic infarction is rare in cirrhotic patients. The diagnosis of the condition is based on clinical findings and splenic imaging. In recent years, ultrasonography and computed tomographic scan have gained popularity over the more classical scintigraphy as the preferred investigations for the diagnosis of splenic infarction. We report three cases of splenic infarction in patients with cirrhosis and portal hypertension. Computed tomographic scan, angiography and ultrasonography failed to identify the lesions and the diagnoses were finally made with the aid of liver--spleen scintigraphy. We suggest that scintigraphy is the investigation of choice if splenic infarction is suspected in patients with congestive splenomegaly secondary to liver cirrhosis.
Effects of octreotide on circulating islet B cell products in endogenous hyperinsulinism
Authors: Krentz Andrew J , Pace Jackie , Somerville Wendy , Clark Penelope M S , Nattrass Malcolm
Published: December 2008

The role of somatostatin analogues in the medical management of insulinomas is unclear. We describe an elderly patient with clinical and biochemical features of endogenous hyperinsulinism attributable to a benign islet B cell disorder whose incapacitating neuroglycopaenic symptoms responded dramatically to octreotide 50 micrograms subcutaneously at 2200 h each night. Octreotide suppressed inappropriate plasma concentrations of insulin thereby preventing fasting hypoglycaemia. Fasting concentrations of proinsulin, and 32-33 split proinsulin, as determined by two-site monoclonal antibody-based immunoradiometric assays, were also suppressed by octreotide.
Spinal ganglioneuroblastoma--complete response to chemotherapy alone
Authors: Raina V , Kamble R , Tanwar R , Singh S P , Sharma S
Published: December 2008

Ganglioneuroblastoma in the spinal region is rare, the treatment of choice being surgical excision. We present a 21 year old male who was diagnosed to have this condition in the dorsolumbar spinal region. The tumour was extending intraspinally and was unresectable. Combination chemotherapy with Adriamycin (doxorubicin hydrochloride), vincristine, cyclophosphamide, etoposide, ifosfamide and cisplatin resulted in histologically proven complete remission. No radiotherapy or curative resection was done. The patient is alive without evidence of disease 24 months later. Never before has chemotherapy been successfully used as the sole modality of treatment in this condition. Our report raises important questions about the management of this rare condition, particularly in a situation of unresectability.
Sexual abuse of the elderly mentally ill
Authors: Benbow Susan M , Haddad Peter M
Published: December 2008

Sexual abuse of the elderly may occur more commonly than is recognized. Reasons for the neglect of this area and possible risk factors are discussed. A definition of elder sexual abuse is proposed, and four case histories, each of which raises various issues about the nature, detection and management of sexual abuse, are described. In the absence of procedures for dealing with elder sexual abuse, professional staff need to be open to its occurrence and to be prepared to carry out thorough, sympathetic, collaborative assessments of both parties involved where it is suspected.
Reporting ventilation-perfusion lung scintigraphy: impact on subsequent use of anticoagulation therapy
Authors: Kaboli P , Buscombe J R , Ell P J
Published: December 2008

Ventilation and perfusion lung scintigraphy is an established and safe noninvasive technique which has been used for nearly 30 years to establish the diagnosis of pulmonary embolism. Recently, in common with other diagnostic tests, there has arisen the need to reassess the effectiveness of this test in the clinical setting. A retrospective analysis of 244 patients undergoing ventilation-perfusion lung scintigraphy was performed. A total of 203 case notes were available. It was found that the majority of reports (68.5%) were described as either high probability for the presence of pulmonary embolism or normal or low probability. A result of 'high probability' changed the clinical management of the patient in 28/46 (61%) of reported cases but in only 5/91 (5.5%) of patients reported as 'normal' or 'low probability'. During the study there were six deaths, five from other causes and one from pulmonary embolism; this patient died despite anticoagulation following a 'high probability' ventilation-perfusion lung scintigraphy. Ventilation-perfusion lung scintigraphy is a safe and effective noninvasive method to diagnose the presence of pulmonary embolism and a test which has a significant effect on patient management.
Secundum atrial septal defect repair: long-term surgical outcome and the problem of late mitral regurgitation
Authors: Speechly-Dick M E , John R , Pugsley W B , Sturridge M F , Swanton R H
Published: December 2008

This study examines the clinical and surgical outcome of a group of 55 patients (mean age 33 years) with secundum atrial septal defect who underwent surgical repair of this defect between 1981 and 1990. A group of 25 of these patients underwent late echocardiographic follow-up.

