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A 69-year-old man developed reduced consciousness of sudden onset. Examination and parameters were normal, except for a Glasgow Coma Scale (GCS) score of six. Brain imaging and blood tests were also normal, except for high plasma ammonia. His past medical history included epilepsy, hypertension and colitis. He was taking multiple antiepileptic medications, including sodium valproate, with no recent dose alterations. Medical intervention led to the sodium valproate being stopped and naloxone being administered. The patient's level of responsiveness and ammonia levels gradually improved. The patient was also being treated with ciprofloxacin for a urinary tract infection and a newly developed syndrome of inappropriate antidiuretic hormone secretion treated with demeclocycline. There is an association between long-term sodium valproate use and low carnitine levels, especially in the setting of polypharmacy. This in turn precipitates hyperammonaemia and encephalopathy. This case highlights the importance of an adequate drug history and the awareness of serious but uncommon adverse effects.

Dementia is a progressive neurodegenerative disease leading to deterioration in cognitive and physical skills. Driving is an important instrumental activity of daily living, essential for independence. However, this is a complex skill. A moving vehicle can be a dangerous tool in the hand of someone who cannot maneuver it properly. As a result, the assessment of driving capacity should be part of the management of dementia. Moreover, dementia comprises of different etiologies and stages consisting of different presentations. As a result, this study aims to identify driving behaviors common in dementia and compare different assessment methods. A literature search was conducted using the PRISMA checklist as a framework. A total of forty-four observational studies and four meta-analyses were identified. Study characteristics varied greatly with regards to methodology, population, assessments, and outcome measures used. Drivers with dementia performed generally worse than cognitively normal drivers. Poor speed maintenance, lane maintenance, difficulty managing intersections and poor response to traffic stimuli were the most common behaviors in drivers with dementia. Naturalistic driving, standardized road assessments, neuropsychological tests, participant self-rating and caregiver rating were the most common driving assessment methods used. Naturalistic driving and on-road assessments had the highest predictive accuracy. Results on other forms of assessments varied greatly. Both driving behaviors and assessments were influenced by different stages and etiologies of dementia at varying degrees. Methodology and results in available research are varied and inconsistent. As a result, better quality research is required in this field.

A 73-year old man with a history of Ménétrier's disease developed a mass in the axilla. Histology revealed this to be a metastatic neuroendocrine carcinoma, most consistent with a lung primary. Computed tomography scan of the thorax showed a 28mm lesion in close proximity to the right bronchus intermedius. Cytological specimen from bronchoalveolar lavage yielded small cell carcinoma cells. Serum chromogranin A and serum gastrin levels were found to be significantly elevated. Ménétrier's disease has been associated with malignancy especially neuroendocrine neoplasms. Small cell lung carcinoma is also a high grade neuroendocrine lung neoplasm. In this report we will bring forward hypotheses about possible links between the two conditions.

Author af liationsBackground: Post-thyroidectomy hypocalcaemia is a common complication with signi cant short and long term complications. The aim of this study was to determine the incidence and predictors of post-thyroidectomy hypocalcaemia (corrected calcium <2.1mmol/l).Method: A total of 183patients who underwent total thyroidectomybetween 2012 and 2015 in a national general hospital were included in this retrospective study. Clinical and biochemical data were obtained from electronic and hard copy medical records.Results: Out of atotalof 183 patients, 142 (77.6%) were female, while 41 were males (22.4%). Ages ranged from 15 to 84 years, with a mean of 50.6 years (SD 15.84 years).There was variation in the incidence of hypocalcemia dependent on the timing of measurement of calcium on post-op day 1 (POD1) and the measuring of calcium on subsequent days. The incidence of post-operative hypocalcaemia on day 1 was 17.5% (n=32). The indications for surgery included Graves' disease (62 patients, 33.88%), multinodular goitre (50 patients, 27.32%), malignancy (28 patients, 16.39%), the presence of a thyroid nodule (22 patients, 12.02%), hyperparathyroidism (18 patients, 9.83%) and in 3 patients (1.63%)the indication was unclear. A lower preoperative uncorrected calciumwas associated with post-thyroidectomy hypocalcaemia (P=0.048). However it was found that the incidence of post-thyroidectomy hypocalcaemia was underestimated by 55.5% if only POD1measurement was used.Discussion: Measuring calcium on POD1may miss patients who would subsequently develop hypocalcaemia. Other possible contributing factors for post-op hypocalcaemia, including age, gender, histology and indication for surgery were not found to be statistically signi cant, and could not be used to predict who will develop hypocalcaemia. This emphasises the need for stringent guidelines for assessing and managing patients undergoing total thyroidectomy and possible associated hypocalcaemia.