bluuebunny/crossref_metadata_2025 huggingface dataset:
Giant coronary artery aneurysms and myocardial infarction: aetiology and management
Authors: Gurtu Rokesh , Uemura Hideki , Tsuda Etsuko , Dubrey Simon W
Published: May 2014

A 28-year-old man developed central chest pain while walking at altitude in South America. An electrocardiogram showed ST segment elevation anteriorly, suggestive of acute myocardial infarction. An echocardiogram demonstrated anteroseptal hypokinesia. Biochemistry confirmed elevated cardiac enzymes.

Coronary angiography revealed giant aneurysms in both right (Figure 1) and left (Figure 2) coronary arteries. Occlusive thrombus in the left anterior descending artery was treated by primary angioplasty.

The patient had no known conventional risk factors or family history for coronary artery disease. Treatment with aspirin, clopidogrel and warfarin was commenced to prevent further coronary thrombosis. Post angioplasty he was repatriated to the UK and remains well on planned long-term therapy with aspirin and warfarin.
The current threat of avian influenza A is real and not a mirage
Authors: Oxford John
Published: May 2014

The greatest outbreak of influenzas in history, the so-called Spanish pandemic of 1918, provides us with a number of lessons which could be learnt. Studies from pathologists working in the British army tell us that the influenza outbreak started in northern France a year earlier, in the vast sprawling British army camp at Etaples (Oxford et al, 2002). Suddenly a new disease emerged with a case fatality of 50%, attacking young soldiers but only in low numbers and inducing a unique clinical feature, heliotrope cyanosis. The reproductive number, being the number of contact infections from an index case (Ro), was low (probably <1) and the outbreaks appeared to be confined to Etaples and Aldershot barracks.
The use of vasopressors in pulmonary hypertension on the intensive care unit
Authors: Price LC , Brett SJ , Howard LS
Published: May 2014

Pulmonary hypertension encompasses a range of disease processes affecting the pulmonary vasculature, defined as a mean pulmonary artery pressure >25 mmHg at rest or 30 mmHg on exercise. Pulmonary hypertension may be idiopathic, or associated with a variety of disorders including left-sided heart disease, lung disease, thromboembolic disease or other miscellaneous causes. Mortality remains significant despite increasing available therapeutic options, and it is likely that patients with pulmonary hypertension will be encountered more frequently.
The beginning of cardiac surgery
Authors: Ellison Harold
Published: May 2014

This year marks the 110th anniversary of the first successful operation on the heart. Over the centuries, from the time of Galen, wounds of the heart were considered fatal. With the advent of anaesthesia and of antiseptic surgery, the latter part of the 19th century saw an explosion in the surgery of the abdominal cavity, of the chest, skull and the limbs, yet the heart was considered to be a ‘no go’ region of the body.
Therapeutic hypothermia after cardiac arrest
Authors: Macdonald Neil , Moonesinghe S Ramani
Published: May 2014

Over recent years there has been growing evidence to support the use of hypothermia in post-cardiac arrest patients. Therapeutic hypothermia is now part of the UK Resuscitation Council guidelines in cardiac arrest, and has become part of many hospitals’ postcardiac arrest algorithm.
Mental Capacity: time to get our act together
Authors: Suresh Kallur
Published: May 2014

The Mental Capacity Act 2005 will become fully operational in England and Wales from 1 October 2007. It enshrines in law several aspects of the mental capacity of individuals and provides clearer guidance to professionals acting on behalf of those who lack capacity. Unlike the Mental Health Act 1983, the Mental Capacity Act affects everyone in England and Wales who is unable make decisions for themselves. It protects those who lack capacity and places obligations on those who care for them. It also has huge implications for doctors and other health-care professionals who take consent from patients for diagnostic or therapeutic procedures. Since April 2007 the Mental Capacity Act has made it a criminal offence to wilfully neglect or ill-treat a person who lacks capacity to make decisions for themselves.
Sexual dysfunction in intensive care survivors
Authors: Griffiths John , Waldmann Carl , Quinlan Jane
Published: May 2014

