bluuebunny/crossref_metadata_2025 huggingface dataset:
Calcification on the chest X-ray: a pictorial review
Authors: Cook C , Styles C , Hopkins R
Published: May 2014

There are numerous causes of calcification on the chest radiograph. Their striking appearance can lead to anxiety among junior medical staff. This article aims to categorize these appearances, and to give examples of the most common causes seen.
Pharmacological management of opiate withdrawal
Authors: Upthegrove RA , Naik PC
Published: May 2014

Opiate misuse is extremely prevalent in the UK. A high proportion of these individuals experience withdrawal symptoms. This article describes the clinical features and discusses the current literature on the pharmacological management of opiate withdrawal.
Non-steroidal hip arthropathy: case histories and differential diagnosis
Authors: Kakar S , Jeffery JA , Bentley G
Published: May 2014

A 74-year-old male patient was admitted for elective hip replacement surgery. X-rays revealed dramatic collapse and deformity of the femoral head over a 13-month period (Figures 1 and 2). He had experienced progressive hip discomfort during an 18-month period before surgery and was taking diclofenac (50 mg three times a day) regularly for discomfort. Despite analgesia, his walking distance had deteriorated from 800 to 100 metres while awaiting surgery.
The workload deficit and hospital doctors: looking for a manageable solution
Authors: Burnham WR
Published: May 2014

NHS hospitals have too few doctors (Department of Health, 2001a), and those we have now are overworked. There is good evidence that patient outcomes improve as the numbers of doctors increases (Jarman et al, 1999), so resolution of this problem is essential.
The role of neurokinin B in pre-eclampsia
Authors: Page Nigel M , Lowry Philip J
Published: May 2014

Pre-eclampsia, a life-threatening disease unique to pregnancy, has been called a disease of theories. To date, there has been no widely accepted predictive test or therapeutic intervention to prevent or delay pre-eclampsia. The discovery of a new placental hormone, neurokinin B, may finally help to answer some of the past mysteries.
Case 3: progressive conduction block
Authors: Sporton Simon , Holdright Diana
Published: May 2014

A 78-year-old man was followed in the medical outpatient clinic for angina pectoris and hypertension. He was treated with aspirin, sotalol and nifedipine. He attended casualty with a history of worsening angina with episodes of pain at rest. An electrocardiogram (ECG) was recorded (Figure 1). What abnormalities were present on the ECG?
Why use non-invasive ventilation in acute respiratory failure?
Authors: Meeran Hanif
Published: May 2014

Non-invasive ventilation (NIV) is any form of ventilatory support applied to patients without the use of an endotracheal tube, including continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) with or without positive end expiratory pressure (PEEP). Provided that patients receive adequate ventilatory assistance using NIV the problems associated with endotracheal intubation can be avoided. These include loss of airway defence mechanisms, ventilator-associated pneumonia, the risks of intubation and extubation, discomfort and sedative drugs. Providing NIV at an early stage on the general ward can prevent further deterioration and may avoid intensive care unit admission.
Serendipitous computed tomographic diagnosis of an underlying cause for diabetes mellitus
Authors: Torreggiani William C , Liu David , Lyburn Iain D , Rowley Victor A , Munk Peter I
Published: May 2014

A 62-year-old man presented with non-specific abdominal pain, which was most marked in the left iliac fossa. He had a 15-year history of diabetes and had been jointly managed by an endocrinologist and his family physician. He was known to have mild renal impairment, which was felt to be secondary to his diabetes. He also had a past history of diverticular disease that had been diagnosed clinically without the use of imaging and had been managed conservatively.
The future of education: Workforce and Development Confederations
Authors: Easmon Charles SF
Published: May 2014

From 1 April 2001, 24 Workforce and Development Confederations (WDC) replaced the Education and Training Consortia across England. There is still confusion and lack of knowledge about both the consortia and the new WDCs, nowhere more so than in the medical world. The WDCs will be key in the development of all sections of the NHS-trained health- and social-care workforce. What were the consortia and how will the WDCs differ from them? What are the origins of both, and how will the WDCs influence education for health-care staff?
The Bicentenary Project of the Royal Society of Medicine
Authors: Grocock Anne
Published: May 2014

The Royal Society of Medicine (RSM) is one of the main providers of continuing professional development for the medical, dental and veterinary professions in the UK, with one of the best postgraduate medical libraries in Europe.
Spinal epidural haematoma misdiagnosed as meningitis
Authors: Hui Andrew CF , Wong Hoi-Tung Wong , Lam Joseph MK
Published: May 2014

A 32-year-old man developed sudden onset neck pain while at work. There was no headache, fever and no history of head or neck injury. He had been in good health. He continued to work and went home after seeing his doctor, who diagnosed muscle strain. Four days later the pain persisted and he was admitted to hospital. Examination revealed marked neck stiffness, generalized hyperreflexia but with preserved power and a fever of 38°C. Urgent computed tomography of the brain was normal. The blood white cell count was normal. CSF analysis revealed red blood cells and some white blood cells, a blood-stained high protein count of 7 g/litre and a low glucose of 0.7 mmol/litre. Simultaneous blood sugar concentration was 6.7 mmol/litre.
Increasing breathlessness, hyperkalaemia and thrombocytosis in a patient with chronic obstructive pulmonary disease
Authors: Hassan Imad SA , Lewis Chris , Kay Allison , Rugman Frank P
Published: May 2014

