bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of metabolic acidosis: does correction with sodium bicarbonate do more harm than good?
Authors: Ashworth A , Carle C , Greenhalgh DL
Published: May 2014

Metabolic acidosis is a very common finding in critically ill patients and is associated with increased morbidity and mortality. Metabolic acidosis in critical care patients is commonly the result of either anaerobic metabolism or failure of excretion of endogenous acid. Other causes include renal or gastrointestinal loss of bicarbonate and the intake of exogenous acids.
The ‘missing piece’ sign: distant migration of a patellar tendon cerclage wire
Authors: Willis-Owen Charles A , Crocker Matthew J , Martin David K
Published: May 2014

A 37-year-old man presented with a tender palpable lump medial to his left patella. Two years previously he underwent surgical repair of a patellar tendon rupture including a protecting cerclage wire. He was informed that the wire did not require removal. There was no further history of trauma subsequent to the surgery. He had no other musculoskeletal problems and no past history of relevance.

Clinical examination revealed a midline scar over the left knee with a tender palpable wire on the medial side of the patella. There were no other significant clinical findings in the knee.

Plain radiographs revealed three wire fragments around the knee (Figure 1). These three fragments did not appear to account for the full circumference of the patellar tendon, raising the concern of a missing piece of wire. A further radiographic survey revealed that the missing wire fragment lay at the anterolateral aspect of the ankle joint (Figures 2 and 3).

On surgical exploration, the wire was located between the peroneus tertius and extensor digitorum longus tendons with the tip just proximal to the superior retinaculum. It was assumed to have found its way from the subcutaneous space anterior to the knee into the anterior compartment of the leg and migrated distally to abut the talus.
Systemic granulomatous disease and syndrome of inappropriate antidiuretic hormone
Authors: Nazir T , Talab SK , Kadir S
Published: May 2014

A 71-year-old man was admitted with generalized tiredness, mild confusion and low-grade pyrexia following the fourth cycle of intravesical bacillus Calmette–Guérin instillation for the treatment of superficial bladder carcinoma. These symptoms were accompanied by some weight loss which was difficult to quantify. His past medical history included type 1 diabetes mellitus, chronic obstructive pulmonary disease and prostatic hyperplasia. He was a smoker and consumed a moderate amount of alcohol. Physical examination was unremarkable with the exception of confusion (abbreviated mental test score 7/10). Initial investigations showed low serum sodium of 122 mmol/litre with normal potassium, renal and thyroid functions. His liver functions were abnormal with aspartate transferase of 76 IU/litre and alkaline phosphatase 286 U/litre. Chest X-ray showed bilateral non-specific reticular changes suggestive of infection. Two sets of blood cultures showed no growth after 72 hours. Urine tests for legionella and pneumococcal antigen were negative.

Computed tomography of the brain revealed deep white matter changes suggestive of small vessel disease. On further investigations urine osmolality was 546 mOsm/kg, serum osmolality 256 mOsm/kg, urine sodium 61 mmol/litre and the short Synacthen test was normal, confirming the diagnosis of syndrome of inappropriate antidiuretic hormone. After fluid restriction to 1 litre per day his sodium level started to improve slowly, but the patient's condition continued to deteriorate with ongoing low-grade pyrexia, confusion and lethargy.

A repeat chest X-ray 5 days later (Figure 1) showed multiple small non-calcified nodules in both lungs raising the possibility of miliary tuberculosis. This was confirmed on high resolution computed tomography scan of the chest (Figure 2) as presence of bilateral diffuse miliary shadowing in keeping with a diagnosis of miliary tuberculosis. In view of his confusion, CSF examination was done to rule out CNS involvement, but this was normal. No endobronchial lesions were identified on bronchoscopy and bronchial washings were sent for analysis and cultures. The patient was started on anti-tuberculous treatment (isoniazid, rifampicin and ethambutol) as well as steroids and pyridoxine. Unfortunately, the patient suffered a cardiac arrest and died a week after starting the treatment. Cultures of bronchial lavage and CSF did not grow any mycobacterium. On post-mortem examination he was found to have multiple small whitish nodules in both lungs, with caseating granulomata, central areas of necrosis and multinucleated giant cells microscopically.
Nocturia, enuresis and snoring: an unusual combination in an adult?
Authors: Dushianthan A , Ebden P
Published: May 2014

A 41-year-old man was seen in a respiratory clinic with symptoms of snoring, sleepiness during the day, enuresis and nocturia. He was waking up a minimum of 6–7 times to micturate every night. He had a past medical history of hypertension. His medication included lisinopril, omeprazole and simvastatin. He denied significant alcohol intake. On examination he was obese with a body mass index of 32 kg/m2, his blood pressure was raised at 170/120 mmHg. Chest examination revealed clear lung fields and otherwise unremarkable general examination. His collar size was 45 cm. His blood tests suggested normal renal, thyroid, calcium and blood sugar profiles. The mid-stream urine did not show any evidence of urinary tract infection. He had an elevated score of 15/24 on the Epworth Sleepiness scale (a questionnaire tool to assess daytime sleepiness).

