bluuebunny/crossref_metadata_2025 huggingface dataset:
Sporadic Creutzfeldt–Jakob disease presenting as stroke mimic
Authors: Winn Simon , Bhalla Ajay
Published: May 2014

A hypertensive 75-year-old woman with hypertrophic cardiomyopathy, hypercholesterolaemia and paroxysmal atrial fibrillation was referred to the author's neurovascular clinic with sudden onset word-finding difficulty and right-sided weakness. Examination confirmed mild right pyramidal drift and expressive dysphasia in an otherwise relatively independent patient. Computed tomography (CT) confirmed a lacunar infarct involving the posterior limb of the internal capsule (Figure 1).

Neurorehabilitation afforded initial improvement, but her family reported deterioration in concentration, coordination and continence control with emotional lability over the next 4 weeks, prompting hospital admission. On examination, she was bedbound, with severe expressive dysphasia (abbreviated mental test score 0/10), dysphagia, global weakness, hypertonia, hyperreflexia and bilateral upper limb myoclonus (more on the right hand side). Repeat CT confirmed previous findings. Lumbar puncture was acellular with a protein count of 0.42 g/dl. Sequential electroencephalograms (EEGs) demonstrated bilateral periodic lateralized epileptiform discharges which were abolished by intravenous lorazepam suggesting nonconvulsive status epilepticus. However, deterioration continued despite antiepileptic therapy.

Magnetic resonance imaging demonstrated bilateral putamen and caudate nucleus enhancement on T2 FLAIR with left temporal lobe cortical ribboning on diffusion weighted imaging (Figures 2 and 3). A subsequent EEG showed an evolving picture, with bilateral triphasic waves (1Hz) (Figure 4) compatible with a diagnosis of probable sporadic Creutzfeldt–Jakob disease. This was supported with a positive cerebrospinal fluid 14-3-3 protein assay. The patient died 59 days after the initial presentation. No tissue diagnosis was made.
Are logbooks of training in anaesthesia a valuable exercise?
Authors: Bould MD , Crabtree NA
Published: May 2014

A logbook of cases experienced and procedures performed is currently required for training in anaesthesia in the UK (Nixon, 2000). But is this process valuable and what are the potential benefits and disadvantages?
Cauda equina syndrome: an anatomically driven review
Authors: Mauffrey C , Randhawa K , Lewis C , Brewster M , Dabke H
Published: May 2014

Cauda equina syndrome results from an injury to the lumbosacral nerve roots below the tip of the conus medullaris, occuring in between 2 and 6% of all laminectomies performed for lumbar disc herniation. This article relates the anatomy of the nervous system of the bladder, rectum, anus and sexual organs to the signs and symptoms of cauda equina syndrome, and reviews the literature for the acute management of these patients.
Travelling to new heights: practical high altitude medicine
Authors: Plant Tracie , Aref-Adib Golnar
Published: May 2014

Over 40 million people travel to high altitude for both work and pleasure each year, and all of them are at risk of the acute effects of hypoxia. This article reviews the prevention, diagnostic features and treatments of these illnesses.
Epistaxis in adults: a clinical review
Authors: Melia Louise , McGarry Gerald
Published: May 2014

Epistaxis can be encountered in a wide range of specialties, and it is vital that doctors and nurses can identify the causes and manage it effectively. When managed correctly the potential morbidity and mortality can be significantly reduced.
A variant of Munchausen syndrome presenting as a gynaecological emergency
Authors: Ogbonmwan Stephen EO , Abidogun Kenny
Published: May 2014

A 42-year-old woman presented to the accident and emergency medicine department and was triaged to the gynaecological emergency unit with vaginal bleeding and incomplete miscarriage of 13 weeks’ gestation, which she brought in as a ‘specimen of products of conception’, following a miscarriage at home, in a plastic bag.

Her last menstrual period was on 11 December 2005, which made her about 13 weeks’ gestation by date. She had three children and had had ‘three miscarriages’ previously. Her periods were regular, bleeding for 4–6 days in a regular cycle of 26–28 days. She had two ‘positive pregnancy tests’ at home but had never had an ultrasound scan before presentation. In her three previous miscarriages, there was no documented evidence of pregnancy either by a positive pregnancy test, elevated beta human chorionic gonadotrophin level, ultrasound scan findings of intrauterine pregnancy, whether viable or non-viable, or histological evidence of products of conception.

She looked very distressed but her general physical examination was normal and her vital signs were within normal limits. Pelvic examination revealed minimal blood in the vagina and the cervix looked normal, but patulous. The uterus felt slightly bulky in size and mobile.

An intravenous line was put up and blood taken for full blood count, C-reactive protein, grouping and saving serum, and serum beta human chorionic gonadotrophin estimation, and a pelvic ultrasound scan was arranged.

The need for hospital admission was explained to complete the investigations and initiate appropriate management. She was also prescribed a course of antibiotics and analgesics.

The specimen, which was in the early stage of decay, was inspected and found to be offensive. It was sent in formalin to the histopathology department for histology.

