bluuebunny/crossref_metadata_2025_split huggingface dataset:
Novel H1N1 influenza and Panton-Valentine leukocidin Staphylococcus aureus necrotizing pneumonia
Authors: Barrett NA , Armstrong-James D , Edgeworth J , Wyncoll D 
Published: May 2014

A 17-year-old man with no significant medical history and no prodromal symptoms presented to the emergency department with a 2-day history of left-sided pleuritic chest pain and a dry cough. His respiratory rate was 16 breaths/minute, pulse 125 beats/minute, blood pressure 113/73 mmHg, temperature 36.6°C and oxygen saturation 93% (fraction of inspired oxygen 0.21). His peripheral blood white blood cell count was 23.1x109/litre and C-reactive protein was 520 mg/litre. Legionella and pneumococcal urinary antigen tests were negative. A chest radiograph (Figure 1) demonstrated rounded consolidation behind the heart. He was admitted for oxygen, clarithromycin and co-amoxiclav therapy. Over 24 hours he became productive of purulent sputum and had a single pyrexial episode at 39.5°C. On the third day he rapidly deteriorated requiring transfer to the intensive therapy unit, where he progressed from conventional mechanical ventilation to high-frequency oscillatory ventilation within hours. His chest radiograph (Figure 2) demonstrated widespread bilateral infiltrates. He was resuscitated and received drotrecogin alfa, according to Surviving Sepsis guidelines (Dellinger et al, 2008), as he did not have haemoptysis. He developed multiple organ failure requiring haemodynamic and renal support. Empiric oseltamivir was commenced and a nasal mucosal swab tested by novel H1N1 influenza real-time reverse transcriptase polymerase chain reaction was positive. Admission blood cultures were sterile, but a sputum sample taken after one dose of co-amoxiclav grew methicillin-sensitive Staphylococcus aureus. All subsequent sputum cultures that day and while in the intensive therapy unit were negative. A working diagnosis of co-infection with novel H1N1 influenza and Panton-Valentine leukocidinproducing S. aureus was made. Linezolid, clindamycin and intravenous immunoglobin were commenced with reference to Health Protection Authority (2008) guidance. Presence of the Panton-Valentine leukocidin (lukS-PV/lukF-PV) gene from the S. aureus isolate was confirmed by polymerase chain reaction at the Health Protection Authority Staphylococcal Reference Laboratory. His multiple organ failure resolved and he was converted back to conventional ventilation after 2 weeks of high-frequency oscillatory ventilation. Significant hospital and community contacts were screened for Panton-Valentine leukocidin-producing S. aureus and offered prophylaxis and/or advice on novel H1N1 influenza exposure. No evidence of nosocomial or inter-familial transmission of either pathogen was found.
Documenting informed consent in elective hip replacement surgery: a simple change in practice
Authors: Isherwood Jennifer , Dean Benjamin , Pandit Hemant 
Published: May 2014

Adequate documentation of informed consent is an important aspect of many doctors’ work and failings in this area may result in patient dissatisfaction or litigation. In 2009 the documentation of risks and complications on the consent forms of patients undergoing primary hip replacement was audited at a specialist centre. Following this audit procedure-specific complication stickers were introduced in an attempt to improve the documentation of the consent process. This article discusses the results of a re-audit and aims to determine if this change in practice had resulted in any significant improvement in documentation. The consent forms of 100 consecutive patients undergoing primary total hip replacement were re-audited using a standardized data collection sheet in order to close the audit loop. The re-audit found that 86 consent forms used the procedure-specific complication sticker to list the potential complications associated with a total hip replacement. Statistically significant improvements in the documentation of fracture, neurovascular damage, leg length discrepancy, failure, premature loosening, death, medical complications, ongoing pain, stiffness, wound healing problems and other were all seen in the 2012 re-audit in comparison to the 2009 audit (P<0.0001). The cheap and simple introduction of procedure-specific complication stickers in order to help surgeons document the process of informed consent has resulted in significant improvements in practice. In the context of patient-focused care and satisfaction in the NHS, it is vital that simple measures such as the introduction of procedure-specific complication stickers are embraced.
A shaggy dog story? A trichobezoar presenting with gastrointestinal perforation
Authors: Hargreaves Nicola J , Howman Elizabeth M 
Published: May 2014

