bluuebunny/crossref_metadata_2025_split huggingface dataset:
Unilateral ocular myasthenia gravis in an acute medical take: is a Tensilon test useful?
Authors: McCarthy D , Patel C , Ahlquist JAO , Stephens JW 
Published: May 2014

A 42-year-old woman presented to an eye clinic with a 2-week history of diplopia. Examination revealed signs of a right sixth nerve palsy. A computed tomography (CT) brain scan was normal. Six weeks later she presented during the acute medical take with increasing diplopia, a drooping right eyelid and unsteadiness. Direct questioning revealed that the drooping became progressively worse throughout the day. She had no relevant past medical history or any regular medication. Examination revealed a partial right ptosis and signs of right third, fourth and sixth nerve palsy. Diplopia on binocular vision resolved on patch testing; neurological examination was otherwise unremarkable, with no evidence of limb weakness. A magnetic resonance imaging scan of the brain and CSF examination were unremarkable. Ocular myasthenia was suspected, anti-acetylcholine receptor antibody test was requested, and a Tensilon test was performed with full resuscitation equipment available. Following the administration of the test dose (2 mg) of intravenous edrophonium (Tensilon) a visible improvement in the right ptosis was observed. Subsequent administration of a further 8 mg edrophonium yielded more marked improvement, with complete correction of the right ptosis (Figure 1) and a subjective decrease in diplopia on right gaze. A diagnosis of unilateral ocular myasthenia gravis was made on the basis of the clinical picture and the positive Tensilon test. A neurological opinion was sought and the patient commenced on pyridostigmine 60 mg four times a day. Further investigations included a CT scan of the thorax which revealed a 2 cm retrosternal mass, compatible with thymic hyperplasia. Five weeks after the positive Tensilon test, a report of strongly positive anti-acetylcholine receptor antibodies (anti-acetylcholine receptor antibodies >8 nmol/litre, normal range 0–0.5 nmol/litre) was received. The diplopia continues to improve and the patient has regular follow up.
Perils of pericardiocentesis
Authors: SH Ng Calvin , Wan Song , Yim Anthony PC , Arifi Ahmed A 
Published: May 2014

A 51-year-old woman underwent elective cardiac surgery for the closure of an atrial septal defect. The surgery was uneventful and the patient was making good progress. On postoperative day 6, she developed shortness of breath, tachycardia and raised jugular venous pressure. Transthoracic echocardiography noted a high pulmonary artery pressure of 65 mmHg (preoperative 78 mmHg), and a 3 cm pericardial effusion with tamponade effect on the right atrium. Pericardiocentesis under echocardiography guidance was performed without difficulty. The drainage from the pericardial catheter was good, and the patient noted immediate improvement in her dyspnoea. However, shortly following the procedure, she complained of increasing breathlessness, dizziness and became visibly pale. The oxygen saturation dropped rapidly from 96% to 53% and then became unrecordable. Systolic blood pressure fell to 52 mmHg and she became severely drowsy (Figure 1). The differential diagnosis included iatrogenic pneumothorax (tension) and myocardial injury. The bedside pericardiocentesis collection bag was then noted to be full to the bursting point of 2 litres with heavily blood-stained fluid. The draining tube was clamped, the bed was put to head down position, resuscitation with oxygen via rebreathable mask, and 1 mg intravenous adrenaline was administered. Intravenous colloid totaling 1.5 litres was actively squeezed into the patient through large intravenous catheters. At that point, the thought of elevating and inverting the pericardiocentesis collection bag to allow return transfusion of its contents did briefly cross the authors' minds. Fortunately, the patient swiftly regained consciousness, but her haemoglobin had fallen from 9.8 to 4.7 g/dl. She was rushed to the operating theatre for emergency surgery, which revealed the pericardiocentesis catheter had punctured and was lying within the right ventricle (Figure 2). The right ventricle was repaired with 3/0 prolene pleget and the pericardial blood clots were removed. The patient recovered well and was discharged 4 days later.
Renal vein thrombosis in a renal allograft
Authors: Summers SA , Partridge W , Laing C , Cook PR 
Published: May 2014