A 72-year--old gentleman with no past history of chronic obstructive pulmonary disease (COPD) was admitted with a history of progressive shortness of breath, increasing over the preceding 2—3 months. His exercise tolerance was decreasing and he was unable to climb stairs without becoming breathless. He described a cough on most days productive of creamy white sputum but he had never coughed up any blood. He denied wheeze, ankle oedema, orthopnoea or paroxysmal nocturnal dyspnoea. There was no history of chest pain. He was not on any medication and had no allergies. He was an ex-smoker. He smoked an average of 20 cigarettes a day (one pack) for almost 30 years giving him a total of 30 pack-years of smoking. He denied drinking alcohol. There were no symptoms referable to any other system.
Hypoplastic left heart syndrome: diagnosis and management
Authors: Andrews Rachel , Tulloh Robert
Published: May 2014

The prognosis of hypoplastic left heart syndrome has improved dramatically in recent years with advances in reconstructive surgery. Many cases are now diagnosed antenatally, allowing parents time to make informed decisions about treatment options.
Bladder and renal stones: management and treatment
Authors: Westenberg A , Harper M , Zafirakis H , Shah PJR
Published: May 2014

The prevalence of renal tract calculi in the population is such that patients may present acutely not only to urologists, but in the setting of any medical specialty. This article aims to enable all practitioners to be able to recognize the condition and instigate early investigation and management before referring to the urologist for definitive treatment.
Tophaceous podagra: ultrasound diagnosis
Authors: Lyburn Iain D , Torreggiani William C , Harris Alison C , Zwirewich Charles V , Munk Peter L
Published: May 2014

A 40-year-old male patient had a 6-week history of intermittent pain and swelling of the metatarsophalangeal joint of the left great toe. There was no history of trauma. Past medical history was unremarkable and the patient was not taking any regular medication. Physical examination of the joint demonstrated swelling and warmth with the overlying skin tense and erythematous. Full blood count was normal.
Anterior abdominal wall ischaemia in association with multiple myeloma
Authors: Durrani AJ , More A , Shibu M , Carver N , Diaz-Cano S
Published: May 2014

A 52-year-old woman with widespread multiple myeloma was referred with an 8-hour history of spreading cellulitis with a central dusky purple area over her lower anterior abdominal skin. There was no crepitus or foul watery discharge although the central area was starting to blister. She was awaiting orthopaedic assessment of cervical spine stability because of tumour infiltration at C5 and C6 levels. She was also being treated for a deep vein thrombosis with warfarin. However, the warfarin had been stopped in error 2 weeks previously, and then restarted 4 days before this episode. She had been commenced on warfarin originally because of a pulmonary embolus following the first course of chemotherapy for treatment of her multiple myeloma.
Use of the bispectral index to monitor anaesthesia
Authors: Gan TJ , Habib AS
Published: May 2014

In October 1996, the Food and Drug Administration approved the use of the first anaesthesia effect monitor in the USA: the bispectral index (BIS) monitor (Aspect MS®, Newton, MA). The BIS is a computer-processed electro-encephalography (EEG) variable, which results in a single number, ranging from 0 (isoelectric EEG) to 100 in the awake state. It is derived by combining several different EEG descriptors: the BetaRatio, the SynchFastSlow and a measure of burst suppression (Rampil, 1998).
Pericardial constriction: diagnosis and management
Authors: Banerjee Shrilla , Swanton R Howard
Published: May 2014

The diagnosis of pericardial constriction is challenging and elusive. It is a post-inflammatory condition that occurs when a thickened, fibrotic, scarred and sometimes calcified pericardium firmly encases the cardiac chambers and restricts filling of the heart, causing venous overload and diminished cardiac output. This review includes the diagnosis and management of this condition.
Screening for carcinoma of the colon: current views
Authors: Axon Anthony
Published: May 2014

Colorectal cancer (CRC) is the second commonest cause of death from malignancy in the UK. Sixty per cent of patients die within 5years of diagnosis because the cancer usually has metastasized before presentation. Increased public awareness of symptoms, the 2-week rule for patients with suspected cancer together with more specialized training for colorectal surgeons and the use of adjuvant chemotherapy and radiotherapy may improve survival rates. However, without a more radical approach, it seems unlikely that more than 50% of patients with this disease will be cured. The cause of CRC is unknown, and although dietary factors play a part in its pathogenesis and certain drugs may inhibit the polyp cancer sequence, primary prevention is not possible at present. Only population screening offers a real opportunity to impact on the mortality of this disease, which in the UK kills roughly one person in fifty.
Current issues in management of miscarriage and early pregnancy bleeding
Authors: Moore Judith , Shillito T Jayne , Walker James J
Published: May 2014

Miscarriage is the most common complication of pregnancy. Up to 50% of all conceptions fail (Kline et al, 1989), most before the woman is aware that she is pregnant, and between 13% (Saraiya et al, 1999) and 22% (French and Bierman, 1962) of known pregnancies miscarry. Despite this frequency of incidence, miscarriage remains poorly managed and understood by many health-care professionals and women alike.
Sports nutrition: an overview
Authors: Maughan Ron
Published: May 2014