A 12-year-old Caucasian girl was admitted urgently with a 2-week history of intermittent left upper quadrant pain. The pain had worsened, radiated to the left shoulder blade and was eased with ibuprofen. There were no other associated symptoms and no history of trauma. A similar episode a year before had resolved spontaneously after several days. On examination she looked well but was pyrexial (temperature 37.7°C). There was a firm, smooth, tender mass extending from the epigastrium to the umbilicus which was not indentable. There was no crepitus, bowel sounds were normal and there were no signs of peritonism. There was a mild neutrophil leucocytosis but a full blood count and electrolytes were otherwise unremarkable. A chest radiograph suggested free gas under both hemi-diaphragms (Figure 1) with a large central soft tissue mass on the plain abdominal radiograph (Figure 2). On ultrasound a gas-filled viscus obscured the epigastrium. Gastrograffin swallow characterized this as a dilated stomach with a large granular filling defect completely filling the body and antrum (Figure 3). There was no obvious ulceration and no gastrograffin leak into the peritoneum. These appearances were highly suggestive of a gastric bezoar. A more detailed dietary history helped to elucidate the nature of the bezoar. Until 2 years previously the family had kept a German shepherd dog and the patient had eaten its hair for most of her childhood. There were no other unusual dietary habits or behavioural problems. Laparotomy and gastrotomy of the dilated stomach delivered a large trichobezoar, cast in the shape of the stomach (Figure 4). There was a 2 cm sealed perforation of benign appearance on the upper greater curve of the stomach, consistent with a pressure ulcer. The patient made an uneventful postoperative recovery.
Causes of the acute abdomen: add thrombophilia to your list
Authors: Skinner Liam J , Kelly John , O'Donnell Martin J , Cotter Paule 
Published: May 2014

A47-year-old male was admitted with a 2-week history of periumbilical discomfort. For 48 hours before admission, the patient suffered from associated vomiting and anorexia. Upon admission the abdominal pain had become more severe and began to radiate to both flanks. His past medical history included a deep vein thrombosis 18 months previously. He was taking Tegretol for epilepsy (seizure free for many years) and regular inhalers for asthma. He had no recent episode of prolonged immobility. He was a non-smoker and did not drink alcohol. On examination, he was obese (96 kg). He had a low grade pyrexia with a sinus tachycardia (120 beats per minute). He was normotensive. Abdominal examination revealed tenderness over the umbilical and epigastric areas. At this stage, there was no evidence of guarding or rigidity and bowel sounds were present. Investigations including serum bioprofile, amylase, coagulation screen, chest X-ray, plain film of abdomen and ultrasound of abdomen were all reported as normal. Full blood count revealed a moderate leucocytosis (13.2 × 109/litre). At this stage he was managed conservatively with intravenous fluids and antibiotics. However, over the next 12 hours, the patient's condition deteriorated and he developed diffuse peritonism with guarding and rebound tenderness. He was prepared for theatre. Laparoscopy demonstrated haemosanguinous fluid and gangrenous loops of small bowel. Laparotomy confirmed the presence of a 24” gangrenous segment of distal jejenum and proximal ileum. Perioperatively, this segment was noted to have good arterial pulsation with obvious clot in the venous arcades. Formal resection with end to end anastomosis was completed. Postoperative recovery was uneventful. After surgery he was anticoagulated with unfractionated heparin. Histology confirmed mesenteric venous infarction. In view of the past history of deep vein thrombosis, a thrombophilia screen was performed. Our patient was heterozygous positive for the factor V leiden mutation. He was anticoagulated and discharged on warfarin indefinitely (under ongoing review).
Penile cellulitis
Authors: Aldeen Taha , Mantell Janet 
Published: May 2014

