bluuebunny/crossref_metadata_2025 huggingface dataset:
Mesenteric ischaemia and peptic ulcers
Authors: Mallinson RH
Published: May 2014

Apreviously well 66-year-old man, a lifelong non-smoker, presented with left-sided abdominal pain and diarrhoea of 7 days duration. He was admitted with a haematemesis and melaena while taking aspirin. On admission his haemoglobin was 15.2 g/dl. Gastroduodenoscopy showed a large gastric ulcer on the lesser curve, with a clot adherent to the base, which was injected with 5 ml of adrenaline 1:10 000 to achieve haemostasis. A CLO test obtained from the gastric antrum showed no evidence of Helicobacter pylori infection. The patient complained of severe constant abdominal pain radiating to his back while taking lansoprazole 30 mg once daily. After 1 week repeat endoscopy showed multiple ulcers in the oesophagus, stomach and duodenum, which were irregular with sloping edges and white sclerotic bases. No biopsies were taken from the ulcers. A computed tomography contrast examination of the abdomen showed an irregular aorta narrowed by atheroma (Figure 1) and normal-looking bowel with no apparent visceral abnormalities. An angiogram was not undertaken.

Ten days after presentation the patient developed an acute abdomen requiring a laparotomy at which necrotic small bowel was found. The upper third of the small bowel was resected. Histology showed the entire small bowel mesentery to be infiltrated with angiosarcoma. The patient died 4 days later. The post-mortem revealed non-healing ulcers and a 20×7×1.5 cm angiosarcoma within the aorta. The coeliac trunk was occluded and the superior mesenteric artery was partly blocked. There was positive immunohistochemical staining with factor VIII-RAg. There were splenic and renal infarcts. The left kidney was infiltrated with tumour.
A woman with tetraparesis and missed beats
Authors: Mak W , Lau CP
Published: May 2014

This patient presented with clinical features consistent with acute cervical myelopathy or Guillain–Barré syndrome but ventricular arrhythmias on the electrocardiogram alerted the authors to a possible toxic cause. The history of drug ingestion was then elucidated, indicating aconitine poisoning from herbal medicine. Aconitine-containing plants are the most frequently encountered herbal agents that cause serious toxicity in Hong Kong (Chan et al, 1993).
Medical treatment of gastro-oesophageal reflux disease
Authors: Jalal PK , Heatley RV
Published: May 2014

Gastro-oesophageal reflux disease is common and is a chronic recurring condition. In view of our improved knowledge about the pathogenesis and complications of gastro-oesophageal reflux, the therapy should be individualized and a cost-effective approach should be attempted in its management.
Renagel®: reducing serum phosphorus in haemodialysis patients
Authors: Burke Steven K
Published: May 2014

Approximately half of all dialysis patients experience persistent hyperphosphataemia, which causes significant problems. Renagel® is a calcium-free, aluminium-free phosphate binder which reduces serum phosphorus in haemodialysis patients by reducing absorption of dietary phosphorus. This article reviews the management of hyperphosphataemia and presents some Renagel® clinical trial data.
Irreversible aromatase inactivation: treatment for breast cancer
Authors: Johnston Stephen RD
Published: May 2014

Third-generation aromatase inhibitors extend treatment options for postmenopausal breast cancer patients refractory to initial antioestrogen therapy. This article reviews advances and recent developments in hormonal therapy, focusing in particular on exemestane, a new class of aromatase inactivator.
Recurrent postdural puncture headache
Authors: Kelly Brendan , McDonnell Conor
Published: May 2014

A14-year-old female presented with a 3-day history of generalized headache, photophobia, neck stiffness and nausea. She had no history of neurological illness or trauma. Clinical examination was normal. Complete blood count, serum urea and creatinine, urine culture and throat swab culture were normal. Dural puncture was carried out under aseptic technique. A 22-gauge Sprotte spinal needle was inserted between the third and fourth lumbar vertebrae, and thirty drops of clear cerebrospinal fluid were removed. Laboratory examination of the fluid was normal, and the patient was treated with analgesics. The headache improved, but did not resolve completely.

She was discharged the following day, but presented 4 weeks later, with a severe, intermittent frontotemporal headache. It was associated with nausea, aggravated by changing posture, and transiently relieved by abdominal pressure. Postdural puncture headache was diagnosed, and a blood patch relieved her symptoms completely.

Four weeks later, she presented with a recurrence of headache. A second blood patch relieved her symptoms again. Four weeks later, she presented again with a recurrence of headache. Computed tomography of brain and magnetic resonance imaging of lumbar spine were normal. She was treated with amitriptyline and carbamazepine. Symptoms improved, and her pain-free intervals became longer. Three months after the dural puncture she still had headache.
Laser revascularization in the management of coronary artery disease
Authors: Clarke SC , Schofield PM
Published: May 2014

In recent years, laser therapy has been evaluated for the treatment of patients with angina who have coronary artery disease which is not amenable to conventional revascularization techniques. The results of transmyocardial revascularization and percutaneous myocardial revascularization are reviewed.
How to write a book
Authors: Kirby Roger S
Published: May 2014

Doctors write books primarily to gain recognition from their peers and credibility with their patients. The key steps involve careful planning of the project, finding the right publisher, ensuring the text is completed on time, and scrupulous checking of the proofs. The end product should be something of which the author is justifiably proud.
Neurosurgery and facial pain
Authors: Eldridge PR
Published: May 2014

