bluuebunny/crossref_metadata_2025 huggingface dataset:
Evidence-based medicine: putting theory into practice
Authors: Irani Mike
Published: May 2014

Evidence-based medicine is an essential tool to ensure the effective and efficient management of patients. A practical and unbiased assessment of clinical evidence can be achieved by asking simple questions about the data. Undertaking this process can reveal a new perspective on traditional treatment approaches.
An unusual rash and end-stage renal failure
Authors: Tan Huck J , Eadington D
Published: May 2014

A 55-year-old man was admitted to hospital with a 2-week history of increasing dyspnoea and peripheral oedema. He gave a 5-year history of intermittent purpuric rash on both legs, with recurrent ulceration at the right lateral malleolus, and arthralgia.
Pulmonary embolism and the electrocardiogram
Authors: Gall Nick , Stafford Peter
Published: May 2014

A 54-year-old man presented with a short-lived episode of blurred vision followed by collapse while shopping. There were no precipitating causes or preceding symptoms. He remained unconscious for less than 1 minute. He recovered sufficiently to continue shopping but presented to casualty 5 hours later with increasing breathlessness. His past medical history included renal colic and a left leg deep vein thrombosis associated with cellulitis 3 years before. His mother had suffered from premature ischaemic heart disease and had died from a pulmonary embolus 25 years before. He took no medication, drank little alcohol but smoked 25 cigarettes per day.
To transfuse or not to transfuse: iatrogenic compromise of women's reproductive careers
Authors: Akkad Andrea , Howarth Edmund , Smith Graham , Scudamore Ian
Published: May 2014

A 21-year-old Indo-Asian woman, who had arrived in the UK 5 months before presentation, consulted her general practitioner because of tiredness and shortness of breath on climbing stairs. There were no significant factors in her history, except that she did not eat red meat. Initial investigation revealed a severe anaemia with a haemoglobin (Hb) concentration of 4.6 g/dl, mean cell volume (MCV) of 49.4 fl, mean cell haemoglobin (MCH) of 11.5 pg, white cell count of 7.4 × 109/litre and a platelet count of 583 × 109/litre. She was promptly referred as an emergency to a general medical ward in a teaching hospital for further management. On admission, physical examination revealed pallor and a tachycardia of 110 beats/minute, but there ware no other significant findings. Her electrocardiogram was normal and there was no evidence of cardiac failure on chest X-ray. She was transfused three units of packed red cells. Subsequently she underwent further investigations, including Hb electrophoresis, vitamin B12 and folate levels, ferritin and transferrin levels, serum urea and electrolytes, liver function tests, blood film for malarial parasites, endomysial and gliadine antibodies, and comprehensive gastrointestinal tract work-up. All investigations were negative with the exception of a positive anti-gliadine immunoglobulin G. The diagnosis of iron deficiency anaemia of unknown cause was made. The patient was given dietary advice and was discharged back under her GP's care 6 months later, having maintained a normal Hb.
The future of journals: where will electronic publishing take us?
Authors: Morris Sally
Published: May 2014

Journals provide much that is of immense value to the researcher and practitioner. Yet the economics of journals are unsustainable; the amount of publishable research is increasing more rapidly than the funds available to buy it. Various alternative models are emerging, none of them without problems. The way forward is not clear, but change is inevitable.
Diagnosing slipped upper femoral epiphysis
Authors: Spence Gavin , Tsiridis Eleftherios , Hashemi-Nejad Aresh
Published: May 2014

The key to diagnosing slipped upper femoral epiphysis is a high index of suspicion. This article summarizes the important clinical features of the disorder and points out the pitfalls in diagnosis.
Tracheostomy in the intensive care patient: surgical or percutaneous?
Authors: Prout Jeremy
Published: May 2014

Tracheostomy is one of the oldest surgical procedures: Egyptian illustrations of the technique date back to 3600 BC, and the Talmul (3rd century AD) describes the use of a reed pipe to stent the trachea of a suffocating goat (Sercer, 1962).
Writing for the popular press: to inform and entertain
Authors: Cooper Carol
Published: May 2014

Many doctors write for consumer publications. Even more would like the chance to do so. This article explains how to bridge the gap between writing scientific papers and writing for the popular press, and offers realistic guidance on how to find a way into this competitive market.
Haemorrhagic rash in infectious mononucleosis
Authors: Ramanan AV , Pike AC , Robinson A
Published: May 2014

A previously healthy 15-year-old boy presented with a 1-week history of a sore throat and maculopapular rash for 3 days. He was seen by his general practitioner 2 days before admission and prescribed penicillin for suspected scarlet fever. The rash was present before antibiotics were commenced.
Case 5: cardiac memory
Authors: Sporton Simon , Holdright Diana
Published: May 2014

A 25-year-old man was seen in the cardiac outpatient clinic with a 10-year history of palpitation. The palpitation, which occurred infrequently and with no obvious precipitant, always started suddenly and was described as fast and regular, associated with a feeling of light-headedness. The attacks usually terminated spontaneously, although on two occasions he had attended casualty following a prolonged episode, where the attacks had been terminated with adenosine. The electrocardiogram (ECG) recorded in the outpatient clinic is shown (Figure 1). What is the diagnosis?
Implications of interscalene brachial plexus block in the elderly patient
Authors: Menon G , Iossifidis A , Jansen VR
Published: May 2014

