bluuebunny/crossref_metadata_2025_split huggingface dataset:
Bilateral synchronous testicular torsion in a young adult
Authors: Dindyal S , Kumaraswamy P , Khattak A , Sooriakumaran P 
Published: May 2014

An 18-year-old man presented to accident and emergency with acute left testicular pain of 2 hours’ duration. He woke up with the pain radiating to his left hemiscrotum, left groin, left iliac fossa and left lumbar flank. Nausea and vomiting accompanied the pain. He had not opened his bowels for 48 hours. He denied any lower urinary tract symptoms or any previous history of genital trauma. His past medical history revealed that he had suffered from intermittent left testicular pain for 3 years and, 6 months before this admission, had been admitted with a similar episode of left testicular pain, which was treated as epididymitis. There was no family history of testicular torsion. On examination, he was apyrexial, distressed with pain and retching. His left scrotum was erythematous and mildly oedematous, lying relatively high. It was extremely tender at the upper pole, which made evaluation of its contents difficult, but a ‘knot-like’ structure was palpated. Cremaster reflexes were absent bilaterally. The right testis was also tender, but on palpation it felt normal and was not swollen. The left inguinal canal and left iliac fossa were also painful. A midstream urine showed no pyuria or haematuria. A kidney-urinary bladder radiograph showed faecal loading of the large bowel. Transverse testicular ultrasound scanning showed a markedly inflamed left epididymis with decreased blood flow. The left distal spermatic cord showed a whorled appearance. The right testis was normal in echotexture, size and blood flow. Bilateral hydroceles were noted. The patient underwent immediate bilateral scrotal exploration, which revealed the left testis to be cyanosed and the cord to be twisted 540° anticlockwise. The right testis was normal in colour and the cord was twisted 360° clockwise. Bilateral bell-clapper deformity was noted. Detorsion, orchidopexy and drainage of serous-coloured hydrocele was performed bilaterally. Postoperatively the patient recovered well and was discharged home 2 days later with an outpatient follow-up appointment. Serum sex hormone levels were all within the normal ranges. Semen analysis was of normal consistency and pH. The count was 38 million, but 54% were immotile and 87% displayed abnormal morphology.
Isolated olfactory nerve agenesis
Authors: Carswell Andrew J , Whinney David , Hollings Nick , Flanagan Philip 
Published: May 2014

An otherwise fit and well 12-year-old girl presented to the otolaryngology clinic with lifelong anosmia. Although she had suffered a nasal injury when she was 4 years old, she was adamant that the deficit pre-dated her injury. Interestingly, her maternal grandfather also complained of this problem. Clinical examination was entirely normal, except for her anosmia. There was no intranasal pathology such as obstructive deviations of the nasal septum or polyposis and cranial nerve examination, including trigeminal stimulation, only confirmed the absence of olfaction. Subsequent imaging with the magnetic resonance scanner revealed a complete absence of the olfactory bulbs and nerves (see Figures 1–3 and compare to the normal image in Figure 4). T2-weighted coronal sections through the anterior cranial fossa were performed. As demonstrated in the normal image (Figure 4), one can expect to see high signal in the olfactory sulcus along the base of the frontal lobe. This was entirely absent in this case, with no other significant pathology apparent. There is a high signal return in the right maxillary sinus of the subject, which is incidental and not related to smell perception. Also, Figure 4 is in a patient with a cyst in the left maxillary sinus. Such incidental, asymptomatic 'sinusitis' on magnetic resonance scans is present in 30–40% of cases (Wani et al, 2001). Both the patient and her mother were counselled about the risks of environmental hazards. No further investigation was deemed necessary, or indeed desired by the patient.
Potential complications of the blind technique of port insertion during laparoscopy
Authors: Shaikh S , MacAuley E , Brittenden J 
Published: May 2014