The patient refused admission into the gynaecological ward and also a transvaginal ultrasound scan which had been arranged. She signed the discharge against medical advice form in spite of advice to the contrary.

Further inquiry of her GP confirmed that she had had treatment for depressive illness in the past and has changed her GP frequently, making it difficult to arrange effective follow-up. The GP promised to a range psychiatric assessment as soon as practicable.

It was not known at this stage that she was not actually having a miscarriage and that the purported products of conception were in fact chicken giblets.
Multiple cranial nerve palsies as a result of perineural invasion by squamous cell carcinoma
Authors: Chan Weng Onn , Madge Simon , Dodd Thomas J , Higgs Braden , Davis Garry
Published: May 2014

A 70-year-old man presented with a 1-month history of right-sided proptosis, ptosis and intermittent dull ache of the right temple. Three years before, a squamous cell carcinoma had been removed from his right temple at another hospital; excision had been initially incomplete, requiring three further operations over 8 months. Two days after the last operation, he developed a right facial palsy, initially thought to be Bell's palsy and managed with prednisone with no effect. His right forehead, cheek and upper lip had also felt numb since around this time. Five months later, he lost hearing in his right ear and reported some loss of balance but no vertigo. Six months later, he lost sight in his right eye secondary to exposure keratopathy; an upper lid gold weight was inserted and right-sided temporalis transfer performed.

Examination revealed a complete right ptosis and 4 mm of proptosis with restricted extraocular movements in all directions. There was a right lower motor neurone facial palsy, reduced sensation in the distribution of the 1st and 2nd division of the trigeminal nerve and sensorineural hearing loss in the right ear. His right cornea was completely vascularized with a visual acuity of counting fingers. There was no relative afferent pupillary defect. No lymphadenopathy was detected. His imaging and histology results are shown in Figures 1 and 2. As a result of these findings, palliative radiotherapy was administered.
Ultrasound in breast imaging
Authors: Lloyd Claire , Hart Dr , Niewiarowski Sylwia , Lim Adrian , Harvey Chris , Cosgrove David
Published: May 2014

Recent developments in the surgical and oncological management of breast cancer and the understanding of the complex genetic basis of the disease have been paralleled by advances in breast imaging. Breast ultrasound (US) has a key role in the assessment of breast disease, together with mammography, clinical examination and needle biopsy.
Flexible cystoscopy: a revolution in urological practice
Authors: Pillai Praveen L , Sooriakumaran Prasanna
Published: May 2014

Flexible cystoscopy has revolutionized the field of diagnostic urology. It can be done under local anaesthesia in the outpatient setting and is thus a highly useful tool. Its role in therapeutic urology is more limited but it still has a place in the management of certain conditions.
The anatomy, diagnosis and pathology of femoroacetabular impingement
Authors: Stafford Giles , Witt Johan
Published: May 2014

Femoroacetabular impingement is a significant cause of osteoarthritis in young active individuals, whose prognosis is directly and positively influenced by early intervention to prevent irreversible joint damage. This article discusses the anatomy, examination findings, radiological features and natural history of the condition.
Cocaine ‘body packers’ and the clinical management of packet rupture
Authors: Peake Simon TC , Das Saroj , Greene Shaun , Dubrey Simon W
Published: May 2014

A 43-year-old Afro-Caribbean man was behaving oddly in the arrivals lounge at London Heathrow Airport. He was agitated, sweating profusely and disorientated. Urinalysis was positive for cocaine, and he was transferred to the local accident and emergency department.

On arrival, he was hyperactive, tachycardic (rate 140/min), hypertensive (blood pressure 235/140 mmHg) and agitated. A plain abdominal radiograph identified multiple, well-defined objects throughout the gastrointestinal tract (Figure 1) with no evidence of bowel obstruction.

Whole bowel irrigation with polyethylene glycol (2 litres/hour orally) was started. The patient remained agitated and hypertensive despite aggressive medical treatment for cocaine toxicity using intravenous diazepam (total 45 mg intravenously over 2 hours) and glyceryl trinitrate (maximum infusion rate 8 mg/hr).

Following surgical consultation, it was decided to perform a laparotomy (Figures 2a and b). In total, 89 packets of cocaine were surgically removed from the stomach, small and large bowel (Figure 2c), with an estimated street value of £50 000–100 000 depending on purity. Postoperatively the patient made an uneventful recovery.
Supervision
Authors: Halpern Helen , McKimm Judy
Published: May 2014

Supervision has been defined in many ways, but is essentially a conversation between professionals aimed at promoting learning, reflective practice and improving patient safety and the quality of patient care.
Psychotic mania induced by the withdrawal of pegylated interferon and ribavirin treatment
Authors: Ganeshalingam Y , Suleman S , Francis M
Published: May 2014

Mr R was a 45-year-old man who had been diagnosed with hepatitis C, genotype 3a. He was commenced on a 16-week course of pegylated interferon-α2a 180 μg per week and ribavirin 400 mg twice daily. He was otherwise healthy and had recently completed the Boston marathon. During treatment the only complaints Mr R made were of sleep disturbance and weight loss as a result of reduced appetite which are recognized side effects of the treatment.