Fifty-two patients underwent repair by direct suturing and three by patch closure. Surgical mortality was nil. There was one late death of a 58 year old who died from cardiac failure 4 years after surgery. Late postoperative morbidity consisted of two patients; one, age 63 at the time of surgery, required mitral and tricuspid valve replacement 6 years later and one, age 77 at surgery, developed cardiac failure 3 years later. Atrial fibrillation persisted in the six patients who had the rhythm before surgery and developed postoperatively in two patients aged 54 and 58. Two patients aged 49 and 57 developed immediate postoperative sinus node dysfunction requiring permanent pacing. The mean age at surgery of those six patients who suffered cardiac morbidity was 60 years. The patients with preoperative angiographic evidence of mitral valve prolapse were significantly older (P < 0.001) and had higher mean pulmonary artery pressures (P < 0.001) than patients with normal valves. There was no significant relationship between shunt size and mitral valve prolapse.

Echocardiographic follow-up showed persistent mitral valve prolapse in all nine patients who developed the condition preoperatively. Five patients developed mitral valve prolapse with mitral regurgitation postoperatively, one of whom needed subsequent mitral and tricuspid valve replacement. These five patient were on average older (mean age 54) but the group was too small to prove significance.

The follow-up data illustrate the current low mortality and morbidity associated with surgical closure of atrial septal defects. Late postoperative echocardiography had revealed not only that mitral valve prolapse persists in those patients who developed the condition pre-operatively but that new cases of mitral valve prolapse with mitral regurgitation can occur after atrial septal defect closure.
Recurrent pseudomonas septic arthritis
Authors: Vickers M H , Price T
Published: December 2008

Episodes of septic arthritis caused by Pseudomonas aeruginosa occurred in a patient with an infected vascular graft. He responded well to antibiotic therapy and removal of the graft was not required. The aetiology of this unusual cause of septic arthritis is discussed.
Hypokalaemic periodic paralysis in a thyrotoxic Polynesian
Authors: Carroll D G
Published: December 2008

Hypokalaemic periodic paralysis in a thyrotoxic Polynesian is described. The possible pathophysiology is discussed. Though common in Orientals, this condition is uncommon in Caucasians and has not been described before in a Polynesian.
Successful treatment of Pseudomonas paucimobilis haemodialysis catheter-related sepsis without catheter removal
Authors: Saltissi David , Macfarlane David J
Published: December 2008

Infection is the most common complication of long-term central venous access lines. We report a case of central venous haemodialysis catheter infection with Pseudomonas paucimobilis, successfully treated by prolonged antibiotic administration without catheter removal. The implications are discussed.
Bone density in osteogenesis imperfecta may well be normal
Authors: Paterson Colin R , Mole Patricia A
Published: December 2008

Osteogenesis imperfecta (OI) is often regarded as a form of osteoporosis. However, the bone fragility is the result of defective collagen and earlier work has demonstrated that cortical thickness, in bones not previously fractured, is usually normal. We have now measured the bone mineral content of the distal forearm in 61 adult patients with well characterized OI.

Three patients with the Silence type III disorder had bone mass values well below the reference interval. For the 47 type I patients and 11 type IV patients, the bone mass was significantly lower than normal (P < 0.001). However 70% of patients had values within the reference interval. One cannot therefore exclude the diagnosis of OI by finding normal values with densitometry.