A37-year-old married man presented to his GP with a 4-day history of itching and painless swelling of his penis. He was treated with a compound antifungal, anti-inflammatory disinfectant cream (Timodine cream, Reckitt & Colman, Hull) without response. Three days later, the patient attended the accident and emergency department at his local hospital with the same complaint. He was diagnosed as having an ‘infected penis’, and was advised instead to attend the genitourinary medicine (GUM) clinic. At the GUM clinic, the patient denied any history of allergy or genital trauma before his complaint. He was in a monogamous sexual relationship with his wife, and only practised peno-insertive vaginal intercourse. He had sexual intercourse 2 weeks previously. There was no significant past medical history. On examination, he was overweight and apyrexial. There was a painless diffusely swollen penis with a ring of crusts at the tip of the foreskin and purulent discharge around the glans penis. There was no urethral discharge and no inguinal lymphadenopathy (Figure 1). There was tenderness on attempting to retract the foreskin. Routine urinalysis for pyuria and proteinuria were negative. Screening for urethral gonococcal and chlamydial infections were negative. However, culture of the purulent discharge taken from the subpreputial sac grew beta-haemolytic group A Streptococcus pyogenes. The patient was initially treated with a 2-week course of amoxycillin and flucloxacillin, and his condition improved dramatically after 4 days.
Tuberculosis as a cause of chronic epididymo-orchitis in a male Caucasian
Authors: McVie JL , Bani-Hani K , Bury RW , Duthie R , Walker SJ 
Published: May 2014

A69-year-old retired white businessman was referred with a 6-week history of painful swelling of the left side of his scrotum. He had received two courses of broad-spectrum antibiotics from his GP which failed to relieve his symptoms. There was no history of scrotal trauma. There was nothing of note in his past medical history apart from angina and chronic laryngitis. On examination the right side of his scrotum was entirely normal, but the left was tense, tender, warm and approximately three times normal size. A scrotal ultrasound demonstrated a normal left testis with a large hydrocele. The left epididymis was enlarged in it's transverse diameter with high vascularity, consistent with epididymitis. The patient was started on oral antibiotic therapy. After 1 weeks treatment the left side of the scrotum had reduced slightly in size but remained painful. Eighteen ml of clear fluid was aspirated from the hydrocele and was sent for culture and sensitivity. No organisms were found. By this stage he had been under review for 9 weeks and had taken antibiotics for a total of 24 days. He requested orchidectomy as he felt unwilling to tolerate the discomfort. At operation an abscess cavity was found surrounding the epididymus and extending close to the external ring. Tissue and a swab was sent for culture and sensitivity and for acid-fast bacilli and the left testicle was removed. His postoperative recovery was complicated by a discharging sinus which resolved with irrigation. The histology report showed extensive areas of necrosis throughout the testis and epididymis with prominent epitheliod cells and many Langhans' type multi-nucleated cells. The appearance was that of florid granulomatous inflammation of the testis and epididymis consistent with a mycobacterium infection. Initial stains for acid-fast bacilli were negative. Subsequently acidfast bacilli were seen in the tissue sample and swabs using oramine phenol counterstained with Ziehl-Nielsen stain. There was a positive culture using Lowenstein Jensen medium, the mycobacteria were sent to a reference laboratory and the species identified as Mycobacterium tuberculosis. He was started on antitubercular treatment. His chest X-ray and intravenous urogram are normal and he remains well 9 months after diagnosis.
The first reported sudden fatality from pulmonary artery compression by a thymic cyst
Authors: Hart Simon R , Ashton-Key Margaret 
Published: May 2014