This article reviews the diagnosis, differential diagnosis and management of trigeminal neuralgia, the commonest facial pain condition treated by the neurosurgeon. The advantages offered by microvascular decompression as a treatment are reviewed and compared with medical treatment and percutaneous techniques.
Keeping the coronary arteries open: current opportunities
Authors: Gershlick AH
Published: May 2014

Thrombolysis has reduced mortality from myocardial infarction, but effective opening of the artery with normal flow continues to be an important goal. Thrombolysis is not always as successful as it should be; alternatives include adjunctive therapy and mechanical opening of the arteries. In patients with acute coronary occlusion opening the artery should continue to be the primary aim.
Starting a research post: some considerations for ward-based doctors
Authors: Turner Martin R
Published: May 2014

Starting a research post after ward-based work can be a leap of faith and, as rewarding as it ultimately is, the initial transition can be a difficult one. This article addresses some of the questions which someone considering research should ask.
A solitary pulmonary cystic mass resulting from hydatid disease mimicking a pericardial cyst
Authors: Kothari P , Aly H Safar , Makker HK
Published: May 2014

A 28-year-old male, who was a non-smoker, presented to the accident and emergency department with right anterior sharp chest pain of 2 days' duration, which was worse on swallowing, lying on his right side and deep inspiration. He had had similar pains, but milder in intensity, for the previous 8 weeks. He gave a history of cough with sputum and a single episode of haemoptysis following a flu-like illness. He had no associated breathlessness, wheeze, indigestion or heartburn. There was no history of trauma to the chest. He was an office worker and lived in London all his life except for holidays on a farm in Ireland during childhood and a recent foreign trip to New Guinea.

He was in pain but had no pallor, clubbing, cyanosis or enlargement of neck lymph nodes. His pulse was regular with a rate of 90/minute, his blood pressure was 130/70 mmHg and his jugular venous pressure was not raised. Cardiac, respiratory and abdomen examination revealed no abnormality. Haemoglobin, white cell count, differential count, platelets, erythrocyte sedimentation rate, urea and electrolytes, and liver function tests were normal. An electrocardiogram showed normal sinus rhythm. A chest radiograph showed a large, round, smooth mass of 7 cm in diameter in the right mid and lower zone adjacent to the right cardiac border (Figure 1). On a computed tomography (CT) scan of the chest, this was seen to be a smooth-walled cyst, containing fluid of water density attenuation (Figure 2). It extended from the right hilum to the anterior chest wall, causing compression of the right middle lobe bronchus and partial collapse of the right middle lobe. A CT and ultrasound scan of the liver showed no similar cysts. The appearance of the cyst was thought to be characteristic of a pericardial cyst. The possibility of hydatid disease was considered. However, hydatid serology (Echinococcus antibodies) was negative (titre 1<16).

In view of the symptomatic nature of the cyst causing chest pain and partial collapse of the right middle lobe, the patient was referred for surgical removal of the cyst. During the operation, a large cystic mass was seen in the right chest, outside the pericardium, displacing and compressing the right middle lobe. The cyst was excised intact with its capsule together with the right middle lobe. The gross appearance of the cyst was thought be consistent with that of a pericardial cyst (Figure 3). However, histological examination of the cyst showed active hydatid with viable germinal membrane and scolices. The patient was given praziquantel 50 mg/kg/day plus albendazole 400 mg twice daily for 7 days to treat any remaining fragments of the hydatid cyst postoperatively. He received further treatment with albendazole 400 mg twice daily for a total of 12 weeks (three 4-week courses with two 2-week breaks) to maximize the chances of eradication.
Multilocated hydatid cysts involving the liver, the spleen and the scapula
Authors: Theodorou Daphne J , Theodorou Stavroula J , Kakitsubata Yousuke
Published: May 2014

A 75-year-old healthy woman presented with mild, right hypochondral discomfort and heaviness present for at least 2 days before admission to the hospital. She also complained of pain in the region of her left shoulder, which was moderate in nature and of approximately 1 year's duration. Shoulder pain had led to the limited use of her left arm. The patient had a history of intimate contact with sheep and dogs. Clinical examination revealed a tender, enlarged liver (5 cm below the right costal margin), as well as a tender scapula on palpation. Laboratory tests showed the white blood cell count to be 7000/mm3 with 8% eosinophils. The erythrocyte sedimentation rate was 30 mm per hour. Serological tests for Echinococcus granulosus, which included immunoelectrophoresis and indirect immunohaemagglutination assay, were strongly positive (IHA 1/800).

A plain abdominal radiograph showed the enlarged hepatic shadow and a curvilinear calcification lying within it (Figure 1). An ultrasound study was then performed to further characterize the lesion. A hyperechoic band located in the right lobe of the liver associated with an acoustical shadow representing dense calcification was found (Figure 2). Two roundish, hypoechoic areas located in the enlarged spleen were found incidentally during the ultrasound examination of the abdomen (Figure 3). The diagnosis of splenic hydatid disease was favoured because of the simultaneous presence of the cystic lesion in the liver. The roentgenographic examination of the left scapula showed multiple, variously sized, round or oval osteolytic lesions, giving a honeycomb appearance of the inferior part of the scapula (Figure 4).