Normal sexual function is an important component of a patient's overall health status. Sexual dysfunction has been described in a variety of patient populations including survivors of critical illness. This review gives an overview of the issues pertaining to sexual dysfunction in patients who have experienced intensive care unit treatment.
Critical care illness and rehabilitation
Authors: Collin Christine
Published: May 2014

Critical care illness is often followed by protracted, slow and incomplete recovery. Survivors given access to specialized rehabilitation achieve a higher level of recovery, with greater independence and less need for social or health-care support long term.
Oliver St. John Gogarty: surgeon, poet and author
Authors: Ellis Harold
Published: May 2014

For its size and population, Ireland has produced more than its statistical share of brilliant doctors. One has only to consider, for example, the eponyms which have come from that island. These include Grave's disease, Colles' fracture, Stokes–Adams attacks, Corrigan's pulse and Freyer's prostatectomy. As well as great clinicians, Ireland has given us many doctors who have found fame outside medical practice – Bethel Solomons, obstetrician and a distinguished Master of the Rotunda, but also the first Jewish mayor of Dublin, and Sir William Wilde (father of Oscar), a distinguished aural surgeon, but better known as a prominent archaeologist of Ireland.
Web-based radiology and medical learning resources for trainee doctors
Authors: Singh Gurmit , Gupta Mradul
Published: May 2014

The first article of this series discussed the use of educational resources on the Internet and how to assess their quality. This article will discuss some quality radiology and medical teaching websites likely to be of benefit to doctors both in training and in daily clinical practice.
Academic foundation programmes
Authors: Hilton Catriona
Published: May 2014

Academic foundation programmes are a new initiative as part of the Modernising Medical Careers development. Aimed at junior doctors interested in an academic career, or just in expanding their understanding of research to enhance their clinical work, they provide an opportunity to spend time in research while also achieving foundation competencies.
Haemothorax
Authors: Reddy N Sreedhar , Hornick Philip
Published: May 2014

Haemothorax is defined as a significant amount of blood collecting in the pleural space. It is most commonly the result of penetrating or non-penetrating chest trauma. Haemothorax unrelated to trauma is considerably less common and can have a variety of causes. Prompt identification and treatment of traumatic haemothorax is an essential part of the management of an injured patient. In cases where haemothorax is unrelated to trauma, a careful investigation of the underlying cause must be performed while the haemothorax is being treated.
Forearm fractures
Authors: Patel RV , Haddad FS
Published: May 2014

The forearm contains two bones, the radius and ulna.
The clinical anatomy of pericardiocentesis
Authors: Ellis Harold
Published: May 2014

The heart and the roots of the great vessels are contained within the conical fibrous pericardium, the apex of which is fused with the adventitia of the great vessels and the base with the central tendon of the diaphragm. Anteriorly it is closely related to the body of the sternum, inferior to the angle of Louis, and is tethered to the back of the sternum by the sternopericardial ligament. On either side of the sternal body, it relates to the third–sixth costal cartilages and it is overlapped by the anterior borders of the lungs. Posteriorly lie the oesophagus, the descending aorta and vertebrae T5–T8, while on either side lie the roots of the lungs, the mediastinal pleura and the phrenic nerves.
The applied anatomy of appendicectomy
Authors: Ellis Harold
Published: May 2014

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

The scaphoid is one of eight carpal bones which lie in two rows (Figure 1). They are articulated together to form a semicircle, the convexity of which is proximal and articulates with the forearm bones. The scaphoid occupies the most radial position (thumb side) in the proximal row. It is a boat-shaped bone, which articulates directly with the radius proximally and is a critical link in the mechanism of the carpus. The scaphoid is commonly divided into four distinct parts: the proximal pole, the waist, the distal body and the tuberosity. It is a key bone to both wrist motion and stability.
Electroencephalograms in the diagnosis and management of the epilepsies
Authors: Koutroumanidis Michael , Aggelakis Konstantinos , Tan S Veronica
Published: May 2014

