Drug treatment of intermittent claudication

Intermittent claudication is a major presenting manifestation of chronic obstructive peripheral arterial disease of the lower limbs. The goals of treatment in the absence of rest pain are relief of symptoms, improvement in walking distance and prevention of progression of disease. The effectiveness of drug therapy for intennittent claudication, however, remains controversial and despite numerous clinical trials, many experts are not convinced of their value. In this article the author describes the drugs most frequently uses and most extensively studied.peer-reviewe

The superior mesenteric artery syndrome

Obstruction of the duodenum by entrapment between the aorta and the superior mesenteric artery (SMA) is a controversial entity. Acceptance of this syndrome as a clinical entity has not been universal because of confusion with other causes of upper gastrointestinal obstruction. Two cases which sharply exemplify the clinical and anatomic features of the SMA syndrome are reported. Symptoms mimic pyloric outlet obstruction but gastroscopy is frequently normal and the diagnosis is made on barium studies. The anatomic features of this entity are a narrow angle between the aorta and the SMA, together with high fixation of the duodenum by the ligament of Treitz. The SMA syndrome may be acute or chronic and responds well to duodenojejunostomy.peer-reviewe

A pilot survey of admissions to two surgical wards

A three months prospective survey of admissions to two general surgical wards, one for men and one for women, was carried out between the 1st of May and the 31st July, 1964. Three hundred and sixty patients have been analysed in various respects: age, disease, length of stay in hospital, weight, height, incidence of diabetes. Of the 360 patients, 228 (63.3%) were males and 132 (36.7%) females. One positive result has been the finding of a number of previously unknown diabetics. It has not been found possible to draw statistically significant conclusions from the figures quoted, one of the chief reasons being the relative smallness of the numbers. Notwithstanding, certain possible trends are suggested and these can serve as a basis for further research.peer-reviewe

Primary hyperparathyroidism in pregnancy : case report and review

A twenty-six year old secundagravida booked her pregnancy at 14 weeks gestation. It was noted in the past obstetric history that the woman had lost her first child at 41 weeks gestation, delivering a stillborn baby weighing 4.2kg. At 34 weeks into the second pregnancy mild polyhydramnios was noted and the patient was admitted. During her hospitalisation the patient complained of having passed a small renal stone. Two serum calcium levels were found to be significantly elevated 3.36mmol/l and 3.2mmol/l. Serum parathormone was found to be significantly elevated - 247pg/ml (Normal levels: 12.0 - 72.0pg/ml) and an ultrasound scan of the neck confirmed the presence of a parathyroid adenoma. A parathyroidectomy was performed and the postoperative period was uneventful. The rest of the pregnancy was uneventful and at 38 weeks gestation a healthy child was delivered vaginally. In view of this woman’s past history and the events occurring during the second pregnancy it may be useful to consider obtaining serum levels of calcium in cases of idiopathic stillbirth.peer-reviewe

Omeprazole-induced delirium

Delirium is a common manifestation in the elderly, with studies quoting a prevalence of up to 14% in the community in those aged 85 years and older. It occurs in 10-34% of patients living in long term care facilities and occurs in 30% of patients presenting to the accident and emergency departments. Despite the fact that 10-42% suffer from delirium during a hospital stay, complicating 17-61% of major surgical procedures, it is unfortunately only recognized in 20-50% of cases. Despite the higher prevalence in the elderly population, it may present in all age groups, identified as per the ‘American Psychiatric Association’ (APA) Diagnostic and Statistical Manual (DSM-IVTR and DSM-V Proposed Revision) criteria. Medications are potential causes for delirium, accounting for as much as 39% of cases of delirium in the elderly, with the latter population being more at risk than other age groups due to altered pharmacokinetic and pharmacodynamics associated with the aging process.peer-reviewe

A possible hazard of splenectomy

The first case of splenectomy in St. Luke`s Hospital of a four months old infant is described. The infant died from a fulminating septicemia just over six weeks after splenectomy. Similar case studies indicated that fulminating infection occurs after splenectomy, particularly in infancy which could result fatal. In this regard, this study recommends that splenectomy should not be performed in the preschool child. Furthermore a careful follow-up of all splenectomised patients is advisable, by also treating any infection no matter how minor it may appear to be.peer-reviewe