Six days after completion of his treatment Mr R was picked up in the street by the police following several complaints from members of public. He was seen trying to damage parked cars and shouting repeatedly that he was God. He was agitated and had to be handcuffed by the police who escorted him to hospital. A physical examination was unremarkable except for a raised pulse rate of 120 beats per minute. There was no significant abnormality in his blood test results.

He was placed on Section 2 of the Mental Health Act for assessment of a suspected mental illness. Mr R had neither a past psychiatric history nor any past family psychiatric history. On admission to the psychiatric ward he believed that he was being followed on CCTV and made sexually inappropriate comments to staff. As he continued to be highly agitated olanzapine 10 mg intramuscularly was administered. Over the next day Mr R remained elated in mood and irritable with paranoid thoughts. Mr R did not require further emergency intramuscular medications as he gradually became calmer and more cooperative.

Three days after admission his mental state and behaviour began to show significant improvement. He had wished not to take oral olanzapine that was prescribed and hence no psychotropic medications were used following the initial olanzapine dose on admission. Mr R said that he had no recollection of being brought in by the police or his psychotic behaviour. He and his family denied that alcohol or illicit drugs had been used. He did recall that his sleep had been very poor, a common feature in mania, in the days before his admission. A computed tomography scan of his head was normal.

Seven days after admission he was visited by his family and allowed leave off the ward as there were no remaining psychotic or manic symptoms. He was later discharged from the ward after uneventful leave at home and remained well 6 months on.
Frozen shoulder: a clinical review
Authors: Loveday DT , Johnston P , Arthur A , Tytherleigh-Strong GM
Published: May 2014

Frozen shoulder is a common condition which can cause considerable morbidity for a prolonged duration. With recognition of the condition's time scale, management can be directed to help reduce the morbidity. Many treatments are recognized and the gold standard is still to be identified.
Workplace-based assessment
Authors: Swanwick Tim , Chana Nav
Published: May 2014

Workplace-based assessment is now widespread throughout medicine. If carried out well, such assessments reconnect teaching and testing to the benefit of the learner. But workplace-based assessment brings a unique set of challenges to medical education and requires fresh thinking about how we consider and construct assessment programmes.
Job planning for consultant trainers
Authors: Black David
Published: May 2014

Effective and transparent job planning for consultant trainers is essential to ensure that there is adequate time to develop trainees. This article sets out the negotiated job planning arrangements that have been implemented in one deanery.
Mittelschmerz mimicking appendicitis
Authors: Durai Rajaraman , Ng Philip CH
Published: May 2014

Mittelschmerz is midcycle abdominal pain related to ovulation (Charlewood, 1958). It happens in 20% of females in the fertile age group, and typically occurs at the site of the ovaries on the side where the ova is released (Krohn, 1949). The exact cause of pain is still debated but it may have some link with the release of serosanguinous fluid causing peritoneal irritation.
Fornix damage from solitary subependymal giant cell astrocytoma causing postoperative amnesic syndrome
Authors: Ibrahim I , Young CA , Larner AJ
Published: May 2014

A 24-year-old right-handed woman with well-controlled insulin-dependent diabetes mellitus presented with a 1-week history of vomiting. She also gave a 1-year history of intermittent generalized headaches without obvious features of raised intracranial pressure. Neurological examination was normal. Structural brain imaging showed hydrocephalus secondary to an intraventricular heterogeneous mass lesion which compressed the left frontal horn (Figure 1) but without any brain parenchymal lesions or signal change. At operation, tumour was found to have invaded the left fornix but spared the thalamus and caudate nucleus. Histologically the lesion was moderately cellular with both ganglionic and astrocytic type cells, without evidence of mitosis or necrosis; appearances consistent with a subependymal giant cell astrocytoma. Neither the patient nor her family had any history of cutaneous stigmata of tuberous sclerosis.

Postoperatively, it became apparent to care staff that the patient had short-term memory problems, repeatedly asking the same question and needing to be reminded about activities to perform. Minimental state examination (MMSE) 2 weeks postoperatively was 14/30. This rose to 24/30 by 10 weeks, and on the Addenbrooke's Cognitive Examination-Revised (ACE-R; Larner, 2007), a more detailed bedside test of cognitive function, she scored 75/100 (Table 1), with evidence of impaired delayed recall for verbal material (ACE-R memory subscore 17/26), and also for visual material (ad hoc object recall test 0/10), with recognition better than recall. There was impaired verbal fluency for both letter and category (ACE-R fluency subscore 3/14).