A 75-year-old, 83 kg woman had been scheduled for a right shoulder replacement. Apart from an asymptomatic hiatus hernia, polymyalgia rheumatica and osteoporosis, she was otherwise healthy. Her medication included omeprazole and prednisolone 5 mg. Preoperative blood tests, electrocardiogram (ECG) and a chest X-ray (Figure 1) were within normal limits.
Tumour markers in ovarian cancer
Authors: Kehoe Sean , Selman Tara
Published: May 2014

While histology remains the gold standard in confirming the presence of ovarian malignancy, tumour markers have evolved to become part of the routine presurgical investigations, enhancing the clinician's ability to suspect that ovarian carcinoma is the likely diagnosis. Such markers also have a role in predicting response to adjuvant therapy and indeed in disease recurrence. Most notable is serum CA125, which was first recognized in the 1980s. Although some rare ovarian tumours do have other specific serum markers, this review will concentrate on CA125 as it has the most prominent role within the present clinical setting.
Lessons from the Bristol Inquiry for education and training in the NHS
Authors: Hicks Brendan
Published: May 2014

The vast body of evidence, analysis and judgment within the Bristol Inquiry report gives rise to a host of recommendations for change. Most are relevant to health systems everywhere and to all parts of those health systems. Some raise issues which cry out to be addressed within the education, training and development of all health professionals.
Case 6: transient ST elevation
Authors: Sporton Simon , Holdright Diana
Published: May 2014

A 50-year-old man presented with a 1-week history of episodes of ischaemictype chest pain always occurring at rest and each lasting for several minutes. A further episode occurred following hospital admission during which an electrocardiogram (ECG)
Nutritional support in acute pancreatitis: the enteral vs parenteral dilemma
Authors: Rao Madhusudan P , Mulleague Larry
Published: May 2014

Acute pancreatitis has an unpredictable outcome with serious complications arising in 20—30% of cases. These run a more fulminant course characterized by pancreatic necrosis and associated cytokine activation resulting in multiorgan failure. These patients require intensive care therapy, nutritional support and often judiciously timed surgery (Lobo et al, 2000). Acute severe pancreatitis imposes a catabolic stress state and ultimately nutritional depletion. Thus early provision of nutritional support is a significant component of the management of patients to ensure optimum recovery (Kalfarentzos et al, 1997). Most patients with mild uncomplicated pancreatitis do not benefit from nutritional support.
The psychiatric consequences of trauma
Authors: Alexander David A
Published: May 2014

Trauma can have marked and sustained psychological effects. Those at high risk thereof can be identified, and effective treatments are available. This review provides guidelines for the effective management of the psychiatric sequelae of trauma.
The burden of depression
Authors: Tylee Andre , Walters Paul
Published: May 2014

Depressive disorders are ubiquitous. Among the general population the prevalence of depression is up to 3%. With the exception of hypertension depression is likely to be the commonest condition seen in primary care. Among medical inpatients up to 25% suffer from depression.
Physiotherapy in the management of cerebral palsy
Authors: Hartley Jeanne
Published: May 2014

While most parents and professionals agree that physiotherapy treatment is beneficial for children with cerebral palsy, evidence as to its efficacy is controversial. Physiotherapy should be seen from the perspective of lifelong management of cerebral palsy and appropriate resources should be identified in adulthood.
Unfinished Business: an opportunity for change
Authors: Heard Shelley , Paice Elisabeth
Published: May 2014

Sometimes an opportunity comes along in the political life of a government that looks so simple and obvious that its real potential can be missed. Unfinished Business: Proposals for Reform of the Senior House Officer Grade (Department of Health, 2002) is such an opportunity. Arising out of recommendations of A Health Service of all the Talents (Department of Health, 2000), the document provides a strategic vision that is potentially far greater than the reform of the senior house officer (SHO) grade. It has implications that will impact widely on the delivery of patient care and how health services will be delivered over decades to come. It invites a 'whole systems' approach to thinking about the shape and delivery of clinical services from medical practitioners.
Phototherapy and systemic treatments
Authors: Reynolds Nick J , Meggitt Simon J
Published: May 2014

A proportion of children and adults with moderate to severe atopic eczema are not adequately controlled with emollients and topical steroids, resulting in significant morbidity and disability. Studies indicate a significant placebo response, so randomized controlled trials of new treatments are vital. This article reviews the evidence for phototherapy and systemic treatments in atopic eczema.
Should we use inhaled nitric oxide in acute respiratory distress syndrome?
Authors: Sivaloganathan M , Stephens R
Published: May 2014

