bluuebunny/crossref_metadata_2025_split huggingface dataset:
Neurosarcoidosis presenting as ghost lesions in the CNS: a diagnostic dilemma
Authors: deSouza RM , Crocker M , Wijesekera L , Hampton T , Silber E , Chandler C 
Published: May 2014

A 50-year-old woman presented with a short history of headaches and dizziness. One week earlier she noticed impaired right leg coordination and had fallen twice. She had no significant past medical history. Examination showed impaired right arm and leg coordination, mild pronator drift and gait ataxia with no other neurological deficits. A magnetic resonance imaging scan of the brain showed an intra-axial mass lesion centred on the right middle cerebellar peduncle with partial effacement of the fourth ventricle and an unusual, slightly nodular pattern of enhancement (Figure 1). A computed tomography scan of the chest demonstrated bilateral nodular hilar masses felt consistent with reactive lymphadenopathy. No single large mass was present. Brain magnetic resonance imaging was consistent with either a primary lesion or atypical metastasis. She commenced dexamethasone 4 mg four times per day and stereotactic biopsy was scheduled. The planning magnetic resonance imaging, 2 weeks later, demonstrated marked reduction in the lesion's size raising the possibility of CNS lymphoma. Surgery was cancelled. Lumbar puncture showed no abnormalities. The steroid dose was reduced as a result of cushingoid sequelae and to establish if the lesion would re-expand. Interval scans showed progressive reduction in mass size despite decreasing steroid doses. Partial signal normalization within the cerebellum with resolution of mass effect and enhancement was observed (Figure 2). Repeat computed tomography of the chest (Figure 3) showed new, small, peripheral, left and right upper lobe pulmonary lesions. Histology following open biopsy of the left-sided lesion showed noncoalescent non-necrotizing granulomata consistent with sarcoidosis. Six months later the patient remains symptom free on prednisolone 2.5 mg once per day.
An unusual case of acute leg weakness
Authors: Duncan MKJ , Howlett DC , Watson GMT 
Published: May 2014

A 41-year-old male presented with progressive leg weakness and difficulty with micturition. He had otherwise been well. Clinical examination was normal apart from reduced power (3–4/5) in his lower limbs and a palpable bladder. The patient was catheterized and had a 1000 ml residual volume. Initial blood tests and magnetic resonance imaging of his brain were normal, but magnetic resonance imaging of the spinal cord revealed extensive abnormality. Figures 1–3 are selected magnetic resonance images of the cervical and upper thoracic cord. Figure 1 shows extensive high signal within the cord on T2 weighting, extending from C3 to the upper thoracic region. The cord itself is expanded and the altered signal extended to the T10 level on further imaging. Figure 3 shows meningeal enhancement (arrows) and this was evident along the whole cord to the conus. There was no compressive lesion. These appearances are consistent with a transverse myelitis. Lumbar puncture showed an increased CSF white cell count, reduced glucose and increased protein levels. The patient was commenced on intravenous methylprednisolone and cefotaxime. His leg weakness progressed with power falling to 0/5. A sensory level was established at T2. Further blood tests showed a normal serum angiotensin-converting enzyme level, no evidence of tuberculosis, normal autoantibodies and negative viral screen including HIV. Syphilis serology (i.e. venereal disease research laboratory (VDRL), Treponema pallidum haemagglutination assay (TPHA) and serum enzyme-linked immunosorbent assay (ELISA)), however, was strongly positive. Further lumbar puncture showed positive CSF antibodies to Treponema pallidum. The diagnosis of syphilitic transverse myelitis was made and his antibiotics were changed to intravenous benzylpenicillin. The patient made a full neurological recovery.
Neonatal white leg: a case of anatomical misjudgment
Authors: Dindyal Shiva , Kumaraswamy Prakash , Sooriakumaran Prasanna , Kiely Edward 
Published: May 2014