He subsequently had an overnight oximetry, which showed 4% oxygenation desaturation index of 80.6 per hour (Figure 1). This is consistent with severe obstructive sleep apnoea hypopnoea syndrome. He was commenced on continuous positive airway pressure with substantial improvement in his sleep apnoea symptoms, including nocturic frequency, and his enuresis is completely resolved.
Sir Gordon Gordon-Taylor: master surgeon in peace and war
Authors: Ellis Harold
Published: May 2014

As a young surgeon in the 1950s I, among the rest of my contemporaries, revered Sir Gordon Gordon-Taylor (‘G-squared-T’) as a brilliant technical surgeon, teacher and father figure. When I was a senior registrar in Oxford, one of his former registrars at the Middlesex Hospital, Mr Tim Till, invited him to visit. Gordon-Taylor said that he wanted to see the ‘young men’ operate, and I was delegated to do a resection of a rectal cancer in front of the great man. He was full of charm and kindness as he watched us, having taken off his jacket and put a gown over his waistcoat, wing collar and bow tie! This year marks the 50th anniversary of his death.
Analgesia for total knee arthroplasty
Authors: Leech Christopher
Published: May 2014

Total knee arthroplasty is commonly associated with moderate to severe postoperative pain. Patients undergoing these procedures are often elderly with multiple co-morbidities and an effective pain management strategy will reduce pain intensity, limit unwanted side effects, and improve surgical outcome by facilitating postoperative rehabilitation (Capdevila et al, 1999). The control of postoperative pain is not only important to the patient, an important humane aspect, but can hasten recovery and hence hospital discharge.
The clinical anatomy of the antecubital fossa
Authors: Ellis Harold
Published: May 2014

To the anatomist, the antecubital fossa is the space through which the principal vascular and nervous trunks pass into the forearm. To the surgeon it is also the site of possible injury to the brachial artery in fractures around the elbow, with the risk of Volkmann's ischaemic contracture constantly in mind. It is here where the surgeon is tempted to use the large superficial veins for venous access, but knows only too well the dangers of inadvertent intraarterial or intraneural injection – something that may well be encountered in a ‘main-line’ drug addict. It is also a convenient site for arterial cannulation and for anaesthetic blocks of the nerves to the forearm.
Identification and management of perioperative cardiovascular risk
Authors: Jones Chris , Sritharan Kaji , Abu-Habsa Mamoun
Published: May 2014

Approximately 25 000 patients die each year in the UK following 1.3 million surgical procedures (Pearse et al, 2006). More than 80% of these perioperative deaths occur in patients who are at significantly high risk for surgery (12.5%) (Pearse et al, 2006). This population tends to be older, have multiple co-morbidities and have undergone major surgery. Notably, 50% were never admitted to a general intensive care unit postoperatively (Campling et al, 1993). Approximately 75% of patients who suffer perioperative death have cardiovascular disease, so it is important to try and identify these patients preoperatively (Mangano, 1990; National Confidential Enquiry into Perioperative Deaths, 2002).
Responsibility: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

For the first time when you start as a foundation doctor, you are medically responsible for patient care and safety. This is different from being a student shadowing, where, even if a doctor asks you to do something, he/she is still responsible for ensuring it is done and acting on any results. Technically, the student could just disappear and not do the task, but the doctor would still carry the can. If something is not done properly, you, as the doctor, should not blame the student, as you are ultimately responsible for ensuring it is done properly.
A practical guide to undertaking out of programme experience in the United States of America
Authors: Sultan P , Qadan M , Pushpanathan E , Carvalho B
Published: May 2014

Since the introduction of Modernising Medical Careers in 2007, training within most specialties has become less diverse with trainees within the same region often gaining similar clinical experience. Newlyemployed consultants are expected to bring new skills and experiences to a department, which can be in the form of research, experience in another specialty, different skill-sets, knowledge of different institutions' practices or postgraduate degrees. Experience at an institution abroad can be very beneficial, and generates much interest and discussion at interview. These experiences reflect trainees' enthusiasm for their specialty and significantly increase the clinical and research profile of a department.
Emergency management of burns
Authors: Findlay John M , Shaw Alex
Published: May 2014

Burns are an important cause of mortality and morbidity, with potentially severe local and systemic consequences. An estimated 250 000 burns are treated annually in UK emergency departments and primary care and patients may deteriorate rapidly. Their emergency management is therefore a crucial skill for junior staff in many specialties. This article provides the reader with the theoretical knowledge necessary to undertake this competently.
The clinical anatomy of examination of the ankle
Authors: Ellis Harold
Published: May 2014

Injuries of the ankle are extremely common. Indeed, most people at some time or other have sustained such an accident, which may range from a minor sprain (a partial ligamentous tear) to a major fracture-dislocation. Accurate clinical assessment of the injury depends on an accurate knowledge of ankle anatomy.
So you want to be… a radiologist
Authors: Monzon Leonardo , Upadhyay Neil , O'Regan Declan
Published: May 2014

Clinical radiologists are medical specialists who provide an imaging service to their patients. Imaging has been one of the most rapidly expanding specialties in recent years and offers an enormous variety of techniques and special interests.
Dealing with managers: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Managers are not all deplorable. They have similar values to doctors when it comes to patient safety and quality. However, they also have conflicting priorities of government targets, finance and staff to deal with.
Trends and controversies in the management of sepsis
Authors: Sritharan Kaji , Jones Chris , Abu-Habsa Mamoun
Published: May 2014

