bluuebunny/crossref_metadata_2025_split huggingface dataset:
Bowen disease of the conjunctiva treated by Mohs resection
Authors: Sheth Hiten G , Jain Rajni , Joshi Naresh 
Published: May 2014

A previously healthy 61-year-old Caucasian woman was referred with a recurrent right upper eyelid lesion. She had first presented to her local ophthalmic service with a 6-month history of an eyelid lump which was initially diagnosed as a presumed chalazion and treated by incision and curettage. On examination visual acuities were 6/6 in either eye and anterior and posterior segment examination was unremarkable. Eversion of the right upper lid revealed a 4 mm lesion arising from the marginal palpebral conjunctiva around the lateral third of the eyelid (Figure 1) and a shave biopsy was performed. This revealed enlarged and atypical keratinocytes with numerous mitoses, consistent with Bowen disease. The patient had no ophthalmic history, was a controlled hypertensive (atenolol 25 mg), and had no risk factors for immunosuppression and no history of lid trauma, other skin cancers or excess sun exposure. The lesion was surgically excised using the Mohs method, frozen section histology confirming clear margins with complete removal. The site was closed directly without the need for lid augmentation or reconstruction and the appearance 2 weeks post-procedure was functionally and cosmetically acceptable(Figure 2). At 6-month follow up there was no clinical evidence of recurrence.
Postoperative cognitive decline, dementia and anaesthesia
Authors: Ballard Clive , Clack Hannah , Green David 
Published: May 2014

The potential for older people to develop cognitive impairment as a consequence of major surgery with anaesthesia has been increasingly recognized over the last 10 years. This article reviews the evidence regarding the incidence, outcome and potential mechanisms of cognitive impairment and considers the specific implications for people with dementia.
Coronary angiography in chronic aortic dissection
Authors: Rao Archana , Hakeem Abdul , Morrison Lindsay 
Published: May 2014

A 67-year-old man was followed up by the thoracic surgeons with annual computed tomography (CT) scans for a chronic type B dissection of his thoracic aorta. He had medically treated hypertension and was a smoker. On the CT scan the descending aorta measured 6.4 cm and elective surgical intervention was planned. The patient was well and relatively asymptomatic with normal renal function. All peripheral pulses were present. He was listed for a coronary angiogram preoperatively. The procedure was undertaken via the right femoral artery. Access was gained easily but it was not possible to advance the guide wire beyond the arch. An arch aortogram was undertaken (Figure 1) which confirmed that the guide wire was in the false lumen. The coronary arteries were intubated via the right brachial approach (Figure 2). It appears that coronary and upper limb perfusion was from the true lumen and the rest from the false lumen.
Emphysematous cystitis
Authors: Casey Rowan , Stunell Helen , Torreggiani William C , Grainger Ronald 
Published: May 2014

A 70-year-old poorly-controlled type 2 diabetic male presented with a 48-hour history of dysuria, frequency and frank haematuria. He described a 6-week history of worsening bladder outflow obstructive symptoms with nocturia and hesitancy. On examination he had a temperature of 37.5°C and tenderness in the left iliac fossa. Digital rectal examination revealed a tender, smoothly enlarged prostate gland. Blood glucose measurement was significantly elevated at 17 mmol/litre and serum white cell count was elevated at 19×109/litre, demonstrating a marked neutrophilia. A plain film of the abdomen demonstrated the presence of a well-defined area of lucency in the region of the bladder suggestive of air within the bladder wall. A large lucent area was also noted in the left lower quadrant suggestive of a large bladder diverticulum distended with air (Figure 1). Based on these findings, a diagnosis of emphysematous cystitis was considered likely and the patient was commenced on broad-spectrum intravenous antibiotics, intravenous fluids and subcutaneous insulin sliding scale. Subsequent computed tomography of his abdomen and pelvis with intravenous and oral contrast confirmed the presence of emphysematous cystitis with a markedly abnormal, thick-walled bladder as well as air within the bladder wall (Figure 2). The large lucency seen in the left lower quadrant on plain film was shown on computed tomography to represent a 9.7 cm bladder diverticulum, also containing air within its wall (Figure 3). There was no evidence of a colovesical fistula. Urine culture demonstrated a significant growth of Escherichia coli. His clinical course was uneventful and he was discharged home well 7 days later on oral antibiotics for a total of 14 days. He is due for further investigation of his lower urinary tract symptoms with cystoscopy.
Isaacs syndrome
Authors: Sharma Neel , Verma Surabhi , Yeung Michelle 
Published: May 2014