Nutritional interventions have the potential to influence the outcome of athletic competition where opponents are closely matched. Sound dietary habits can also influence the adaptations that occur in response to training. This article summarizes some of the strategies that the athlete can use to enhance performance.
Carcinoma-induced diffuse pulmonary haemorrhage
Authors: Baird RD , Shee CD
Published: May 2014

Diffuse pulmonary haemorrhage is an uncommon disorder usually associated with the vasculitides, collagen vascular diseases or anti-basement membrane antibody disease (Schwarz and Brown, 2000). Malignancy is not well recognized as a cause of widespread alveolar haemorrhage, and this paper describes a case caused by metastatic carcinoma in which the diagnosis was only finally confirmed at post-mortem examination.
Bronchoscopic and angiographic findings in Dieulafoy's disease of the bronchus
Authors: Ben Hope-Gill , Bandipalyan V Prathibha
Published: May 2014

There have been several case series describing Dieulafoy's disease of the gastrointestinal tract, the majority presenting with massive haematemesis. The defining feature is an aberrant arterial vessel protruding into the lumen of a viscus, usually the stomach (Farrell and Bennett, 1992). The spectrum of disease has been extended to include the bronchial tree (Sweerts et al, 1995; Van der Werf et al, 1999). This article reports the bronchoscopic and angiographic images of a case of Dieulafoy's disease of the bronchus which have not previously been published. It is also the first reported case that has been successfully treated by embolotherapy.
An ex-intravenous drug addict with confusion and apathy
Authors: Chan Koon H , Cheung Raymond TF , Fong Gardian CY , Ho Shu L
Published: May 2014

Wernicke's encephalopathy is an acute neurological disease, which is the result of thiamine deficiency. Cases in people who are not alcoholics are increasingly recognized. This case reports a Chinese man who was probably poorly nourished as a result of his intravenous drug addiction. During his initial admission to the intensive care unit, he was given parenteral nutrition containing high carbohydrate content without vitamin supplementation. Three weeks after discharge, he was readmitted because he had been suffering confusion for 1 week.
Elevated alpha-fetoprotein levels in a woman with ovarian teratoma
Authors: Huang Shou-Cheng , Lau Man-Tak
Published: May 2014

This article reports a young woman who was a hepatitis B carrier with persistent abnormal liver function and who was accidentally found to have elevated serum a-fetoprotein (AFP) levels (>1000mg/litre). Hepatoma was suspected, but a relatively common and benign mature cystic ovarian teratoma was finally diagnosed. Elevated AFP levels have been reported in mixed germ cell tumours and pure endodermal sinus tumours (yolk sac tumour) of the ovary (Bonazzi et al, 1989; Kawai et al, 1992; Piura et al, 1995), but no reports have yet mentioned AFP elevation in benign cystic teratomas (Kawai et al, 1992). Thus, the role of AFP is worthy of more attention.
Long-term outcomes of childhood meningitis
Authors: Fellick JM , Thomson APJ
Published: May 2014

Meningitis and meningococcal disease remain a major source of anxiety to paediatricians and parents alike. Survival rates have improved with rapid diagnosis and appropriate management. However, survivors remain at risk of long-term neurodevelopmental sequelae.
Neuroimaging to predict preclinical Alzheimer's disease
Authors: Kumari Veena , Mitterschiffthaler Martina T , Sharma Tonmoy
Published: May 2014

Alzheimer's disease is common in the elderly and causes tremendous distress to patients and their carers. With the advent of newer pharmacological treatments, significant improvement in the early diagnosis of Alzheimer's disease is required. This article examines the usefulness of neuroimaging techniques to predict Alzheimer's disease in prediagnosis individuals.
Anaesthetic management of the elderly surgical patient with cognitive impairment
Authors: Crowe Suzanne
Published: May 2014

Up to 25% of patients over 80years of age have cognitive impairment. A chronic, progressive decline in global intellectual function is often referred to as dementia, of which Alzheimer's disease is the commonest form. Dementia can include behavioural and communication difficulties, making patients challenging to both assess and manage.
Prostate cancer: management and controversies
Authors: Lee Frank , Patel Hitendra RH
Published: May 2014

Advances in the management of prostate cancer are associated with uncertainties and controversies in screening, who and when to treat, the best treatment option for localized disease and what to do with biochemical relapse after presumed curative treatment.
Collecting national data on hospital-acquired infections
Authors: Swann Andrew
Published: May 2014

Approximately 10% of patients acquire an infection while in hospital (Emmerson et al, 1996). On average such infections increase mortality seven-fold, patient costs three-fold and the length of stay by 11 days. In financial terms the estimated cost of hospital-acquired infection (HAI) for the financial year 1994–95 was approximately £1 billion (Plowman et al, 2000). Like road traffic accidents not all HAIs are preventable but expert opinion suggests that the number of infections could be reduced by 15–30%.
Thyroid abscess: an unusual case secondary to biliary sepsis
Authors: Mathew John , Goodfellow Peter , Chadwick David R
Published: May 2014