Reassessed 9 months later, almost 1 year after tumour excision, the patient and her family noted continuing subjective improvement in memory but she needed external memory aids to remind herself of appointments, and remained vague about happenings in the year before her surgery, suggesting some possible retrograde memory impairment. She was now at ceiling on the MMSE (30/30) and on ACE-R scored 88/100 (Table 1) with improved delayed recall for verbal material (ACE-R memory subscore 21/26) and visual material (ad hoc object recall test 4/10). Verbal fluency for letter and category was also improved (ACE-R fluency subscore 8/14).
Depression in elderly inpatients: are we doing enough?
Authors: Hall Jocelin I , Furmedge Daniel S
Published: May 2014

As medical students, we are often informed that we are the ‘best people’ to talk to elderly inpatients, because we have the time to listen to their stories without the looming spectre of other never-ending ward jobs. We are told to make the most of this opportunity, as it is a luxury that will not be afforded to us come qualification.
The emergency airway
Authors: Goon Serena SH , Stephens Robert CM , Smith Helen
Published: May 2014

The ‘can't intubate, can't ventilate’ scenario is a nightmare for all clinicians who manage airways. Cricothyroidotomy is one of several emergency airway management techniques. Cricothyroidotomy is a short-term solution which provides oxygenation, not ventilation, and is not a definitive airway.
The attributes of a good medical trainee: how to build your portfolio
Authors: Shalhoub Joseph , Sikkel Markus B
Published: May 2014

Never before have medical trainees been asked to select a specialty at such an early stage in their careers. It has therefore become imperative that both medical students and junior doctors are wise to the competition they will face. They should aim to develop a medical portfolio that will provide the evidence required to excel, both at the application form and interview stages of the selection process.
Orbital cellulitis: assessment and management
Authors: Fincham Gregory , Bhutta Mahmood F
Published: May 2014

Orbital cellulitis is an infection of the orbital soft tissue contents. It is a potentially sight-threatening condition, associated with intracranial complications. Accurate assessment and prompt specialist referral for appropriate medical and possible surgical management is essential in avoiding complications.
A shift in the life of a medical student working as a health-care assistant
Authors: Ahmad Ahmir
Published: May 2014

Despite having been on the wards for over a year as a medical student, I realized that I knew very little about the work of nurses. This prompted me to work as a healthcare assistant. This article describes some of my thoughts from this experience.
Extending palliative care to patients with Parkinson's disease
Authors: Wilcox Sarah K
Published: May 2014

Patients with Parkinson's disease have an illness which shortens their life and involves a heavy symptom burden for patient and carer. This article discusses some common palliative care issues pertinent to patients with Parkinson's disease.
Amyloid heart disease
Authors: Dubrey Simon W , Falk Rodney H
Published: May 2014

Heart involvement can have devastating consequences. The clinical consequences will depend on the type of amyloid, the extent of systemic involvement and treatment options. Patients in whom disease recognition is late have poor outcomes, because of the severity of cardiac compromise and the necessarily aggressive treatments.
Anaesthesia for the bleeding tonsil
Authors: Pushpanathan E , Sultan N , Sultan P
Published: May 2014

Tonsillectomy is a common procedure, with over 50 000 operations performed annually in the UK (Royal College of Surgeons of England, 2005). Just over half of these patients are under 15 years of age. Postoperative complications of a tonsillectomy include dysphagia, nausea and vomiting, pain, infection and bleeding.
Arnold-Chiari malformation
Authors: Durai Rajaraman , Fernandes Carl , Ng Philip CH
Published: May 2014

A 65-year-old man, with a past medical history of appendicectomy and bowel resection for volvulus, presented with a 2-day history of acute abdominal pain. The patient was diagnosed as having small bowel obstruction secondary to adhesion which did not settle with conservative management. He required a laparotomy, adhesiolysis and resection of 2 inches of small bowel. Five days after his laparotomy, he suffered a brief episode of loss of consciousness, so a computed tomography scan and subsequent magnetic resonance imaging scan of the head were performed.
Novel H1N1 influenza and Panton-Valentine leukocidin Staphylococcus aureus necrotizing pneumonia
Authors: Barrett NA , Armstrong-James D , Edgeworth J , Wyncoll D
Published: May 2014

A 17-year-old man with no significant medical history and no prodromal symptoms presented to the emergency department with a 2-day history of left-sided pleuritic chest pain and a dry cough. His respiratory rate was 16 breaths/minute, pulse 125 beats/minute, blood pressure 113/73 mmHg, temperature 36.6°C and oxygen saturation 93% (fraction of inspired oxygen 0.21). His peripheral blood white blood cell count was 23.1x109/litre and C-reactive protein was 520 mg/litre. Legionella and pneumococcal urinary antigen tests were negative. A chest radiograph (Figure 1) demonstrated rounded consolidation behind the heart. He was admitted for oxygen, clarithromycin and co-amoxiclav therapy.

Over 24 hours he became productive of purulent sputum and had a single pyrexial episode at 39.5°C. On the third day he rapidly deteriorated requiring transfer to the intensive therapy unit, where he progressed from conventional mechanical ventilation to high-frequency oscillatory ventilation within hours. His chest radiograph (Figure 2) demonstrated widespread bilateral infiltrates. He was resuscitated and received drotrecogin alfa, according to Surviving Sepsis guidelines (Dellinger et al, 2008), as he did not have haemoptysis. He developed multiple organ failure requiring haemodynamic and renal support. Empiric oseltamivir was commenced and a nasal mucosal swab tested by novel H1N1 influenza real-time reverse transcriptase polymerase chain reaction was positive. Admission blood cultures were sterile, but a sputum sample taken after one dose of co-amoxiclav grew methicillin-sensitive Staphylococcus aureus. All subsequent sputum cultures that day and while in the intensive therapy unit were negative.