A 32-year-old previously fit and healthy woman underwent laparoscopy, dye test, hysteroscopy and endometrial biopsy as part of the investigation of infertility, under the care of a consultant gynaecologist in a remote district general hospital. A radial umbilical incision was made, and the abdomen was raised by hand. An initial attempt was make to insert a trifin nailed trocar gently with a screwing movement, but the failure of this manoeuvre was attributed to relaxed thick fascia or a blunt trocar. A Veress needle was therefore introduced to its full length and was then withdrawn to half length; pneumoperitoneum was established. A good view of the pelvic organs was obtained and no abnormality was observed. The patient became haemodynamically unstable although no obvious source of bleeding was identified. A laparotomy was performed through a right subumbilical paramedian incision and a large haematoma was noted anteriorly on the left side overlying the inferior vena cava and aorta, extending up to the left renal pedicle and down to the pelvic brim. The lateral extensions of the haematoma were contained at the peritoneal reflections. It was unclear which vessel was injured and as intensive therapy unit care was not available on site and the haematoma was contained, the incision was closed and the patient was transferred to the authors' tertiary care centre. Blood loss at this point was a 50 ml clot. On arrival the patient was unstable, acidotic and in coagulopathy with a systolic blood pressure of 50 mmHg. A second laparotomy was performed by extending the previous incision proximally into the epigastrium. A 1 cm tear at the origin of the right internal iliac artery was seen and repaired along with a tear of a right lumbar artery, which was ligated. The patient remained in the intensive therapy unit for 48 hours and received a total of 36 units of packed red cells transfusion plus factor 7, fresh frozen plasma and platelets. Further postoperative recovery was uncomplicated. The patient developed secondary depression after the incident and also experienced intermittent abdominal pain.
Concurrent emphysematous cholecystitis and emphysematous cystitis in a non-diabetic patient
Authors: Ayoub Tariq , Arshad Ilyas , Donnellan Imelda 
Published: May 2014

A 84-year-old non-diabetic man presented with central colicky, abdominal pain. The pain was worse on movement and radiated to his back. It began 2 weeks before admission and had progressively become worse. During this time, he had two episodes of vomiting and one episode of diarrhoea. There was no associated jaundice or weight loss. He had long-standing anaemia as a result of angiodysplasia. He did not complain of any urinary symptoms but had a previous history of chronic renal failure, hydronephrosis and transurethral resection of the prostate. On examination he had a temperature of 36.8°C, a regular pulse rate of 85/min and blood pressure of 109/95 mmHg. He had tenderness in the right para-umbilical region and an ejection systolic murmur in the aortic region without any radiation (he had a previous history of aortic valve replacement). Blood tests showed a haemoglobin of 10.7 g/dl, white cell count of 17.5×109/litre, urea of 11.8 mmol/litre and creatinine of 181 μmol/litre. Blood glucose on admission was 4.6 mmol/litre. Urine dipstick showed ++ leucocytes but was negative for nitrites. Urine microscopy showed the presence of >105/cm3 of Escherichia coli and numerous white cells but no red cells. Blood culture was negative. Computed tomography of the abdomen showed an enlarged gall bladder with intraluminal air within the gall bladder wall and an air fluid level within the gall bladder itself (Figure 1). No calculi were seen within the gall bladder. Coincidentally the scan also showed air pockets within the bladder wall (Figures 2a and b). He was treated with intravenous cefuroxime and metronidazole for 5 days as well as being fluid resuscitated. Once his temperature subsided he was discharged on a 5-day course of amoxicillin as advised by the microbiologists. A follow-up computed tomography scan showed complete resolution of the emphysematous cholecystitis and emphysematous cystitis.
An unusual case of acute onset lower lip numbness
Authors: Hegarty Anne , Hodgson Tim 
Published: May 2014