An 82-year-old man was admitted to the surgical ward as an emergency with clinical features suggestive of acute cholecystitis. At the time of admission, his temperature was 37.1°C. Laboratory tests showed a white cell count (WCC) of 11.6 × 109/litre, a C-reactive protein (CRP) of 14 mg/litre and altered liver functions (bilirubin 25 μmol/litre, alkaline phosphatase 336 iu/litre). The rest of the haematological and biochemical investigations were normal. He had a coexisting goitre that had been present for over 60 years. He was clinically and biochemically euthyroid with a free thyroxine of 17.1 pmol/litre and a thyroid-stimulating hormone of 0.27 mU/litre. Ultrasound scan of the abdomen showed calculous cholecystitis, and the rest of the scan showed nothing else of significance. The patient was started on broad-spectrum antibiotics.

His condition deteriorated in the next 48–72 hours with features of systemic sepsis. Abdominal examination did not show any evidence of clinical deterioration. At about the same time he was noted to have erythema and tenderness over his goitre with a slight increase in size (Figure 1). There was no evidence of any pressure symptoms. The inflammatory markers started to rise (WCC = 16.2 × 109/litre, CRP = 108 mg/litre). Blood culture was performed after the initiation of antibiotic therapy, and was found to be negative. Because of the large size of the goitre and clinical evidence of retrosternal extension a computed tomography scan of the neck was done rather than an ultrasound scan (Figure 2). Abscess of the thyroid was suspected and an attempt was made to aspirate, but this had to be abandoned as the pus was very thick. The thyroid was explored through a classical transverse incision and its capsule incised. A large quantity of pus and degenerative thyroid tissue was removed, and a corrugated rubber drain was left in place for drainage. The culture of the thyroid contents grew Klebsiella, sensitive to third generation cephalosporins. The patient was placed on cefuroxime for 7 more days, following which he made a gradual and uncomplicated postoperative recovery (Figure 3).
Does trauma trigger multiple sclerosis? 2: A medicolegal view
Authors: Weatherby MJC , Weatherby SJM , Hawkins CP
Published: May 2014

Set against the scientific debate in multiple sclerosis are a number of medicolegal cases in which the scientific evidence has been examined in the context of specific events. It is instructive to understand something of the legal approach to cause and association, and to consider this in relation to individual cases.
Laparoscopic surgery for inflammatory bowel disease
Authors: Bullen Timothy F , Hershman Michael J
Published: May 2014

Laparoscopic surgery for inflammatory bowel disease is an expanding field, which has physical benefits to the patient and economic benefits to the trust and community.
Developments in clinical electrophysiology
Authors: Sporton Simon , Schilling Richard
Published: May 2014

Knowledge about arrhythmia mechanisms is expanding rapidly, as a result of molecular biology, cellular electrophysiology and whole heart studies in animals and humans. Most clinically important arrhythmias result from reentry while others have a focal origin: both can be cured by catheter ablation. Antiarrhythmic drugs have disappointing efficacy, tolerability and safety, so attention has shifted to curative catheter ablation and use of implantable devices.
Angiomyofibrosarcoma: a rare ischiorectal fossa swelling
Authors: Satheshkumar T , Saklani AP , Banerjee D , Jones DRB
Published: May 2014

A33-year-old woman presented with a painful lump in the right gluteal region, 7 months after normal vaginal delivery of her child. There was no history of altered bowel habits, bleeding per rectum, dyspareunia or difficult labour. On examination she was afebrile. Local examination revealed asymmetry with a tender lump in the right gluteal region and some redness of the overlying skin. Rectal examination revealed a tender right lateral rectal wall. Magnetic resonance imaging (Figure 1) revealed a 12×8×8 cm complex ‘cyst’ in the right ischiorectal fossa displacing the levator ani upward and the rectum medially, with an apparent pseudo capsule. In the T1-weighted sequences, it had higher signal intensity than the bladder. On T2-weighted sequences, the lesion was of very high intensity. Also in the surrounding fat were multiple linear foci of high intensity, representing oedema or increased vascularity. In view of the location, it was suggested that this could be an abscess.

Examination under anaesthesia revealed a boggy swelling in the ischiorectal fossa. An incision to drain this abscess revealed no pus, however, a soft fatty lump protruded from the incision. The incision was extended and a soft tissue mass 12 cm in diameter was enucleated. The cavity was packed and skin incision closed after 3 days. Histopathology revealed an angiomyxoid tumour, extending to the resection margins. Subsequently she was sent to a specialist centre. Computed tomography of the chest was normal. After discussion with the patient about the possibility of incontinence and stoma, re-excision was performed.