A working diagnosis of co-infection with novel H1N1 influenza and Panton-Valentine leukocidinproducing S. aureus was made. Linezolid, clindamycin and intravenous immunoglobin were commenced with reference to Health Protection Authority (2008) guidance. Presence of the Panton-Valentine leukocidin (lukS-PV/lukF-PV) gene from the S. aureus isolate was confirmed by polymerase chain reaction at the Health Protection Authority Staphylococcal Reference Laboratory. His multiple organ failure resolved and he was converted back to conventional ventilation after 2 weeks of high-frequency oscillatory ventilation. Significant hospital and community contacts were screened for Panton-Valentine leukocidin-producing S. aureus and offered prophylaxis and/or advice on novel H1N1 influenza exposure. No evidence of nosocomial or inter-familial transmission of either pathogen was found.
Guillain–Barré syndrome: a review
Authors: Dua Kanika , Banerjee Arnab
Published: May 2014

Guillain–Barré syndrome is an autoimmune disease which is a common cause of acute neuromuscular paralysis and should be suspected in all patients with unexplained motor weakness. Specific management strategies are more effective if given early in the course of the disease.
The Limberg flap in sacrococcygeal pilonidal sinus disease
Authors: Shetty Rajesh , Payne Richard
Published: May 2014

Pilonidal sinus disease can sometimes pose a surgical challenge because of prolonged wound healing problems and recurrence rates. This article describes a simple transposition flap which can be used for pilonidal sinus disease by general surgeons with good results.
Surgical education: the new curriculum and training in the UK
Authors: John Ajo K
Published: May 2014

Surgical education in the UK has been changing in the past two decades, as a result of the Calman reforms and Modernising Medical Careers. The surgical curriculum has been planned to promote global competence development and based on modern concepts of adult learning.
Involving patients in clinical education
Authors: McKimm Judy
Published: May 2014

The interdependent relationship between the clinical teacher, the learner and the patient is a vital part of clinical education. Changing health services and patient expectations have stimulated the need for teachers to consider patients' rights and needs as active participants and partners in clinical teaching.
So you want to be … a cardiac surgeon
Authors: Westaby Stephen
Published: May 2014

Cardiac surgery emerged as a specialty in the 1950s following the development of diagnostic angiography, the heart–lung machine and cardioplegic solutions to provide reversible cardiac standstill. Bioengineering laboratories contributed prosthetic heart valves, vascular grafts, pacemakers and artificial hearts. Many of the great pioneers had the courage to fail: deaths were frequent and regarded as inevitable. This gradually changed throughout the 1980s with improved cardiopulmonary bypass technology, blood conservation techniques and critical care (Westaby, 1997). Publication of cardiac surgical outcomes in the USA (Burack et al, 1999) and the Bristol Inquiry in 2001 then changed the landscape irreversibly.
So you want to be … a child and adolescent psychiatrist
Authors: Ather Muhammad , Salmon Gill
Published: May 2014

Child and adolescent psychiatry specializes in the study, diagnosis, prevention and treatment of psychopathological disorders of children, adolescents, and their families.
Radiology of acute pelvic injuries
Authors: Kiu AKC , Khan SHM
Published: May 2014

Pelvic girdle injuries are usually sustained in road traffic accidents or falls from height. These are associated with significant morbidity and mortality despite constituting a small percentage of all skeletal injuries, as a result of the soft tissue injuries within the pelvis which involves the pelvic vessels, nerves and urinary tract.
Discharge summaries: a guide for foundation doctors
Authors: Simpson A , Lakkol S , Alnaib M
Published: May 2014

Junior doctors have many responsibilities, including attending ward rounds, organizing investigations, assessing patients and creating discharge summaries. Many of the skills needed are learnt during final year medical school placements. However, discharge summary technique is not always well demonstrated to students, and this can lead to confusion and inefficient use of time when faced with multiple patients to discharge for the first time. This article outlines key areas which need to be addressed.
The role of multi-detector computed tomography in imaging hernias
Authors: Laurence Isabel , Ngan-Soo Eleanor , Gandhi Sanjay
Published: May 2014

Clinical presentation of a hernia is often non-specific or atypical and in these circumstances diagnosis and management decisions can be aided by imaging. This review contains diagrammatic illustrations, explanations and computed tomography examples of the different types of external, internal and diaphragmatic hernias.
Improved diagnostic procedures in attenuated mucopolysaccharidosis
Authors: Hendriksz Dr Chris
Published: May 2014

General physicians and rheumatologists play a key role in suspecting a diagnosis of mucopolysaccharidosis for a range of multi-organ presenting symptoms in adults. Prompt diagnosis and treatment maximizes outcomes for these rare and extremely debilitating diseases. Earlier diagnosis may help to prevent irreversible disease.
The whole child with developmental disorders
Authors: Kirby Amanda , Thomas Marie
Published: May 2014