Nitric oxide produced in the lung causes pulmonary vasodilation. In acute respiratory distress syndrome, ventilation—perfusion mismatch produces arterial hypoxaemia while increased pulmonary vascular resistance causes pulmonary hypertension. In theory, nitric oxide preferentially reaches ventilated alveoli, selectively vasodilating vessels, thus improving oxygenation and reducing pulmonary vascular resistance. But should we use nitric oxide in practice?
Diagnosis and immediate care of wrist and hand
Authors: Warwick David
Published: May 2014

About a fifth of injuries presenting to the accident and emergency department involve the hand or wrist. In this article, the more common injuries, and the rarer ones which should not be missed, are presented.
Systemic lupus erythematosus presenting with brainstem lesions
Authors: CHA Tan , A Rahman
Published: May 2014

Systemic lupus erythematosus (SLE) is a multiorgan autoimmune disease. Owing to its varied presentation, it can be difficult to diagnose. This article reports two cases in which young women with features of brainstem dysfunction were diagnosed as having gliomas and treated accordingly, suffering severe side effects of treatment. In both cases, the subsequent course of events suggested that SLE, rather than glioma, was responsible for the original presentation.
Tonsillectomy and variant Creutzfeldt-Jakob disease
Authors: Johnson Alan
Published: May 2014

Tonsillectomy and adenoidectomy remain common operations of proven benefit. The risk of developing variant Creutzfeldt-Jakob disease (vCJD) and its transmission on surgical instruments have led central government to pilot the use of disposable instruments for this operation. This editorial discusses the issues related to this decision and the risks associated with implementing it.
Restoring post-prandial insulin release in type 2 diabetes
Authors: Andrews John
Published: May 2014

Tight blood glucose control is a primary aim of type 2 diabetes treatment. Combining metformin with the amino acid derivative, nateglinide, tackles both beta cell dysfunction and insulin resistance, and produces a greater decrease in haemoglobin A1c levels than treatment with either drug alone.
Diagnosis and management of thyroid eye disease
Authors: Denniston Alastair , Dodson Paul , Reuser Tristan
Published: May 2014

Recent advances are helping elucidate the pathogenesis and improve the management of thyroid eye disease. While biochemical investigations and imaging may be supportive, ophthalmological and medical clinical assessments remain the key to the diagnosis and management of this sight-threatening disorder.
Update on pancreatic cancer
Authors: Magee Conor J , Shekouh Ali , Ghaneh Paula , Neoptolemos John P
Published: May 2014

Pancreatic cancer is one of the commonest causes of cancer death worldwide. Patients with pancreatic cancer benefit from resectional surgery (improved quality of life) and adjuvant treatment (enhanced survival). This review covers advances in the understanding of the development of pancreatic cancer, state-of-the-art clinical management and, finally, novel treatment and screening techniques.
Kidney cancer: current management guidelines
Authors: Lee Frank , Patel Hitendra RH
Published: May 2014

Renal cell carcinoma accounts for 2% of all cancers. Medical progress has improved the outcome of early but not advanced disease. This article highlights the current practice for the management of renal cell carcinoma.
Using an interactive chemotherapy training package to improve patient safety
Authors: Cushen Noreen , Bacon Alison , Roddis Mike
Published: May 2014

All health-care professionals involved in the use of cytotoxic chemotherapy, if they are to avoid serious harm to patients, can benefit from an interactive training package in the safe use of these drugs. This article discusses a pilot study of a training CD-ROM which was undertaken in a cancer unit.
Brain imaging in psychiatry: what has it done for the patient?
Authors: Sharma Tonmoy , Sheringham Jessica
Published: May 2014

From a research perspective, it is easy to become excited by the kinds of findings that neuroimaging has delivered in psychiatry; by allowing us to view the undisturbed living brain, we now have a better picture of neurobiological characteristics of different conditions. But what does it add to the clinical management of psychiatric illnesses?
The Royal College of Physicians specialist registrar shift survey
Authors: Mather Hugh M
Published: May 2014

A survey of all medical specialist registrars in the UK reveals that a large majority oppose shift working patterns because of their adverse impact on training and quality of life, and on continuity and quality of patient care. This conflicts with the current drive to switch virtually all trainees to shifts by 2004, to comply with the European Union Working Time Directive. More debate is urgently needed.
Bouveret's syndrome: an unusual case of pyloroduodenal obstruction
Authors: Menon NJ , Reid PJ , Ribeiro BF
Published: May 2014

Intestinal obstruction from gall-stones is relatively infrequent. Even less frequent is the incidence of gastric outlet obstruction from gall-stones. Bouveret in 1896 described the syndrome of gastric outlet obstruction caused by gall-stone incarceration. This article reports a case of Bouveret's syndrome treated surgically by a single stage procedure.
Pneumatosis coli in a case of caecal volvulus
Authors: Lawrentschuk Nathan , Nguyen Hung
Published: May 2014

Pneumatosis coli is an uncommon medical condition which, if not recognized, may result in unnecessary surgical intervention. This case highlights the link between pneumatosis coli and other conditions affecting the large bowel, as well as demonstrating its association with chronic obstructive airways disease.
The office of the coroner: past, present and future
Authors: Rheinberg Nicholas
Published: May 2014