A 57-year-old retired factory worker was admitted to the accident and emergency department complaining of a 3-month history of painful stiffness of his hands and toes. In addition he complained of generalized weakness, numbness and a tingling sensation of both his upper and lower limbs as well as weight loss. He was keen to mention that his stiffness had been long lasting and was even present during sleep. There was no significant past medical history. On general examination a mild weakness affecting the distal region of all four limbs were noted in addition to myokymia. He was also remarkably unsteady on his feet. There was no evidence of excessive perspiration or muscle wasting. A routine full blood count, urea and electrolytes, liver function and creatinine kinase were unremarkable. The patient was referred for electromyography testing which demonstrated evidence of neuromyotonia and myokymia. Antibody testing to voltage-gated potassium channels was not performed. The patient was prescribed phenytoin 50 mg twice daily. After 1 week his symptoms had improved substantially and at 1-month follow up the patient was practically asymptomatic.
Dressler's syndrome post-pacemaker insertion
Authors: Porter Gordon , Doherty John , Wong Roger 
Published: May 2014

A 75-year-old man underwent placement of a dual-chamber pacemaker for symptomatic sinus node disease in a tertiary referral centre. Three days after the procedure, he presented to the emergency department in the same hospital with right-sided, pleuritic chest pain and a diagnosis of pulmonary embolus was considered, although excluded by investigations which included spiral computed tomography and d-dimer. He was discharged, only to return the next day with increasing dyspnoea, and a transthoracic echo confirmed the clinical diagnosis of a significant pericardial effusion with early signs of tamponade physiology. In the operating room 700 ml of blood-stained fluid was aspirated and the patient's symptoms improved dramatically. Chest X-ray and pacemaker interrogation did not necessitate re-positioning of the pacemaker leads. One month later he returned to his local hospital complaining of increasing dyspnoea and a chest X-ray (Figure 1) demonstrated a large right pleural effusion and a smaller effusion on the left. There was a moderate pericardial effusion without tamponade (Figure 2). The larger of the pleural effusions was aspirated with improvement in the patient's symptoms, but recurrence of the fluid, persistent symptoms, a low grade fever and a high erythrocyte sedimentation rate, led to consideration of Dressler's syndrome. The patient was commenced on prednisolone 60 mg daily and both his symptoms and the pleural effusion resolved.
Elongated styloid process or Eagle's syndrome
Authors: Vaidhyanath R , Kenningham R 
Published: May 2014

A 39-year-old woman presented to the maxillofacial clinic of the authors' institution with a 2-year history of pain in the right side of the throat radiating to the right face and ear. On clinical examination, there was scarring in the anterior pillar of the fauces, more prominent on the right side. There was no ulceration or palpable neck mass. The temporomandibular joints were normal. The patient gave a history of tonsillectomy 19 years ago. An orthopantomogram (Figure 1) demonstrated elongated styloid processes bilaterally, measuring 4.4 cm on the right and 4 cm on the left. Palpation of the styloid process following review of the orthopantomogram resulted in exacerbation of the patient's symptoms on the right side. Unenhanced computed tomography (Figure 2) of the neck confirming the clinical diagnosis of elongated styloid process or Eagle's syndrome. The patient underwent right-sided styloidectomy through an intra-oral approach. She was symptom free at 1 year follow-up.
Silent sinus syndrome: a cause of enophthalmos
Authors: Vaidhyanath R , Kenningham R 
Published: May 2014