Diagnostic difficulties do not occur in type III patients and our main objective was to recruit as many individuals as possible with OI types I and IV. In the type IV disease, the diagnosis can be particularly difficult without a positive family history. Since the evaluation of bone density by subjective examination of radiographs is a much less precise procedure, most patients with type I and IV OI would be expected to have 'normal' appearances with this assessment. Osteogenesis imperfecta cannot be excluded on the basis of apparently normal bone density or cortical thickness with routine radiographs.
Leprosy presenting as unilateral foot drop in an immigrant boy
Authors: Choe Wonsick
Published: December 2008

This is a case report of a boy who presented with unilateral foot drop approximately 1 year after traumatic injury from skateboarding. Exploratory surgical operation was eventually performed, and histological examination of the surgical specimen revealed leprous peripheral neuropathy of the peroneal nerve. The patient had immigrated from Vietnam to the United States 3 years previously. The occurrence, albeit rare, of this entity in the immigrants from endemic leprosy regions is discussed.
Indian herbal remedies for diabetes as a cause of lead poisoning
Authors: Keen R W , Deacon A C , Delves H T , Moreton J A , Frost P G
Published: December 2008

Herbal remedies from the Indian subcontinent have been found to have high concentrations of heavy metals and unsupervised treatment may result in toxicity. We report the case of an Indian patient with hepatitis who was found to have lead poisoning where the source was traced to ethnic remedies he had been taking for diabetes.
The Jarisch-Herxheimer reaction in leptospirosis
Authors: Vaughan Carl , Cronin Cornelius C , Walsh Elizabeth Kenny , Whelton Michael
Published: December 2008

Three patients with leptospirosis whose condition worsened after initiation of antibiotic therapy are reported. Their clinical deterioration appeared to be due to the development of the Jarisch-Herxheimer reaction rather than to progression of their underlying infection. Relevant aspects of the management of patients with leptospirosis are discussed.
Small bowel obstruction due to encapsulation and abnormal artery
Authors: Adedeji O A , McAdam W A F
Published: December 2008

A case of peritoneal encapsulation is reported. Of fourteen reported and two anecdotal cases, this is the third case with small bowel obstruction. Bowel malrotation is associated with the condition and in our case an abnormal artery was the cause of obstruction. We support previous authors' suggestions that, if the condition is found incidentally at laparatomy, it should be treated surgically by excision of the peritoneal sac and division of any tight band.
Intestinal spirochaetosis
Authors: Lo T C N , Heading R C , Gilmour H M
Published: December 2008

Two cases of intestinal spirochaetosis are described. The first case improved with treatment while the second case improved spontaneously without any intervention. Controversy over treatment and pathogenicity of intestinal spirochaetosis is discussed with review of previous publications.
Prevalence of dyspepsia: the epidemiology of overlapping symptoms
Authors: Grainger S L , Klass H J , Rake M O , Williams J G
Published: December 2008

Studies of the epidemiology of dyspepsia have been complicated by the use of different symptom definitions, subject populations and time frames of investigation. Published figures for the prevalence of dyspepsia vary from 20% to 40%, of which perhaps only a quarter can be attributed to peptic ulcer disease. General practitioners see only a fraction of the dyspepsia within the community, the majority of which is either ignored or treated by self-medication. However, dyspepsia still accounts for about 3-4% of all general practice consultations and for about 14% of all patients attending. In about half of all cases, even extensive investigation reveals no underlying organic lesion.

There has been much recent interest in the clinical value of grouping dyspeptic symptoms into particular subtypes. These have been called ulcer-like, dysmotility-like and reflux-like. Although these patterns have descriptive value, there is no evidence that they result from discrete pathophysiological processes. Indeed, studies both in general practice and in the community show a large degree of overlap between them.
Serious unexpected sinus infection discovered by CT scanning for presumed neurological disease
Authors: Swift Andrew C , Gill Geoffrey V
Published: December 2008

Serious infection in the paranasal sinuses may present with symptoms suggestive of neurological disease and thus lead to delay in the diagnosis and subsequent treatment. We present three such cases in whom the initial diagnoses had been acute optic neuritis, a posterior communicating aneurysm and an intracranial space occupying lesion. The fourth patient had meningitis but the paranasal sinuses had not initially been considered as a possible source of infection. The current methods of diagnosing sinusitis are discussed.
The timing of breast cancer surgery within the menstrual cycle
Authors: Corder A P , Cross M , Julious S A , Mullee M A , Taylor I
Published: December 2008

The effects of the timing of surgery, fine needle aspiration cytology (FNAC) and mammography within the menstrual cycle were investigated retrospectively in 211 premenopausal breast cancer patients. The day of surgery within the menstrual cycle was known for 157 women whose menstrual cycles were regular. Recurrence and survival were closely similar whether surgery was performed during days 3-12 or at other times (days 0-2 or 13-32) in the cycle. Outcome was also unrelated to the timing of mammography which was known in 101 cases. There were no significant differences in recurrence or survival associated with the timing of FNAC when all patients were considered.