Histology suggested low grade, sarcomatous changes in a pre-existing myofibroblastic lesion, either angiomyxoma or angiomyofibroblastoma. Immunostaining was positive for desmin and weakly positive for actin and calponin. Staining for caldesmin and myogenin were negative. CD34 was present in few scattered spindle cells. No adjuvant therapy was given. She had one admission since then with a wound collection, which was drained.
Can simulators be used to assess clinical competence?
Authors: Wantman Adam
Published: May 2014

In the last 10 years, the use of simulation for training in the field of anaesthesia has been growing steadily. There are currently four centres around the UK that are using high fidelity simulators to train not only anaesthetists, but also surgeons, accident and emergency doctors, operating department assistants, intensive therapy unit nurses and house officers in both technical and non-technical skills (behavioural issues).
Irritable bowel syndrome: unravelling the mysteries
Authors: Hunter JO
Published: May 2014

The irritable bowel syndrome (IBS) has long been the Achilles heel of gastroenterology. IBS is a syndrome of abdominal pain accompanied by a change in bowel habit for which no cause can be discovered on standard investigations. The diagnosis thus depends on the exclusion of more serious pathology. As IBS is the most common chronic gut disorder seen in the Western World, accounting for as many as 50% of referrals to gastrointestinal outpatients, the cost of repeated negative investigations is alarming (Talley et al, 1995).
Acute compartment syndrome: diagnosis and immediate care
Authors: Choudhary RK , Waseem M , Thalva R , Dunlop DG
Published: May 2014

Acute compartment syndrome is an uncommon but potentially limb-threatening condition whose early recognition and treatment can prevent or reduce serious complications. Identifying at-risk patients and appropriate investigation is the key.
The eye in cardiac and cardiovascular disease
Authors: Taylor Simon , Lightman Professor Susan
Published: May 2014

There is an extensive range of cardiac and cardiovascular disease that can have ophthalmic manifestations and only the most commonly occurring examples are discussed below. The eye in diabetes is discussed in a separate article in this series.
The NHS and leadership
Authors: Lees Peter D
Published: May 2014

Anumber of recent initiatives show that the NHS is serious about leadership development. It has declared the attributes it expects of its leaders (Department of Health, 2002a), published a code of conduct for NHS managers (Department of Health, 2002b) and established a significant number of leadership programmes for managers and clinicians alike. Fundamental to this initiative is the NHS Leadership Centre which has its origins in the NHS Plan and which is an integral part of the Modernisation Agency.
Principles of management in oral cancer
Authors: Swinson BD , Witherow H , Amin M , Kalavrezos N , Newman L
Published: May 2014

Squamous cell carcinoma is the most common oral malignancy, with a relatively poor prognosis. Treatment of oral cancer has a major impact on afflicted patients because it affects speech, swallowing and mastication. Surgery is the main treatment of oral cancer, as a single modality or combined with radiotherapy. Vigilance is vital for early diagnosis and better overall prognosis.
Acute pancreatitis presenting as a case of splenic rupture
Authors: Adelekan MO , Nasmyth DG , Joglekar VM
Published: May 2014

A31-year-old woman, who had experienced some epigastric pains 10 days earlier, presented acutely with upper abdominal pain of 24 hours duration. There was associated nausea and vomiting. She had a past history of depression and excess alcohol consumption. Her only medication was ibuprofen for joint pains.
The current uses of botulinum toxin
Authors: Swift Andrew
Published: May 2014

Botulinum toxin is an extremely powerful neurotoxin that is a product of the anaerobic bacterium Clostridium botulinum and is responsible for the condition botulism. Public awareness of the toxin has recently been raised by its development as a weapon for biological warfare and its facial cosmetic effects. However, the acute paralytic illness after some forms of food poisoning had been recognized for many years and an association with a neurotoxin was demonstrated over a century ago.
Anaesthesia for coronary artery bypass: should it differ off-pump and on-pump?
Authors: Zimbler N , Ashley EMC
Published: May 2014

The advent of suction myocardial stabilizers has caused a resurgence in offpump coronary artery bypass (OPCAB). It may avoid end-organ injury associated with cardiopulmonary bypass, e.g. stroke, neuropsychological and renal dysfunction. Both low- and high-risk patients have improved outcomes with OPCAB (Moshkovitz et al, 1995; Nierich et al, 1999; Arom et al, 2000).
Medical litigation: past, present and future
Authors: Neale Graham
Published: May 2014

Before the 20th century legal actions against doctors were very unusual. Poor outcome of serious illness was commonplace and the general population understood little of disease processes. Moreover attitudes were very different.
Diabetes and the heart
Authors: Harvey John N
Published: May 2014

Cardiovascular (CV) disease is the main cause of mortality and morbidity in patients with diabetes. In those with type 2 diabetes there is a 2–4-fold increased risk of CV events and mortality (Stamler et al, 1993). Modifiable factors associated with increased risk are well established: higher circulating levels of low density lipoprotein-cholesterol (LDL-C), low high density lipoprotein-cholesterol (HDL-C), smoking, obesity, hypertension and microalbuminuria. The incidence of coronary events increases with the degree of hyperglycaemia but the effect starts in the non-diabetic glucose range (Coutinho et al, 1999). Thus, patients with impaired glucose tolerance have high rates of coronary events similar to those seen in patients with type 2 diabetes. The early and late mortality of myocardial infarction (MI) in diabetes is double that of nondiabetic individuals.
Medical management of severe traumatic brain injury
Authors: Martin Daniel , Smith Martin
Published: May 2014