A 21-year-old previously well female student presented to accident and emergency having woken in the early hours of the morning with severe chest pain. On arrival she appeared, very unwell and breathless. For 1 week she had complained of a severe upper respiratory tract infection associated with chest pain which had been attributed to pleurisy. There was a strong family history of coronary heart disease but no risk factors for venous thrombosis or history of drug abuse. Over the next few minutes she began to look moribund with breathlessness and confusion. During physical examination, which was normal apart from tachypnoea and tachycardia, she had a cardiac arrest. Advanced cardiopulmonary resuscitation for electromechanical dissociation was commenced and after two cycles the rhythm changed to ventricular fibrillation. Tension pneumothorax was excluded by intercostal fine needle aspiration and an endotracheal tube inserted. After 20 minutes of resuscitation, sinus rhythm was restored with a blood pressure of 100/50 mmHg. Physical examination revealed no rash, normal abdominal examination and no abnormal respiratory signs. She regained consciousness and sat up in an agitated state for about 30 seconds. An arterial blood gas showed pO2 10 KPa, pCO2 4 KPa, pH 6.97, bicarbonate 7.3 mmol/litre. Haemoglobin was 12g/dl, total white cell count 18.2 (neutrophils 5, lymphocytes 10). Electrolytes were normal. A chest radiograph and electrocardiogram were about to be taken when cardiac output was lost during another electromechanical dissociation arrest. Resuscitation was restarted having established central venous access, which showed a central venous pressure of about +10 cmH20. Over the next 30 minutes cardiac output could not be re-established and nearly an hour after the initial cardiac arrest the patient was pronounced dead. Post-mortem revealed an 8.0 cm diameter non-communicating cyst in the mediastinum. This was adherent to the left atrium anteroinferiorly and there was external compression of the pulmonary artery anterosuperiorly. It was unilocular, tense, thin-walled and collapsed when punctured revealing a cloudy white serous fluid. The trachea contained thick secretions consistent with resolving pneumonia and there were multiple pulmonary foci of consolidation. There were bilateral pleural effusions each measuring 300 ml and pulmonary oedema, but no evidence of pulmonary emboli. Otherwise, the heart, pericardium and cardiovascular system were normal apart from a small blood-stained pericardialeffusion. Histological examination showed that the cyst had a thin fibrous wall and was lined by cuboidal cells. Immunohistochemistry showed that these cells were positive for the specific cellular antibodies CAM 5.2 and AUA 1 indicating an epithelial rather than mesothelial origin. These findings are consistent with tissue of thymic origin.
Temporal arteritis in the absence of headache
Authors: Sibal Latika , Scoones David J , Bilous Rudy 
Published: May 2014

A 75-year-old woman was admitted to hospital with diplopia on leftward gaze. She underwent thyroidectomy several years ago for thyrotoxicosis with subsequent hypothyroidism for which she was on thyroxine replacement. A microcytic, hypochromic anaemia had been diagnosed a few weeks before admission. She gave no history of headache, eye pain or visual loss. On examination, she was pale and had a left sixth nerve palsy. Tenderness over the temporal arteries was notably absent. A diagnosis of mononeuritis was made with a differential diagnosis of isolated ophthalmic Graves’ disease. Biochemical parameters were as shown in Table 1. Abdominal ultrasound and computed tomography scan of the head were unremarkable; in particular, no swelling of the extraocular muscles was noted. An upper gastrointestinal endoscopy and colonoscopy were performed to investigate the anaemia. A mild Campylobacter-like organism test (for Helicobacter pylori infection) proved positive for gastritis, and areas of patchy erythematous mucosa of uncertain significance were seen. Temporal artery biopsy was performed 11 days after admission and while awaiting biopsy results, she was commenced on prednisolone 60 mg daily. Histopathology confirmed giant cell arteritis, showing fragmentation of the internal elastic lamina and an inflammatory cell infiltrate including lymphocytes and multinucleate giant cells (Figure 1). Within a week of commencing steroids, her diplopia improved and resolved completely in 10 days. She was discharged on prednisolone 20 mg daily and followed up in the outpatient clinic. She remains on reducing doses of steroids along with etidronate and calcium supplementation.
A case of hypertension and hyperkalaemia
Authors: Michael Atef B , Wallis Peter 
Published: May 2014

A52-year-old man was referred urgently to hospital by his GP because he had hyperkalaemia (7.3 mmol/litre; normal range 3.5–5.0 mmol/litre). Two months previously he was diagnosed as having diabetes mellitus when he was admitted to hospital with diabetic ketoacidosis. At that time his plasma sodium was 126 mmol/litre (normal range 133–147 mmol/litre), potassium 2.7 mmol/litre, urea 18 mmol/litre (normal range 2.5–7.5 mmol/litre) and creatinine 159 μmmol/litre (normal range 60–120 μmol/litre). Bendrofluazide, nifedipine and atenolol were stopped. Six weeks later he felt unwell, visited his doctor, and was found to be hypertensive. He was started on lisinopril 5 mg once daily. Ten days later he was still hypertensive, and lisinopril was increased to 10 mg once daily and routine plasma urea and electrolytes were measured. His past medical history includes a Colles' fracture in 1992. At this time, hypertension and hyperkalaemia were noted and investigated. He was diagnosed as having Gordon's syndrome. Three of his daughters and two of his granddaughters were also found to have the syndrome. His father had been hypertensive and died suddenly at the age of 40 years. His uncle had also died suddenly at the age of 33 years. On examination his height was 1.60 m, body mass index (BMI) was 30 kg/m2 and blood pressure was 168/75 mmHg. Heart, chest, abdominal, and neurological examination were normal. The electrocardiogram did not show manifestations of hyperkalaemia. The hyperkalaemia was treated with insulin/glucose infusion. Lisinopril was stopped and bendrofluazide was started with normalization of plasma potassium level and blood pressure.
Carotid diaphragm: an unusual and easily missed cause of internal carotid artery stenosis
Authors: Raman S , Osborn GD , Khan PY , Winter RK , Champ CS , Lewis MH 
Published: May 2014