The generic term ‘epilepsy’ embraces a particular group of disorders of the CNS but by itself is of limited clinical value. Intense clinical and genetic research over the last few decades has identified a large number of well-defined epilepsy syndromes with different clinical, electroencephalograms (EEG), neuropsychological and neuroimaging profiles, natural history and prognosis, conditions that ultimately require different management. There is evidence that early treatment can reduce the risk of seizure recurrence (First Seizure Trial Group, 1993), and its efficacy depends largely on the appropriate drug choice in relation to the particular clinical syndrome. Therefore, a diagnosis of epilepsy is no longer sufficient; identification of the particular form or syndrome is the cornerstone of meaningful, optimal management.
The applied anatomy of rectal examination
Authors: Ellis Harold
Published: May 2014

In the examination of any part of the body, the clinician must carry out a two-staged process. First, he/she must decide which anatomical structure is involved and, second, what is the pathological condition involving that structure. There is no better example of this principle than in the performance of a rectal examination.
The use of computed tomography for screening can be effective and safe
Authors: Giles John , Marshall John
Published: May 2014

The development of multislice computed tomography (CT) and the associated newer CT techniques over 5 years ago led to a surge in interest in the potential use of this exciting modern technology in preventative medicine. An initial rapid expansion in the provision of such screening tests in an uncontrolled manner led to increasing mistrust and scepticism among both the media and the medical establishment.
Abdominal pain in a 9-year-old: omental torsion masquerading as appendicitis
Authors: St J Floyd Jr M , Kelly BJ , Udani P , Nabri M , O'Donnell N , Morrison P
Published: May 2014

A 9-year-old boy was referred to the emergency department by his GP with abdominal symptoms. He complained of periumbilical pain for 3 days which had gradually radiated to his right iliac fossa in the 12 hours before presentation. The pain was colicky, intermittent in nature and exacerbated by moving or eating. There was associated anorexia and nausea but no vomiting. Bowel pattern had remained normal throughout and no urinary symptoms were noted. On presentation he graded the pain as 10/10. A collateral history was taken from his mother who verified the symptoms. There was no history of trauma.

On examination he was flushed, dehydrated but apyrexial. Cardiorespiratory examination was normal. Abdominal examination revealed tenderness and guarding in the right iliac fossa. Bowel sounds were normal and he had a positive Rovsing's test. Laboratory investigations revealed a normal full blood count (white cell count of 8.76 × 106), a normal renal profile and a normal serum amylase. Erythrocyte sedimentation rate was marginally elevated at 18 mm/hr. Urinalysis was normal.

A clinical diagnosis of appendicitis was made. A Lanz incision was made and on opening the peritoneum blood-stained fluid was noticed. On close inspection the appendix looked healthy and a routine appendicectomy was carried out. The incision was extended medially and the caecum and small bowel were fully inspected with no pathology identified. Near the right hepatic flexure an area of necrotic omentum was identified with thrombosed veins. Another area of omentum was seen which had twisted upon itself (omental torsion). This was excised and tied with vicryl sutures. Postoperatively, the patient went home on day 3 after an uneventful recovery. Histopathology revealed a normal appendix. The excised omentum revealed fat necrosis and ischaemic changes consistent with torsion (Figure 1).
Theories, types and treatments of diabetic neuropathy
Authors: Gabriel Dr Carolyn
Published: May 2014

An understanding of the complex aetiology of diabetic neuropathy, the commonest neuropathy in the developed world, aids management of this condition, and helps to avoid potentially very disabling complications.
A fresh start for hospital IT systems?
Authors: Rayner Hugh C
Published: May 2014

The Health Informatics Report published by the Department of Health in July this year admits that delivering electronic care record systems in hospitals ‘has not progressed as quickly as people would wish’. It recognizes that ‘there is a need for interim initiatives so patient information can be made available across different IT systems, different care providers and different care settings ahead of strategic systems’ (Department of Health, 2008). With local development no longer held back in anticipation of the ‘strategic systems’, where should IT developers and clinicians focus their collective efforts?
A killer at large: acute aortic dissection
Authors: Assar Ahmed N , Zarins Christopher K
Published: May 2014