This article reviews the current guidelines for the management of patients with severe traumatic brain injury from presentation in the accident and emergency department, through transfer, to specialist treatment in a neurocritical care unit.
Cerebellar arteriovenous malformation presenting with bilateral proptosis mimicking caroticocavernous fistula
Authors: Bhidayasiri Roongroj , Hathout Gasser M , Heyming Theodore W , Ovbiagele Bruce
Published: May 2014

A 21-year-old man presented with a 3-year history of bulging and redness of his right eye associated with double vision. He had a history of facial trauma 5 years previously. These symptoms, which had progressed over the year preceding the presentation, were accompanied by a bilateral pounding headache and gait unsteadiness with veering to the right. On examination, he had bilateral pulsating exophthalmos that was more marked on the right with a loudly audible orbital bruit. Mild soft tissue swelling of the right eyelid along with dilated veins in the right conjunctival fornices was observed. His visual acuity was 20/20 and there was no papilloedema. Eye movement examination showed restricted up-gaze, in conjunction with skew deviation, the right eye being hypertropic. Although impaired convergence was observed, there was no convergence retraction nystagmus. Right lateral rectus palsy and right sensorineural hearing loss were noted. Coordination testing revealed right finger to nose and heel to shin ataxia associated with a slightly wide based gait.

The magnetic resonance images showed several findings of interest. There was a massive right cerebellar arteriovenous malformation, with a large tangle of vessels extending into the quadrigeminal plate and perimesencephalic cistern with mass effect on the right aspect of the midbrain (Figure 1). There was bilateral proptosis, significantly more pronounced on the right, with enlargement of the left lateral rectus muscle and bulging of the right cavernous sinus. Surprisingly, no significant enlargement of the right superior ophthalmic vein was noted (Figure 2). Cerebral angiography showed a massive right cerebellar arteriovenous malformation, fed by the bilateral posterior inferior cerebellar arteries, anterior inferior cerebellar arteries and superior cerebellar arteries, as well as direct branches from the basilar artery and right posterior cerebral artery. Superficial venous drainage was observed directly to the right transverse and sigmoid sinuses, as well as to the deep venous system, with an enlarged straight sinus, vein of Galen and internal cerebral veins. There was also retrograde forward-directed venous flow filling the right cavernous sinus and the inferior petrosal sinus. Emanating from the right cavernous sinus (Figure 3), there were two anterior directed veins: a smaller superior one, representing a cortical vein and a larger inferior vein, representing the right superior ophthalmic vein, which was only mildly dilated. The inferior ophthalmic vein was not visualized. No fistulous communication between the carotid artery and cavernous sinus was seen.
Time for a change in breast cancer therapy?
Authors: Cameron David
Published: May 2014

Taken together, recent studies make a powerful case for the licensing of aromatase inhibitors in the adjuvant setting, offering an alternative to tamoxifen which has long been the gold standard in breast cancer therapy in the prevention of recurrence.
Body piercing: a growing problem
Authors: Esen Umo I
Published: May 2014

Until recently body piercing was mainly confined to the ears and/or nose. In the last few years there has been a significant increase in the prevalence of body piercing which, in some instances, has had serious health consequences. This industry has the potential to significantly damage or interfere with health care. Urgent legislation is needed to remedy this situation.
Poisoning
Authors: Nadarajah Premala , Hayden Mark J
Published: May 2014

Paediatric poisoning is common; most occurrences are accidental and harmless. The accurate assessment of lethality, appropriate supportive care and avoidance of unnecessary and dangerous decontamination techniques prevent harmful intervention.
Can we treat lower limb critical ischaemia with chemical sympathectomy?
Authors: Smart Jamie , Brandner Brigitta
Published: May 2014

Chemical lumbar sympathectomy was first introduced into medical practice in the 1920s. It has been used to treat a variety of conditions from muscular spasm to hyperhydrosis, although it has been used most widely in the treatment of complex regional pain syndrome and also in the treatment of critical ischaemia of the lower limb.
Long-term management of atherothrombosis
Authors: Fox Keith AA
Published: May 2014

While clinical trials of specific antithrombotic agents can reduce the risk of vascular events in at-risk patients, understanding the results of these studies is key to optimizing benefit and minimizing risk.
Pulmonary hypertension: a rare but serious complication of ventriculoatrial shunts
Authors: Sharma R , Mcleod AA
Published: May 2014

A 34-year-old woman presented with a 6-month history of progressive dyspnoea. Past history included cerebral palsy and epilepsy. At the age of 14 years she had a ventriculoatrial (VA) shunt for hydrocephalus secondary to congenital aqueduct stenosis. There was no past history of deep vein thrombosis, liver disease, appetite suppressant use, intravenous drug abuse or other systemic disease.

On examination she was unwell with central cyanosis, tachypnoea (respiratory rate 36 breaths per minute), sinus tachycardia (heart rate 120 beats per minute), and blood pressure 100/60 mmHg. There was ankle oedema, raised jugular venous pressure, accentuated pulmonary second sound and a right ventricular gallop.