On the basis of clinicoradiological features and laboratory findings a diagnosis of hydatid disease was proposed. A thorough clinical, radiological and ultrasonographic search did not reveal any other sites of hydatid cysts. The patient proceeded to surgery where she underwent local hepatic resection, splenectomy and local total excision with a wide healthy margin in the scapula. Histological examination of the material excised from the liver, the spleen and the scapula confirmed the diagnosis of hydatid disease. The patient made an uneventful postoperative recovery and was discharged 1 week later. Pain subsided totally following surgery. At follow-up examination 6 and 12 months later, the patient remained asymptomatic, and had no clinical or radiological evidence of the disease in the primary sites or elsewhere.
Lipogranulomatous adenopathy: a characteristic but under-recognized presentation of Whipple's disease
Authors: Turkington P , MacDonald A , Greenstone M
Published: May 2014

A50-year-old Caucasian male was admitted with a left popliteal vein thrombosis confirmed on Doppler ultrasound scanning. He was previously well and there was no obvious precipitating cause for his venous thrombosis. Apart from pallor and the swollen left calf there were no abnormal findings on routine examination and he was anticoagulated with heparin followed by warfarin.

Investigations revealed a hypochromic microcytic anaemia (haemoglobin 8.3 g) and a marginally raised serum alkaline phosphatase. Other investigations including a myeloma screen, autoimmune profile and neutrophil cytoplasmic antibodies were negative. An intra-abdominal malignancy was suspected although faecal occult bloods were negative on three occasions and tumour markers (carcinoembryonic antigen (CEA) and CA 19.9) were normal. Upper gastrointestinal endoscopy demonstrated mild gastritis and a normal-looking duodenum only. Computed tomographic (CT) scanning of the abdomen and thorax revealed massive retroperitoneal and retrocrural adenopathy extending down to the small intestinal mesentery (Figure 1). The abdominal viscera were otherwise normal and there was no mediastinal Iymphadenopathy.

Small bowel Iymphoma was suspected and he underwent first a laparoscopic biopsy of the mesenteric Iymph nodes and subsequently a laparotomy. There were no abnormal findings apart from the retroperitoneal Iymphadenopathy. On both occasions the histological appearances of the Iymph nodes were the same: the Iymph node architecture was destroyed by large lipid-containing spaces. There was also infiltration by numerous lipid containing macrophages, and occasional multinucleate giant cells (Figure 2). No cause for these changes could be recognized clinically or pathologically.

Three months after his initial presentation he developed weight loss, mild diarrhoea, vague abdominal pain and a rash on his legs. A systemic vasculitis was suspected but a skin biopsy showed non-specific changes only. However, 1 week later he died suddenly at home, apparently having been markedly dyspnoeic for the preceding 48 hours.

At postmortem he was found to have a severe constrictive pericarditis, which was felt to be the probable cause of his death. There was no evidence of pulmonary embolism. The liver showed congestive ‘nutmeg’ changes. There was evidence of a panserositis with inflammation of pericardium, pleura and peritoneum. Bowel histology was not performed because of autolysis. However, the histology of the mesenteric Iymph nodes was reviewed and on this occasion stained with periodic acid Schiff. This was taken up by bacilliary organisms in the macrophages found in the Iymph nodes. The features were considered diagnostic of Whipple's disease.
Empirical treatment of sepsis in neutropenic patients
Authors: Klastersky Jean
Published: May 2014

Mortality associated with febrile neutropenia has dramatically decreased over the last three decades; a pivotal role has been played by the concept of hospital-based empirical therapy with broad-spectrum combinations of antibiotics. Nevertheless, there is evidence that a subgroup of patients with febrile neutropenia might benefit from less aggressive treatments.
Cardiac troponin levels in patients with impaired renal function
Authors: Donaldson Alison , Cove-Smith Rodney
Published: May 2014

Cardiac troponins are important indicators of myocardial damage. Recent studies have shown that serum cardiac troponin levels are raised in at least 50% of patients with renal disease. The mechanisms and implications of these findings are discussed.
Childhood leukaemia: the medical cost of cure
Authors: Mardlin Philip , Chessells Judith M
Published: May 2014

More than 1 in every 1500 individuals in the UK between 16 and 44years of age has survived childhood cancer. This article describes the medical cost of cure in survivors of acute leukaemia, the most common form of childhood cancer.
Skills training using multimedia and models
Authors: Kneebone Roger L
Published: May 2014

All doctors need basic surgical skills. Learning and retaining such skills requires repeated practice. This article describes structured training provided by a multimedia computer program combined with practice on simulated tissue models.
The use of botulinum toxin in ophthalmology
Authors: Denniston Alastair , Reuser Tristan
Published: May 2014

As the diversity of clinical applications for the botulinum neurotoxin continues to grow, exciting developments are occurring in its use around the eye, where indeed its benefits were first recognized. These include use to treat strabismus, eyelid disorders and a number of other ocular conditions.
Overview of restless legs syndrome
Authors: Amar Khaled
Published: May 2014

Restless legs syndrome is a common movement and sleep disorder, which can significantly reduce quality of life. Restless legs syndrome is probably related to dopamine imbalance and may have a primary or secondary aetiology. It is greatly underdiagnosed, yet potentially treatable.
The surgical management of faecal incontinence
Authors: Francombe James , Carter Paul S , Hershman Michael J
Published: May 2014