A 61-year-old woman with end-stage renal disease secondary to post-streptococcal glomerulonephritis received a live related transplant from her brother in 1980. For 23 years she had no medical or nephrological problems and had excellent transplant function with creatinine ranging from 60–80 μmol/litre. In 2004 a cystic lesion was noted on her right breast, biopsy of which revealed a high grade B cell non-Hodgkin's lymphoma. Ten days before admission she noticed pain over her transplant kidney and over the ensuing days she reported passing progressively less urine. Initial blood tests were suggestive of pyelonephritis with a neutrophil leucocytosis (white cell count 19.1×109 cells/litre) and acute phase response (C-reactive protein 58 mg/litre). Her creatinine was 368 μmol/litre. An ultrasound scan of the transplant kidney demonstrated globally poor perfusion and the renal vein could not be demonstrated (Figure 2). This was in stark contrast to a scan performed 1 year earlier (Figure 1). A transplant nephrectomy was performed uneventfully that night and confirmed the diagnosis of renal vein thrombosis.
Subcutaneous endometrial deposit: an unusual cause of right iliac fossa pain
Authors: A Hodnett Philip , McSweeney Sean E , Bogue Conor , Kelly Denis , Redmond H Paul , Maher Michael M 
Published: May 2014

A 35-year-old woman presented to hospital with a 7-day history of worsening right iliac fossa pain. The patient reported a 7-month history of intermittent right iliac fossa pain, associated with a palpable nodule in the right iliac fossa. This nodule showed apparent increase in size and tenderness, on palpation, during her menses. Twelve months previously, the patient had undergone a caesarean section.Plain film of the abdomen was unremarkable. Ultrasound examination using a high frequency probe (7.5 MHz) showed a 2 cm nodule in the subcutaneous fat of the anterior abdominal wall superficial to the right rectus abdominus musculature which was hypoechoic relative to adjacent subcutaneous fat and of inhomogenous echotexture with low level internal hyperechoic echoes. Doppler interrogation showed a single vascular pedicle entering the mass at the periphery (Figure 1a). The margins were slightly irregular. There were no ultrasound features of incisional hernia. Computed tomography with intravenous and oral contrast revealed a 2 cm solid, slightly spiculated nodule, located in the subcutaneous fat without involvement of the anterior abdominal wall musculature and parallel to the Pfannensteil incision (Figure 1b). The nodule was hyperdense compared to rectus abdominus musculature following intravenous contrast enhancement, measuring approximately 80 Hounsfield units. There was minimal stranding of the surrounding subcutaneous fat. Differential diagnosis included haematoma, abscess, sebaceous cyst, enlarged lymph node, desmoid tumour, and malignant tumours such as malignant melanoma, or metastatic breast or renal cell carcinoma. Percutaneous biopsy using a 17 gauge coaxial needle system was performed under ultrasound guidance (Figure 2a). Histopathological examination confirmed endometrioma (Figure 2b).
Pleural mesothelioma presenting as recurrent pneumothoraces
Authors: Bright-Thomas Rowland J , Ahmed Rizwan Y , Pearson Stanley B , Muers Martin F , Luksza Andrew R , Turkington Peter M 
Published: May 2014

A 79-year-old man presented with a 2-week history of increasing dyspnoea and reduced exercise tolerance. He was previously fit and well with no medical history of note. He was an ex-smoker of 25 pack years. Examination findings were of a right pneumothorax which was confirmed by chest X-ray. A chest drain was inserted and the lung expanded fully. He was discharged after 2 days but was readmitted 6 weeks later complaining of recurrent breathlessness over a 24-hour period and chest X-ray again revealed a large right pneumothorax. Once again a chest drain was inserted with good result. Four weeks later the problem recurred. An occupational history revealed that he had worked for 40 years as a shipwright in a shipyard with regular asbestos exposure. A right thoracotomy and pleurectomy was performed – the pleura appeared normal macroscopically but histology demonstrated pleural infiltration by an epithelial-type malignant mesothelioma. He died 4 months after pleurectomy in an advanced cachectic state. Post-mortem confirmed a malignant mesothelioma.
Has Lemierre's syndrome become a bacteriological diagnosis?
Authors: Hill Uta G , Vallis Martin P , Cotter Tim , Hegarty Michael A 
Published: May 2014