Acute aortic dissection is one of the most fatal acute cardiovascular disorders that has challenged physicians and surgeons for decades. This article provides an up-to-date overview of the aetiology, pathophysiology, diagnosis and treatment of this condition.
Endobronchial carcinoid: an unusual cause of wheezing and chest pain
Authors: Farmer AD , Zanetto U , Lewis MJV
Published: May 2014

A 73-year-old man presented to the authors' clinic with profuse rectal bleeding, defaecatory urgency and symptomatic anaemia. He had been treated for prostatic adenocarcinoma 12 months previously, with neoadjuvant hormones and radiotherapy (total dose of 60 Gy). Chronic radiation proctitis was confirmed endoscopically and histologically in the absence of any other left-sided colonic pathology.

His initial medical management with sucralfate enemas and oral metronidazole failed. However, he withheld consent for further topical or endoscopic treatment despite continued symptomatic deterioration and transfusion dependency, presenting a therapeutic impasse.

Oral thalidomide (75 mg/day) was started and he made an excellent symptomatic response and became transfusion independent. However, 23 days after starting thalidomide peripheral neuropathy ensued, a well documented side effect (Mileshkin and Prince, 2006), which resolved rapidly following its discontinuation.

His symptoms and anaemia rapidly re-emerged and at this point he consented to endoscopic therapy with argon plasma coagulation. An unprepared flexible sigmoidoscopy, to the rectosigmoid junction, demonstrated features of chronic radiation proctitis and argon plasma coagulation was applied exclusively to the rectum. However, the patient developed sudden onset abdominal pain necessitating abandonment of the procedure. A chest radiograph showed free air under the right hemidiaphragm. An emergency laparotomy revealed multiple perforations and lacerations in the proximal descending colon without abdominal contamination. A Hartmann’s procedure was performed. A direct perforation as a sequelae of the procedure is unlikely as multiple perforations and lacerations were evident proximal to the upper limit of the examination. Furthermore, no perforation was observed in the rectum or sigmoid where the argon plasma coagulation was applied. As bowel preparation was not administered before the flexible sigmoidoscopy and given the aforementioned findings at laparotomy, the likely cause of the perforation was an intracolonic gas explosion, a rare iatrogenic complication of using thermocoagulative endoscopic techniques within the colon.

The patient died 16 days postoperatively of multiorgan failure.
Obstetric services in the UK: what we need now
Authors: Setna Zeryab , Tuffnell Derek
Published: May 2014

Pregnancy and childbirth should be a safe and memorable experience for both women and their partners. This article discusses the current position of maternity services, their strengths and limitations, and suggests future directions required to improve these services further.
Neurosarcoidosis presenting as ghost lesions in the CNS: a diagnostic dilemma
Authors: deSouza RM , Crocker M , Wijesekera L , Hampton T , Silber E , Chandler C
Published: May 2014

A 50-year-old woman presented with a short history of headaches and dizziness. One week earlier she noticed impaired right leg coordination and had fallen twice. She had no significant past medical history. Examination showed impaired right arm and leg coordination, mild pronator drift and gait ataxia with no other neurological deficits.

A magnetic resonance imaging scan of the brain showed an intra-axial mass lesion centred on the right middle cerebellar peduncle with partial effacement of the fourth ventricle and an unusual, slightly nodular pattern of enhancement (Figure 1). A computed tomography scan of the chest demonstrated bilateral nodular hilar masses felt consistent with reactive lymphadenopathy. No single large mass was present. Brain magnetic resonance imaging was consistent with either a primary lesion or atypical metastasis.

She commenced dexamethasone 4 mg four times per day and stereotactic biopsy was scheduled. The planning magnetic resonance imaging, 2 weeks later, demonstrated marked reduction in the lesion's size raising the possibility of CNS lymphoma. Surgery was cancelled. Lumbar puncture showed no abnormalities.