Chest X-ray showed cardiomegaly with prominent pulmonary arteries (Figure 1). Electrocardiogram demonstrated right axis deviation, dominant R wave in V1 and ST depression across the precordial leads (Figure 2). On room air her arterial partial pressures of oxygen and carbon dioxide were 7.1 KPa and 3.2 KPa respectively. Transthoracic echocardiography showed dilated right ventricle and right atrium with severe tricuspid regurgitation and moderate pulmonary regurgitation. Estimated pulmonary artery pressure was 100 mmHg. There was no evidence of intracardiac thrombus and left ventricular systolic function normal. A ventilation perfusion scan showed multiple sub-segmental perfusion defects. Cardiac catheterization confirmed severe pulmonary hypertension (pulmonary vascular resistance 1048 dynes/sec/cm2) with normal left heart pressures and no intracardiac shunt. Calculated cardiac index was low (1.5 litre/min/kg) with high right atrial pressure (20 mmHg) and low mixed venous oxygen saturation (50%). Pulmonary angiography and chest computed tomogram with contrast showed thrombus in the main pulmonary trunk extending into the proximal right and left pulmonary arteries. Duplex ultrasonography of both legs suggested no evidence of deep vein thrombosis. A thrombophilia, vasculitis and infection screen was negative.

The patient was commenced on nasal continuous positive airways pressure, high flow oxygen, intravenous heparin and intravenous colloid with haemodynamic stability maintained for the first 4 days. After this she became more hypoxic and hypotensive so fluids were stopped and a frusemide, dopamine and prostacyclin infusion commenced to reduce right ventricular distension with some improvement. Because of her deteriorating haemodynamic state, pulmonary thromboendarterectomy was performed with removal of extensive thrombus from the proximal pulmonary tree. The patient died in the immediate postoperative period.

Postmortem showed a distended and hypertrophied right heart with extensive chronic thromboembolic changes in the distal pulmonary tree. The tip of the VA catheter in the right atrium had no signs of infection and at this time was free of thrombus. The coroner concluded cause of death was pulmonary hypertension secondary to longstanding thromboembolic disease.
Aggressive angiomyxoma of the vulva
Authors: Baruah S , Latthe P , Bhatti NR , Ghataura SS
Published: May 2014

A 33-year-old nulliparous women presented with a 4-week history of a painful vaginal swelling. There had been no relevant medical or gynaecological history of note and she was using the combined oral contraceptive pill (Cilest, Janssen-Cilag, High Wycombe, Bucks) for contraception. On pelvic examination, she had a tender right labial swelling 3×3×2 cm in size. The surrounding area showed no evidence of inflammation.

Systemic examination was unremarkable. The clinical diagnosis made was of a right Bartholin cyst. At examination under anaesthesia and excisional biopsy, the lesion appeared to be a cystic, fleshy-looking lesion located on the right labia majora, but was also seen to be extending towards the right ischiorectal fossa. The area was excised and multiple grey fragments (the largest being 110×45×20 mm) were submitted for pathological examination.

The lesion was well sampled and consisted of a mass of rather featureless spindled and stellate cells set in a myxoid and fibrillary background. It was highly vascular with considerable areas of red cell spillage into the stroma and some of the larger vessels showed medial hypertrophy. There was evidence of infiltration into adjacent muscle.

The other main differential diagnosis considered was angiomyofibroblastoma, but the perivascular condensation and zonality was not seen, nor was the plasma cell or epithelioid component. The tumour was positive for desmin (marker for intermediate cytoskeletal filaments), but negative for smooth muscle actin, S100 and epithelial membrane antigen. The appearance was in keeping with an aggressive angiomyxoma.

On confirmation of histology, the patient was sent to the gynaecological oncology team for further follow up, and magnetic resonance imaging was planned for identification of any invasion by tumour in case of recurrence.
Achilles tendon rupture: still not fully understood
Authors: Cullen NP , Haddad FS
Published: May 2014

Achilles tendon pathology has presented dilemmas to patients, athletes and physicians as far back as ancient Greece. The medical literature on the subject is extensive, with many hotly contested debates over differing, often contradictory, aetiologies and treatments.
Situation critical? Nosocomial infections and antibiotic resistance on intensive care
Authors: Terblanche Marius , Brett Stephen J
Published: May 2014

Nosocomial infections are very common, occurring in up to 33% of patients admitted to intensive care units (ICU). Diagnosing these infections can be difficult and infecting organisms are now often resistant to first-line empiric antibiotics.
Atrial fibrillation 1: classification and clinical implications
Authors: Alchaghouri Samir
Published: May 2014

A trial fibrillation is a common arrhythmia that has significant clinical implications. It increases the risk of stroke and mortality. Various cardiac and extra-cardiac pathologies can lead to the development of atrial fibrillation. Determining the underlying cause is essential in assessing the prognosis and guiding the management.
Training the future consultant in obstetrics and gynaecology
Authors: Blott Maggie
Published: May 2014

The training period for specialist registrars is now shorter and the demography of both gynaecology and obstetrics is changing rapidly. The specialist training in obstetrics and gynaecology must ensure that the future consultant is appropriately and adequately trained.
Causes of a widened mediastinum: a pictorial review
Authors: Barnard SA , Cook CKL
Published: May 2014

A widened mediastinum is a common finding on the plain chest radiograph. It is often encountered in the acute setting, where correct interpretation is essential to guide immediate management.
Fracture protection in osteoporosis with risedronate
Authors: Boonen Steven , Vanderschueren Dirk
Published: May 2014