A baby girl of 28 weeks' gestation was delivered by emergency caesarean section because of fetal distress. At delivery her heart rate was >100 beats per minute, she cried and gasped, and was initially given bag and mask ventilation. She was subsequently intubated. An umbilical artery catheter was sited with aseptic technique for continuous blood pressure monitoring and arterial blood gas sampling. A second cannula was inserted into an umbilical vessel thought to be an umbilical vein. However, X-ray showed it to be malpositioned and probably arterial, and so it was removed immediately. Three hours later her left leg had turned white (Figure 1). She was consequently transferred to the neonatal unit where recombinant tissue plasminogen activator infusion was commenced. The whiteness did not disappear and no pulse reappeared below the femoral artery. However, the dusky red area above the knee resolved and, after a few days, an obvious area of demarcation of the ischaemia was seen at knee level. The patient subsequently underwent a through-knee amputation and has been fitted with a prosthesis.
Tracheo-oesophageal fistula diagnosed with multidetector computed tomography
Authors: Hodnett PA , McSweeney SE , Coyle J , Barry J , Plant R , Maher MM 
Published: May 2014

A 61-year-old man presented acutely to hospital with respiratory distress. He had a background history of recurrent respiratory tract infections. Chest radiograph showed bilateral lower lobe air-space opacification. Subsequently the patient developed acute respiratory decompensation and respiratory arrest requiring endotracheal intubation. The patient was admitted to the intensive care unit, and intensive care unit staff noted that unusually high positive end expiratory pressure values were required to maintain adequate oxygenation. Another notable finding was repeated reflux of air through the patient's oropharynx. The endotracheal tube was replaced with a larger calibre endotracheal tube without improvement. The possibility of tracheooesophageal fistula was considered and the patient underwent flexible bronchoscopy and contrast oesophagography, none of which showed a tracheo-oesophageal fistula. Clinical concern for tracheooesophageal fistula persisted and the patient continued to require mechanical ventilation. Multi-detector computed tomography (Aquilion 4, Toshiba Medical Systems, Toshiba, Tokyo, Japan) extending from hyoid bone to lung bases was performed with the following technical parameters: 120 kVp, 225 mAs, 1 mm slice thickness in helical mode with table speed of 0.75 and pitch of 3, without intravenous contrast administration. An attending radiologist and intensive care physician were present during the examination and the images were reviewed and discussed during the study. A subtle, focal, ill-defined thinning of the trachea was identified at the level of the endotracheal tube cuff (Figures 1a and b). A decision was made to repeat the study following temporary deflation of the endotracheal tube cuff and advancement of endotracheal tube into the right mainstem bronchus. This demonstrated a posterior tracheal defect with oesophageal communication, confirming a tracheo-oesophageal fistula at the site of thinning on the earlier imaging phase. Multiplanar reconstructions in the sagittal plane (Figures 1b and 2b) and virtual bronchoscopy (Figure 3) (Vitrea workstation, Vital Images Minnetonka, Minnesota, USA) confirmed the presence of a tracheo-oesophageal fistula at the level of the endotracheal tube cuff. Three days later, with the aid of multi-detector computed tomography and the multiplanar reconstructions, focused conventional bronchoscopy confirmed the presence of the tracheo-oesophageal fistula. The patient succumbed to overwhelming sepsis 2 weeks later.
Paediatric necrotizing pancreatitis
Authors: Sachiththanandan Sajitha , Rajendran Nirooshun , Rohatgi Ashish , Reddy Marcus 
Published: May 2014

A 13-year-old boy was admitted with a 7-week history of worsening epigastric pain and vomiting. There was no prior history of similar episodes, jaundice or viral infection. There was no family history of hyperlipidaemia. His only comorbidity was obesity with a body mass index of 36.6 kg/m2. On examination he was tachycardic and tachypnoeic with a tender epigastrium. Blood results showed a leucocytosis, normal liver function tests and normal cholesterol, C-reactive protein and amylase levels. An ultrasound scan was performed but did not reveal any detail because of his body habitus. A computed tomography scan showed a necrotic pancreas and that gallstones were present. The patient deteriorated, becoming increasingly septic, and was transferred across to a paediatric intensive care unit. Initial management consisted of fluid resuscitation, intravenous protein pump inhibitors, intravenous antibiotics, parenteral nutrition and surgical review. He initially responded to treatment, but then deteriorated with worsening sepsis requiring readmission to the paediatric intensive care unit. The repeat computed tomography scan (Figure 1) revealed bilateral pleural effusions, free fluid in the abdomen and peripancreatic inflammation. He showed signs of abdominal compartment syndrome and was taken to theatre for a laparotomy. The operative findings were a necrotic pancreas with over 5 litres of free fluid. A pancreatic necrosectomy and laparostomy was performed (Figure 2). Between 60 and 70% of his pancreas was involved and removed. The rest of his postoperative course was uneventful. He was discharged on Creon supplements, insulin and an antihypertensive. His weight had dropped from 106 kg on admission to 84 kg. After further surgical and paediatric review as an outpatient he later underwent an open cholecystectomy with an ontable cholangiogram.
A neonate with fetal distress and anaemia
Authors: Pugalenthi A , Sridhar AV , Fisher R 
Published: May 2014