In the subset of lymph node negative patients (n = 32), however, FNAC outside days 3-12 was associated with a significantly decreased rate of relapse (RR = 0.25, 95% CI = 0.07-0.9) and death (RR = 0.10, 95% CI = 0.02-0.9). These patients, however, also had significantly smaller tumours (median = 2 cm, interquartile range = 2-3 cm) than patients having FNAC on days 3-12 of the cycle (median = 3, interquartile range = 2-4) (Mann-Whitney: z = 2.11, P = 0.04).

We have not confirmed that surgery or FNAC during days 3-12 of the cycle is associated with a poorer outcome than interventions during other parts of the cycle.
Splenectomy in patients with undiagnosed splenomegaly
Authors: Cronin C C , Brady M P , Murphy C , Kenny E , Whelton M J , Hardiman C
Published: December 2008

Of splenectomies performed in the Cork Regional Hospital over an 11 year period, ten were undertaken primarily for diagnostic purposes. A definitive histological diagnosis was established in nine patients, seven of whom had lymphoma, two with Hodgkin's disease and five with non-Hodgkin's lymphoma. The weight of the excised spleen in all patients with lymphoma exceeded 1 kg; in all those with a diagnosis other than lymphoma, the spleen weighed less than 1 kg. A majority of patients also had symptomatic improvement from reversal of hypersplenism and from relief of the mechanical pressure effects of an enlarged spleen. Operative mortality was zero.

Diagnostic splenectomy is a worthwhile procedure. Most patients will have lymphoma.
Attitudes of junior medical staff to requesting permission for autopsy
Authors: Hinchliffe Stephen A , Godfrey Hugh W , Hind Charles R K
Published: December 2008

The attitudes of junior medical staff in a university teaching hospital to requesting postmortem examination were assessed. Following completion of 100 death certificates, autopsy was sought in only 28 cases (and refused in 18). The majority of staff were unaware of the reported benefits of autopsy, despite their inclusion in the local medical handbook and had received no training in how to seek permission for a necropsy. Formal education programmes have been shown to improve hospital autopsy rates and the results of this study suggest that these would be welcomed by junior medical staff.
Use of ketorolac by continuous subcutaneous infusion for the control of cancer-related pain
Authors: Myers Kathryn G , Trotman Ivan F
Published: December 2008

Ketorolac tromethamine is a newly available non-steroidal anti-inflammatory drug which is suitable for parenteral administration. We have given it by continuous subcutaneous infusion to 36 patients with pain due to advanced cancer. Improvement in pain control occurred in 29 (80%). A reduction in the dose of concomitant opioid analgesia was possible in 22 (76%) and a reduction in opioid-related adverse effects occurred in 16 (73%) of these. Ketorolac was most effective in patients who had bone or visceral pain. It was mixed safely with diamorphine in a syringe driver at concentrations up to 4 g diamorphine/10 ml and 120 mg ketorolac/10 ml. Infusion was well tolerated for periods of up to 115 days (mean 21 days; median 15 days; range 3-115 days). Four patients experienced gastrointestinal bleeding and one colonic perforation to which treatment with ketorolac may have been a contributory factor. No other clinically significant adverse effects were observed.
Anorexia nervosa and necrotizing colitis: case report and review of the literature
Authors: Sakka Samir , Hurst Paul , Khawaja Hamid
Published: December 2008

A 20 year old woman with anorexia nervosa and severe weight loss developed extensive necrotizing colitis after being admitted to hospital for stabilization of her weight. Necrotizing colitis with anorexia nervosa has been reported previously. We report a second case. We believe necrotizing colitis is a true complication of anorexia nervosa and should be considered in the differential diagnosis in patients with primary anorexia who develop an acute abdomen.
T cell non-Hodgkin's lymphoma presenting in the first trimester of pregnancy
Authors: Lees C C , Tsirigotis M , Carr J V L , Richards M A
Published: December 2008