The coroner cannot pretend to be a member of the oldest profession - doctors, lawyers and prostitutes might lay prior claim - but he/she is a member of one of the oldest legal institutions in England and Wales. There were coroners in Saxon times but it was not until 1194 that the office was revived, to remain as an institution through to the present time.
Surviving childhood cancer
Authors: McDowell Heather P
Published: May 2014

The 5-year overall survival rate for children and adolescents diagnosed with cancer has dramatically improved in recent years and now stands at 80% (Ries et al, 2002). One estimate is that 1 in 900 people aged 15-44years in the United States is a survivor of childhood cancer. Increasing numbers of successfully treated children and adolescents are growing up into adults, raising the question of survival, but at what cost?
Compensation for failed sterilization
Authors: Esen Umo I
Published: May 2014

Two recent Court of Appeal decisions have modified the hitherto settled rules governing the compensation payable following failed and negligently performed sterilization. Compensation is now possible other than for the pain and suffering of the pregnancy where the child or mother is disabled.
Fractures of the ankle
Authors: Coull R , Williams RL
Published: May 2014

This article is aimed at accident and emergency and orthopaedic senior house officers. While this review is not exhaustive, it attempts to emphasize some key points as an aid to the safe initial management of ankle fractures as they are such common injuries, whose management can be more clearly understood by the application of basic principles.
Bladder cancer: a current update
Authors: Masood Shikohe , Wazait Hassan D , Arya Manit , Patel Hitendra RH
Published: May 2014

In the UK, 10 000 new cases of bladder cancer are reported per annum. Earlier diagnosis and better care have improved survival rates, but the incidence is still rising. This article updates the current understanding of bladder cancer diagnosis and management.
The eye in rheumatology
Authors: Odufuwa TO , Lightman S
Published: May 2014

The eyes are involved in many different types of arthritis and different types of arthritis are associated with particular types of eye problems. Dry eyes are a feature of many patients with arthritis but other types of ocular involvement include scleritis and uveitis. Scleritis is most common in patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and Wegener's granulomatosis whereas uveitis occurs in ankylosing spondylitis, other seronegative arthritides, Behçet's disease and juvenile idiopathic arthritis (JIA).
Sevoflurane or halothane for induction in acute airway emergencies in children?
Authors: Smith Jonathan
Published: May 2014

As children have much narrower airways than adults a small amount of swelling (from infection, inflammation or tumour) can lead to significant and rapidly progressive airway obstruction. Induction of anaesthesia and endotracheal intubation is sometimes required to secure the airway in an emergency.
Chronic lung disease in infancy following prematurity
Authors: Gaillard Erol A , Shaw Ben NJ
Published: May 2014

Survival of extremely preterm infants has improved with modern neonatal intensive care. Chronic lung disease of prematurity, however, remains an important clinical problem and this article reviews the changing presentation and discusses new concepts of its aetiology.
The eye in diabetes
Authors: Mohamad Muhaya
Published: May 2014

Diabetes mellitus (DM) affects more than 100 million people worldwide. In Western countries the prevalence is between 2 and 4% of the population while in Asia the incidence is increasing (King et al, 1998). Population studies all over the world show that the prevalence of type 2 DM is escalating and is likely to reach epidemic proportions. In 1985, the estimated population of diabetic individuals in the world was 30 million but by 1995 it had increased to 135 million. Based on current trends, epidemiologists predict that the population of diabetic individuals will increase to 300 million by 2025.
Developments in understanding and management of inflammatory bowel disease
Authors: Hershman Michael J
Published: May 2014

Inflammatory bowel disease represents a group of disorders still of unknown aetiology. In recent years, an enormous literature has developed representing increased understanding and better diagnosis and treatment. There is unquestionably a worldwide increase in the incidence of inflammatory bowel disease, particularly Crohn's disease. This increase occurred in parallel with the increased intake of a ‘Western diet’.
Medical management of ulcerative colitis
Authors: Thuraisingam Adrian , Leiper Keith
Published: May 2014

Patients with ulcerative colitis have no increased mortality compared to population controls and the disease can be cured be colectomy. This review concentrates on the medical management of ulcerative colitis including the management of active colitis, acute severe colitis and first presentation of colitis, maintenance of remission and long-term complications.
Medical management of Crohn's disease
Authors: Thuraisingam Adrian , Leiper Keith
Published: May 2014

Current evidence strongly suggests that Crohn's disease is caused by an abnormal response to enteric flora. This review examines the current evidence for medical management of Crohn's disease, particularly focusing on alternative therapies to corticosteroids in managing disease relapses and preventing long-term complications.
Surgery for inflammatory bowel disease
Authors: Bullen Timothy F , Hershman Michael J
Published: May 2014

Ulcerative colitis is potentially cured by total excision of the colon and rectum. Crohn's disease is an unremitting condition in which operations are frequently multiple and in which the minimum amount of bowel possible should be excised.
Parasites and the eye
Authors: Berdoukas Paula , McCluskey Peter
Published: May 2014