A baby girl was delivered by emergency caesarean section for fetal bradycardia at 37 weeks' gestation. The 20-week fetal anomaly antenatal scans had showed no obvious abnormalities. At birth the baby looked pale and floppy, needing resuscitation with bag and mask. The Apgar scores were 6 and 8 at 1 and 5 minutes respectively. The baby weighed 1.98 kg. On examination she was noted to be pale with an abdominal mass extending from the left hypochondrium to the right iliac fossa. The initial blood results showed a low haemoglobin of 9.9 g/dl with normal white cell and platelet count. The urea, creatinine, electrolytes, C-reactive protein and liver functions tests were in the normal neonatal range. The Coombs test was negative. There was no evidence of haemolytic anaemia. She received packed cell transfusion for correction of anaemia. An abdominal X-ray showed a paucity of gas in the lower abdomen (Figure 1). Ultrasound of the abdomen and pelvis showed a large pelvic mass with numerous irregular fluid-filled spaces. The liver, biliary tree and the kidneys were normal. A computed tomography scan of the abdomen and pelvis (Figure 2) with contrast showed a 7×5×5 cm low attenuation mass arising from the pelvis and extending into the abdomen, most likely to be right ovarian in origin. Laparotomy showed a large right-sided ovarian cyst with haemorrhagic areas. She underwent right oopherectomy which on macroscopic examination showed multiple blood-filled cysts. Histopathology of the mass suggested a luteinized follicular cyst with no malignant features. She made good postoperative recovery and on follow up at 5 months of age, she was growing and developing normally with no ongoing problems related to the ovarian cyst.
Delayed diagnosis of blunt traumatic diaphragmatic hernia
Authors: Jones C , Dawson S , Badger SA , Epanomeritakis E 
Published: May 2014

A 52-year-old man presented with a 3-day history of left shoulder-tip pain and shortness of breath, in the background of abdominal pain for 3 weeks. The patient had been admitted 4 months previously following a fall onto his left posterior chest wall, when he sustained a left-sided pneumothorax and fractures of the left 6th, 7th and 8th ribs posteriorly. At that time a computed tomography scan showed a left-sided pneumothorax with associated basal atelectasis and consolidation. On this, the second admission, initial observations were stable, apart from a mild tachypnoea. Abdominal examination was normal, but respiratory auscultation revealed bowel sounds in the left hemithorax. The chest radiograph showed a new left-sided pneumothorax and large bowel in the left chest (Figure 1). Abdominal radiography confirmed this, with some mildly dilated loops of bowel. A computed tomography scan demonstrated a left diaphragmatic rupture with associated intra-thoracic incarcerated large bowel, a left hydropneumothorax and mediastinal shift to the right (Figures 2 and 3). Subsequently, the patient underwent a transverse colectomy with colostomy formation, along with diaphragmatic repair through a left thoraco-abdominal approach. Gastrointestinal continuity was later restored electively.
Trans-Atlantic cryptogenic stroke
Authors: Pareek Nilesh , Lee Lorraine , James Rachael 
Published: May 2014

A 27-year-old airline steward presented with a sudden onset of left-sided hemiparesis, which completely resolved in 48 hours. He had just completed a long-haul flight from the USA to England. He was previously fit and well, took no medications and was an occasional smoker and binge drinker. Physical examination on admission confirmed a left-sided hemiparesis and a left-sided upper motor neurone facial palsy. Cardiovascular and respiratory examinations were normal. His admission bloods, chest radiograph and computed tomography scan of the brain were all normal. Magnetic resonance imaging of his brain (Figure 1) showed a small right-sided cerebral infarct in the internal capsule. Magnetic resonance angiography of his neck did not demonstrate carotid artery dissection. Venous Dopplers of the lower limbs were normal. Standard transthoracic echocardiography was normal. A bubble contrast echocardiogram demonstrated a small right to left shunt at rest (Figure 2a). With release of the Valsalva manoeuvre, there was complete opacification of the left heart (Figure 2b) consistent with a large patent foramen ovale. The patient has now been enrolled into the Patent Foramen Ovale and Cryptogenic Embolism trial.
‘This medical student just gets sicker’
Authors: Bhalla Rekha , Das Satya S , Chin Aleong Joanne , Philpott Douglas , Fry Alastair , Simcock David E 
Published: May 2014