A 66-year-old woman presented to the ophthalmology unit with a 3-month history of a 'receding right eye'. The patient noted occasional drooping of the right upper eyelid but no disturbance of vision. Clinical examination revealed deep right superior sulcus. Hertel ophthalmometry confirmed enophthalmos of 3 mm on the right side. Visual acuities were 6/6 bilaterally, eye movements were normal and visual fields were normal on testing by confrontation. There was no history of previous orbital trauma or significant sinus disease, particularly recurrent acute sinus disease. Computed tomography of the orbits was requested to exclude orbital disease. Computed tomography findings were complete opacification of the right maxillary sinus with occlusion of the maxillary ostium, downward displacement of the floor of the right orbit and enlargement of the right middle meatus. Mucosal thickening is noted in the left maxillary sinus (Figure 1). The right maxillary sinus volume was reduced with inward bowing of its walls (Figure 2). Thre patient underwent a right middle meatal antrostomy. Three months after surgery the patient's symptoms had improved and hence an orbital floor repair was not considered
Atrial pacing wires: an uncommon cause of postoperative hiccups
Authors: Doshi H , Vaidyalingam R , Buchan K 
Published: May 2014

A 60-year-old man was admitted to the cardiac intensive care unit following elective coronary artery bypass grafting. His past medical history included ischaemic heart disease and hypertension. Persistent bradyarrhythmias had necessitated temporary pacing before termination of cardiopulmonary bypass. This was achieved using right atrial epicardial pacing wires. On admission to the unit he was being paced at 80 beats per minute with a blood pressure of 132/68 mmHg, central venous pressure of 9 mmHg and an arterial oxygen saturation of 98%. The immediate postoperative period was uneventful and he was weaned off ventilatory support as per departmental protocol. Following extubation the patient complained of hiccups. On examination he had diaphragmatic contractions only on the right side synchronous with the pacing rate. At this point, as his heart rate had increased the pacing rate was reduced. This reduced the frequency of hiccups and switching off the pacemaker lead to the resolution of hiccups.
Lethal cause of abdominal pain: a diagnosis not to be missed
Authors: Durai Rajaraman , Ruhomauly Sha-Nawaz , Kerwat Rajab , Hoque Happy 
Published: May 2014

A 77-year-old woman was brought to the accident and emergency department with a 11-day history of abdominal pain. She was in shock and required resuscitation. She had attended the accident and emergency a few days before and had been discharged home with a diagnosis of non-specific abdominal pain. The previous abdominal X-ray is shown in Figure 1. Her past medical history included bilateral below knee amputation for peripheral vascular disease, pacemaker for heart block and hypertension. On examination, post-resuscitation, she was confused and apyrexial with a heart rate of 100 beats/minute and a blood pressure of 110/70 mmHg. Her abdomen was diffusely distended with minimal tenderness in the epigastrium and supra-umbilical region. There was no rigidity or guarding. Bowel sounds were normal. Digital rectal examination showed soft faeces. Blood test showed a haemoglobin of 6.6 g/dl (down from 11 g/dl during her previous accident and emergency visit). There was slight impairment of renal function with a urea of 11 mg/dl and creatinine of 160 mg/dl. The rest of the blood tests were within normal limits. Arterial blood gases showed metabolic acidosis with a pH of 7.2 and lactate of 3 mmol/litre. A computed tomography scan of the abdomen was performed. 1. What is the differential diagnosis? 2. What can you find in the abdominal X-ray? 3. What can you find in the computed tomography scan? 4. What is the treatment? 5. What is the prognosis of this patient? The differential diagnoses in this case are peritonitis from hollow viscus perforation, ischaemic bowel and leaking abdominal aortic aneurysm. The abdominal X-ray (Figure 1) shows minimal dilatation of the right and transverse colon and a tortuous calcified aorta. However the upper aortic calcification is not obvious. Computed tomography scan shows an abdominal aortic aneurysm which commences immediately distal to the origin of the right renal artery with not involving the bifurcation. There is leakage from this aneurysm (Figure 2b arrow) which has a maximum diameter of 5 cm. There is a periaortic haematoma which extends anteriorly to displace the loops of bowel anteriorly (Figure 2b). There is free fluid in the peritoneal cavity (Figure 2a). The right kidney is well perfused but the left kidney shows no evidence of perfusion (Figure 2c). There are some calculi in the left pelvis. In this patient, palliation was felt to be the most appropriate treatment option (her case was discussed with the on-call vascular surgeons). The patient died a few hours after her hospital admission. In a relatively fitter patient, open surgery is the treatment of choice.
The acute medical abdomen: Henoch–Schönlein purpura presenting with peritonitis and nephritis
Authors: Sritharan Kaji , Karim Ahmed , Ijaz Samia , Raymond Sebastian 
Published: May 2014