The steroid dose was reduced as a result of cushingoid sequelae and to establish if the lesion would re-expand. Interval scans showed progressive reduction in mass size despite decreasing steroid doses. Partial signal normalization within the cerebellum with resolution of mass effect and enhancement was observed (Figure 2).

Repeat computed tomography of the chest (Figure 3) showed new, small, peripheral, left and right upper lobe pulmonary lesions. Histology following open biopsy of the left-sided lesion showed noncoalescent non-necrotizing granulomata consistent with sarcoidosis. Six months later the patient remains symptom free on prednisolone 2.5 mg once per day.
Flying without wings and hoping for no turbulence
Authors: Trask Nicole
Published: May 2014

It's my first day as a Foundation Year 2 co-pilot. Fully registered overnight but manned with a handful of aviation-led Team Resource Management lessons I transfer from London City to Stansted. I feel anxious but ready for the challenge.
A newly described tumour: Burkitt's sarcoma
Authors: Ellis Harold
Published: May 2014

Fifty years ago, in the November issue of the British Journal of Surgery for 1958, a short, five and a half page, nicely written and well-illustrated paper was published entitled ‘A sarcoma involving the jaws in African children’. It originated from the Department of Surgery of the Makerere Medical School in Kampala, Uganda and its sole author was a medical officer in the Colonial Medical Service, Denis Parkins Burkitt. At the time, this paper aroused very little interest; today it is one of the most commonly quoted articles on cancer epidemiology.
Outcomes of emergency admission of older patients: impact of cognitive impairment
Authors: Thompson K , Allen SC
Published: May 2014

Many older patients admitted to hospital as an emergency present with cognitive impairment. This review examines whether this is detected reliably by health-care professionals, and considers how it has an impact on outcome for the patient.
An unusual case of acute leg weakness
Authors: Duncan MKJ , Howlett DC , Watson GMT
Published: May 2014

A 41-year-old male presented with progressive leg weakness and difficulty with micturition. He had otherwise been well. Clinical examination was normal apart from reduced power (3–4/5) in his lower limbs and a palpable bladder.

The patient was catheterized and had a 1000 ml residual volume. Initial blood tests and magnetic resonance imaging of his brain were normal, but magnetic resonance imaging of the spinal cord revealed extensive abnormality. Figures 1–3 are selected magnetic resonance images of the cervical and upper thoracic cord.

Figure 1 shows extensive high signal within the cord on T2 weighting, extending from C3 to the upper thoracic region. The cord itself is expanded and the altered signal extended to the T10 level on further imaging. Figure 3 shows meningeal enhancement (arrows) and this was evident along the whole cord to the conus. There was no compressive lesion. These appearances are consistent with a transverse myelitis.

Lumbar puncture showed an increased CSF white cell count, reduced glucose and increased protein levels. The patient was commenced on intravenous methylprednisolone and cefotaxime. His leg weakness progressed with power falling to 0/5. A sensory level was established at T2. Further blood tests showed a normal serum angiotensin-converting enzyme level, no evidence of tuberculosis, normal autoantibodies and negative viral screen including HIV. Syphilis serology (i.e. venereal disease research laboratory (VDRL), Treponema pallidum haemagglutination assay (TPHA) and serum enzyme-linked immunosorbent assay (ELISA)), however, was strongly positive. Further lumbar puncture showed positive CSF antibodies to Treponema pallidum. The diagnosis of syphilitic transverse myelitis was made and his antibiotics were changed to intravenous benzylpenicillin. The patient made a full neurological recovery.
Caecal volvulus
Authors: Sharma Neel , Glassman Dr Daniel
Published: May 2014