Patients with sepsis are frequently encountered in emergency departments and hospital wards, but may be at different stages of the disease process. In the UK, Intensive Care National Audit and Research Centre data collected in 2005 estimated that 36 800 patients per year die of sepsis, more than the annual mortality from breast cancer and bowel cancer combined (Daniels, 2007). International guidelines were published in 2004 and updated in 2008 (Dellinger et al, 2008) aiming to improve outcomes from sepsis syndromes through promotion of evidence-based practice. While components of the guidelines continue to be the subject of debate, prompt appropriate action will have the greatest impact on mortality and morbidity. This article gives a practical, evidencebased approach to the early management of the septic patient and outlines some areas of controversy.
Prescribing intravenous fluids: how to get it right
Authors: Knight Alexandra
Published: May 2014

Fluid prescription is an important task, which is often delegated to the most junior team members. Poor understanding can result in inappropriate and potentially dangerous prescriptions. This article aims to improve the confidence of junior doctors when confronted with this problem.
An introduction to non-invasive cardiac imaging
Authors: Boardman Henry , Sugihara Conn
Published: May 2014

According to the World Health Organization (2009), an estimated 17.1 million people died from cardiovascular disease in 2005 (29% of global deaths), 7.2 million from coronary heart disease. It is the number one killer globally and with new and more complex ways of investigating the heart non-invasively, it is important to understand what is available and when to use each modality. This article explains how the different forms of non-invasive cardiac imaging work, their advantages and disadvantages (Table 1), when to use each one and finally what developments are likely in the future. Some may not be available in all hospitals, but access and availability to cardiac imaging is likely to change significantly in the future.
So you want to be … a neonatologist
Authors: Storey Imogen , Philpott Alex
Published: May 2014

Neonatology is a relatively new and rapidly expanding speciality. Traditionally a subspecialty of paediatrics, the first Certificate of Completion of Specialist Training in neonatal medicine was awarded in 1997 and consultants in neonatology now practise wholly within a neonatal intensive care service.
Helping to prevent hospital medication errors
Authors: Roberts Karen
Published: May 2014

In the Medical Defence Union's experience, medication errors are a common type of adverse incident in secondary care. In a busy hospital environment, mistakes can occasionally happen when prescribing, dispensing or administering medicines and the consequences for some patients can be serious. This article looks at some of the medication errors that can occur and considers steps that could help to reduce the risk and improve patient safety.
So you want to be … a critical care physician
Authors: Brealey David A , Singer Mervyn
Published: May 2014

There is no speciality quite like it, working as part of a small, highlyskilled, multidisciplinary team, you actively take on the sickest patients within the hospital. Your role is not only to support the patient's acutely failed organs while attempting to diagnose and treat the underlying cause, but also to deal with a multitude of ethical, moral and organizational challenges. No one discipline takes on such a diverse range of patients and pathologies as critical care; a good understanding of physiology in health and disease is vital, but a working knowledge of other disciplines, particularly medicine, anaesthesia and surgery, are equally important. Indeed, it is one of the few remaining bastions of holistic hospital medicine.
Managing the media 1: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

At some point, a journalist may approach you, or you may contact the media yourself. This could be the medical or lay press. You could be:
Patient confidentiality
Authors: Keegan Michael , Levenson Ros
Published: May 2014

‘All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.’ (Hippocrates, 4th century BC)
Initial management of acute trauma
Authors: Naser Ammar , Stephens Robert CM , Das Rita
Published: May 2014

A trauma team should consist of two to four doctors, three to five nurses, a radiologist or radiographer and porters. Before the patient arrives the team leader should assign each member a specific role (including someone to document findings and organize investigations), gowns and gloves should be put on and equipment checked.
So you want to be … a plastic surgeon
Authors: Joshi Jatin R , Sivakumar Bran
Published: May 2014

Plastic and reconstructive surgery is a varied and extremely rewarding specialty which encompasses a wide variety of subspecialties that can make a tangible difference to the lives of patients.
Managing the media 2: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

At some point, a journalist may approach you, or you may contact the media yourself. This could be the medical or lay press.
The applied anatomy of appendicectomy
Authors: Ellis Harold
Published: May 2014

Acute appendicitis is a common surgical emergency and appendicectomy is the most commonly performed emergency abdominal operation in the western world. The satisfactory performance of this operation depends on a clear understanding of the anatomy of the appendix and its variations, In man, the appendix is a vestigial organ, small and functionless, compared with the large bulky structure seen in herbivores. In these grasseating animals the mucosa of the appendix secretes the enzyme cellulase, which digests the cellulose walls of the ingested plant food. The appendix arises from the posteromedial aspect of the caecum, about 2.5 cm inferior to the ileocaecal valve (Figure 1). Its length varies greatly, from a tiny structure 12 mm long to an impressive 22 cm. One patient the author operated upon had an appendix which passed from its right iliac fossa origin on the caecum across the lower abdomen to reach the sigmoid colon, against which its perforated gangrenous tip was adherent.
Orbital swelling: a simplified guide
Authors: Creavin AL , Creavin ST , Khooshabeh R
Published: May 2014