This case report details of the presentation of a young woman in the first trimester of her pregnancy with lethargy, weakness, vomiting, pyrexia and lymphadenopathy. Extensive investigation revealed an advanced T cell lymphoma and only the second reported case in pregnancy to our knowledge. We discuss her management and subsequent chemotherapy in the context of a short review of the literature spanning the last decade.
Reversible digital clubbing in acute myeloid leukaemia
Authors: Bhandari S , Wodzinski M A , Reilly J T
Published: December 2008

A 43 year old woman presented with acute myeloid leukaemia, marked finger and toe clubbing, and a hilar mass. Biopsy of the hilar mass was not technically possible, but it almost certainly represented a granulocytic sarcoma since chemotherapy induced rapid resolution of the mass along with reversal of the clubbing and remission of the leukaemia. Relapse of the leukaemia 21 months later was associated with return of the clubbing. It is hypothesized that an abnormal circulation within the granulocytic sarcoma may have accounted for the development of clubbing.
The features and aetiology of Fournier's gangrene
Authors: Efem S E E
Published: December 2008

This paper reports a clinical study of 20 cases of gangrenous ulcers of the scrotum and/or of the penis (Fournier's gangrene) and a review of previous publications. Even though found mostly in elderly male patients, the disease spares no age group and can involve the external genitalia in neonates and women as well. The disease is a necrotising fasciitis of infective origin and always has a portal of entry of the infecting organisms even though it may be so trivial as to be undetected. The commonest portals of entry of infection are periurethral sepsis, groin wound sepsis, anorectal sepsis, prostatic sepsis and trauma. The infecting organisms comprise both aerobic and anaerobic organisms such as Escherichia coli, Streptococcus pyogenes, Pseudomonas aeruginosa, Klebsiella pneumonia, Proteus mirabilis, enterococci, Bacteroides fragilis and anaerobic streptococcus. Fournier's gangrene is probably the same disease as necrotizing fasciitis occurring in other parts of the body, but modified by the peculiar anatomy of the genitoperineum.
Clinical presentation of orthostatic hypotension in the elderly
Authors: Craig G M
Published: December 2008

Fifty cases of orthostatic hypotension in the elderly are analysed. Three main modes of presentation were identified: (1) falls or mobility problems; (2) mental confusion or dementia; or (3) predominantly cardiac symptoms. Selected case histories are given to illustrate diagnostic difficulties. Medication was responsible for orthostatic hypotension in 66% of patients and striking examples of polypharmacy were encountered. However, 34% of cases were not iatrogenic. Only 14% of patients had overtly postural symptoms. A high index of suspicion is needed to diagnose orthostatic hypotension in the elderly and the condition is often overlooked. The paper provides useful diagnostic clues for clinicians.
Tumour lysis syndrome after treatment of chronic lymphocytic leukaemia with fludarabine
Authors: Montalban Carlos , Liaño Fernando , Aguilera Abelardo
Published: December 2008

Fludarabine is one of the most recent and promising therapeutic agents for chronic lymphocytic leukaemia. We describe a patient who developed tumour lysis syndrome after the first course of treatment with fludarabine and call attention to this uncommon but potentially lethal complication that has not been previously taken into account in this neoplasia. It should always be anticipated when patients are treated with new and effective drugs.
Cytomegalovirus myocarditis following liver transplantation
Authors: Stack William A , Mulcahy Hugh E , Fenelon Lynda , Hegarty John E
Published: December 2008

Cytomegalovirus (CMV) infections are commonly found in patients on immunosuppressive therapy following liver transplantation. However, acute myocarditis is an extremely rare manifestation of CMV infection in this setting. We report the case of a patient who developed acute myocarditis with severe biventricular failure with a cardiac ejection fraction of less than 10%, 6 weeks following orthotopic liver transplantation. Systemic CMV infection was diagnosed on the basis of a clinical viraemia, the presence of CMV antigen in urine, blood, and throat swab, and an associated four-fold rise in serum antibody titres to CMV. A full recovery ensued following treatment with standard anti-cardiac failure therapy and a 10 day course of intravenous ganciclovir.
Effect of acute cytomegalovirus infection on drug-induced SLE
Authors: Schattner Ami , Sthoeger Zeev , Geltner David
Published: December 2008