The surgical management of faecal incontinence is complex and technically demanding. Surgery should only be offered once the aetiology has been correctly identified and the patient has been counselled regarding outcomes of success. This may only approach 80%, with long-term results declining with time.
Recent developments in the treatment of faecal incontinence
Authors: Carter Paul S , Francombe James , Hershman Michael J
Published: May 2014

Many patients with faecal incontinence can be cured using a simple anal sphincter repair. Some patients are unsuitable for this either because the sphincter is absent, too extensively damaged or anal sphincter repair has failed. In these patients novel treatments have been introduced to augment, replace and stimulate the anal sphincter.
Neuroimaging violence in the mentally ill: what can it tell us?
Authors: Das Mrigendra , Kumari Veena , Barkataki Ian , Sharma Tonmoy
Published: May 2014

Incidents of aggression and violence in severe mental disorders like psychosis, personality disorders and substance misuse disorders are higher than in the general population. Recent advances in neuroimaging techniques may help to predict violent behaviour in mentally ill individuals and to identify anomalies in brain functioning that may be amenable to treatment.
The abdominal radiograph: a pictorial review
Authors: Cook C , Campbell-Smith TA , Hopkins R
Published: May 2014

The plain abdominal radiograph is one of the most frequently requested X-ray examinations by junior surgical and accident and emergency staff. Interpretation is often difficult, but this review outlines normal appearances, suggests a strategy for evaluation, and covers the common pathological appearances seen in hospital practice.
Mullerian duct cyst: a case history and literature review
Authors: Kiberu SW , Haray PN , Ilott J
Published: May 2014

A mullerian duct cyst results from an abnormality of regression of the mullerian system (Yoshinori et al, 1999). The prostatic utricle is a homologue of the female uterus and is a caudal remnant of paramesonephric ducts (Morgan et al, 1979; Smith and Middleton, 1979).

Mullerian cysts usually present as small mid-line masses between rectum and bladder neck or prostate (Yoshinori et al, 1999). This article presents a case report.
Saline or Hartmann's solution: is it still a controversy?
Authors: Stephens Rob , Grocott Mike
Published: May 2014

Anaesthetists and other clinicians have long debated the relative merits of using Hartmann's (or lactated Ringer's) solution instead of normal saline during operations. Until recently there have only been case reports that have highlighted the possibility of a ‘dilutional acidosis’ occurring when saline was used to replace massive blood loss.
Eating problems in young children
Authors: Douglas Jo
Published: May 2014

Over the past 10 years, there has been increasing recognition of the importance of eating problems in young children. Paediatricians are now also recognizing the importance of managing this problem in the context of a wide range of medical disorders. Multidisciplinary assessment and treatment is essential to manage the wide variety of childhood eating problems.
Diagnosis and immediate care of fractures of the knee
Authors: Patel RV , Kucheria R , Haddad FS
Published: May 2014

In the UK the three commonest bony injuries around the knee are tibial plateau fractures, supracondylar and intercondylar fractures of the femur and patellar fractures. This review will summarize the initial management of these injuries and of rarer but significant more minor fractures that must not be missed. The review will concentrate on the injury to the knee, but every trauma patient must be assessed fully following advanced trauma life support guidelines.
What neuroimaging tells us about psychopathic disorders
Authors: Dolan Mairead
Published: May 2014

The concept of psychopathy and its neurobiological basis are discussed. Structural (computed tomography, magnetic resonance imaging) and functional (positron emission tomography, functional magnetic resonance imaging, single photon emission tomography) studies in antisocial and psychopathic samples are reviewed in this article.
Carpal tunnel syndrome
Authors: Sen D , Chhaya S , Morris VH
Published: May 2014

Carpal tunnel syndrome is the most commonly diagnosed entrapment neuropathy. This review looks at the current body of evidence to help determine optimal practice for the diagnosis and management of this condition.
Gall-stone ileus: imaging features
Authors: Lyburn Iain D , Harris Alison C , Torreggiani William C , Papadouris Dimitrios C , Cheifetz Rona E , Zwirewich Charles V
Published: May 2014

Gall-stone ileus is a well-known, but uncommon cause of intestinal obstruction. Preceding symptoms of biliary disease are absent in most cases and the presentation is often vague and non-specific (Reisner and Cohen, 1994). Plain abdominal X-ray is often inconclusive, but may show classical signs (Rigler et al, 1941). Ultrasound and computed tomography (CT) are useful in making the diagnosis (Summerton et al, 1995; Swift and Spencer, 1998). This paper presents abdominal X-ray, sonographic and CT findings in a patient with surgically proven gall-stone ileus.
Pyrexia of unknown origin: a swollen gland and a glass of milk
Authors: Turner NM , Dwarakanath AD
Published: May 2014

Brucellosis is a disease which has rarely been seen in the UK since the pasteurization of milk. It often presents as a pyrexia of unknown origin and should be considered in the differential diagnosis. A case report is presented where the diagnosis was initially thought to be tuberculosis but months later was found to be brucellosis. The article then presents a summary of brucellosis and its management.
What are the appropriate triggers for red cell transfusion?
Authors: Sodhi Manisha
Published: May 2014