Swelling in and around the orbit is common but many doctors may have difficulty forming a differential diagnosis for an orbital swelling. It is important to be able to differentiate the causes of orbital swelling either because they are common (e.g. thyroid eye disease) or because they are rare (e.g. mucormycosis) but may result in loss of vision or even death (Gamba et al, 1986; Rootman, 2001; Tanaka et al, 2004; Kanski, 2007; Lutt et al, 2008). This article outlines the assessment of orbital swelling.
So you want to be … a rheumatologist
Authors: Farrow Sarah J , Kingsley Gabrielle H
Published: May 2014

Even in the 19th century, when rheumatoid arthritis, the most common of the serious rheumatic diseases, was first defined, sufferers moved inexorably towards life in a wheelchair. As late as the 1950s, the only widely available treatments were aspirin for symptom relief, and cortisone which had severe side effects. However, rheumatoid arthritis was one of the first fields in medicine where treatments were subjected to controlled trials. The benefits of injectable gold, the earliest disease-modifying drug, were demonstrated by Fraser in 1944–5, following which this treatment became widely available.
Information governance: a guide for the foundation year doctor
Authors: Trivedi Deepali , Joshi Madhavi , Hooke Rachel
Published: May 2014

Information governance is an important aspect of patient care. All staff, including foundation doctors, must abide by the principles.
Diagnosis and management of degenerative neck pain
Authors: Rogers BA , Brogan K , Little NJ
Published: May 2014

Neck pain is a common presenting complaint, but the precise patho-aetiology is often unclear. Broadly speaking, the cause of neck pain can be considered as degenerative or non-degenerative (Table 1). While detailing the important non-degenerative causes the clinician should not miss, this article reviews the diagnosis and management of the common degenerative orthopaedic causes of neck pain.
Online generic induction for doctors in training:an end to repetition?
Authors: Nathavitharana KA
Published: May 2014

Multi-professional collaboration across the West Midlands has developed an online generic induction package consisting of 18 statutory, mandatory and general modules. The material incorporates best practises in e-learning, including an assessment component.
The NHS breast screening programme
Authors: McMahon MA , Sharma N , Dodwell D
Published: May 2014

This article reviews the NHS breast screening programme and outlines some of the issues it currently faces.
Capillary blood gas as a substitute for arterial blood gas: a meta-analysis
Authors: Richter Sophie , Kerry Claire , Hassan Neelam , Chari Aswin , Lunn Daniel , Nickol Annabel
Published: May 2014

Arterial blood gas sampling forms a vital part of bedside investigation but is invasive and physician dependent. This study aimed to determine whether capillary blood gas sampling could provide an accurate and less invasive substitute for the measurement of blood gases and pH.
Developing effective clinical audit
Authors: Davies Huw TO
Published: May 2014

Clinical audit received a mixed press when it was formalized as part of the health-care reforms in the early 1990s, and has continued to mixed reviews ever since. However, the latest governmental stipulations on clinical governance envisage a revitalized role for clinical audit. This paper advises on avoiding some of the pitfalls that await the unwary in developing effective clinical audit projects.
Primary adrenal B cell lymphoma
Authors: Fearon Paul , Rahilly Maeve
Published: May 2014

A 57-year-old man presented with a 12-hour history of abdominal pain of sudden onset. The pain was localized to the right upper quadrant, and there were no relieving or aggravating factors. There was also no associated nausea or vomiting. Clinical examination revealed tenderness and voluntary guarding in the right upper quadrant, but no signs of rebound or peritonism. His only other symptom was night sweats which had been occurring for 2 years. There was no relevant past medical or family history.

An ultrasound scan of the abdomen demonstrated a 7.5×6.6×4 cm mass, superior to and separate from the right kidney and separate from the right lobe of liver. The mass contained multiple internal echoes and had appearances consistent with an adrenal mass. The other abdominal organs including the contralateral adrenal gland appeared within normal limits.

The ultrasound findings were confirmed on abdominal computed tomography (CT) scan and followed up by urine biochemistry, chest X-ray and routine blood tests, which were all normal. Protein electrophoresis showed a diffuse increase in γ-globulins (15 g/litre; range 4–7 g/litre). A CT-guided adrenal biopsy was performed which yielded a core of mostly necrotic tissue on which the differential diagnosis of malignant lymphoma or tuberculosis was raised. The patient proceeded to right adrenalectomy, which was uncomplicated.

A spherical tumour mass 85×80×75 mm (weight 230 g), with a smooth capsule and some normal adrenal gland attached to one pole, was resected. Opening the tumour revealed mostly necrotic yellowish material containing flecks of calcification. Histological examination showed some viable tumour at the periphery of the mass destructively infiltrating residual normal adrenal gland. The neoplastic cells were arranged in solid sheets and possessed large vesicular nuclei and 1–2 nucleoli. There was a high mitotic and apoptotic rate. The neoplastic cells were immunoreactive for leucocyte common antigen and the B cell marker L26, and the appearances were thus of a diffuse high grade B cell lymphoma (Figures 1 and 2).