A 41-year-old man presented with a 6-day history of worsening generalized, colicky abdominal pain associated with fever, non-bloody diarrhoea, vomiting and joint swelling. This was preceded by an upper respiratory tract infection for which he was prescribed antibiotics. On examination, the patient was febrile with generalized abdominal tenderness and peritonitis localized to the right iliac fossa. Investigations revealed an elevated white cell count of 14.0×109/litre (neutrophils 11.0×109/litre) and a C-reactive protein of 120 mg/litre. Abdominal X-ray (Figure 1) showed a decreased bowel gas pattern. An initial diagnosis of antibiotic-related colitis was made. The patient's symptoms did not resolve and computed tomography scanning of the abdomen was performed and revealed focal jejunal thickening with associated mesenteric inflammation and free fluid within the pelvis (Figure 2). This suggested either inflammatory bowel disease or focal bowel ischaemia, and since the clinical picture favoured the former, broad spectrum intravenous antibiotics and steroids were commenced. The patient later developed generalized peritonitis and underwent laparotomy. At surgery, a large amount of serosanguinous free fluid was found, a 30 cm segment of jejunum was thickened and inflamed and the small bowel mucosa was congested. The abdominal cavity was washed out and a jejunal biopsy was performed which demonstrated vasculitis (Figure 3). Two days post-laparotomy the patient developed a polyarthritis and a purpuric rash over the limbs. Blood tests revealed an erythrocyte sedimentation rate of 65 mm/hour; rheumatoid factor, anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies, complement C3 and C4 levels were unremarkable. The rash and arthritis improved, but 2 weeks later the patient developed macroscopic haematuria. Urinalysis demonstrated proteinuria; serum albumin was 20 g/litre and serum urea and creatinine were 8.4 mmol/litre and 135 μmol/litre respectively. A 24-hour urine collection showed a protein loss of 0.5 g/24 hours and a creatinine clearance of 53 ml/min. Core biopsy of the renal cortex and medulla revealed focal, segmental proliferative glomerulonephritis, consistent with an immunoglobulin A nephropathy. The patient was managed with an angiotensin-converting enzyme inhibitor, aspirin, furosemide, prednisolone and mycophenolate and made a full recovery.
Mandibular coronoid process hyperplasia causing restricted mouth opening
Authors: Vaidhyanath R , Raj V 
Published: May 2014

A 52-year-old Caucasian woman underwent pre-anaesthetic evaluation before myomectomy for uterine fibroids. She had limited mouth opening of 10 mm (intra-incisal) and her lateral excursive movements were poor. There was no history of trauma or known temporomandibular dysfunction. The patient had not previously undergone surgery under general anaesthesia. She was not concerned about her limited mouth opening and had not sought medical help for it. Orthopantomogram (Figure 1) and unenhanced computed tomography of the mandible in the closed (Figure 2a) and open mouth (Figure 2b) positions were performed. The orthopantomogram and computed tomography showed bilateral mandibular coronoid process hyperplasia. In the open mouth position, the elongated coronoid processes impinge on the zygomatic arch, limiting the mouth opening. The patient underwent bilateral mandibular coronoidectomy (Figure 3). Intra-incisal opening improved to 28 mm following surgery and she subsequently underwent myomectomy.
Cardiac amyloidosis: non-invasive diagnosis and current treatment strategies
Authors: Lodge FM , Dubrey SW , Collinson J , Prasad SK 
Published: May 2014