To transfuse or not to transfuse when the haemoglobin (Hb) level falls - this is a hotly debated subject at present for a number of reasons. There are serious risks associated with blood transfusion (Williamson et al, 1999) including acute haemolytic reactions, immunomodulation, infections and possibly new variant Creutzfeldt-Jakob disease (vCJD). The National Blood Transfusion service expects that the introduction of a test for vCJD-contaminated blood (currently being developed) will reduce the availability of blood and is anticipating serious shortage. The cost of blood, which is already around £100 per unit, is expected to rise.
Statin therapy in people with diabetes and high-risk patients
Authors: Wierzbicki Anthony S
Published: May 2014

Lipid lowering forms part of the treatment of atherosclerosis. Primary prevention is dependent on identification and treatment of patients at high risk of which patients with diabetes are the clearest example. This article reviews the role of lipid lowering in high-risk individuals.
The employment, attitudes and aspirations of non-training grade doctors
Authors: Cooper Nicola , Burr Bill
Published: May 2014

Acute care in the NHS is increasingly delivered by junior doctors who receive little educational supervision. There is a continuing dramatic increase in the numbers of trust doctors. Staff grades are also increasing in number and face many frustrations.
Peripartum cardiomyopathy: a forgotten diagnosis?
Authors: Olagundoye VO , Seow Y , Ashworth MA
Published: May 2014

Peripartum cardiomyopathy (PPCM) is a rare form of left ventricular failure with potentially fatal consequences, occurring during the last month of pregnancy or within the first 5 months after delivery. Diagnosis is by excluding all other causes of left ventricular failure and demonstrating characteristic echocardiographic findings. Management is similar to that of left ventricular failure of other causes.
The role of human patient simulators in health-care training
Authors: Blackburn Tim , Sadler Chris
Published: May 2014

The use of human patient simulators in UK health-care training is increasing. These devices are educational tools for imparting knowledge, teaching technical skills, drill training and human factors training for single or multidisciplinary groups. This article explores some of the ways in which they are used, illustrated with examples of simulation training at Barts and the London Medical Simulation Centre.
Spinal subdural haematoma after epidural anaesthesia: a diagnosis not to be missed
Authors: Constantoyannis Constantine , Shahidi Saheed , Kourtopoulos Harry
Published: May 2014

A63-year-old man was admitted to the authors' department because of lower back pain and paraparesis. The patient had undergone an operation 5 weeks earlier to excise a wart on the little toe of his left leg, under epidural anaesthesia. During induction of anaesthesia, immediately after the puncture the patient developed severe back pain radiating to legs with reflex movement of both legs. After the procedure, the patient experienced difficulty in walking and bladder emptying. The pain was relieved with oral medication and the patient was discharged on the second day after surgery although he complained of difficulty with walking. His doctors reassured him that the problems would be transient. The symptoms persisted and he had to use a urinary catheter.

On physical examination he was normal. Neurological examination revealed a proximal weakness of both legs (3/5), with increased tendon reflexes. There was sensory loss of L2–S1 distribution.

Magnetic resonance imaging (MRI) showed a subdural mass extending dorsally to the spinal cord. On T1-weighted images, the subdural mass was mixed iso-hyperintense and showed a craniocaudal extension from T12 to L1 (Figures 1 and 2). The MRI findings were consistent with an intradural haemorrhage and clot formation. No coagulation abnormality was detected.

The patient underwent a T12–L1 laminectomy. After opening the dura, a grayish membrane filled with adhesions and xanthochromic blood clot was found dorsally to the cord. The spinal cord was compressed and displaced by the haematoma towards the ventral part of the spinal cord. The degradated blood clot was removed and part of the membrane was also removed. The underlying cord seemed to be traumatized by the needle in the midline of the dorsal surface.

On follow-up examination 1 and 3 months after surgery, the patient was free of pain, but only a partial motor recovery (4/5 muscle strength on the left leg) had taken place. The sensory impairment was restricted to mild paraesthesia. The bladder function did not improve.
A giant pilar tumour of the scalp
Authors: Javaid Muhammad , Morris Paul , Logan Andrew
Published: May 2014

An 85-year-old woman presented with a slowly growing lesion on her scalp which had been present for the last 20 years. In the last 2 years the lesion had started to grow rapidly. There was no relevant family history of a similar lesion.

On examination a 20x20 cm dome-shaped mass was seen which was multiloculated, consisting of solid and cystic areas (Figure 1). It was fixed to the underlying skull, the overlying skin was stretched and there were no signs of ulceration or secondary infection. There was no lymph node palpable in the neck.

Plain X-rays showed thinning of the skull possibly as a result of local compression. To facilitate excision, the lesion was decompressed intraoperatively by aspirating blood-stained fluid. Excision included the pericranium as the lesion had adhered to it (Figure 2). The reconstruction was performed by bilateral transposition flaps raised from the temporal regions and the donor defects were covered by a split skin graft.