Staging procedures including bone marrow trephine biopsy and CT scanning of the chest, abdomen and pelvis did not demonstrate any evidence of disease elsewhere. The patient received chemotherapy (cyclophosphamide, mitozantrone, vincristine and prednisolone) and has maintained a complete remission for 12 months.
Breastfeeding and HIV infection: a global perspective
Authors: Newell Marie-Louise
Published: May 2014

Each day more than 1600 children worldwide become infected with the human immunodeficiency virus (HIV), mostly because they are born to an HIV-infected mother. Mother-tochild transmission of HIV can occur before, during or after delivery. In the absence of specific interventions about 25–35% of children at risk are infected, reducing to less than 15% without breastfeeding. With prophylactic antiretroviral therapy and elective caesarean section the risk can be further reduced to below 2% (European Collaborative Study, 1999).
Interpreting reported health-care benefits
Authors: Neilson Aileen R , Davies Huw TO
Published: May 2014

When reading published reports on the benefits of different treatments or health-care programmes, readers are generally interested in judging the applicability of the results to their own settings. Thus they need to be able to identify what consequences (and costs) were included in the evaluation. This short paper describes the different categories of ‘benefit’ that may arise from health-care interventions and explains some of the methodological considerations in their measurement. It provides simple advice on avoiding the common pitfalls when interpreting the value offered by a particular treatment or configuration of health services.
High intensity training and the heart
Authors: Montgomery Hugh , Woods David
Published: May 2014

Absence may make the heart grow fonder, but exercise makes the heart grow stronger. This review discusses the cardiac impact of high intensity training, and discusses the possible mechanisms underlying the risk and benefit of such training.
Interferon beta-1a in relapsing-remitting multiple sclerosis
Authors: Blumhardt Lance
Published: May 2014

The accumulated results from multiple trials have unequivocally demonstrated beneficial effects of interferon beta-1a on disease activity in relapsing-remitting multiple sclerosis, both for clinical and magnetic resonance endpoints. New data suggest that low doses administered once weekly are relatively ineffective and that higher, more frequent doses are required for optimal benefit.
Magnetic resonance imaging and ischaemic stroke
Authors: Tress Brian M
Published: May 2014

Recent successes in the management of acute ischaemic stroke have emphasized the importance of early diagnosis and treatment. Patients with a ‘brain attack’ are best managed as a medical emergency. Imaging is vital in identifying infarct as well as tissue at risk and is best done with ultrafast magnetic resonance imaging.
Continuing professional development in the private sector
Authors: Vallance-Owen Andrew
Published: May 2014

The whole question of continuing professional development (CPD) is now inextricably linked with the General Medical Council's (GMC) move towards regular revalidation for all medical practitioners. This will require doctors to prove that they are competent, that their skills are up to date and that they are willing to undergo continued monitoring of those skills; under the procedures, records of a doctor's performance will be kept on file locally and continually updated (Kmietowicz, 1999).
Eating disorders: the brain, bones and exercise
Authors: Bryant-Waugh Rachel , Lask Bryan
Published: May 2014

Eating disorders such as anorexia nervosa and bulimia nervosa present a far greater health problem than is generally acknowledged, and their assessment and management is both complex and challenging. They are characterized by excessive concern with the control of body weight and shape, accompanied by grossly inadequate, irregular or chaotic food intake.
Blue and breathless
Authors: Seaton RA , Nathwani D , Kirk J , France AJ
Published: May 2014

A25-year-old HIV-antibody positive female had been admitted to hospital on 12 occasions with respiratory infections over a 3-year period. Pneumocystis carinii pneumonia (PCP) had been suspected twice but never proven and sputum culture for tuberculosis was repeatedly negative. Her CD4 count was 6/mm3. Treatment had been problematic. Antiretroviral therapy was not tolerated, she reported a rash with cotrimoxazole and nebulized pentamidine provoked severe bronchospasm. During her twelfth hospital admission PCP was suspected despite negative induced sputa. She completed treatment with intravenous pentamidine and corticosteroids followed by oral clindamycin with primaquine. Following discharge dapsone 100 mg thrice weekly was started as secondary prophylaxis. Twelve days later she was readmitted with worsening dyspnoea, fever and vomiting. Inadvertently she had taken 300 mg dapsone daily for 4 days. Physical examination revealed a deeply cyanosed patient. Respiratory rate was 50/minute, heart rate 130/minute, temperature 37.6°C and blood pressure 120/70 mmHg. Chest radiograph showed a diffuse bilateral pneumonia and arterial blood gases breathing air revealed a PaO2 of 8.37 kPa, PCO2 of 3.92 kPa and a calculated oxygen saturation of 93.3%. Haemoglobin concentration was 9.7 g/dl, blood film demonstrated 6% reticulocytes with Heinz body inclusions and the methaemoglobin level was 30%.