A 58 year old woman developed systemic symptoms, interstitial lung disease, splenomegaly, leukopenia and anti-histone and anti-nuclear antibodies (ANA), while treated with hydralazine for hypertension. Five months after presentation she was admitted with high fever, skin rash and atypical lymphocytosis due to acute cytomegalovirus (CMV) infection. Worsening leukopenia and increased ANA were found, and high titres of anti-DNA antibodies, anti-cardiolipin antibodies and rheumatoid factors appeared. Hydralazine was stopped and the patient gradually became asymptomatic. All autoantibodies spontaneously disappeared (over 16 weeks), and the white cell count and spleen size became normal. The patient was found to be a slow acetylator and to have both HLA-DR4 and selective IgA deficiency.

Thus, a multifactorial genetic susceptibility to develop drug-induced lupus was brought out in stages first by hydralazine and then by CMV, yet all manifestations and autoantibodies resolved spontaneously, demonstrating the complex interplay of varied environmental factors with a genetic predisposition in the pathogenesis of autoimmunity.
Pseudohyperkalaemia associated with hereditary spherocytosis in four members of a family
Authors: Alani F S S , Dyer T , Hindle E , Newsome D A , Ormerod L P , Mahoney M P
Published: December 2008

Pseudohyperkalaemia was detected in four members of a family all of whom have hereditary spherocytosis with normal white blood cells and platelets counts. The degree of pseudohyperkalaemia was related to the time between sampling and cell separation, and inversely related to the temperature in which the sample was left to stand before cell separation. A fifth member of this family was free from both conditions. The association suggests linkage at a membrane level.
45,X Turner syndrome with normal ovarial function and multiple malformations of the aorta
Authors: Apostolopoulos T D , Kyriakidis M K , Kitsiou S A , Galla-Voumvouraki A D , Tsezou A N , Toutouzas P K
Published: December 2008

We present a case of a female patient with monosomy of X chromosome in peripheral lymphocytes and skin fibroblasts, normal ovarian function and associated multiple congenital abnormalities of the aorta: bicuspid aortic valve, dilatation of the ascending aorta and multiple cystic structures of the aortic wall, complicated by endarteritis. We review the literature on fertile women with 45,X karyotype and the possible pathogenetic mechanisms of the aortic defects described as 'cystic medial necrosis of the aorta'.
Osteomyelitis and infective endocarditis
Authors: Speechly-Dick M E , Swanton R H
Published: December 2008

Osteomyelitis is thought to occur as a complication of infectious endocarditis in as many as 6% of cases of endocarditis. We describe this association in three patients. Osteomyelitis may be difficult to diagnose in patients with endocarditis because symptoms such as fever, bone pain and stiffness are common to both illnesses, therefore physicians need to have a high index of suspicion to avoid missing this important complication. We recommend that patients with endocarditis and persistent or localized musculoskeletal symptoms should be investigated to exclude osteomyelitis. Plain radiographs can be normal in 50% of cases of osteomyelitis in the early stages or show only minor abnormalities, but bone scans are highly sensitive. We suggest that a bone scan is performed if radiography is unhelpful, since a diagnosis of osteomyelitis can effectively be excluded if the bone scan is normal. We advocate close follow-up of these patients with prolonged antibiotic treatment consisting of at least 6 weeks of intravenous therapy, and 3 months or longer of oral therapy.
Unusual cause of orthopnoea: primary tracheal tumour mimicking left ventricular failure
Authors: Antonios Tarek F , Singer Donald R J , Millard F J C , Wilson Allan G , MacGregor Graham A
Published: December 2008

An 84 year old woman who was a heavy smoker presented with clinical features suggestive of acute exacerbation of chronic obstructive lung disease complicated by left ventricular failure. She responded poorly to treatment and then the finding of stridor, only when she was in the supine position, led to the diagnosis of a primary tracheal tumour, a rare but important cause of unexplained shortness of breath.
Influenza vaccination: do the aged reap the benefit?
Authors: Morgan R , King D , Turnbull C J
Published: December 2008