Histology reported a complex cystic lesion lined by stratified squamous epithelium showing abrupt keratinization and calcification. There was no dermal invasion noticed and excision appeared complete. The histological features were consistent with a proliferative pilar tumour of the scalp. The patient was discharged home 3 days after surgery and remained recurrence free after 9 months follow up (Figure 3).
Recent advances in percutaneous coronary intervention
Authors: Patil Arun , Thomas Martyn
Published: May 2014

Following development of the Seldinger technique of femoral cannulation in 1953 and selective coronary angiography in 1958, invasive cardiology has seen many changes. In 1977, Gruentzig introduced balloon dilatation of the coronary artery, which revolutionized this field. Since then advances have included use of an intracoronary stent, introduction of glycoprotein IIb/IIIa inhibitors, use of platelet adenosine diphosphate receptor antagonists in combination with aspirin, intracoronary brachytherapy and drug-eluting stents. In the near future cardiovascular gene therapy and myocardial cell transplantation could prove major advances.
Chemotherapy and radiotherapy of bronchial carcinoma
Authors: Barlow Clare S , Rudd Robin M
Published: May 2014

The treatment of lung cancer is important as it represents a global health burden. Many therapies are used including surgery, radiotherapy, chemotherapy, laser therapy, stenting, supportive care and biological agents. Treatment for individual patients is best assessed by a multidisciplinary approach. This article focuses on treatment with chemotherapy and radiotherapy.
The eye in malignant disease
Authors: Lau Chun H , Taylor Simon
Published: May 2014

The eye and its adnexae (the extraocular muscles, orbit, orbital walls and eyelids) can be involved in malignant disease, either as the primary source of the tumour or as a site of secondary metastatic involvement. Indeed, there is a wide variety of different tumours which are known to affect the eye, this diversity being a consequence of the richness of the ocular tissues present. In addition, disorders of vision or eye movements may be the presenting signs and symptoms of intracranial malignancy.
The current status of Paget's disease of the bone
Authors: Keen Richard W
Published: May 2014

Paget's disease is a metabolic bone disease characterized by abnormalities of bone turnover, structure and architecture. The disease is of unknown aetiology, although both genetic and environmental factors have been implicated. Treatment is indicated for patients with active disease and currently bisphosphonates are the first-choice management option.
Reform of the Mental Health Act: its direction and impact
Authors: Zigmond Tony
Published: May 2014

The legal framework which determines what doctors can do to their patients, under what circumstances and with what limitations is determined by Parliament (statute law), the courts (common law) and the General Medical Council (as arbiter of medical ethics). In a nutshell we must put the needs of our patients first, we must have the consent of those patients who are able to decide for themselves, we must act in the best interests of the patient if they lack capacity, we must not ignore advance refusals and we must not partake in euthanasia. Emergencies may preclude a full assessment of these issues. It is generally agreed that relying on common law does not give a satisfactory framework for the care and treatment of those who lack medical decision-making capacity. Scotland now has an Incapacity Act 2002 and the government has agreed to introduce a bill for England and Wales.
Chronic pelvic pain and irritable bowel syndrome
Authors: Gupta Janesh K , More Swati , Justin Clark T
Published: May 2014

This article describes the common association between chronic pelvic pain and irritable bowel syndrome. The aim of the diagnosis and management of chronic pelvic pain and irritable bowel syndrome is to improve the quality of life of the patient. Methods of diagnosis, treatment and overall management for these two challenging conditions are outlined in this article.
Should we treat severe sepsis with activated protein C?
Authors: Mackillop Andrew
Published: May 2014

Sepsis is an infection-induced syndrome defined as the presence of two or more of the following features of systemic inflammation:
Movement, visceral and autonomic disorders: use of botulinum toxin
Authors: Moore A Peter
Published: May 2014

This article reviews the development of botulinum toxin treatment, how it works, the range of conditions it can treat and the benefits and side effects. It sets out how it is used in practice in specialist units.
Stapled haemorrhoidectomy: a novel procedure
Authors: Ashraf Shabbir , Srivastava Pankaj , Hershman Michael J
Published: May 2014

Stapled haemorrhoidectomy is an effective procedure for symptomatic haemorrhoids with mucosal prolapse. The advantages over the conventional surgical technique include reduced postoperative pain, shorter hospital stay and earlier return to work.
Walking problems in young children
Authors: Tennant S , Monsell F
Published: May 2014

This article attempts to define normal development throughout childhood and provide straightforward advice in the physical assessment of the child in this situation. It also attempts to outline the groups of conditions that lead to walking abnormalities and highlight the salient physical features and special investigations that are required to make these diagnoses with confidence.
Anatomy: the future teaching of undergraduates
Authors: James DRC , Purkayastha S , Paraskevas P , Shafiq O , Darzi Sir A , Athanasiou T
Published: May 2014

The time devoted to the teaching of anatomy to medical students has long been under pressure. Much work has been devoted to how best to teach anatomy in both a time-efficient and costeffective manner. This article discusses the main methods of teaching anatomy and their respective advantages and disadvantages as evidenced in the literature. Suggestions are made as to how best to teach anatomy to medical students in the future.
Metastatic prostate cancer to lung with normal prostate specific antigen levels
Authors: Lawrentschuk Nathan , Webb David R , Mitchell Catherine A
Published: May 2014

A 77-year-old man presented with significant lower urinary tract symptoms, complaining of urinary frequency and poor flow. He had a normal feeling prostate. A cystoscopy was unremarkable apart from a polyp in the prostatic urethra that was biopsied. Histology revealed adenocarcinoma of the prostate, Gleason combined grade 8 (4+4). Transrectal ultrasound and biopsy was performed confirming adenocarcinoma in three of six cores. A bone scan and a computed tomography (CT) scan revealed no evidence of metastatic disease.