A 26-year old female medical student presented to hospital with a 2-week history of abdominal pain, fevers and vomiting. There was no history of smoking, alcohol, foreign travel or animal contact. Examination revealed hepatomegaly and temperature of 38°C. Initial blood results were haemoglobin 9.1 g/dl, white cell count 2.7×109/litre, platelets 130×109/litre, alanine aminotransferase 199 IU/litre, aspartate aminotransferase 62 IU/litre, alkaline phosphatase 247 IU/ litre, international normalized ratio 1.4, sodium 133 mmol/litre. Admission chest radiograph was normal (Figure 1a). Hepatitis screen showed prior infection with hepatitis A and cytomegalovirus. Human immunodeficiency virus and autoimmune profile serology were negative. On day 4 the patient developed a dry cough and hypoxia. Chest radiograph revealed basal pulmonary infiltrates (Figure 1b). The patient was treated for ‘atypical’ pneumonia with co-amoxiclav, clarithromycin and continuous positive airway pressure on the intensive care unit. Over the next 48 hours she deteriorated, requiring intubation and ventilation; teicoplanin was added. Computed tomography scanning showed patchy pulmonary air space shadowing, pleural effusions, ascites and normal pelvic images. Pleural fluid aspiration and drainage revealed transudate effusions and a bronchoscopy and bronchoalveolar lavage was performed. Exhaustive microbiology investigations of blood (including multiple serological studies for bacteria and viruses), CSF (<1 white blood cell, glucose 3.8 mmol/litre, protein 460 mg/litre), urine, stool, sputum, nasopharyngeal aspirate, pleural and bronchoalveolar lavage fluid failed to identify an infectious cause for the patient's illness. She was extubated after 36 hours with complete resolution of chest radiological infiltrates. Lack of clinical improvement, persisting pyrexia, deteriorating pancytopenia and liver function tests prompted further investigation with liver and bone marrow biopsies. Ziehl–Neelsen staining of a liver biopsy (Figure 2) and bone marrow demonstrated the presence of granulomatous inflammation and acid-fast bacilli. Acid-fast bacilli were abundantly seen in under 5 minutes of starting histological inspection of tissue sections. Mycobacterium tuberculosis was confirmed by tissue culture, and found to be sensitive to rifampicin by the reference laboratory using rapid reverse hybridization. A good clinical response was seen with non-hepatotoxic anti-tuberculous therapy, including amikacin, ofloxacin and ethambutol, since standard therapy resulted in marked hepatitis. First-line antituberculous drugs were then gradually introduced. The patient made a full recovery with resolution of liver function tests and blood counts.
Crohn's disease and enterovesical fistulae: common things are common
Authors: Randall David , Tittle Victoria , Wright Gavin , Blanshard Christine 
Published: May 2014