An 84-year-old Caucasian woman was referred by her primary care dentist to the authors' department with progressive lower lip numbness of 2 months' duration initially noticed by the patient during toothbrushing. The paraesthesia was initially intermittent but became permanent within 1 month. The patient had not sustained any injury to the jaws and no dental treatment had been provided before symptoms started. A course of empirical antibiotics had no impact. She was previously diagnosed with hypertension, ischaemic heart disease and atrial fibrillation for which she was prescribed lisinopril, valsartan, atorvastatin, digoxin and warfarin. She had no known allergies. She was a non-smoker and drank alcohol occasionally. She was the main carer for her husband who suffers from multiple sclerosis. Clinical examination revealed reduced sensation to light touch and pinprick in the distribution of the left mental nerve. No other cranial nerve abnormalities were noted. Apart from mild tenderness in the left buccal sulcus opposite the lower left first premolar and a polyp-like lesion on the lower left lip, no other intraoral abnormalities were found. Initial blood tests including full blood count, haematinics, liver and renal function, glucose, erythrocyte sedimentation rate and bone profile were performed to rule out possible systemic causes of mental paraesthesia and were unremarkable. A panoramic radiograph (Figure 1) showed generalized osteoporosis with a loss of the lower border cortex and inferior dental canal outlines bilaterally. Subsequent magnetic resonance imaging (Figure 2) revealed extensive T1 areas of low marrow signal throughout the skull vault, skull base, cervical vertebrae and the clavicles with the entire left side of mandible showing reduced T1 signal in keeping with mandibular marrow replacement. The appearances were consistent with extensive bone metastatic disease with marrow infiltration of the left side of the mandible involving the mental nerve. Further blood tests revealed normal immunoglobulins and absence of paraprotein. Oncological referral and further investigation including chest X-ray, whole body computed tomography scan and bone marrow aspiration and trephine confirmed a diagnosis of follicular lymphoma.
Dysphagia in a 30-year-old woman: too old for a congenital abnormality?
Authors: Longcroft-Wheaton G , Ellis R , Somers S 
Published: May 2014

A 30-year-old woman presented to the acute medical take with nausea and vomiting of 48 hours' duration. Clinical examination showed no evidence of bowel obstruction. X-rays showed no abnormalities and blood tests were unremarkable. A gastroenterology opinion was sought. A closer probing of the history revealed that the vomiting consisted of regurgitation of completely undigested food contents shortly after eating. As an infant she had been diagnosed with a ‘narrow’ oesophagus, but had been told by paediatricians that she would ‘grow out of it’. She was of short stature, and on closer questioning revealed that she had always found eating difficult and had a poor appetite. The possibility of partial oesophageal atresia was raised. A gastroscopy was performed which revealed almost complete obstruction of the oesophagus at 35 cm. On barium swallow a thin string-like 4 cm passage into the stomach was evident, enough to allow the passage of fluids (Figures 1–3). A computed tomography scan was performed to further delineate the anatomy and to exclude a mass lesion associated with the stricture. Owing to the severity of the stenosis, it was felt that dilatation would only provide temporary relief and could be potentially dangerous, with a high risk of perforation. A surgical review was requested and it was decided that a Merendino jejunal transposition may be required to allow effective swallowing. The patient was consented for this elective procedure, and she was fed on a liquid diet of build-up products for 3 weeks. Surgery went ahead as planned. However, during the operation it was decided that the changes were not as severe as previously felt and that a simple myotomy would provide adequate relief, with the option to proceed to more aggressive surgery at a later date if needed. It was probable that a degree of the narrowing seen on imaging was caused by inflammation from eating solid foods, and that this had improved on the liquid diet. The postoperative period was complicated by an anastomotic leak. However, the patient recovered quickly from this and was discharged home shortly afterwards. In the 3 months post surgery she continued to improve, and she is now able to eat a normal diet without difficulty.
A multidisciplinary team approach to weaning from prolonged mechanical ventilation
Authors: Black Claire J , Kuper Martin , Bellingan Geoff J , Batson Steve , Matejowsky Claire , Howell David CJ 
Published: May 2014