Several weeks post cystoscopy his prostate specific antigen (PSA) level was raised at 8.1μg/litre (normal <4.0 μg/litre); however, this settled 2 weeks later at 3.3 μg/litre. After discussion, he was commenced on hormone ablation therapy (cyproterone acetate, a steroidal antiandrogen) because of ongoing voiding symptoms and a further normal cystoscopy. A biochemical response to treatment was achieved with his PSA falling to 0.6 μg/litre. This remained low 6 months later, so the antiandrogen was ceased, with a view to recommencing if symptoms developed or if his PSA rose.

He presented to his GP 6 months after cessation of therapy with shortness of breath. His PSA remained low at 0.2 μg/litre. A CT scan of his abdomen was normal but the chest X-ray (CXR) revealed multiple pulmonary nodules, with no pleural effusion or pulmonary oedema (Figure 1). A CXR performed at diagnosis of his prostate cancer was normal.

The thoracic unit was consulted, with the possibility of a new primary neoplasm raised, given his normal PSA and the fact that he was an ex-smoker. Bronchoscopy was performed with negative cytology and biopsy. A wedge biopsy of the right lung was then undertaken reporting positive histology consistent with metastatic prostatic adenocarcinoma, comparable to previous biopsies (Figure 2). Immunohistochemistry for PSA (Figure 2) and prostatic acid phosphatase were both positive, confirming the metastasis to be of prostatic origin. Upon review 1 month after his biopsy, a rapid acceleration was noted with his PSA climbing to 22 μg/litre. Hormone ablation treatment was commenced and a subsequent radionuclide bone scan revealed metastatic prostate cancer to his pelvis.
Neurogenic T waves after subdural haematoma
Authors: Kumar Rajeev , Fisher Miles
Published: May 2014

A 63-year-old woman, living alone, was admitted following a fall. She had not lost consciousness and did not have a fit. Her only complaint was of dull headache. On arrival she was haemodynamically stable, did not have any external injury marks and there were no focal neurological findings. An electrocardiogram (ECG) revealed bifascicular block with widespread, deep, symmetrical T-wave inversions consistent with subendocardial ischaemia (Figure 1). The patient denied any chest pain, palpitations or cardiac symptoms. She had received a coronary artery bypass graft for triple vessel coronary disease 2 years before and was symptom free since. She did have bifascicular block in her previous ECGs, but the T wave changes were new developments.

Her creatine kinase and cardiac troponin I, performed in proper time frame, were not elevated and she did not have any electrolyte abnormalities. Sequential ECGs continued to show similar T changes. In view of the history of fall she was not commenced on usual antiplatelet and antithrombotic therapy. An urgent computed tomography scan of the head was arranged which revealed a right parietal subdural haematoma about 1.1 cm in maximum thickness with no midline shift. Management was conservative on the advice of the neurosurgeon. An exercise thallium scan failed to show any significant perfusion defects and echocardiogram was normal.

She made good progress and uneventful recovery. At outpatient clinic review 4 weeks later, all T-wave changes had resolved (Figure 2). It was concluded that ischaemic-appearing ECG changes were neurogenic, secondary to her head injury with subdural haematoma.
A collaborative approach to producing a patient information leaflet
Authors: Fletcher Heather
Published: May 2014

Communication and information giving are necessary and important activities to enable healthcare services to refect ‘best practice and care that focuses on the needs of the patient. The specialist ophthalmic nurse plays an important role in giving patients information and providing support in the clinical environment. Written patient information is a valuable communication tool that can be purely educative (a quick and easy method of giving medical information), produced to empower the reader to be able to access help or used to equip the reader with knowledge for making important decisions about health care and treatment. Leaflets are widely used to support clinical practice and are generally rated as useful by patients; however, a common and recurring criticism is that patients do not understand the content. Involving patients in the development of written information is advocated because it enables the users of services to express their views and concerns.

Aim:

To introduce a written patient information leaflet about ocular melanoma and referral to a specialist treatment centre. The provision of written information will be of benefit to patients by supporting the clinical consultation and enabling access to local services.

Participants:

Five males who had been referred to a specialist centre with melanoma of the eye, and two female relatives.

Method:

Participants were asked to complete a preliminary survey and were then invited to join a discussion-group meeting to express their views about information needs based on their past experiences.

Results:

Responses by the group revealed the distress and trauma of being diagnosed and the times when their information needs were not fully met. Being able to access help was rated as an important concern for the group. The views of the participants have been incorporated into a new patient information leaflet.
Non medical personnel carrying out intravitreal injections — for
Authors: Gibbons Helen , Mapani Adam
Published: May 2014

There are between 21–26 000 new cases of wet age-related macular degeneration diagnosed each year. All extended roles are audited to ensure safe practice and high quality care is being delivered.
Comparison between non-contact and rebound tonometry in patients with acute eye symptoms
Authors: Borgenvik Helena , Ramsay Marika Wahlberg , Nilsson Maria
Published: May 2014

Aim:

To evaluate the agreement between three non-contact tonometric techniques in an emergency setting.