Activated charcoal, high flow oxygen and 2 mg/kg intravenous methylene blue was commenced. Piperacillin-tazobactam and gentamicin were added for presumptive severe hospitalacquired pneumonia and she was transfused one unit of blood. PaO2 improved to 31.8 kPa on 100% oxygen but she remained deeply cyanosed. The methaemoglobin level 12 hours later was 34% so a further bolus of methylene blue followed by an infusion (0.1 mg/kg/hour) was administered. During the administration of methylene blue pulse oximetry showed a dramatic fall in oxygen ‘saturation’. Twenty-four hours later methaemoglobin level was 1.7% and by day three <1% with an oxygen saturation of 88% measured by pulse oximetry. Following discontinuation of methylene blue on day five an arterial blood sample showed PaO2 was 11 kPa on air with a calculated oxygen saturation of 96%. Repeat chest X-ray showed a right middle-lobe bulla with partial clearing of the infiltrates. She was discharged on day 12 at her own request but died 3 weeks later in hospital following admission with a pneumothorax and severe pneumonia. Autopsy was refused.
Who needs an implantable defibrillator?
Authors: Fitchet Alan , Fitzpatrick Adam P
Published: May 2014

Ventricular arrhythmias account for 80% of sudden cardiac deaths. The implantable defibrillator (ICD) is an effective means of preventing these deaths. This article discusses which patients may benefit from ICD implantation and addresses the cost-effectiveness of their use.
Fatal cardiovascular complication 19 years after treatment for fibrosarcoma
Authors: Galloway Malcolm , MacLeod Dominic , Wedzicha Jadwiga , Sheaff Mike
Published: May 2014

Fibrosarcoma accounts for 3% of all primary bone tumours. It most commonly occurs in the metaphyseal areas of long bones around the knee, and may metastasize to the lungs (Neff, 1991). Here we report a case of a fatal cardiovascular complication 19 years after successful treatment of fibrosarcoma with chemotherapy and radiotherapy.
Cardiology fellowship subspecialty training opportunities in Canada
Authors: Mazeika Peter , Prasad Neeraj
Published: May 2014

Overseas experience broadens horizons, provides a different perspective on medicine and enhances a doctor's professional credibility. This article covers cardiology subspecialty training opportunities in Canada and offers advice on finding a job, the application process and acclimatization into Canadian life.
Major threats to childbirth in developing countries
Authors: Paruk Fathima , Moodley Jack
Published: May 2014

Biological, psychological or social elements may constitute a threat to childbirth. In developing countries, major threats to childbirth mainly caused by restricted health service budgets may be overcome by the introduction of appropriate screening tests, implementation of evidence-based medicine protocols, and a primary health-care approach to maternity services.
What will we do without to get what we really want?
Authors: Connelly Peter J
Published: May 2014

Successful clinical governance can only occur if staff, managers and commissioners are prepared to accept that traditional solutions are not necessarily the most appropriate. Accurate assessment of clinical risk and the development of strong and effective clinical teams with clear leadership, multidisciplinary appraisal and clearly defined implementation plans will help to shape good practice.
Record of In-Training Assessment (RITA): a look at ethical issues in assessment
Authors: Sim Fiona
Published: May 2014

Assessment is now an integral and compulsory part of specialist medical training in the UK. In looking at the ethical issues involved in assessment, several practical problems emerge, which need to be addressed if the process is to have validity and meet the needs of specialist registrars and patients.
Human immunodeficiency virus and acute fulminant infection
Authors: Lucas DN , Soni N , Gill JK , Nelson M
Published: May 2014

The complications of human immunodeficiency virus (HIV) infection can result in life-threatening dysfunction requiring support in the intensive careunit (ICU). HIV is frequently overlooked as part of the differential diagnosis in those presenting with acute life-threatening infection. Consideration of the possibility of HIV infection and its related disorders, even in areaswhere HIV is thought uncommon, is increasingly important. Failure to do so may result in a fatal outcome or a more complicated course of illness, as well as inadvertently denying those patients that survive access to new treatments.
I smell a rat!
Authors: Gordon IJ , Sherwood Jones E
Published: May 2014

This is a case history with a difference. The year was 1938 and the story was told to one of us in 1946 by Henry Cohen (HC), then Professor of Medicine at Liverpool (Figure 1). Bothdiagnosis and successful treatment were made in the patient's home without any of the customary investigations. The case is reported because it still provides lessons: there are no substitutes for wide-ranging knowledge and its thorough clinical application
Stigma of anxiety
Authors: Hallstrom Cosmo
Published: May 2014

Some 15% of the population suffer from pathological anxiety, making it the most common of all psychiatric conditions (Costa E Silva, 1998). Anxiety disorders are poorly conceptualized, rarely diagnosed and inadequately treated (Hale, 1997). They are taken for granted, yet remain a major source of emotional distress, chronic morbidity and high health-care resource utilization. Greater awareness, earlier recognition and more aggressive treatments would improve the prognosis, and overcome the stigmatization and undervaluation of patients with these disorders (Lloyd et al, 1996).
Pulmonary embolism: clinical features and management
Authors: Wood MK , Spiro SG
Published: May 2014

Pulmonary embolism (PE) often presents diagnostic difficulties, as its presentation is varied and non-specific. This article attempts a logical approach to the management of a patient with suspected PE, starting with how it may occur, the assessment of clinical probability of PE and subsequent investigations and treatment.
Computerized evaluations of their education and training by senior house officers in the West Midlands
Authors: Wall David , Whitehouse Andrew , Campbell Ian , Kelly Stephen , Cook Stephen
Published: May 2014