A 58-year-old man presented complaining of severe colicky abdominal pain over a 24-hour period. He also complained of persistent bilestained vomiting a few hours after the pain had started. There was no significant past medical or surgical history. The patient was afebrile with a temperature of 36.9°C, blood pressure of 105/65 mmHg and a pulse rate of 110 beats/minute. Abdominal examination revealed significant diffuse abdominal tenderness and notable peritonisim. Investigations revealed a white cell count of 17.7×109/ litre, a C-reactive protein level of 123 mg/ l and normal urea and electrolytes. A plain radiograph of the abdomen demonstrated dilatation of the small bowel with the caecum projecting over the small bowel (Figure 1).
Systemic sclerosis: an update for clinicians
Authors: Herrick Ariane L
Published: May 2014

Recent advances in the management of systemic sclerosis highlight the importance of early diagnosis and assessment, before irreversible tissue injury has occurred. This review will discuss diagnosis, subtyping, and the major clinical features and their management.
Joseph Towne, master modeller in wax
Authors: Ellis Harold
Published: May 2014

A visit to the Gordon Museum at Guy's Hospital reveals some remarkable treasures. There you will discover the original pathological specimens put down by Thomas Addison, Richard Bright and Thomas Hodgkin of their eponymous diseases. You also cannot help but admire the beautiful wax models of anatomical preparations made by Joseph Towne, the 200th anniversary of whose birth, in 1808, we celebrate this year.
Human rights and restraints
Authors: Hughes Rhidian
Published: May 2014

The principles set out in the Universal Declaration of Human Rights, the European Convention on Human Rights and similar instruments encourage fairness, respect, equality, dignity and autonomy for all. In the UK the Human Rights Act 1998 makes these rights legally binding. The principles underpinning these rights reflect basic needs that enable us all to live full lives with maximum dignity and respect. These core societal values are at the heart of high quality health and social care. People should be put at the centre of all decisions about their care in a person-centred way. In doing so people's experiences of care, the quality of their lives, health and wellbeing can be improved.
Venepuncture technique training vs practice: a survey of foundation year 1 doctors
Authors: Schoeman Scarpa , O'Connor Edmund Fitzgerald , Harrison Rowan , Muirhead-Smith Andrew , Shah Mohammad Ali , Ware Nicholas
Published: May 2014

This survey investigated potential disparity between foundation year 1 doctors' formal undergraduate venepuncture training and their actual clinical practice. Is there still a high prevalence of needle and syringe use?
Neonatal white leg: a case of anatomical misjudgment
Authors: Dindyal Shiva , Kumaraswamy Prakash , Sooriakumaran Prasanna , Kiely Edward
Published: May 2014

A baby girl of 28 weeks' gestation was delivered by emergency caesarean section because of fetal distress. At delivery her heart rate was >100 beats per minute, she cried and gasped, and was initially given bag and mask ventilation. She was subsequently intubated. An umbilical artery catheter was sited with aseptic technique for continuous blood pressure monitoring and arterial blood gas sampling. A second cannula was inserted into an umbilical vessel thought to be an umbilical vein. However, X-ray showed it to be malpositioned and probably arterial, and so it was removed immediately. Three hours later her left leg had turned white (Figure 1). She was consequently transferred to the neonatal unit where recombinant tissue plasminogen activator infusion was commenced.

The whiteness did not disappear and no pulse reappeared below the femoral artery. However, the dusky red area above the knee resolved and, after a few days, an obvious area of demarcation of the ischaemia was seen at knee level. The patient subsequently underwent a through-knee amputation and has been fitted with a prosthesis.
Self-motivation: a guide for the foundation year doctor
Authors: Trivedi Deepali , Sanghera Sherminder , Hooke Rachel
Published: May 2014

People always want to achieve something, and foundation year doctors are no exception. However, the main difference between one who succeeds and one who does not is the drive to achieve the desired goal. Motivation is this drive to achieve progress and develop. Motivation refers to the initiation, direction, intensity and persistence of human behaviour (Geen, 1994).
So you want to be … an anaesthetist
Authors: Down Jim
Published: May 2014

Did you spend 5 years at medical school to become a sleep technician…
So you want to be … a paediatrician
Authors: Cade Alan
Published: May 2014