Material:

Two hundred and fifty eight patients were recruited from the emergency room at St Erik Eye Hospital in Stockholm during a 3 week period in March 2010. In 224 right eyes it was possible to obtain complete and reliable measurements from all techniques.

Method:

All patients were examined with the CT-80A, R7CR and Icare, by the same examiner, in a random order. For each patient the diagnoses for each eye and the presence of corneal lesions, if any, were recorded. A difference between measurements of more than 3 mmHg was considered as clinically relevant.

Result:

The correlations between the intraocular pressure (IOP) values obtained with the different techniques were high, r2ranged from 0.65 to 0.87 (p<0.0001 in all comparisons). There was a very small (median about 1 mm), but statistically significant difference between IOPCT-80A and both IOPG and IOPCC. A difference between the highest and lowest IOP value of more than 3 mmHg was found in 97 of the 224 patients (56.7%).

Conclusion:

All instruments for IOP measurement evaluated in this study proved to be useful for use in the emergency room. The corneal lesions in a small subgroup of patients did not seem to influence the biomechanical properties of the cornea enough to affect the IOP.
Optic disc imaging — the influence of quality on image analysis
Authors: Martin Lene , Vancea Lucian
Published: May 2014

Aim:

To evaluate the influence of image quality on the measurement of optic disc cupping in fundus photographs.

Material:

Data from 58 patients, aged 30 to 85 years, with suspected or manifest glaucoma were analyzed.

Methods:

Measures of the optic cup area were performed by a semi-automatic planimetric program, the Retinal Size Tool (RST), on the fundus photographs. The cup size measure was compared with corresponding value in the Heidelberg retina tomograph (HRT), using the Glaucoma Probability Score (GPS) program. The quality of the fundus photographs was graded by an Automated Quality Evaluation program (AQE), and by two independent observers.

Results:

Sixty-two percent of the fundus photographs were classifed as acceptable or better by the AQE, while the independent observers classified only one image (2%) as not acceptable for visual evaluation of the optic disc. RST cup size measures both from images with acceptable and poor quality showed good correlations with HRT GPS measures.

Conclusion:

Planimetric measurements of optic disc parameters could be performed also on images with low over-all quality according to automatic analysis of illumination and sharpness.
The realities of evidence-based practice in clinical practice
Authors: Gilsenan Irene
Published: May 2014

Evidence-based practice (EBP) is the gold standard of care but away from all the theory and jargon, what does it mean to busy practitioners. This article will look at the process of EBP and how this translates to ophthalmic clinical practice.
Clinical update — prescribing in ophthalmology
Authors: Sherratt Amanda , Needham Yvonne , Barrett Emma , Overall Susie
Published: May 2014

This is the second in a series of two articles discussing prescribing in advanced ophthalmic nursing practice in the UK. With the support of ophthalmic nurse practitioners this article explores issues relating to medicines management, the patient's experience and clinical effectiveness. The benefits to patients and professional staff in expedient, quality and cost-effective treatment within ophthalmic care, are identified. Exemplars of ophthalmic nursing practice highlight how services may be significantly more streamlined though non medical prescribing in hospitals.
Toxic anterior segment syndrome
Authors: Janet Marsden
Published: May 2014

Toxic anterior segment syndrome is a significant post-operative complication of surgery which may cause long-term problems for the patient and result in poor visual outcomes. Ophthalmic personnel are very aware of the possibilities of infection, especially during surgery, but ultimately it does not really matter what the causes of post-operative inflammation are, whether infective or sterile, the consequences for the patient may be similar. It is important that all ophthalmic personnel recognize the factors that may result in this sterile inflammation and recognize that sterility and toxicity are different things — instruments and other equipment used in surgery may be sterile, but still toxic to the eye. In this way, we can protect patients from this less well known, unforeseen consequence of surgery.
A comparison of the Canon TX-20P™ non-contact tonometer and pachymeter in healthy eyes
Authors: Jansson Ulrika , Brautaset Rune , Cerviño Alejandro , Nilsson Maria
Published: May 2014

Background:

The aim of this study was to compare the intraocular pressure (IOP) and the central corneal thickness (CCT) measurements obtained with the Canon TX-20P™ with IOP measured with Goldmann applanation tonometer (GAT) and the CCT measured with ultrasound (US) pachymetry in healthy eyes.

Methods:

Thirty one healthy voluntary subjects participated in the study, age ranging from 16 to 81 years (mean age 50.9 years). In total 58 eyes were selected for analysis. All measurements were performed by the same examiner. The measurements were taken in the same order in all subjects: Canon IOP and CCT, Goldmann IOP and US CCT.

Results:

A strong correlation was found between IOP for both CCT compensated and raw values (R2 0.79 and 0.71 respectively) and CCT (R2 0.80) readings from GAT and US pachymetry as compared with the Canon TX-20P™, however, a small but statistically significant difference was found in both IOP and CCT measurements.

Conclusions:

The Canon TX-20P™ is a compelling two-in-one non-invasive instrument that allows both IOP and CCT measurements. The Canon TX-20P™ has acceptable agreement for IOP measurements, especially the CCT compensated IOP, as compared with GAT and for CCT when compared with US in healthy subjects. However, it remains to be evaluated if such an agreement can be found in subjects with abnormal IOP and CCT.