A 39-year-old Caucasian male presented with a 5-day history of acute severe left iliac fossa pain (radiating to the umbilicus), vomiting and episodic pneumaturia associated with brown urinary sediment. There had been no reported alteration in bowel habit, anorexia or weight loss. On examination he was apyrexial and haemodynamically stable with only mild tenderness limited to the area of the left lower rectus sheath, inferior to the umbilicus. Four years earlier he had been diagnosed with Crohn's disease at a nearby hospital, following a similar episode of left iliac fossa pain; the diagnosis of Crohn's disease was based on computed tomography findings of a thickened ascending colon despite normal histology at colonoscopy. Since the diagnosis of Crohn's disease he had remained on regular mesalazine, with five episodes of similar pain (and occasional pneumaturia) treated with intravenous steroids for presumed exacerbations of Crohn's disease. Given the history of pneumaturia he was pending an outpatient magnetic resonance imaging scan to establish the presence of an enterovesical fistula. At admission, initial investigations revealed a negative urine dipstick for leucocytes and nitrites and only mildly raised inflammatory markers. A computed tomography scan demonstrated an abnormal sigmoid colon adherent to the bladder and anterior abdominal wall (Figure 1). There was also evidence of fluid within the left rectus abdominal sheath and of a fistulous tract between the bladder and sigmoid colon (Figure 2). Flexible sigmoidoscopy revealed an area of narrowing with tight angulation in the sigmoid colon and an abnormal red spot of uncertain aetiology, but there was no evidence of Crohn's disease macroscopically or histologically. Flexible cystoscopy showed thickening of the anterior dome of the bladder with a likely fistula opening superiorly, with non-specific cystitis on histology. Multidisciplinary team discussions concluded that the findings were more suggestive of a localized perforation of a sigmoid diverticulum 4 years earlier leading to secondary inflammatory erosion with the creation of a persistent enterovesical fistula. He therefore underwent a sigmoid colectomy and bladder wall repair. At operation a mass was found in the left iliac fossa adherent to the bladder and abdominal wall and 5 ml of pus drained from an abscess in the anterior abdominal wall. Histology showed an inflamed and ulcerated diverticulum in the sigmoid and an acute and chronic inflammation with foreign body type multinucleated giant cell reaction in the bladder. The patient made a good recovery postoperatively with an early discharge and his longstanding medication for Crohn's disease was stopped.
Improving patient safety: risk analysis of the glaucoma process
Authors: Ayala Marcelo , Parmer Eva , Landstedt Gunilla , Karlen Hedvig , Bjarman Eva 
Published: May 2014

Objective To improve the quality of care provided for glaucoma patients. Methods A multidisciplinary team consisting of a hospital doctor, nurses and a secretary performed a prospective risk analysis of the process of care provided for glaucoma patients. The design of the study was the Healthcare Failure Mode and Effect Analysis (HFMEA). Failure modes were defined and classified according to their criticality, in order to identify priority actions for improvement. Criticality indices were calculated by multiplying occurrence and severity scores. Results The most critical failure modes were the lack of specialist doctors and/or delayed appointments. Conclusions Using HFMEA, we were able to identify the most critical failure modes of the complex process of care provided for glaucoma patients and suggest subsequent improvement measures. Follow-up indicators were defined to assess implementation.
Intracameral antibiotics for the prevention of endophthalmitis in cataract surgery
Authors: Legg Kerrie 
Published: May 2014

Aim: To determine if there is enough evidence to support the use of intracameral antibiotics for the prevention of endophthalmitis post cataract surgery. Method: A systemic review of English language articles was conducted by performing a broad search using Medline/ProQuest, Science Direct, the Cochrane Library and Embase. The search was restricted to articles published between January 2005 and October 2010. The terms endophthalmitis and intracameral antibiotics were used to initiate the search but the term cataract was used for further exclusion. The population base incorporated adult patients undergoing cataract surgery. Limitations include one author as a reviewer of the titles resulting from the literature searches. A team review would give a more robust methodological quality. Results: Of the 493 results that were identified in the literature search 451 citations were excluded after screening titles and abstracts. Forty two publications were included for this review and were identified as being relevant after scrutiny. Publications showing retrospective data far exceeded the number of prospective case controlled studies negatively affecting the number of high quality articles reviewed. A randomized controlled study released by the European Society of Cataract and Refractive Surgeons (ESCRS) published results in 2006 showing a near _fivefold decrease in the rates of post-operative endophthalmitis with the use of intracameral cefuroxime. This study was discontinued due to ethical considerations. The study observed a clear benefit from the use of intracameral cefuroxime. Moxifloxacin has not been truly evaluated and has a potential for bacterial resistance. Topical antibiotics are unreliable relying on patient compliance and requiring frequent administration. From this review an effective solution for endophthalmitis prevention remains unclear. Conclusion: Intracameral cefuroxime administered at the time of surgery seems to work well for reducing the incidence of post-operative endophthalmitis as it is a broad spectrum and cost-effective antibiotic. The major barrier to its clinical use is the lack of a commercial preparation which increases the threat of dilution errors, which is known to be toxic to human endothelial cells.