Systemic parasitic infections can result in intraocular inflammation. They are a major cause of blindness in many parts of the world. Infection usually results from bloodborne transmission of the organism to the eye or ocular adnexal structures. Diagnosis is often made from clinical patterns of disease in the eye, with laboratory investigations and imaging to support the diagnosis. Various local and systemic therapies are available, but may have limited success in preserving vision.
A rare presentation of caecal adenocarcinoma
Authors: Wong MC , Nandhra H , Gowrie BJN , Shah EF
Published: May 2014

This paper describes an unusual case of caecal adenocarcinoma which had perforated through to the anterior abdominal wall. Colocutaneous fistula is an uncommon complication of colonic cancer which is more typically associated with sepsis and ischaemia of the bowel, inflammatory bowel disease and trauma. On rare occasions, as in this case, the colocutaneous fistula may be the initial presenting complaint.
Parapharyngeal abscess: a diagnosis not to miss
Authors: Hobbs CGL , Pinder DK
Published: May 2014

A15-year-old girl presented with a 3-week history of sore throat, which had been unresponsive to penicillin. She had also recently developed a painful swelling in the left side of the neck. On examination she had tonsillitis and a large tender mass in the jugulodigastric region on the left side. This was hard and non-fluctuant with no overlying cellulitis or erythema. Ultrasound confirmed cervical lymphadenitis and she was commenced on intravenous antibiotics.

Despite an initial improvement in her symptoms, on the third day after admission she remained pyrexial and developed a left spastic torticollis. A computed tomography (CT) scan was performed which showed a large parapharyngeal abscess (Figure 1). This was incised and drained immediately and she was discharged home 4 days later having made an excellent recovery.

A week later, however, she was reviewed in clinic and was found to have an ipsilateral Horner's syndrome. After 6 months, this has yet to recover (Figure 2).
The surgical treatment of bronchial carcinoma
Authors: Halstead James C , Screaton Nicholas , Ritchie Andrew J
Published: May 2014

This article considers the current place of surgery in the treatment of bronchial carcinoma. Aspects of the diagnosis of this condition will be covered, but the main focus falls on the surgical procedures, their complications and the outlook for these patients according to tumour stage.
An unusual case of nephrocutaneous fistula
Authors: Tan YK , Valerio D
Published: May 2014

An 86-year-old Caucasian woman presented with a 2-day history of a painful swelling in the left upper thigh anteriorly. She also gave a recent history of recurrent urinary tract infection associated with macroscopic haematuria, against a background of a long-term indwelling catheter for complete urinary incontinence. She denied any change in bowel habit and her weight had also been stable. Her past history included a hysterectomy, dynamic hip screw insertion for fractured right neck of femur and coronary artery disease.

On examination she was apyrexial with no signs of anaemia, jaundice or lymphadenopathy. The left thigh swelling was confirmed to be an abscess. Abdominal and rectal examinations were unremarkable. The abscess was subsequently incised and drained. A substantial amount of pus was released. Culture of the pus yielded Proteus and Escherichia coli. Unfortunately the left thigh wound failed to heal up completely resulting in a constantly discharging sinus (Figure 1).

A sonogram was then performed which revealed a fistulous track passing closely to the left greater trochanter and then superiorly projected over the left iliac wing. It then tracked medially towards the spine and particularly towards a small staghorn-like calculus on the left side. At no time was contrast seen to spill intra-abdominally (Figure 2). A subsequent computed tomography scan demonstrated that the fistulous track lay anterior to the neck of femur and passed superiorly in front of the hip joint before entering the iliacus muscle compartment retroperitoneally. The contrast then tracked superiorly until it reached the iliac crest. It continued superomedially and retroperitoneally towards the lower pole of the left kidney which contained a staghorn-like calculus. Contrast was also seen in the bladder (Figure 3). The patient did not have intravenous pyelography.

A diethylene triamine pentaacetic acid (DTPA) renogram was carried out which confirmed that the patient had a non-functioning left kidney but good function of the right kidney.

This woman subsequently underwent a left nephrectomy through a midline incision. The left kidney was shrunken and tethered retroperitoneally, and was associated with a well-defined fistulous track. The track was opened and curetted and an associated abscess cavity involving iliacus muscle drained.

Histology of the kidney confirmed chronic pyelonephritis with scarring and presence of calculus in the dilated pelvicalyceal system.

The patient made a straightforward postoperative recovery. At follow-up 3 months postoperatively, the thigh sinus had healed completely and the patient was asymptomatic.
Obtaining and using human tissues for research: ethical and practical dilemmas
Authors: Furness Peter N
Published: May 2014

The wide publicity given to the inappropriate retention of organs at post-mortem has resulted in new regulations governing the use of all human samples. thical review and explicit consent are required, even for research using urine samples. This editorial argues that the result, far from protecting patients, is now damaging patients' interests.
The eye in endocrine disease
Authors: Lau Chun H , Lightman Susan
Published: May 2014

The eye and its adnexae can be involved in several different ways in endocrine disorders and the ocular manifestations vary. Ocular symptoms and signs may herald the diagnosis and patients may present with early or late signs of disease.
Infection as a cause of irritable bowel syndrome
Authors: Spiller RC
Published: May 2014