Developmental disorders commonly overlap and, rather than being discrete conditions, are on a continuum. Given the evidence for this it is proposed that clinical services need to develop integrated approaches and pathways, working with education as this has potentially positive time, cost and quality outcomes.
Exercise and the patient with chronic kidney disease
Authors: Stride Matthew
Published: May 2014

For patients with chronic kidney disease, the importance of regular physical activity should not be overlooked. The case is put forward that physical activity promotion and exercise prescription should become an integral part of the care of these patients, especially those requiring haemodialysis.
Diagnosis and management of necrotizing fasciitis
Authors: Hunter John , Quarterman Clare , Waseem Mohammed , Wills Alan
Published: May 2014

Necrotizing fasciitis is a rapidly progressive, life-threatening soft tissue infection which is rapidly fatal unless diagnosed promptly and treated with immediate debridement of necrotic tissue. As early clinical suspicion is paramount to improved survival, this review aims to increase awareness of the condition.
Preventing acute kidney injury: identifying risk and reducing injury
Authors: Hoefield R , Power A , Williams N , Lewington AJP
Published: May 2014

There is currently no specific pharmacological therapy for acute kidney injury. This article describes how to identify patients at risk of acute kidney injury and what measures can be implemented to reduce the risk.
How to self train in basic laparoscopic skills
Authors: Sharma Mitesh , Horgan Alan
Published: May 2014

Training in laparoscopic skills has a long learning curve and requires regular practise. It is vital that surgical trainees start training in basic laparoscopic skills early in their career. Time-restricted training and patient safety has lead to the development of training models to learn these skills outside the operating room. This article provides a framework for and practical solutions to home-based laparoscopic training.
The MAGICC and practical approach to rheumatology transition
Authors: Tattersall Rachel S , McMahon Anne-Marie
Published: May 2014

This article describes the inception and continuing evolution of a seamless adolescent rheumatology service across a children's and adult hospital. This service is still a work in progress but its principles are embedded in the MAGICC approach: Moving on in adolescence, Growing up In Collaboration and Coping.
Juvenile idiopathic arthritis: in adolescence and beyond
Authors: Fisher Corinne , Sen Debajit
Published: May 2014

Juvenile idiopathic arthritis differs markedly from adult rheumatoid arthritis. It encompasses all childhood arthritis of unknown cause, representing a group of diseases with a wide variety of clinical manifestations andoutcomes. Many patients will suffer active disease and complications into adulthood.
The future training of surgeons to manage patients with cleft lip and palate disorders
Authors: Drake-Lee Adrian , Sandhu Davinder
Published: May 2014

Senior surgical fellowships have developed in an ad hoc way. To combat this, the four surgical colleges working with a lead deanery have instituted structured training to cover the more advanced tuition required to practice surgery at a higher level in several areas. Ideally all surgeons treating cleft lip and palate patients should be trained this way to ensure an adequate standard is met. This article explores the issues around this.
Exertional heat stroke
Authors: Adams Tom , Stacey Ese , Stacey Simon , Martin Daniel
Published: May 2014

Exertional heat stroke is a potentially lethal condition that can occur in otherwise healthy individuals participating in endurance exercise. Its recognition in the field and effective, prompt treatment by active cooling is essential if mortality and permanent neurological morbidity is to be avoided.
Hair loss in hospital medicine: a practical guide
Authors: Macbeth Abby , Harries Matthew
Published: May 2014

Alopecia may indicate underlying systemic disease and is associated with significant impairment of quality of life. A thorough history and examination, including specialist techniques, can give vital clues to the aetiology. This article provides an overview of the common and important hair loss disorders for the busy clinician.
Management of open fractures of the lower limb
Authors: Ali Adam M , Noyes David , Cogswell Lucy K
Published: May 2014

This article gives a practical guide for the management of open lower limb fractures. It outlines the referral criteria and pathway for definitive care in a specialist centre, the initial management steps that should be taken in the emergency department, and the principles of fixation, soft tissue coverage and antibiotic therapy.
Flashes, floaters and fuzz
Authors: Nagendran Sonali T , Thomas Dhanes , Gurbaxani Avinash
Published: May 2014

Flashing lights (photopsia) and floaters are common visual phenomena and patients frequently present to hospital with these symptoms. This article provides a guide for the non-specialist to the different pathologies that may result in photopsia and floaters.
Takotsubo cardiomyopathy
Authors: Morley-Smith Andrew C , Lyon Alexander R , Omerovic Elmir
Published: May 2014

How can an earthquake cause cardiogenic shock? Can a bereft lover really die from a broken heart? Takotsubo cardiomyopathy is an intriguing reversible condition which still mystifies and excites the layman and physician alike. This article explores the clinical essentials for recognizing and managing this group of complex patients.
Insulin: standard therapy following oral hypoglycaemic failure in type 2 diabetes?
Authors: English Patrick
Published: May 2014

The cost burden of managing type 2 diabetes and its complications could overwhelm the NHS in the next 20 years. The available therapies should be used wisely to conserve resource and maintain health. This article outlines a strategy for use of the available treatments.
Documenting informed consent in elective hip replacement surgery: a simple change in practice
Authors: Isherwood Jennifer , Dean Benjamin , Pandit Hemant
Published: May 2014

Adequate documentation of informed consent is an important aspect of many doctors’ work and failings in this area may result in patient dissatisfaction or litigation. In 2009 the documentation of risks and complications on the consent forms of patients undergoing primary hip replacement was audited at a specialist centre. Following this audit procedure-specific complication stickers were introduced in an attempt to improve the documentation of the consent process. This article discusses the results of a re-audit and aims to determine if this change in practice had resulted in any significant improvement in documentation.