A 70-year-old Irish man presented with several months of breathlessness and lethargy, which had become acutely worse over the preceding week. Exercise tolerance had decreased to around 40 yards, having previously been unlimited. Other symptoms included episodes of dizziness on standing and an occasional cough productive of small amounts of white sputum. There was no previous history of cardiac disease or any regular medication. Examination revealed pitting oedema up to the mid-thigh and a grade 4 pansystolic murmur consistent with mitral regurgitation. There was decreased air entry and dullness of both lung bases. The abdomen was mildly distended with ascites and there was non-tender, smooth hepatomegaly extending to 4 cm below the costal margin that had been documented 2 years previously. A 12-lead electrocardiogram (Figure 1) demonstrated atrial fibrillation with right bundle–branch block and complexes of less than 0.5 mV in amplitude in the limb leads. Echocardiography showed a left ventricular wall thickness of 16 mm (normal range 7–12 mm), but with preserved left ventricular function. There was mild mitral and aortic regurgitation. Myocardial perfusion imaging demonstrated normal resting left ventricular function with no evidence of inducible ischaemia and an ejection fraction of 60%. A thickened myocardium was noted, as well as mild irregular areas with reduced uptake throughout the myocardium in a non-coronary distribution, that was presumed to be artefact. Subsequent to these investigations, it was found that echocardiography had been conducted in 2000 after two siblings had been diagnosed with hereditary amyloidosis caused by a mutation in the transthyretin gene. The patient was positive for the mutation, but had no evidence of amyloid disease at this time. The family was part of a large West Irish pedigree with an autosomal dominant alanine substitution in the gene at position 60. The diagnosis was subsequently confirmed using cardiac magnetic resonance scanning (Figure 2).
Rheumatic mitral valve disease in pregnancy
Authors: Dubrey Simon W , Kohli Sanjay K , Grocott-Mason Richard , Dhanjal Mandish K , Punjabi Prakesh P , Nihoyannopoulos Petros , Nelson-Piercy Catherine 
Published: May 2014

A 32-year-old Nepalese woman with known rheumatic mitral valve disease presented 17 weeks into her first pregnancy with exertional breathlessness and wheezing, leading to expectoration of foamy pink liquid. Her history included percutaneous balloon mitral valvotomy at the age of 25 years, after which she had remained asymptomatic and fully active. She had three episodes of acute pulmonary oedema and was transferred to a tertiary centre for further management. An echocardiogram suggested severe mitral stenosis (mitral valve area 1.0 cm2) and pulmonary hypertension (mean pulmonary artery pressure 87 mmHg). She had further episodes of pulmonary oedema despite maximal medical therapy with diuretics, cardioselective beta blockers (dose limited because of systolic hypotension), digoxin, nitrates and anticoagulation. At 21 weeks' gestation, an emergency St Jude metallic valve was implanted. Unfortunately, intrauterine death occurred 2 days postoperatively, likely caused by pre-eclampsia or haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. The patient recovered well and continues on warfarin and a small dose of beta blocker.
The ‘missing piece’ sign: distant migration of a patellar tendon cerclage wire
Authors: Willis-Owen Charles A , Crocker Matthew J , Martin David K 
Published: May 2014

A 37-year-old man presented with a tender palpable lump medial to his left patella. Two years previously he underwent surgical repair of a patellar tendon rupture including a protecting cerclage wire. He was informed that the wire did not require removal. There was no further history of trauma subsequent to the surgery. He had no other musculoskeletal problems and no past history of relevance. Clinical examination revealed a midline scar over the left knee with a tender palpable wire on the medial side of the patella. There were no other significant clinical findings in the knee. Plain radiographs revealed three wire fragments around the knee (Figure 1). These three fragments did not appear to account for the full circumference of the patellar tendon, raising the concern of a missing piece of wire. A further radiographic survey revealed that the missing wire fragment lay at the anterolateral aspect of the ankle joint (Figures 2 and 3). On surgical exploration, the wire was located between the peroneus tertius and extensor digitorum longus tendons with the tip just proximal to the superior retinaculum. It was assumed to have found its way from the subcutaneous space anterior to the knee into the anterior compartment of the leg and migrated distally to abut the talus.