An Atypical Presentation of Rheumatoid Arthritis as an Asymmetrical Arthropathy.

We report a rare entity of distinctly asymmetrical rheumatoid arthritis (RA) in a 71-year-old Chinese lady with a history of cervical radiculopathy secondary to trauma sustained during childhood. The joints on the side of the paresis were spared from severe clinical and radiological manifestations of RA. We review the plausible mechanisms that could explain the link between neurological impairment and rheumatoid joint involvement.

Prime time to resuscitate clinical medicine and kill diagnostic greed?

Modern healthcare faces the challenges of rising costs, increasing expectations of patients and changing disease patterns. Physicians practise medicine in an era of easy availability and access to a plethora of modern and sometimes expensive diagnostic aids. The powerful utility of clinical skills cannot be underestimated nor lost. The physician has a powerful platform to encourage the rational use of tests, prevent wasteful overutilisation and ensure that tests do not cause more harm than benefit in physical, emotional or financial terms. Diagnostic skills should not be substituted by diagnostic greed. It is possible to do more for the patient rather than to the patient.

Clinical Ward Rounds-Challenges and Opportunities.

Hospitalised patients' needs are complex and the ward environment is demanding of time and resources that must be optimised. Clinical ward rounds in hospitalised patients are fundamental to patient care. Ward rounds in recent years have undergone changes which have contributed to reduced professionalism and opportunities to learn as well as increased distrust of patients of the care they receive. Calls for a revival of the traditional ward rounds have been sounded which we must contextualise in modern settings. This commentary calls for a clearer definition of the purpose of ward rounds, outlines the roles and responsibilities of those involved in rounds, defines a 4-step process in the conduct of a ward round, and seeks support from hospitals' management in the facilitation and implementation of these.

Cribriform morular variant of papillary thyroid carcinoma in a patient with an incidental neck lump: a case report and review of the literature.

The cribriform morular variant of papillary thyroid carcinoma (CMV-PTC) is a rare morphologic entity that is associated with familial adenomatous polyposis (FAP). We report a case of a young lady with an incidentally discovered right-sided neck nodule on ultrasonography with a diagnosis of CMV-PTC confirmed on thyroidectomy and review the literature associated with the clinical presentation, imaging characteristics, pathological findings and the association with FAP.

Novel association of thymic carcinoid with a germline mutation in a kindred with multiple endocrine neoplasia 1 (MEN1).

Multiple endocrine neoplasia 1 (MEN1) is an autosomal dominant syndrome characterized by a triad of endocrine (parathyroid, enteropancreatic and pituitary) tumors. Familial MEN1 is defined by one first-degree relative having at least one of these 3 main tumors, and is associated with germline mutations in the MEN1 gene on 11q13 in a large proportion of cases. MEN1 patients may also develop non-endocrine tumors, notably thymic carcinoid. These are rare tumors found predominantly in men, and are a major cause of death in MEN1 due to their insidious nature, lack of effective treatment and unpredictable recurrence. Prophylactic thymectomy has been advocated for prevention but continued surveillance for recurrence is necessary. Although genotype-phenotype correlation in MEN1-related thymic carcinoid is inconsistent, there is a high prevalence of truncating mutations in this condition. We describe a father and son with MEN1, associated with thymic carcinoid (father) and the truncating mutation R29X (son), which was not previously reported in MEN1-related thymic carcinoid, and review the literature about thymic carcinoids in MEN1. Our cases illustrate the importance of a high index of suspicion for early diagnosis and lifelong surveillance in MEN1, and the utility of genetic analysis in defining surveillance for MEN1-related thymic carcinoid.

Unravelling the mystery in a case of persistent ACTH-independent Cushing's syndrome.

INTRODUCTION: We present a rare variety of adrenocorticotrophic hormone (ACTH)-independent Cushing's syndrome known as primary pigmented nodular adrenocortical disease (PPNAD). CLINICAL PICTURE: The patient initially underwent unilateral adrenalectomy for what was thought to be a left adrenal adenoma. OUTCOME: Partial resolution of symptoms and demonstrable persistent hypercortisolism after surgery prompted further evaluation with findings leading to the diagnosis of Carney complex. A review of the adrenal histology was consistent with PPNAD. CONCLUSION: This entity of PPNAD, which has rarely been reported in Asians, forms part of the Carney complex. The diagnosis may not be simple and straightforward, as illustrated in this patient.

Long-term treatment outcome in acromegaly.

A number of groups have developed guidelines to indicate whether an individual with acromegaly has been cured by treatment. However, studies to date do not provide a robust definition of biochemical remission of the disorder based on correlation with long-term outcome. Available data suggest that those with a random serum growth hormone (GH) level of <2.5 microg/l, or a glucose-suppressed GH level of <1 microg/l following treatment have mortality figures indistinguishable from the general population. However, the confidence limits for these mortality estimates are quite wide. It remains possible that growth hormone levels lower than 1 microg/l for random samples, or even lower when using ultrasensitive GH assays, may indicate superior outcome, but this remains to be confirmed. There are limited data relating serum insulin-like growth factor-I (IGF-I) levels to outcome, although normalisation of serum IGF-I clearly improves outcome compared with continued elevation of measurements after treatment. Current evidence suggests that a post-treatment random serum GH <2.5 microg/l and a normal serum IGF-I value defines biochemical cure. Available data suggest that achieving similar growth hormone levels after treatment also reduces the prevalence of chronic complications of the disorder, which is subsequently reflected in improved mortality.

The clinician meets the computer--uneasy bedfellows.

The transformation of healthcare has been one of the great, but unfulfilled, promises of the information technology revolution. This disappointment has been due in part to the enormously complex processes involved in bedside clinical care. Selective adoption of advances in information technology has resulted in enhancement of point-of-care healthcare delivery, medical record management and professional communication. However, the introduction of these refinements has encountered resistance, as well as sparked new challenges. The exciting progress in this field is reviewed, with reference to global and local developments.

High prevalence of psychiatric morbidity in a medical intensive care unit.

This study seeks to determine the prevalence of psychiatric morbidity within a medical intensive care unit, examine its correlation with the various physiological parameters and delineate any clinical predictors for psychiatric morbidity. Seventy-seven patients who gave informed consent were administered the General Health Questionnaire (GHQ), Acute Physiological And Chronic Health Evaluation II (APACHE II) and thyroid function tests were performed. A high prevalence of psychiatric morbidity was found (36.4%). However, no statistically significant association was found between psychiatric morbidity and gender, age, APACHE II scores and thyroid function indices. Nevertheless, it is hoped that the index of suspicion for psychiatric morbidity can be raised in order to optimise the clinical management of patients within this setting.

A case report of the use of magnesium sulphate during anaesthesia in a patient who had adrenalectomy for phaeochromocytoma.

INTRODUCTION: Patients with phaeochromocytoma have haemodynamic instability during adrenalectomy. CLINICAL PICTURE: A case showing major swings of blood pressure during tumour handling. TREATMENT: Magnesium sulphate infusion alone failed to prevent severe hypertension. OUTCOME: The patient had to be given phentolamine and sodium nitroprusside to control the severe hypertension. CONCLUSION: The greatest value of magnesium sulphate is in controlling catecholamine release at induction and intubation, and in association with other agents in controlling arrhythmias and hypertension during tumour handling.