Objective: To establish whether multidisciplinary team-led strategies to maintain continuity across the weaning process result in an increase in the proportion of patients surviving prolonged mechanical ventilation and reduce the length of time patients are ventilated. Design: A quality improvement programme was conceived and implemented for patients receiving mechanical ventilation for ≥21 days. Setting: University teaching hospital general intensive care unit. Interventions: The introduction of long-term weaning plans. Measurements and main results: intensive care unit survival odds ratio and 95% confidence interval 0.181 (0.06–0.49) P<0.01 and hospital survival odds ratio and 95% confidence interval 0.2 (0.08–0.61) P<0.01. Duration of mechanical ventilation (median and 95% confidence interval) 53 days (32–74) vs 42 days (39–44) P=0.03. Conclusions: Long-term weaning plans led by a multidisciplinary team were associated with a reduction in intensive care unit and hospital mortality, and duration of mechanical ventilation in patients ventilated for ≥21 days. Strategies to maintain continuity in this complex patient group are likely to be fundamental to improving outcome.
The Best Practice Tariff helps improve management of neck of femur fractures: a completed audit loop
Authors: Khan SK , Weusten A , Bonczek S , Tate A , Port A 
Published: May 2014

Background: The Best Practice Tariff incentivizes hospitals in the UK to improve the care they deliver, and includes a requirement to deliver multiprofessional care to patients with neck of femur fractures. The Best Practice Tariff for 2010–11 included six targets: (1) surgery within 36 hours, (2) admission under consultant-led joint orthopaedic–geriatric care, (3) admission using a multidisciplinary assessment protocol, (4) review by a geriatrician within 72 hours, (5) geriatrician-directed multi-professional rehabilitation, and (6) assessment for falls and bone protection. The authors chose to audit their Trust's compliance with these targets. Methods: A retrospective audit was conducted in 2011 at the authors’ university-affiliated tertiary care hospital, which is a regional major trauma centre. Only patients 65 years or older, with fragility-type neck of femur fractures who were treated surgically at the authors’ unit and were eligible for geriatric review and multiprofessional rehabilitation, were included. The results of this audit (2010–11 Best Practice Tariff targets) were analysed and a series of procedural and logistical measures were introduced. A re-audit was performed in April 2012 for 2011–12, and the results for the 2 years were compared using appropriate statistics (Chi square tests and analysis of variance). Thirty-day mortality was compared using the summary hospital-level mortality indicator. Results: A total of 410 patients were eligible for Best Practice Tariff in 2010–11, which increased to 463 in 2011–12. The changes from the first year's audit helped increase the rates for 36-hour surgery from 48.3% to 73.4% and for 72-hour geriatric review from 68.8% to 81.8% (P<0.05). The annual Best Practice Tariff achievement increased from 31.7% to 61.3% (P<0.05). The summary hospital-level mortality indicator declined from 96.5 to 61.3. Conclusions: Focusing on poorly satisfied Best Practice Tariff indicators can produce a significant improvement in the per capita Best Practice Tariff achievement. Further studies are needed to assess the health and financial gain in detail.
Basilar artery aneurysm: an unusual cause of intractable hiccups
Authors: Li ML , Gupta A , Thomas P , Richards AJ 
Published: May 2014