An audit of 100 elderly in-patients with appropriate medical conditions revealed that 63% had not been vaccinated this winter. 74% would have accepted vaccination if offered. A general practitioner questionnaire found that 42% relied on elderly patients coming forward and requesting vaccination. Unfortunately, many elderly patients are still missing out on influenza vaccination.
Guillain-Barré syndrome following meningococcal meningitis
Authors: Puri V , Khalil A , Suri V
Published: December 2008

A case of Guillain-Barré syndrome following meningococcal meningitis is reported. The diagnosis was made on clinical grounds and the results of electrophysiological studies. The patient recovered spontaneously. Guillain-Barré syndrome following meningococcal infection has not to our knowledge been reported previously.
Multiple sclerosis presenting as late functional deterioration after poliomyelitis
Authors: Chroni E , Howard R S , Panayiotopoulos C P , Spencer G T
Published: December 2008

We describe five patients with previous poliomyelitis who developed multiple sclerosis (two laboratory supported definite and three clinically definite). The initial symptoms of functional deterioration developed a mean of 30 years following poliomyelitis. Initial functional deterioration was due to progressive limb weakness or impaired mobility and in three cases this led to an initial diagnosis of post-polio muscular atrophy. The clinical diagnosis became apparent with the subsequent development of characteristic clinical features, including optic nerve, brainstem, cerebellum, and spinal cord involvement. The occurrence of multiple sclerosis in these patients emphasises that late functional deterioration may be apparently unrelated to previous poliomyelitis. Furthermore, characteristic clinical features may be masked by the severe pre-existing neuromuscular and orthopaedic impairment leading to diagnostic delay and confusion with the ill-defined clinical syndrome of progressive post-polio muscular atrophy.
A patient with co-existing bronchial carcinoid tumour and bilateral phaeochromocytoma
Authors: Chan H H L , Yeung V T F , Chow C C , Ko G T C , Cockram C S
Published: December 2008

We report a 31-year-old Chinese man with bronchial carcinoid tumour and bilateral phaeochromocytoma. His sister also gave a history of bilateral carotid body paraganglioma. This case demonstrates the importance of screening for other endocrine disorders in patients with foregut carcinoid tumours.
Primary hyperaldosteronism due to an adrenal adenoma in a 14-year-old boy
Authors: Rodriguez-Arnao J , Perry L , Dacie J E , Reznek R , Ross R J M
Published: December 2008

Conn’s syndrome due to an adrenal adenoma is very rare in children. This paper reports a 14-year-old boy with primary hyperaldosteronism due to an adrenal adenoma. His biochemistry data were compatible with either bilateral adrenal hyperplasia or an adrenal adenoma. A dexamethasone test did not suppress aldosterone levels. Venous catheter sampling and 75Se-selenomethylcholesterol scanning suggested that the hyperaldosteronism originated at the right adrenal. Computed tomography showed an 8-mm low-density nodule in the right adrenal gland and magnetic resonance imaging confirmed the nodule which had high signal intensity on T2-weighted images consistent with a functioning adenoma. Surgery confirmed the right adrenal adenoma, and the patient was cured by right adrenalectomy. This case illustrates the difficulty of defining the aetiology of primary hyperaldosteronism and we review the biochemical and scanning techniques available to aid in diagnosis. Hypertension is unusual in children and endocrine causes are very rare, but Conn’s syndrome should always be considered in the differential diagnosis.
Yellow nail syndrome and xanthogranulomatous pyelonephritis
Authors: Danenberg H D , Eliashar R , Flusser G , Rosenmann E , Chajek-Shaul T
Published: December 2008

We report a case of a 74-year-old woman exhibiting the yellow nail syndrome in association with ipsilateral xanthogranulomatous pyelonephritis. Nephrectomy resulted in complete resolution of the pleural effusion and slow improvement of the yellow nails. This report calls attention to the renal-related pleural effusion, and to the thorough investigation needed for the yellow nail syndrome.