Osteoporosis is a major public health problem in the UK, and will become even more common as the population ages. This article will review osteoporosis management and a first-line treatment, risedronate (Actonel), which has been shown to preserve bone quality and reduce the risk of both vertebral and non-vertebral fractures within 6 months of initiation of therapy.
Ogilvie's syndrome: a rare complication of inguinal hernia repair
Authors: Hamilton SW , Jabbar AA
Published: May 2014

A 49-year-old man had an open, tension-free, mesh (Lichtenstein) repair performed under general anaesthetic for a left-sided direct inguinal hernia. His immediate postoperative recovery was uneventful and he was discharged the following day. He was readmitted as an emergency 2 days later with intermittent abdominal pain, nausea and complete constipation. On examination his abdomen was slightly distended, but was not tender. X-ray (Figure 1) showed dilated loops of small bowel with gas in the colon and rectum.

He was managed conservatively. However, over the next 24 hours his symptoms became worse with increasing abdominal pain and vomiting. He was still passing no flatus. His abdomen became more distended and generally tender to light palpation. Repeat X-ray (Figure 2) revealed markedly distended small bowel and a grossly distended caecum. He proceeded to theatre as the caecal distension was increasing and he had developed signs of peritoneal irritation.

At laparotomy his bowel was free from the left hernia repair and no mechanical cause for the obstruction was found. The colon was distended to the rectum and the caecum was 10 cm in diameter with tearing almost imminent. It was therefore decompressed with an aspiration needle and on-table sigmoidoscopy. Appendicectomy was performed and the stump used to place a caecostomy. Recovery was slow but he was discharged home 2 weeks after readmission.
Performance-related pay – two months in
Authors: O'Connell Suzanne
Published: May 2014

What ever you think about the merits of performance-related pay, it has arrived in our classrooms. Suzanne O'Connell looks at how the early stages of implementation are working out in practice
Getting to grips with the new primary programmes of study
Authors: Kirkup Catherine
Published: May 2014

The publication of the new primary national curriculum gives schools a great opportunity to make a gradual transition to the new programmes of study. Catherine Kirkup offers some pointers
Taking the primary curriculum outdoors
Authors: Crawford Heather
Published: May 2014

With the pressures of the curriculum and key stage 2 tests, it can be difficult to take pupils outside of the classroom. However, Heather Crawford offers some ideas for how outdoor learning can link into the primary curriculum
Are you ready for life after levels?
Authors: O'Connell Suzanne
Published: May 2014

‘Levels’ and ‘sub-levels’ are key vocabulary in staffroom discourse. What will happen when this established method of assessing pupil progress is removed from the primary school glossary? Suzanne O'Connell investigates.
Ask Brenda: Ten rules for classroom teachers
Authors: Bigland Brenda
Published: May 2014

Our staff are “hit” with so many guidelines and actions to follow in the classroom. How can we focus the mind on the critical and yet make them smile and remember that the job is about enjoying and achieving as professionals as well?
‘Structured conversations’ to engage parents
Authors: Blandford Sonia
Published: May 2014

Quality parent/carer engagement has a positive impact on pupil attainment. But it is about more than just ‘getting on’ with them and requires deeper, more meaningful links. Professor Sonia Blandford discusses the potential of ‘structured conversations’
Writing for publication
Authors: Gibbons Helen
Published: May 2014

Writing for publication is something that nurses and allied health professionals receive little or no training in and therefore many who would like to write lack the confidence in their ability to do so. With the launch of The International Journal of Ophthalmic Practice, it is hoped that many nurses and allied health professionals will feel empowered and encouraged to write for the journal and share their knowledge and good practice. This article will endeavour to encourage new authors to submit an article for publication.
Patient reported outcome measures in ophthalmology
Authors: Whiteing Nicola , Cox Carol , Bentley Peter
Published: May 2014

Ophthalmic care providers are experiencing pressure to improve the quality of care, effectiveness and efficiency with which clinical care is delivered. Patient reported outcome measures (PROMs) are an effective mechanism for determining high quality care and identifying areas for improvement. Information obtained from PROMs is useful in discerning the patient experience as well as whether patients perceive their health outcomes have been achieved. Clinicians involved in ophthalmic care are well placed to determine the type of PROM to be used with their patient population as well as implementing changes to healthcare delivery subsequent to PROM data collection, assessment and evaluation.
The reality of international ophthalmic peri-operative training
Authors: Machin Heather
Published: May 2014

For developed nations and developed regions, competency training and assessment in nursing has been the gold standard for the standardization of nursing practice.

As national and international nursing communities continue to increase their interest and dependence on competencies, which ultimately offer patients a standardized and expected level of care, nurses are able to contribute to their career advancement and professional development through the simple task of completing a competency training and assessment programme at their place of work. While competency development is going into full throttle in developed nations of the world, the same competency standardization has not reached nurses in lesser developed nations with equal zeal, and nurses within these systems continue to fall behind their international counterparts.

This paper follows the development initiative of ORBIS International to provide developing and emerging economy peri-operative ophthalmic nurses with the opportunity to access standardized and sustainable competency training, education and assessment resources.