DiGeorge syndrome presenting as hypocalcaemia-induced seizures in adulthood

Introduction. DiGeorge syndrome is a developmental defect commonly caused by a microdeletion on the long arm of chromosome 22 or less frequently by a deletion of the short arm of chromosome 10. Case report.We report a case of a gentleman with mild dysmorphic features who presented with hypocalcaemia-induced seizures and an associated thyroid mass with a background of learning difficulties and abnormal immune function. Discussion. DiGeorge syndrome was initially described in 1967 by Angelo DiGeorge. The majority of cases are due to a novel mutation. The resulting learning difficulties, congenital heart disease, palatal abnormalities, hypoplasia/aplasia of the parathyroid and thymus glands, and immune deficiency generally lead to diagnosis in childhood. Presentation in adulthood is rare but must be borne in mind when dealing with cases of hypocalcaemia even in the absence of florid phenotypic features. A link with malignant disease has also been reported and should lead to prompt investigation of concerning masses.peer-reviewe

The role of the A C395 IFNGR1 mutation in determining susceptibility to intracellular infection in Malta

Background: The first human mycobacterial susceptibility gene was identified amongst four children on the island of Malta in 1995. All affected children were homozygous for a nonsense mutation at position 395 of the interferon gamma receptor 1 (IFNGR1) gene, and all but one died of overwhelming mycobacterial infection. The population of Malta has high rates of infection with intracellular pathogens; leishmania, brucellosis and tuberculosis are all endemic, while leprosy, which was previously endemic, has only recently been eradicated. We hypothesised that heterozygous carriers of the IFNGR1 gene mutation, while resistant to infection with poorly pathogenic organisms, may have increased susceptibility to infection with more virulent pathogens. Methodology and Result: Screening patients with a past history of intracellular infection and healthy newborns for the presence of the IFNGR1 A->C395 mutation, using sequence specific primer PCR, did not identify any carriers of the mutation. Conclusion: These results suggest that the IFNGR1 mutation is unlikely to be of public health significance on Malta.peer-reviewe

Parathyroid carcinoma : clinical course, diagnosis and management

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism often resulting in severe hypercalcaemia. It tends to follow a rather aggressive course with a high propensity for locoregional spread and distant metastasis. En bloc resection is the mainstay of treatment, with surgery also playing a role in the palliation of hypercalcaemia for recurrent and metastatic disease. While adjuvant chemotherapy and radiotherapy have shown disappointing outcomes, bisphosphonates and calcimimetic agents are effective in the management of recalcitrant hypercalcaemia in parathyroid carcinoma. We report a case of parathyroid carcinoma in a lady who initially presented with a neck mass, severe hypercalcaemia, a bony swelling over the shin and elevated parathyroid hormone levels. The diagnosis was confirmed histologically following a thyroid lobectomy, isthmectomy and parathyroidectomy. In the three years which followed the patient received two courses of palliative radiotherapy, two thoracotomies for pulmonary metastatectomy, an extensive neck re-exploration and fashioning of a tracheostomy for aggressive local recurrence with invasion of the larynx.peer-reviewe

Cancer-associated abdominal vein thrombosis

Cancer is associated with an increased risk of developing venous thromboembolism, due to its direct influence on the three pillars of Virchow’s triad (e.g., compression on the blood vessels by the tumour, blood vessels invasion, and cytokine release), together with the effect of exogenous factors (such as chemotherapy, radiotherapy, surgery). In cancer patients, the risk of thrombosis at unusual sites, such as splanchnic, ovarian and renal vein thrombosis, is also increased. Abdominal vein thromboses are frequently incidental findings on abdominal imaging performed as part of the diagnostic/staging workup or the follow-up care of malignancies. There is little evidence on the management of unusual site venous thromboembolism in cancer patients since there are only a few specific recommendations; thus, the management follows the general principles of the treatment of cancer-associated deep vein thrombosis and pulmonary embolism. This narrative review summarises the latest evidence on cancer-associated abdominal vein thrombosis, i.e., thrombosis of the splanchnic, ovarian and renal veins.peer-reviewe