A70-year-old retired lorry driver was admitted as an emergency with a 2-day history of moderate amount of haematemesis, nausea, vomiting and intractable hiccups. He was a known hypertensive and 5 years previously had an episode of subarachnoid haemorrhage. Complications required the insertion of a Rickman reservoir shunt. Since the time of the subarachnoid haemorrhage, his hiccups had been almost constant despite taking chlorpromazine tablets 25 mg three times a day.On examination, he had intractable hiccups. Cardiovascular, respiratory and abdominal examination were normal. Neurological examination revealed a right-sided partial third nerve palsy (with ptosis and pupillary sparing). He also had a right-sided squint operation during childhood. More detailed examination of the cranial nerves revealed mild right-sided glossopharyngeal and hypoglossal nerve palsies. Routine full blood count, blood biochemistry, chest X-ray and abdominal ultrasound scan were normal. Upper gastrointestinal endoscopy revealed a hiatus hernia with mild oesophagitis. He was started on omeprazole.In view of the neurological findings and past history of subarachnoid bleed, a magnetic resonance imaging brain scan was performed. This revealed a large basilar artery aneurysm with a significant mass effect on the brainstem at the level of the border of fourth ventricle (Figures 1–3).Alternative drug treatment in the form of nifedipine 10 mg three times a day was initiated instead of chlorpromazine and the hiccups resolved completely. On follow-up in the clinic a few months later, there was no recurrence of the hiccups.
Coronary artery fistula: a rare cause of a left to right shunt
Authors: James P Rachael , Davies Robert H , Hardman Suzanna MC 
Published: May 2014

A48-year-old woman presented with increasing breathlessness on exertion. A continuous murmur had been noted 6 years earlier and attributed to a patent ductus arteriosus. At referral, examination revealed a systolic murmur (2/6) continuing across the second sound into late diastole (1/4), audible at the left sternal edge. Her electrocardiogram showed sinus rhythm, a normal axis and non-specific ST changes in the inferior leads. A transthoracic echocardiogram demonstrated impaired left ventricular function, most marked in the anterior wall, and a well circumscribed area of turbulent flow in the region of the interatrial septum but no shunt at this level (using Doppler and colour coding). These findings were suggestive of a vessel running through the interatrial septum which was subsequently confirmed using transoesophageal echocardiography (Figures 1 and 2). Running a tortuous course from its origin at the left main coronary artery, through the interatrial septum to drain into the right atrium, the serpiginous appearance of the vessel was typical of a coronary artery fistula. The left ventricular hypokinesia and fistula were confirmed at cardiac catheterization but no additional atherosclerotic disease was demonstrated. A thallium perfusion scan, including adenosine vasodilation, failed to demonstrate any perfusion defect. Nonetheless the left coronary artery to right atrial fistula and left ventricular impairment suggested the patient's symptoms were a function of inadequate myocardial perfusion resulting from coronary artery steal and the patient was referred for surgical ligation. At surgery a 1 cm fistulous dilatation of the left main stem of the left coronary artery was found: the fistula then coursed over the roof of the left atrium and down through the interatrial septum to drain into the right atrium. The fistula was ligated as it crossed over the roof of the left atrium. The patient made an uneventful postoperative recovery. When assessed several months later her symptoms had fully resolved and repeat echocardiography confirmed normal left ventricular function.
Learning perimetry: the Swedish way
Authors: Martin Lene M 
Published: May 2014

Aim: To report experiences from teaching perimetry to ophthalmic nurses during their education at the Karolinska Institutet, Stockholm, Sweden. Subjects and methods: The number of occasions for performing perimetry, both under supervision and independently, during clinical practice were counted and the students' comments analyzed. A computer program for simulation of manual perimetry using the Goldmann apparatus was developed and tested by 20 students. Results: The number of occasions during which students could practise perimetry was variable, depending on the site where the clinical practice period took place, especially regarding manual Goldmann perimetry. The median number of computerized perimetry examinations performed, both under supervision and independent, was approximately 40. The median number Goldmann perimetry examinations performed was two (range zero to five), all under supervision. The students underwent 5-25 training sessions with the computer program. They reported that the program was easy to use, even fun, and that they appreciated the opportunity to practise when and where they wanted. Some student also reported that the simulation training improved confidence and performance in the real perimetry testing situation. Conclusion: Training in planning, performing and evaluating visual field examinations using computerized perimetry appears to be sufficient during current clinical practice periods, but there is a lack of training possibilities for Goldmann Perimetry. A simulation program provides unlimited training opportunities and can be used in parallel to clinical practice.