The normal response to infection, such as vomiting and diarrhoea, is protective and beneficial. However, in about 10% of patients these protective changes persist and may contribute to the development of post-infective irritable bowel syndrome, which may persist for many years. New insights into the pathogenesis of this condition suggest novel, effective ways of treatment.
Oral agents for erectile dysfunction
Authors: Kalsi JS , Minhas S , Ralph DJ , Kell PD
Published: May 2014

Erectile dysfunction is a common disease affecting the lives of millions of men worldwide. Sildenafil was the first oral treatment licensed for male erectile dysfunction. However, there are now a number of other options available. In this article the currently available oral treatments are reviewed.
A cirrhotic patient with fever and abdominal pain in the presence of ascites
Authors: Wai-Sun Wong Vincent , Lik-Yuen Chan Henry
Published: May 2014

The patient was a 64-year-old woman suffering from diabetes mellitus and Child's grade B hepatitis B virus-related liver cirrhosis. In November 2001, she complained of persistent dull right upper quadrant pain and fever for 2 days. She did not notice any jaundice, tea-coloured urine or pale stool. There was no increase in abdominal distension.
Case reports: here or to go?
Authors: Hall Nigel
Published: May 2014

It is a truism to say that medicine is a subject in which rarity is common. Anecdotal stories of the bizarre, the unusual, of extraordinary coincidences that all of us witness during our practising lives fuel idle conversations in the coffee room but there is more to such stories than mere repartee. Such ‘case reports’ were the earliest form of medical reporting and yet they still reserve a place in the medical literature today. But what is their value? Are they really worthy of record or are they anachronistic in today's world of clinical trials and consensus statements? By definition case reports do not fit into the norm or the predictable, they do not obey established rules of behaviour and so they test our preconceived ideas about how clinical events proceed and are linked. This is their strength, not their shortcoming.
Quality of care for babies born at 27-28 weeks gestation
Authors: Subhedar Nimish V
Published: May 2014

Prematurity (birth before 37 completed weeks gestation) accounts for approximately 13% of all livebirths but almost half of all neonatal deaths. There is a close, inverse relationship between survival and gestation: only approximately 1 in 10 babies born at 23 weeks gestation survive to discharge from hospital, whereas at 28 weeks gestation and beyond the situation is reversed with 9 out of 10 babies expected to survive (Lee et al, 2000; Wood et al, 2000).
Regional block or general anaesthesia?
Authors: Al-Haddad M , Coventry DM
Published: May 2014

When patients require surgery on a finger, a ring block is usually used without much consideration given to general anaesthesia (GA). However, if the procedure involves the hand, GA becomes the technique of choice for most anaesthetists, unless there are significant co-existent medical problems. Regional anaesthesia is perceived by most anaesthetists to be safer for many of these patients, but if used only occasionally, it is unlikely to have the success that the regular practitioner might anticipate. For many anaesthetists, unreliability has led to premature abandonment of the techniques. For others, the techniques provide a very useful and satisfying alternative to GA for many routine procedures in patients with or without co-existing morbidity.
Clinical management and algorithms in osteoporosis
Authors: Bubbear Judith , Keen Richard
Published: May 2014

The aim of management in osteoporosis is to reduce the risk of fractures. Case-finding strategies are currently recommended to identify subjects at high risk of future fracture who will benefit most from therapy. This article reviews these approaches and discusses the current and future treatment options that are available for patients with osteoporosis.
Dancing eyes
Authors: Storey Imogen , Denniston Alastair , Denniston Sarah
Published: May 2014

A7-month-old girl was referred by her GP with a 6-hour history of ‘jittery eyes’. During the preceding day she had been ‘grizzly’ and non-specifically unwell. Her mother reported that on the day of admission she had had rigors and abnormal eye movements. The child had no significant past medical history. There was a family history of epilepsy.

Paediatric review noted a miserable child with an inflamed right tympanic membrane and sudden eye movements up and to the right. An electroencephalogram was performed which was normal and a provisional diagnosis was made of right-sided otitis media with associated nystagmus resulting from putative labyrinthine involvement. The child was started on a course of amoxycillin and admitted. After 24 hours her condition had improved and she was discharged, pending an ophthalmology review 4 days later.

At the ophthalmology review it was noted that although the child appeared generally well, she was distressed by recurrent sudden conjugate dextro-elevatory eye movements associated with simultaneous backward jerks of the head. She was ataxic but the examination was otherwise normal. The opinion of a paediatric ophthalmologist was sought, the diagnosis of opsoclonus was made and further investigation arranged.

Chest radiography revealed bilateral paravertebral mass in the lower thoracic region (Figure 1). Magnetic resonance imaging confirmed this and showed anterior extension encircling the aorta and displacing the inferior vena cava (Figure 2). Considerable enhancement with gadolinium was noted. No involvement of liver, spleen or cranium was seen. A bone scan and marrow trephine was normal. An MIBG (metaiodobenzyl guanidine) scan showed increased uptake in the lower thoracic right paraspinal area. Tumour biopsy revealed rosettes of small round cells consistent with neuroblastoma.