The consent forms of 100 consecutive patients undergoing primary total hip replacement were re-audited using a standardized data collection sheet in order to close the audit loop. The re-audit found that 86 consent forms used the procedure-specific complication sticker to list the potential complications associated with a total hip replacement. Statistically significant improvements in the documentation of fracture, neurovascular damage, leg length discrepancy, failure, premature loosening, death, medical complications, ongoing pain, stiffness, wound healing problems and other were all seen in the 2012 re-audit in comparison to the 2009 audit (P<0.0001).

The cheap and simple introduction of procedure-specific complication stickers in order to help surgeons document the process of informed consent has resulted in significant improvements in practice. In the context of patient-focused care and satisfaction in the NHS, it is vital that simple measures such as the introduction of procedure-specific complication stickers are embraced.
Managing trauma in the pregnant woman
Authors: Hayden Brigid , Plaat Felicity , Cox Charles
Published: May 2014

This article discusses the major causes of trauma in pregnancy and outlines management strategies. The resuscitation model of airway, breathing and circulation is emphasized, with modifications appropriate to the physiological changes in pregnancy and the needs of the fetus.
Expanding organ donation in the UK: ethical, moral and logistical dilemmas
Authors: Dave Rajiv , James Camilla , Ahmad Niaz
Published: May 2014

In the UK, three patients die every day waiting for an organ transplant. Despite there being 18.7 million donors currently registered in the UK, donation rates remain low. This review discusses the legal, ethical and social aspects of organ donation in the UK, and looks at some controversial solutions adopted in other countries.
Characterizing benign liver lesions and trauma with contrast-enhanced ultrasound
Authors: Wills Mark , Harvey Chris J , Kuzmich Siarhei , Afaq Asim , Lim Adrian , Cosgrove David
Published: May 2014

Microbubbles as an ultrasound contrast agent allow characterization of focal liver lesions. This article summarizes the ultrasound appearances and enhancement characteristics of benign liver lesions, focal fatty sparing and focal fatty change, and blunt liver trauma.
Traumatic pneumothorax: a review of current practices
Authors: Harrison Mark
Published: May 2014

Traumatic pneumothoraces are a common presentation to any emergency department. This article explores the evidence behind thoracostomy drain insertion, and the necessity for the procedure on all patients.
Slipped capital femoral epiphysis: a review
Authors: Sharma V , Oddy MJ
Published: May 2014

Slipped capital femoral epiphysis is an important hip condition that is steadily increasing in incidence. Clinicians and health-care workers who regularly work with children or adolescents need to be fully aware of its presenting features and diagnostic pathways to prevent a delay in diagnosis.
How to write a case report
Authors: Ghadiri-Sani M , Larner AJ
Published: May 2014

This article briefly looks at the reasons for, and mechanics of, writing case reports and case series for publication. The authors argue for the importance of this narrative form of medical knowledge in the development of clinical reasoning skills.
Persistent auditory hallucinations and treatment challenges
Authors: Pandarakalam James P
Published: May 2014

Despite improved neurotransmitter identification and emergence of novel antipsychotics, treatment of auditory hallucinatory experiences is frustrating. Interest has developed in non-pharmacological approaches to this problem – these do not eliminate the voices but reduce the distress associated with the experience.
Improving the outcome of acute stroke management
Authors: Hennerici Michael
Published: May 2014

Recent research into stroke mechanisms suggests that it may be possible to reduce mortality and improve functional outcome in stroke patients, provided clinicians act quickly and appropriately. In this article, standards for optimal stroke management with new therapeutic strategies aiming to restore cerebral blood flow and to protect brain neurons will be discussed.
The needle phobic obstetric patient
Authors: Rees SGO , Eltringham RJ , Ughovwa SA
Published: May 2014

A 22-year-old primagravida with grade IV placenta praevia (placenta completely covering cervical os) presented for elective caesarean section at 38 weeks' gestation. She suffered from severe needle phobia. The previous day a blood sample for cross-match had been obtained under significant duress but on the day of surgery she was adamant, despite counselling regarding the risks to herself and the fetus, that she would not tolerate another percutaneous needle puncture while awake. On examination she was very anxious, her peripheral veins were barely visible or palpable and her airway was unremarkable. As a precaution, topical local anaesthetic (EMLA) had been applied to the dorsum of her hands and her antecubital fossae.
Reproductive health in women with cystic fibrosis
Authors: Willett Mark J , Ellis Andrée G
Published: May 2014

