Pasireotide therapy in a rare and unusual case of plurihormonal pituitary macroadenoma.

Unlabelled: We report the use of pasireotide in a rare and unusual case of pituitary macroadenoma co-secreting GH, prolactin and ACTH. A 62-year-old Caucasian man presented with impotence. Clinically, he appeared acromegalic and subsequent investigations confirmed GH excess and hyperprolactinaemia.

Successful two-stage revision of a KineSpring® joint unloading implant: a case study.

Few nonsurgical treatment options are available to the patient with debilitating knee osteoarthritis (OA) that is refractory to conservative care. The KineSpring® System joint unloading implant is a unique device that reduces the load carried by the medial compartment of the knee joint by up to 13 kilograms during the stance phase of gait. We report a case of a male patient who underwent implant with the KineSpring System for symptomatic knee OA but subsequently required revision due to local infection.

Randomized study comparing fascia and cartilage grafts in myringoplasty.

Objectives: The study compares the medium-term outcomes of myringoplasty procedures using fascia and cartilage grafts.

Methods: Patients with chronic otitis media with perforations larger than 50% of the size of the tympanic membrane were included in a randomized, controlled, prospective clinical trial. The perforations were repaired with either temporalis fascia (20 ears) or cartilage (18 ears) grafts selected randomly.

Nonischemic central retinal vein occlusion in an adolescent patient with ulcerative colitis.

Inflammatory bowel disease (IBD) can present with extraintestinal manifestations occasionally involving the eye. Retinal vein occlusions are rarely seen and have never been reported in the pediatric population though vascular thrombosis can be associated with IBD. Here, we present a case of what we believe is the youngest reported patient with nonischemic central retinal vein occlusion (CRVO).

Surgical management of troublesome mastoid cavities.

Objective: To examine the reasons for discharging mastoid cavities, the operative findings during revision surgery, and the medium-term outcome.

Patients: One hundred and forty revision mastoidectomies in 131 patients were studied. Post-operatively, patients were followed up at three, six and 12 months and then yearly.

A problem in diagnostic imaging.

Many pathological processes can present as a swelling in the groin. We present a case of complex, ruptured pyonephrosis causing a psoas collection, which in turn presented clinically as an apparent right "incarcerated inguinal hernia." The patient was successfully treated with antibiotics and ultrasound-guided drainage of the abscess.

Topical vaginal estrogen therapy in managing postmenopausal urinary symptoms: a reality or a gimmick?

Postmenopausal estrogen deprivation has been suggested as a risk factor for lower urinary tract dysfunction including stress incontinence, overactive bladder and recurrent urinary tract infection. These symptoms could have enormous effects on individuals and health-care providers in terms of impact on quality of life and cost. Recent randomized, controlled trials suggested that systemic hormone replacement therapy does have a negative effect on female lower urinary tract function, probably because of the progestogen component.

Titanium versus nontitanium ossicular prostheses-a randomized controlled study of the medium-term outcome.

Objective: The study compares the medium-term outcome of ossiculoplasty using titanium and nontitanium prostheses.

Study Design: Randomized controlled, prospective clinical trial.

Setting: District general hospital.

Case series and literature review: popliteal artery injury following total knee replacement.

We present a case series and literature review of injury to the popliteal vessels during total knee replacement (TKR). This is rare but may be limb-threatening with devastating consequences for the patient. An individual surgeon will see few cases.

Perioperative cardiac arrest in a patient with previously undiagnosed Becker's muscular dystrophy after isoflurane anaesthesia for elective surgery.

A previously fit 12-yr-old boy, who had no previous history of anaesthesia, underwent general anaesthesia using isoflurane for an elective circumcision. After uneventful surgery and anaesthesia, he suffered a cardiorespiratory arrest in the recovery room. Prompt oxygenation and cardiopulmonary resuscitation (CPR) were instituted.

Picture quiz: answer.

While peripheral lesions account for a significant proportion of cases presenting with isolated motor hand weakness (Box 1), this case illustrates the importance of recognizing infarction of the hand knob area as a cause for such a presentation. An accurate history is essential, along with a detailed systemic and neurological examination performed, particularly looking for other neurological findings that may hint towards a peripheral cause or involvement of more areas cortically. The presence of weakness of all muscle groups is unusual in peripheral nerve lesions and led in this case to the initial investigation with cerebral MRI, which provided the diagnosis.

Picture quiz: 'the upper hand'.

