A thymic neuroendocrine tumour in a young female: a rare cause of relapsing and remitting Cushing's syndrome.

UNLABELLED: We present a case of a young female patient with a rare cause of relapsing and remitting Cushing's syndrome due to ectopic ACTH secretion from a thymic neuroendocrine tumour. A 34-year-old female presented with a constellation of symptoms of Cushing's syndrome, including facial swelling, muscle weakness and cognitive impairment. We use the terms 'relapsing and remitting' in this case report, given the unpredictable time course of symptoms, which led to a delay of 2 years before the correct diagnosis of hypercortisolaemia. Diagnostic workup confirmed ectopic ACTH secretion, and a thymic mass was seen on mediastinal imaging. The patient subsequently underwent thymectomy with complete resolution of her symptoms. Several case series have documented the association of Cushing's syndrome with thymic neuroendocrine tumours (NETs), although to our knowledge there are a few published cases of patients with relapsing and remitting symptoms. This case is also notable for the absence of features of the MEN-1 syndrome, along with the female gender of our patient and her history of non-smoking. LEARNING POINTS: Ectopic corticotrophin (ACTH) secretion should always be considered in the diagnostic workup of young patients with Cushing's syndromeThere is a small but growing body of literature describing the correlation between ectopic ACTH secretion and thymic neuroendocrine tumours (NETs)The possibility of a MEN-1 syndrome should be considered in all patients with thymic NETs, and we note the observational association with male gender and cigarette smoking in this cohortAn exception to these associations is the finding of relatively high incidence of thymic NETs among female non-smoking MEN-1 patients in the Japanese compared with Western populationsThe relapsing and remitting course of our patient's symptoms is noteworthy, given the paucity of this finding among other published cases.

Successful pregnancy after liver transplantation in progressive familial intrahepatic cholestasis, type 1.

A woman who had undergone liver transplantation for genetically documented ATP8B1 disease/progressive familial intrahepatic cholestasis, type 1, successfully conceived, carried, and was delivered of a healthy child. The pregnancy and its management are described; implications are discussed.

Seasonal changes in the photosynthetic capacity of canopy oak (Quercus robur) leaves: the impact of slow development on annual carbon uptake.

The photosynthetic development of pedunculate oak ( Quercus robur L.) sun leaves in a mature woodland canopy in Oxfordshire, southern England, was investigated in situ during 3 years with contrasting weather conditions. Development of full photosynthetic capacity (indicated by light-saturated net assimilation rates, A(max), typical of the summer period) took between approximately 50 and 70 days after budbreak in different years. This slow development means that these leaves do not utilise a substantial fraction of the seasonal peak of solar irradiance. During the late autumn senscence period the photosynthetic capacity declined over a 2-week period, but as this is a time of low irradiance, the loss of potential photosynthesis was relatively small. The consequences of these developmental changes and differences in bud break dates for daily and seasonal leaf carbon balance were investigated through a simple light-response photosynthetic model. Seasonal changes in photosynthetic capacity would decrease annual carbon uptake per unit leaf area by about 23% compared to that potentially possible if leaves photosynthesised at peak rates throughout the growing season. This difference is likely to be up to 30% larger in years with late budburst and as low as 18% in years with early budburst.

Developing an evidence-based procedure: maintenance of central venous catheters.

This article describes the creation of an evidence-based guideline as part of a learning experience of a group of clinical nurse specialists. The guideline was the product of a utilization-focused integrated review of the literature conducted with the guidance of a nurse researcher. Key aspects of the evidence-based recommendations, as well as factors that facilitated or hindered this effort, are shared.

Dominant pattern extraction from 3-D kinematic data.

A new method for the extraction of a repeating pattern in cyclic biomechanical data is proposed--singular value decomposition pattern analysis (SVDPA). This method is based on the recent work of Kanjilal and Palit [14], [15] and can be applied to both contiguous and repeated trials without being constrained to be strictly periodic. SVDPA is a data-driven approach that does not use a preselected set of basis functions; but instead utilizes a data matrix with a special structure to identify repeating patterns. Several important features of SVDPA are described including its close relationship to the Kahunen-Loève transform. The dominant pattern is defined as the average energy component (AEC). The AEC is obtained from the SVD of the data matrix and is equivalent to the optimal [maximal signal-to-noise ratio (SNR)] ensemble average pattern. The degree of periodicity and SNR for the AEC are defined explicitly from the singular values of the data matrix. We illustrate the usefulness of SVDPA for dominant pattern extraction by applying it to the quasiperiodic three-dimensional trajectory of a marker attached to the trunk during treadmill locomotion. The AEC obtained for the normalized trajectory and error estimates at each point suggests that SVDPA could be a useful tool for the extraction of the fine details from cyclic biomechanical data.

Evidence-based practice and the role of nursing leadership.

A new term, evidence-based practice, is beginning to appear both in the healthcare literature and at professional, conferences. Its meaning, however, is not always clear, nor is its full implication for nurse administrators explained. This article provides a pragmatic definition of evidence-based practice developed in the nursing division at Baystate Medical Center, Springfield, Massachusetts. It outlines steps required to institutionalize evidence as a routine part of nursing practice and provide examples of its use.

A method for the correction of drift in movement analysis.

A method is proposed for the correction of drift over cyclic three-dimensional kinematic data during treadmill locomotion. An adaptive least-squares drift correction algorithm (ALSDC) is developed from the operational definition of no drift. This method includes automatic selection of least-squares polynomial degree and sequential processing of large data sets.

A method for the recovery of noisy missing data in movement analysis.

A new method is proposed for the accurate recovery of missing marker data obtained from movement tracking systems. The method has the form of a least-squares cubic polynomial approximation which is realized by the recursive expansion of orthogonal polynomials.

Rotational and translational movement features of the pelvis and thorax during adult human locomotion.

The kinematics of the pelvis and thorax are important in gait studies since their movement patterns are closely related to gait efficiency and 'smoothness' of locomotion. The purpose of this study was to identify features of normal gait patterns for later comparisons with pathological and developmental gait patterns. A two camera SELSPOT system interfaced with an HP1000 minicomputer was used to obtain three-dimensional kinematic/temporal data for the pelvis and thorax. Data from treadmill walking of eight adults were used for within subject (at different speeds) analyses. The analyses revealed a very complex pattern with a set of breakpoints which was consistent over all subjects. Some features were invariant over a range of walking speeds although the total range of motion changed considerably.

A new method to measure foot contact.

A new method to measure foot contact is described. It consists of a pressure sensitive transducer attached to one end of a flexible silicone rubber tube. A reliable indicator of foot contact is obtained with the tube glued to the outer perimeter of the sole of a shoe.