The diagnosis was therefore of thoraco-abdominal neuroblastoma stage 3. This was not resectable and chemotherapy was started as per the European Infant Neuroblastoma Protocol. She made rapid improvement with radiographic reduction in tumour size and dramatic improvement in her neurological features.
Cirrhotic ascites: a review of management
Authors: Sivayokan Tharshanan , Dillon John F
Published: May 2014

Ascites is a common and debilitating complication of cirrhosis where optimizing management can have satisfying results. New therapeutic and interventional developments have demonstrated improved outcomes. These are reviewed and integrated with established management techniques including consideration of liver transplantation.
A vascular left atrial myxoma causing obstructive symptoms
Authors: Butler Rob , Webster Mark , Greaves Sally
Published: May 2014

A 63-year-old Chinese lady presented with acute dyspnoea, palpitations and a short history of intermittent presyncope. Her dyspnoea was worse on lying flat, improved on standing, and had an effort-related component. She had had a similar episode of positional dyspnoea 3 months earlier, while visiting relatives in China. There was no history of constitutional symptoms or signs consistent with systemic embolization.

On admission, her cardiac rhythm was an atrial tachycardia, which terminated with intravenous adenosine. A mid diastolic murmur was then heard on examination, and investigated by echocardiography (Figure 1). This demonstrated a left-sided intra-cardiac mass (5.8 cm x 4.2 cm) attached to the atrial septum, consistent with an atrial myxoma. There was obvious prolapse through the mitral valve, associated with a functional mitral inflow gradient of 9 mmHg.

A coronary angiogram (Figure 2), performed before surgical removal of the tumour the next day, demonstrated a single feeding vessel arising from the right coronary artery, supplying a large vascular mass. The left coronary system was normal.

At operation, a large, smooth, gelatinous mass was excised, including its broad-based attachment to the intra-atrial septum. The atrial septum was repaired with a pericardial patch. Histology demonstrated features typical of a cardiac myxoma. Postoperatively she has remained well.
Artificial oxygen carriers for trauma: myth or reality?
Authors: Mackenzie Colin F , Bucci Cyndi
Published: May 2014

Two-unit blood transfusion accounts for one third of blood use in trauma patients. Artificial oxygen carriers have no need for cross-match, allow volume expansion, prolonged storage at 1–38°C, and improve rheology to reverse ischaemia. Haemoglobin-based oxygen carriers can provide a vital alternative given the predicted future shortfall in blood donations.
Pharmacogenetics and cardiovascular disease management
Authors: Weston Clive FM
Published: May 2014

Patients differ in their response to drugs. Part of this variability may reflect genetically-determined characteristics of target genes or metabolizing enzymes. A knowledge of an individual's genetic makeup could allow drug therapy to be targeted at those most likely to benefit.
Is preoperative pacing for bifascicular and trifascicular heart block necessary?
Authors: O'Malley S , Ashley EMC
Published: May 2014

Whether to place a temporary pacing wire in patients with bi- or trifascicular block before anaesthesia is a dilemma because of concerns about progression to complete heart block (CHB). CHB usually occurs in patients with acute myocardial infarction, more commonly if there is pre-existing or new bundle–branch block. The cumulative incidence of chronic bi- and trifascicular heart block progressing to CHB in the general population at 5 years is 4.9%, or 1% per year (McAnulty et al, 1982).
Suicide: causes and prevention
Authors: Kapur Navneet
Published: May 2014

Approximately 5000 individuals complete suicide in England and Wales every year, a rate of around 10 per 100 000 per year (Appleby et al, 2001). There are an additional 800 suicide deaths each year in Scotland which has an even higher suicide rate. Suicide is a major cause of premature mortality and is now the commonest cause of death in young men. The key questions are what causes suicide and what might be done to prevent it?
Shoulder pain in sports
Authors: Cobiella Carlos E
Published: May 2014

Shoulder pain in athletic individuals is common, particularly in those sports that are upper limb dominant. It is important to make an accurate diagnosis so that appropriate treatment can be directed at the cause.
Developing maternity services in Scotland
Authors: Smith Norman C
Published: May 2014

Close scrutiny of the maternity services in Scotland has been necessary because of the falling birth rate, the European working time directive, the geographically diverse population and the public expectation of good quality care. This article describes how this is being done.
Melanoma vaccines
Authors: Elliott Bruce , Dalgleish Angus
Published: May 2014

Melanoma vaccines offer new hope to patients with metastatic melanoma, although convincing survival advantages have yet to be reported. This review outlines the progress made in this exciting field of research and looks ahead to the future.
Paediatric acute abdomen
Authors: Hammond Phil , Curry Joe
Published: May 2014

A large proportion of children assessed in hospital with abdominal pain will leave with no definitive diagnosis. The challenge is to treat the majority of children with self-limiting but benign conditions and to swiftly identify and treat the child with an uncommon but potentially life-threatening cause of pain.
To do or defer: a case with adult congenital heart disease
Authors: Walker David , Walker Fiona
Published: May 2014