A 76 year-old right-handed man presented acutely with a sudden onset of weakness affecting his right hand only. This happened while working in the garden. On detailed history taking, he denied any previous symptoms, trauma or prodromal illnesses.

Premenopausal bleeding: When should the endometrium be investigated?--A retrospective non-comparative study of 3006 women.

Objective: There is lack of consensus amongst professional organizations as regards the cut-off age for endometrial sampling of premenopausal women presenting with abnormal uterine bleeding (AUB) to exclude endometrial hyperplasia or carcinoma. Therefore we conducted this study to quantify the prevalence of hyperplasia and carcinoma in different age categories in premenopausal women with AUB to identify the appropriate cut-off age for endometrial sampling.

Study Design: A retrospective review of the histopathology reports of endometrial samples taken from 3006 women presenting with AUB and aged from > or =30 to < or =50 years at Ipswich Hospital, UK, from 1 January 1998 to 31 December 2007.

The relationship between gonadotrophic hormones and progesterone in the mid-luteal phase.

Context: It is known that progesterone (PRG) exerts a negative feedback on gonadotrophic hormones in the mid-luteal phase. However, we are unaware of any data in the literature that states the nature of this relationship, for example, is it linear or not?

Objective: To determine the relationship between gonadotrophic hormones and PRG in the mid-luteal phase using routine clinical assays and routine clinical patient data.

Methods: Retrospective mid-luteal phase serum follicle-stimulating hormone (FSH), leutinizing hormone (LH) and PRG data from 393 women were obtained from the laboratory computer system.

Investigation of outpatients referred to a chemical pathologist with potential pseudohyperkalaemia.

Background: Pseudohyperkalaemia is when the in vitro blood potassium concentration is artefactually raised while the in vivo concentration is normal. With unexplained hyperkalaemia, pseudohyperkalaemia needs to be excluded to avoid unnecessary and potentially detrimental therapy. There are numerous causes, but no systematic approach for the investigation of outpatients with potential pseudohyperkalaemia exists in the literature.

Irregular surface compensation for radiotherapy of the breast: correlating depth of the compensation surface with breast size and resultant dose distribution.

Irregular surface compensation uses dynamic multileaf collimators to modify the fluence to an irregular surface along the cranio-caudal axis. The depth of the compensation surface can be varied by specifying a user-defined parameter called the transmission penetration depth (TPD). In our institution, a review has been carried out of 60 breast patients treated using irregular surface compensation of the tangent fields.

Comparison of reflective and reflex testing for hypomagnesaemia in severe hypokalaemia.

Aim: To compare the impact and effectiveness of introducing reflective and reflex testing of magnesium in severe hypokalaemia.

Methods: All specimens with [K] < or =2.5 mmol/l were retrospectively identified in three 6-month periods: baseline, with reflective testing, and with reflex testing.

Levonorgestrel-releasing intrauterine system--the discontinuing story.

Levonorgestrel-releasing Intrauterine System (LNG-IUS) is licensed for use as a contraceptive, for the treatment of heavy menstrual bleeding and during estrogen replacement therapy. It is publicized as a local source of progestogen with minimal systemic adverse effects. However, there is overwhelming evidence of elevated serum and tissue levels of levonorgestrel, and high discontinuation and dissatisfaction rates amongst users.

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 1: Is ultrasound or chest x ray best for the diagnosis of pneumothorax in the emergency department?

ED transthoracic ultrasound is better than plain x ray in the diagnosis of pneumothorax in the supine patient. CT thorax is the gold standard for diagnosis.

Postcoital bleeding: a study of the current practice amongst consultants in the United Kingdom.

Objectives: To measure the variations amongst consultant gynaecologists all over the UK in managing women with postcoital bleeding (PCB).

Study Design: A questionnaire was sent to 1020 consultant gynaecologists in the UK, using the database of The Royal College of Obstetricians and Gynaecologists, enquiring about their opinions and the details of practice.

Results: Six hundred and fourteen (60%) replies were received.

Case report. An unusual cause of a patient presenting with an acutely locked knee: multiple benign fat pad cysts.

Benign ganglion (synovial) cysts within the knee are uncommon and especially so when located in the infrapatellar fad pad. They cause many non-specific symptoms but usually present as a swelling. We report the case of a young gentleman with multiple benign synovial cysts within the fat pad causing a locked knee, which was treated with arthroscopically assisted open excision.