A 79-year-old retired railway worker presented to the ophthalmology department with a history of two episodes of transient loss of vision in the left eye, each lasting approximately 10 minutes, highly suggestive of amaurosis fugax. He had an extensive past medical history including a myocardial infarction, hypertension and peripheral vascular disease. In addition, he was an ex-smoker on lipid-lowering drugs and was taking regular aspirin. On physical examination, he had bilateral carotid bruits but no other cardiovascular or neurological abnormality was demonstrated. He was referred to the department of vascular surgery following duplex scanning of his carotid arteries. Initial duplex scanning carried out by an experienced sonographer revealed increased peak systolic and end diastolic velocities in the right internal carotid artery, indicating a greater than 70% stenosis. Velocities in the left internal carotid artery were normal, excluding stenosis, although slight turbulence of flow was noted. As these results did not correlate with the clinical scenario, a repeat duplex scan was performed. It was only on the second occasion by careful scanning of the left internal carotid artery that a thin diaphragm across the carotid bulb with a small central lumen was identified (Figures 1a and b). The high velocity blood flow through this lumen associated with turbulent flow downstream correlated with a greater than 70% stenosis of the left internal carotid artery. An echolucent, eccentric plaque causing a tight stenosis of the left external carotid artery was also noted. A left carotid endarterectomy was performed and the intraoperative findings correlated with the ultrasound findings. The excised specimen is shown in Figures 2a and b. The patient made an uneventful postoperative recovery and is now asymptomatic. Histology confirmed that the 2.2 cm x 1.5 cm tubular, internal carotid artery atheromatous plaque contained a thin diaphragm 6 mm across with a 1 mm central hole. The diaphragm was composed of dense fibrous tissue while the central lumen was lined by endothelium (Figures 3a and b).
Ophthalmic advanced practice nursing roles in New Zealand
Authors: Raynel Susanne , Marsden Janet 
Published: May 2014

Aim: To obtain a snapshot of ophthalmic advanced practice roles and how/why they developed in New Zealand.Methods: The survey tool used was an adaptation of one designed and utilized in the UK to gain a 'snapshot' of advanced practice roles in ophthalmic nursing in the UK. The survey consisted largely of pre-coded questions with the opportunity for free text. The survey is made up of two sections, one requesting information about what the roles are and the other about role preparation and education. Ethical approval was obtained from the Regional Ethics Committee for the survey.Results: The findings reveal that advanced practice roles are well established in ophthalmic practice in New Zealand. The roles are predominantly part time with most combining two or more roles, with most roles expanding since implementation. Preparation for the roles was varied with some requiring no education while others were required to have post-graduate papers; several of the respondents have undertaken post-graduate education.Discussion: The main driver for the development of advanced practice roles was policy driven with the implementation of Reduced waiting times for Public Hospitals Elective Services. The most common advanced role undertaken is that of cataract; this is not surprising with the amount of negative publicity ophthalmology services have received for long delays in treatment. Nurses who wish to hold the title of Nurse Practitioner in New Zealand must complete an approved masters degree and this may contribute to the number of nurses undertaking post-graduate study.Planning for the roles was multidisciplinary in the majority of cases.Conclusion: Advanced practice roles in ophthalmic nursing in New Zealand are well established with nurses, in partnership, driving change and service development to achieve targets and benefit patients.