The life expectancy of women with cystic fibrosis has doubled in the last 20 years. A major implication of this is the advent of previously unseen reproductive health problems. We review the management problems presented by these women throughout their reproductive lives, including pregnancy.
Evidence-based guidelines for early stroke management
Authors: Pushpangadan Majnu , Wright John , Young John
Published: May 2014

Stroke disease is the commonest neurological emergency encountered by the junior medical team. We have reviewed the literature to produce a series of substantiated guidelines to assist the admitting doctor in managing early stroke care optimally.
Professional competence in medicine
Authors: Southgate Lesley
Published: May 2014

Professional competence in medicine is under the microscope following a year of government and media attention directed at the performance of doctors and outcomes for patients. The ability of the profession to self-regulate has been questioned and the roles of the state, the universities, the Royal colleges and the postgraduate deans are shifting. This paper provides a context for considering these important changes.
Has surgical subspecialization gone too far?
Authors: Black John
Published: May 2014

Subspecialization is currently fashionable, but with present hospital organization, the need to cover emergencies and the lack of convincing evidence for its superiority, the tide is on the ebb and the place of the general surgeon is secure.
Specialist registrar training in obstetrics and gynaecology: have we got it wrong?
Authors: Wright Charles SW
Published: May 2014

The introduction of the Calman proposals for radical reform of the training of young doctors is now nearly 3 years past. Obstetrics and gynaecology was one of the first major specialties to go through the convulsions of transition and it has emerged on the other side well organized and in tune with the requirements of the reforms, but just how are they perceived by the trainees and trainers?
Confounded by confounding: separating association from causation
Authors: Davies Huw TO , Williams Fiona LR
Published: May 2014

Health-care professionals need to be able to distinguish causal relationships from simple associations in two main areas: when unravelling the aetiology of diseases, and when assessing the effects of therapies. In each of these the presence of confounding can seriously mislead. This short report explains the nature of confounding and outlines criteria that can be applied to help distinguish causality from mere statistical associations.
Aiding clinical decisions with decision analysis
Authors: Tavakoli Manouche , Davies Huw TO , Thomson Richard
Published: May 2014

As clinical decision making gets ever more complex, new analytical approaches are being developed to help. Decision analysis is used to structure complex decision problems in an uncertain environment by systematically linking decision choices with expected outcomes. Such models can include the probabilities of outcomes, patient preferences and costs. These models can help to advise about therapeutic avenues. This paper examines the nature of decision analysis, and explores the pitfalls that arise in interpreting the findings from published studies.
A shaggy dog story? A trichobezoar presenting with gastrointestinal perforation
Authors: Hargreaves Nicola J , Howman Elizabeth M
Published: May 2014

A 12-year-old Caucasian girl was admitted urgently with a 2-week history of intermittent left upper quadrant pain. The pain had worsened, radiated to the left shoulder blade and was eased with ibuprofen. There were no other associated symptoms and no history of trauma. A similar episode a year before had resolved spontaneously after several days.

On examination she looked well but was pyrexial (temperature 37.7°C). There was a firm, smooth, tender mass extending from the epigastrium to the umbilicus which was not indentable. There was no crepitus, bowel sounds were normal and there were no signs of peritonism.

There was a mild neutrophil leucocytosis but a full blood count and electrolytes were otherwise unremarkable. A chest radiograph suggested free gas under both hemi-diaphragms (Figure 1) with a large central soft tissue mass on the plain abdominal radiograph (Figure 2).

On ultrasound a gas-filled viscus obscured the epigastrium. Gastrograffin swallow characterized this as a dilated stomach with a large granular filling defect completely filling the body and antrum (Figure 3). There was no obvious ulceration and no gastrograffin leak into the peritoneum. These appearances were highly suggestive of a gastric bezoar.

A more detailed dietary history helped to elucidate the nature of the bezoar. Until 2 years previously the family had kept a German shepherd dog and the patient had eaten its hair for most of her childhood. There were no other unusual dietary habits or behavioural problems.

Laparotomy and gastrotomy of the dilated stomach delivered a large trichobezoar, cast in the shape of the stomach (Figure 4). There was a 2 cm sealed perforation of benign appearance on the upper greater curve of the stomach, consistent with a pressure ulcer. The patient made an uneventful postoperative recovery.
Clinical governance: an educational perspective
Authors: Hill Peter
Published: May 2014

Clinical governance is a novel concept with potentially profound implications for the practice of medicine in the next millennium. What the term might mean from the perspective of patients, and doctors in the health service of the future is explored in this article. All this has significant educational implications and these are considered.
Inflammatory pseudotumour of the liver: a rare complication of diverticulitis?
Authors: Coleman Mark , Rees Myrddin
Published: May 2014

Despite advances in radiological imaging, space-occupying lesions of the liver occasionally defy all attempts at pre-surgical diagnosis. We present a case of a rare inflammatory pseudotumour of the liver.
Movicol in treatment of constipation and faecal impaction
Authors: Ungar Alex
Published: May 2014

To resolve severe constipation or faecal impaction requires the induction of a large increase in faecal water content that hitherto has only been achieved with enemas. A novel iso-osmotic laxative has been shown to achieve a similar effect from oral dosing.