A computerized monitoring system of senior house officers' evaluations of their education and training has been developed in the West Midlands. Four successive surveys over 2 years show some significant improvements in their education and training.
Measuring satisfaction with hospital training: why we need a standardized national questionnaire
Authors: Hand Christopher H
Published: May 2014

Trusts, deaneries and Royal colleges use different questionnaires to measure satisfaction with hospital training. A case is made for a standardized national questionnaire. This could be the first step towards a more coordinated system of training evaluation and approval.
Improving outcomes in colonic cancer
Authors: Carter Paul S , Hershman Michael J , Myint Arthur Sun
Published: May 2014

Many of the symptoms of colon cancer do not start until the tumour has spread outside the bowel, and treatment at this stage has reduced chances of cure. Early detection and the optimum combination of surgery and adjuvant treatment can make a significant impact on outcome.
Retained gall-stone as a differential diagnosis of acute appendicitis
Authors: Salih Ali K , Insall Robert L
Published: May 2014

A52-year-old female suffering repeated attacks of cholecystitis underwent an otherwise straightforward laparoscopic cholecystectomy. At completion the gall bladder was seen through the laparoscope to rupture during its removal via the umbilical incision. A single stone was noted to fall from the gall bladder into the peritoneal cavity and this was easily retrieved. No other spilled stones were seen at completion laparoscopy. The immediate postoperative recovery was uneventful and the patient was allowed home on the following day.

Eight weeks later the patient presented as an emergency with central abdominal pain which radiated to the right iliac fossa. There was associated nausea and vomiting and a tachycardia but no fever or bowel upset. Clinical findings included tenderness and guarding in the right iliac fossa but normal bowel sounds and rectal examination. Chest and abdominal radiographs were normal, as were blood count, glucose, amylase, renal and liver function tests. A clinical diagnosis of acute appendicitis was suspected and the right iliac fossa was explored through a muscle-splitting incision. A normal appendix was found and was removed but there were fibrinous adhesions and inflammation around a gallstone surrounded by the mesentery of the terminal ileum. The adhesions were divided and the gallstone removed, followed by peritoneal lavage. The patient again made an uneventful recovery and was allowed home, free of symptoms, 72 hours later.
The treatment of malignant cerebral tumours
Authors: Short SC , Brada M
Published: May 2014

Malignant cerebral tumours are uncommon. While a large proportion are resistant to conventional therapies there are a significant number of curable malignant brain tumours that require recognition and appropriate therapy.
Recent advances in the sleep apnoea/hypopnoea syndrome
Authors: Packham Stuart , Ebden Philip
Published: May 2014

This review highlights some of the advances in sleep apnoea/hypopnoea syndrome made over the last few years, particularly in diagnosis and treatment. Recent evidence of the controversial associations of sleep apnoea/hypopnoea syndrome with increased morbidity and mortality, particularly from cardiovascular disease, is presented.
Variant Creutzfeldt-Jakob disease: an update
Authors: de Silva Rajith N
Published: May 2014

There cannot have been many medical publications this decade that have had an impact to equal that of the paper by Robert Will and colleagues on a ‘new variant’ of Creutzfeldt–Jakob disease (CJD), published in the Lancet in April 1996 (Will et al, 1996). This did not simply affect the scientific community, but also farming, economics, politics and diplomacy.
The thiazolidinediones: a new class of antidiabetic agents
Authors: Barnett Anthony
Published: May 2014

Insulin resistance is a fundamental feature of type 2 diabetes and is strongly associated with metabolic disorders which predict increased cardiovascular risk, including hypertension and dyslipidaemia. A new class of insulin-sensitizing agents, the thiazolidinediones, reduce insulin resistance and improve glycaemia both as monotherapy and in combination with sulphonylureas or metformin.
Knee arthroscopy in the day surgery unit
Authors: Hamilton Mark A , El-Behesey Basel
Published: May 2014

General anaesthesia is usually the preferred technique, but spinal anaesthesia has many advantages in day-case surgery. It is easy to perform, has a rapid onset of action, blocks only the region being operated on, and provides good muscle relaxation and early postoperative analgesia. Spinal anaesthesia limits postanaesthetic nursing care, is less expensive and reduces the nausea and vomiting associated with general anaesthesia. However, day-case spinal anaesthesia remains controversial because of concerns over postdural puncture headache, backache and delayed micturition while prolonged motor blockade may preclude early mobilization and discharge.
A simple guide to nystagmus
Authors: Lueck Christian J
Published: May 2014

Nystagmus is a potentially mind-boggling subject, as over forty different types are recognized. However, by classifying the various types into a small number of categories, the clinician can make sense of them, and so make use of a very important clinical sign.
Management of venous and cardiovascular thrombosis: enoxaparin
Authors: Harvey DM , Offord RH
Published: May 2014

Enoxaparin has strong clinical evidence that supports its license in a broad spectrum of therapeutic indications, including thromboprophylaxis in surgical patients, medical patients bedridden because of acute illness, the once-daily treatment of venous thromboembolism and the treatment of unstable angina and non-Q wave myocardial infarction.
Anticoagulant therapy and referral form
Authors: Rose PE
Published: May 2014