A 35-year old woman presented to her GP with a 2-day history of sore throat, myalgia and fever. A provisional diagnosis of acute viral pharyngitis was made and conservative treatment with analgesia recommended. However, her symptoms increased in severity with the addition of severe pain in the left thigh and hip necessitating hospital admission 5 days later. On examination, she was tachycardic, tachypnoeic and hypotensive with basal crepitations in the right lung and reduced mobility of the left hip. She had a neutrophil leucocytosis (33×103/litre) and a high C-reactive protein level of 230 g/litre. The chest X-ray showed consolidation of the right middle lobe with multiple nodular infiltrates throughout both lung fields. Aspiration of the hip joint showed numerous white cells but the culture was sterile. Severe community-acquired pneumonia and infective arthritis of the hip were suspected and she was treated with benzylpenicillin, clarithromycin and flucloxacillin, but 36 hours following admission, her condition deteriorated because of the sepsis and she was transferred to the intensive care unit for ventilatory and inotropic support. Culture of the blood taken on admission yielded an anaerobic gram-negative rod which was subsequently identified as Fusobacterium necrophorum by the reference laboratory. As it was sensitive to penicillin, metronidazole and clindamycin, the antibiotic treatment was changed to high doses of all three. The pneumonia resolved, inflammatory markers returned to normal and the mobility of her left hip improved; 14 days after admission, she was well enough to be discharged home with oral amoxicillin and metronidazole for a further 4 weeks and appropriate outpatient follow-up.
Improving patient handover between teams using a business improvement model: PDSA cycle
Authors: Luther Vishal , Hammersley Daniel , Chekairi Ahmed 
Published: May 2014

Background Medical admission units are continuously under pressure to move patients off the unit to outlying medical wards and allow for new admissions. In a typical district general hospital, doctors working in these medical wards reported that, on average, three patients each week arrived from the medical admission unit before any handover was received, and a further two patients arrived without any handover at all. A quality improvement project was therefore conducted using a ‘Plan, Do, Study, Act’ cycle model for improvement to address this issue. Method P – Plan: as there was no framework to support doctors with handover, a series of standard handover procedures were designed. D – Do: the procedures were disseminated to all staff, and championed by key stakeholders, including the clinical director and matron of the medical admission unit. Results S – Study: Measurements were repeated 3 months later and showed no change in the primary end points. A – Act: The post take ward round sheet was redesigned, creating a checkbox for a medical admission unit doctor to document that handover had occurred. Nursing staff were prohibited from moving the patient off the ward until this had been completed. This later evolved into a separate handover sheet. Six months later, a repeat study revealed that only one patient each week was arriving before or without a verbal handover. Conclusions: Using a ‘Plan, Do, Study, Act’ business improvement tool helped to improve patient care.
Tachycardia-induced cardiomyopathy caused by atrial flutter responding to DC cardioversion
Authors: Rinaldi Christopher A , Thompson David S 
Published: May 2014

A58-year-old man presented in February 1996 to his local hospital with a true posterior myocardial infarction for which he received thrombolysis. He subsequently underwent exercise testing which was terminated because of chest pain and anterior ST depression of >2 mm after 6 minutes of a Naughton Balke protocol. He proceeded to coronary angiography which demonstrated severe triple vessel coronary artery disease. The left ventriculogram demonstrated posterior hypokinesis but overall left ventricular (LV) contractile function was well preserved with an ejection fraction (EF) calculated at 49%. He was in sinus rhythm and had chronic stable angina. In September 1996 he underwent revascularization on prognostic grounds. Five days postoperatively he developed atrial flutter for which he was started on amiodarone 200 mg once daily and subsequently discharged. Two weeks later he was readmitted with progressive dyspnoea and peripheral oedema. He was found to be in clinical heart failure and atrial flutter with a ventricular rate of 150. He subsequently underwent a successful DC cardioversion reverting to sinus rhythm following a single 200J DC shock. He was discharged on amiodarone 200 mg once daily, frusemide 80 mg once daily, enalapril 10 mg once daily and aspirin 75 mg once daily. In November 1996 he presented in atrial flutter with heart failure. An echocardiogram was performed showing a dilated hypokinetic left ventricle with an EF of approximately 20% (Table 1). He was anticoagulated and underwent a further DC cardioversion in February 1997 which successfully reverted him to sinus rhythm. Echocardiography was performed following reversion to sinus rhythm (Table 1) which revealed a dilated LV with global systolic dysfunction and functional mitral regurgitation (EF=30%). In April 1997 he reverted to atrial flutter and had significant effort dyspnoea with an exercise tolerance of 50 yards. He was again successfully cardioverted and commenced on sotalol 80 mg twice daily in an attempt to maintain sinus rhythm. He subsequently remained in sinus rhythm with a marked symptomatic improvement (New York Heart Association Grade 1 dyspnoea and no clinical evidence of cardiac failure). Echocardiography in July 1997 demonstrated a significant improvement in LV dimensions and systolic contractile function (EF=50%) with values equivalent to pre-surgery.
Sudden visual loss and headache: important symptoms of pituitary disease
Authors: Morris AHC , Anderson DF , Browning AC , Mandel CJ , Barker CS , Green WT 
Published: May 2014