If you proceed, you are making the following assumptions. The patient has a minor heart problem, which you may justify by the fact that there are no murmurs, and she is only under follow up by her local cardiologist. You are also reassured by the patient's explanation of her diagnosis and absence of reported symptoms.
Enteral nutrition
Authors: Bowling TE
Published: May 2014

Enteral nutrition is feeding the gastrointestinal tract either with food, oral supplements or via tube. It is generally safe, easy to administer and free of major complications. The most common problems relate to the tubes themselves, such as blockage and stoma infection.
Falls and their prevention in old age
Authors: Radhamanohar Macherla
Published: May 2014

Falls in old age present a threat to the everyday activities of elderly people and pose a challenge to health-care professionals. Why are falls common in elderly people and how can we address this major problem?
The new NHS framework for handling performance concerns
Authors: Black David A
Published: May 2014

There have recently been important changes in the procedures for handling performance issues among medical and dental employees. The author explains the background, explores the practicalities, and discusses the challenges and unresolved issues for medical managers.
A delayed diagnosis of stiff person syndrome
Authors: Yeow Toh Peng , Tomkin Gerald H
Published: May 2014

A 37-year-old industrial designer presented in February 2002 with a 6-week history of thirst, polydipsia and polyuria. Urine dipstick showed glucose and 3+ ketones. Diabetes was diagnosed following fasting glucose of 13 mmol/litre and glycosylated haemoglobin (Hba1c) of 10.3%. He was commenced on insulin therapy.

He had been healthy until 1995 when he described the onset of muscle spasm and pain in upper back and shoulders. There was no obvious precipitating injury. He described the muscle over his left shoulder tightening up like a knot. It subsequently spread to his neck, upper and, later, lower back, giving significant rigidity and pain. Exertion and sporting activities cause his whole back to seize up with extreme pain afterwards. The spasms spread to his legs twice in the last 7 years, but the rigidity was fortunately only short lasting. He sought advice from a chiropractor and various medical specialists including an orthopaedic surgeon, rheumatologist and pain consultant. He had many investigations including isotope bone scan and magnetic resonance imaging (MRI) scan of cervical and thoracic spine which were all normal. There was no explanation for his symptoms and no diagnosis was given. He was prescribed baclofen, which brought some relief.

Clinical examination was normal except for markedly increased tone of muscles over his left shoulder. There was no obvious truncal rigidity or exaggerated lumbar lordosis and no pyramidal or extrapyramidal signs. He was clinically euthyroid.

Antiglutamic acid decarboxylase (GAD) 65 antibody was highly elevated at 220 U/ml (normal range (NR) <1 U/ml; >100 U/ml associated with neurological disease). Thyroid function test showed normal free thyroxine of 16.3 pmol/litre (NR 10–25.0 pmol/litre) with elevated thyroid-stimulating hormone of 8.43 mU/litre (NR 0.4–4 mU/litre) and positive thyroid peroxidase (TPO) antibody at 82 IU/ml (NR <37.0 IU/ml). Nerve conduction studies showed no evidence of neuropathy. Electromyograph studies were not done because of the difficulty of excluding voluntary movement from this quite painful test. Full blood count, renal, liver and bone profile were normal. CSF was not examined.

The typical history of painful muscle spasm and strongly positive anti-GAD 65 antibody suggested the diagnosis of stiff person syndrome. The association with an autoimmune condition, in this case type 1 diabetes, and elevated TPO antibody levels further supports the diagnosis.
Managing cancer-related skeletal events with bisphosphonates
Authors: Rule Simon
Published: May 2014

Bone metastases cause considerable morbidity. This article discusses the benefits of bisphosphonates, which are now well established in the treatment of skeletal complications across a wide range of tumour types.
Non-accidental injury
Authors: Larcher Vic
Published: May 2014

The rigorous investigation and management of actual or possible abuse in children requires the systematic, comprehensible and timely documentation of concerns, and evidence that they have been properly addressed (Laming, 2003). All professionals having contact with children should be aware of the possibility of abuse, know what to do if they suspect it and must be responsible and accountable for their actions. This article will be concerned mainly with physical abuse, especially the types which may present to accident and emergency departments.
Consultant contract: the view of the Hospital Consultants and Specialists Association
Authors: Campion Stephen
Published: May 2014

The Hospital Consultants and Specialists Association (HCSA) has consistently argued that the new contract was ‘bad for patients, bad for the NHS and bad for consultants’. The Secretary of State for Health took a different line and welcomed the contract as a good deal for all. That difference of opinion is not in itself surprising. Events over the past few weeks and months justify close scrutiny as the time approaches for consultants to decide whether to accept the new terms and conditions of service.
New aspects of inner ear research
Authors: Brors Dominik , Bodmer Daniel
Published: May 2014

At birth, one in 850 babies are profoundly deaf, and hearing loss affects more than 50% of all people over 60 years of age. While hearing loss caused by disease of the external and/or middle ear is treatable, hearing loss as a result of damage to and loss of hair cells and/or auditory neurons can only be alleviated using prosthetic devices such as hearings aids or cochlear implants.