Many hospitals use the recommendations contained in the British Committee for Standards in Haematology anticoagulant guideline documents to develop local protocols for anticoagulant management. A combined anticoagulant treatment chart and referral form has been produced to help incorporate the recently updated recommendations for oral anticoagulation into day-to-day practice.
Both service and training demand attention in obstetrics and gynaecology
Authors: Biggs John
Published: May 2014

New proposals for workforce planning, training and ways of working in the NHS are under consideration. Aspects of service, training and workforce in obstetrics and gynaecology that call out for change include training in the senior house officer grade, especially for GPs and non-EC doctors, and the work of consultants. Proposals for change present a golden opportunity for the specialty to lead in new systems of both service and training, which are closely linked.
Current strategies for mechanical ventilation in acute lung injury
Authors: Marshall Richard P
Published: May 2014

Non-invasive modes of ventilation may be adequate for some patients with less severe acute lung injury (ALI) but invasive positive pressure ventilation is usually required. Ventilation strategies for such patients have changed significantly in recent years, as it is has become increasingly apparent that the process of ventilation itself may contribute to lung injury.
Simvastatin: building on success
Authors: Gaw Allan
Published: May 2014

Over a decade after launch, simvastatin remains the most widely-prescribed statin in the UK. This has resulted from a growing body of long-term outcome data, a steadily expanded range of indications, an extended dose range and proven cost-efficacy.
Vaginal hysterectomy
Authors: Farkas Andrew
Published: May 2014

Vaginal hysterectomy represents the ultimate minimal access hysterectomy. The indications for the procedure extend well beyond those of prolapse. Good training and advances in surgical technique allow the removal of enlarged fibroid uteri as well as vaginal oophorectomy. This article also considers the complications which may follow.
How to present the findings of research
Authors: Davies Huw TO
Published: May 2014

Providing an account of research involves telling a story during which four key questions are answered: why did you start, what did you do, what did you find out and what does it mean? It is the third of these — what did you find out — that is at the heart of any research paper. Ensuring that the key messages emerge from the data is the duty of the author and requires considerable skill and craft.
Food intolerance and allergy in gastrointestinal disorders
Authors: Dear Keith LE
Published: May 2014

Approximately 60 tonnes of food passes through the gastrointestinal tract in an average lifetime. With a surface area second only to the respiratory tract, it is surprising that adverse reactions to food do not occur more frequently.
Will coronary artery surgery disappear in 10 years' time?
Authors: Palmer Nicholas D , Newall Nicholas , Ramsdale David R
Published: May 2014

Over the past 20 years, percutaneous coronary intervention has progressively developed and matured, and many patients with severe coronary artery disease can now be revascularized non-surgically. So are the days of coronary artery bypass graft surgery numbered?
An unusual cause of third nerve palsy
Authors: Morris GC , Gupta A
Published: May 2014

A74-year-old Caucasian, non-hypertensive, non-diabetic, otherwise fit male presented to the outpatient department with a 1-week history of painless left ptosis and diplopia of gradual onset. There were no other neurological symptoms.

Examination revealed partial left third nerve palsy (i.e. ptosis, eyeball fixed down and outward but with normal reacting pupil). There was no other neurological deficit and systemic examination was normal.

Investigations revealed normal full blood counts, erythrocyte sedimentation rate, glucose, electrolytes, thyroid function test, serum immunoglobulins, chest X-ray and negative antinuclear and rheumatoid factor. Computed tomography brain scan with contrast enhancement was normal. The third nerve palsy improved spontaneously to normal over a period of 3–4 weeks.

The patient re-presented 2 months later, this time with features of gradual painless partial right third nerve palsy (ptosis, eyeball fixed down and out with normally reacting pupil). Again there was no further neurological deficit and systemic examination was normal.

Following this assessment, the anatomy of the third cranial nerve was considered in detail leading to a positive Tensilon test to confirm the diagnosis of ocular myasthenia gravis. Computed chest scan did not reveal any evidence of thymoma. Anti-acetylcholine receptor antibodies were absent. He has remained well on a small dose of pyridostigmine.
The clinical and diagnostic features of mitral valve disease
Authors: Chambers John
Published: May 2014

Mitral valve disease remains common, and requires regular clinical and echocardiographic review. Surgery is indicated soon after the development of symptoms or at the first sign of left ventricular decompensation in mitral regurgitation or of the right ventricle in mitral stenosis.
Current management of hypertrophic cardiomyopathy
Authors: Golledge Peter , Knight Charles J
Published: May 2014

Hypertrophic cardiomyopathy is a familial cardiac disorder with heterogeneous expression and a diversity of morphological, functional and clinical features. Some individuals with hypertrophic cardiomyopathy may be asymptomatic while others are disabled by symptoms of angina and breathlessness. This article summarizes the genetics, pathophysiology and present management of this important condition.
Understanding screening: requirements for a successful programme
Authors: Davis Julian PL , Crombie Iain K , Davies Huw TO
Published: May 2014

Screening has generally been successful in identifying those at risk from disease. This success has led to the belief that screening in the general population is always a good thing. However, there are pitfalls which must be avoided if screening programmes are to achieve what is intended for them.