A63-year-old man presented to the ophthalmology department with a 24-hour history of loss of vision in the right eye and 3 days of severe frontal headache. Six weeks earlier a supero-temporal field defect was observed in the left eye during examination by his optician. A routine referral to the ophthalmology department for assessment of possible glaucoma was made. On examination he was alert and orientated. The visual acuity was hand movements in the right eye and 6/12 in the left eye with a dense right relative afferent pupillary defect. Visual fields tested by confrontation demonstrated a bitemporal loss. This was confirmed by formal Goldmann visual fields (Figure 1). There was no papilloedema or external ophthalmoplegia and further ophthalmic examination was unremarkable. There were no focal neurological signs and his blood pressure was normal. Serum prolactin was 400U/litre (normal range: 100–500 mU/litre). A computerized tomography scan (Figure 2) revealed an intrasellar mass expanding the sella turcica and extending into the suprasellar cistern. There were small high density foci suggesting a recent haemorrhage within a pituitary adenoma. The patient underwent transphenoidal decompression of the pituitary tumour and histopathology confirmed haemorrhagic pituitary adenoma. Repeat visual fields within 1 week of surgery (Figure 3) illustrate dramatic recovery of visual function. Two weeks postoperatively, the patient's visual acuity had improved to 6/24 in the right eye and 6/9 in the left with continued improvement in the visual field. After 5 months his visual acuity was 6/18 right and 6/6 left with almost complete recovery of his visual fields and he was able to return to driving.
An unusual case of recurrent septicaemia
Authors: Robinson Catherine , Cole David , Chambers Stephen 
Published: May 2014

A52-year-old farmer presented with a 1-week history of fever, rigors and myalgia. Three days before admission he had developed pleuritic left-sided chest pain. Clinical examination revealed a temperature of 38.4°C and bibasal pulmonary crepitations. Chest radiograph showed an area of patchy pulmonary opacity at the left lung base and a few small areas of opacity in the right lung. A presumptive diagnosis of pneumonia was made. Blood cultures subsequently grew Staphylococcus aureus and treatment with intravenous flucloxacillin was commenced. No other focus of infection was found, investigations included normal transthoracic echocardiogram and abdominal ultrasound scan. The patient rapidly improved; however, 2weeks later he again became febrile. Further blood cultures grew Klebsiella pneumoniae. An abdominal computed tomography scan showed a high density linear structure straddling the second part of the duodenum and the inferior vena cava, representing a foreign body (Figure 1). Clot could be seen in the vena cava where it had been penetrated. Multiple ill-defined opacities seen in the lung base were consistent with embolization of the lungs. A plain abdominal radiograph showed the foreign body was a 4cm sewing needle (Figure 2). The needle and clot were removed surgically through an incision in the inferior vena cava and culture of specimens yielded both Staphylococcus aureus and Klebsiella pneumoniae (Figure 3) . The patient was treated with cefuroxime and made an uneventful recovery but had no recollection of having swallowed the needle.
Atopic eczema and staphylococcal endocarditis: time to recognize an association?
Authors: Conway DSG , Taylor AD , Burrell CJ 
Published: May 2014

An 18-year-old man presented with a 3-day history of malaise, pyrexia, confusion and left knee pain. He had a history of atopic eczema since the age of 6 months but was otherwise well. He had worn a dental brace for the past 2 years without complications and had no recent dental intervention. There was no history of intravenous drug abuse. On examination he was pyrexial at 39.0°C, clinically dehydrated, with a sinus tachycardia of 100 beats per minute and a systemic blood pressure of 130/80 mmHg. He had eczematous lesions on his face, arms and legs. Auscultation revealed no cardiac murmurs and lung fields were clear. There were no stigmata of endocarditis. He was mentally obtunded with a Glasgow Coma Score of 14/15 but had no other neurological signs. The left knee demonstrated a full range of movement and no obvious effusion. Orthopaedic opinion was of a reactive arthritis. Chest and left knee radiography was unremarkable. C-reactive protein (CRP) was elevated at 251mg/litre, haemoglobin was 12.4g/dl, leukocytes 11.7×109/litre (with 89% neutrophils) and platelets 26×109/litre. A screen for disseminated intravascular coagulopathy was negative. He was hyponatraemic (sodium 125 mmol/litre) and mildly uraemic (urea 7.8 mmol/litre, creatinine 91μmol/litre). Blood cultures grew Staphylococcus aureus sensitive to flucloxacillin and gentamicin. Computed tomography (CT) of the brain showed generalized cerebral swelling with effacement of the basal cisterns, but no focal abnormality. Treatment was initiated with intravenous flucloxacillin, gentamicin and fluid replacement. The following day he developed severe pulmonary oedema and haemodynamic compromise necessitating admission to the intensive care unit for inotropic support and ventilation. Urgent transoesophageal echocardiography showed a 2x2 cm vegetation on the anterior mitral valve leaflet (Figure 1) with marked prolapse and severe mitral regurgitation. There was systolic flow reversal in the pulmonary veins. Left atrial size was normal and left ventricular function good. He underwent emergency mitral valve replacement with a St Jude mechanical valve (St Jude Medical Inc, St Paul, Minnesota, USA). At operation there was seen to be almost complete destruction of the anterior mitral valve leaflet. His postoperative recovery was good, completing 6 weeks of antibiotic therapy, and repeat CT showed resolution of the cerebral oedema. During the admission he experienced an exacerbation of his eczema and was treated with topical steroids and emollients by the dermatologists.
Post-intubation tracheal stenosis
Authors: Ahmad I , Pahor AL 
Published: May 2014

A42-year-old insulin-dependent diabetic woman was admitted in the intensive care unit with aspiration pneumonia following an episode of hypoglycaemia. She was managed by mechanical ventilation with endotracheal intubation. During her stay she had a pulmonary embolism for which she was heparinized. Myocardial infarction further delayed her weaning from the ventilator. She remained intubated for 11 days. She was discharged after 3 weeks hospital stay, in a satisfactory condition. After 3 weeks, she presented as an ear, nose and throat emergency with breathing difficulty. She was found to have biphasic stridor and arterial oxygen saturation concentration ranged from 70 to 80%. Flexible naso-laryngoscopy showed normal vocal cords. A plain X-ray lateral view of the neck showed narrowing of the air column in the upper trachea. Her flow–volume curve showed features of severe tracheal obstruction with a reduction in peak expiratory and inspiratory flow. All routine blood tests and chest X-ray were normal. She was managed by humidified oxygen, intravenous hydrocortisone (100 mg three times a day) and co-amoxiclav (1.2 g three times a day). She responded to this treatment very well. A tomogram of larynx and trachea performed the next day showed a narrowing of theupper tracheal lumen (Figure 1). Flexible bronchoscopy showed a ring of granulations, resulting in a circumferential narrowing of the upper trachea of 2–2.5 cm in length. She settled with conservative treatment. Serial flow–volume curve measurements also showed a significant improvement. She was discharged after a week and maintained on a reducing dose of oral steroids for 2 weeks. She is still under close follow-up.
Patients' right to refuse treatment
Authors: Sedgwick Emma 
Published: May 2014

The recent decision by the High Court to allow a woman paralysed from the neck down to end her life by refusing treatment upholds a competent patient's right to decline treatment, even if this would lead to his or her own death [Re B v NHS Trust 2002]. The ruling, that a woman known as Miss B could have a ventilator keeping her alive switched off, reinforces a doctor's duty to respect a competent patient's wishes. However, doctors facing difficult decisions such as this often need to seek clarification from the High Court before acting.