The typical impression of a paediatrician is that of a gentle, kind-hearted soul, dedicated to the cause, who wears Wallace and Gromit socks and ties that play tunes.
Practical management of inpatient diabetes regimens
Authors: Robertson Doug
Published: May 2014

People with diabetes may be admitted to hospital as a result of diabetic emergencies such as diabetic ketoacidosis or hyperosmolar non-ketotic hyperglycaemic syndrome, or for illness or surgery unrelated to diabetes. Hospitalized people with diabetes need good glycaemic control as much as they do at home, or perhaps even more, considering the stresses associated with illness or surgery.
A guide to the adult intensive care unit
Authors: Frost Paul , Wise Matt P
Published: May 2014

An intensive care unit (ICU) is a designated area offering facilities for the prevention, diagnosis and treatment of multiple organ failure and represents the highest level of continuing patient care. It requires a minimum of one to one nursing, monitoring of numerous physiological variables and provision of multiple organ support. Illnesses that precipitate ICU admission are frequently unanticipated and associated with a high mortality and morbidity. It is not surprising then, that many trainee doctors can find visits to the ICU intimidating and stressful. Moreover a lack of awareness of common ICU policies and practices can result in clinical errors that adversely affect patient care. An elementary knowledge of ICU design, intensive care organization and adherence to some simple visiting rules allows trainee doctors to avoid many of these pitfalls.
Musculoskeletal ultrasound in adults
Authors: Harvey Chris J , Hart Jonathan L , Lloyd Claire R , Babar Syed
Published: May 2014

Ultrasound is widely used in the imaging of many musculoskeletal conditions (Van Holsbeeck and Introcaso, 2001; McNally, 2005). Advances in technology, including higher resolution probes, power Doppler sonography, extended field-of-view imaging and compound imaging, have expanded its applications in musculoskeletal disorders.
Antibiotic prescribing
Authors: Evans D , Shakur R , Scott D
Published: May 2014

Antibiotics are commonly prescribed by junior doctors, sometimes based upon previous discussions but often when the rest of the team are unavailable, and sometimes under pressure from other members of the health-care team. Complete coverage of all issues pertinent to the prescribing of antibiotics is outside the scope of this article. The intention is to focus on clinical areas of key importance in terms of frequency of occurrence in the work of a junior doctor.
Ten steps to better communication
Authors: Chahl Pavan
Published: May 2014

Good communication skills are the foundations on which a good doctor–patient relationship is established. They have a significant influence on patient satisfaction and are likely to lead to a more satisfying career in medicine. This article is aimed at medical students and trainees in the early stage of their career, and it focuses on the key ingredients of good communication (Table 1).
Careers support
Authors: Elton Caroline
Published: May 2014

In the wake of the Modernising Medical Careers reforms, the issue of careers support has risen up the medical education agenda. This article looks at best practice in providing careers support to junior doctors and considers how to advise trainees whose career plans you believe to be unrealistic.
Harvey Cushing: a founding father of neurosurgery
Authors: Ellis Harold
Published: May 2014

Harvey Cushing died 70 years ago, on 7 October, 1939, in his 71st year, of a myocardial infarction. He founded a school of neurosurgery whose disciples spread throughout the world, introduced the meticulous documentation of the clinical and pathological details of cerebral tumours, developed techniques of operative surgery which are now standard practice, has an endocrine disease which bears his name and even produced one of the best known medical biographies, the two-volume Life of Sir William Osler, which won the Pulitzer Prize for 1926.
Choledocholithiasis
Authors: Amerasekera Steve
Published: May 2014

A 79-year-old man with a previous cholecystectomy re-presented with right upper quadrant pain. His liver function tests showed a cholestatic picture. Ultrasound showed dilated intrahepatic ducts and a dilated common bile duct. No gallstones were identified.
Tracheo-oesophageal fistula diagnosed with multidetector computed tomography
Authors: Hodnett PA , McSweeney SE , Coyle J , Barry J , Plant R , Maher MM
Published: May 2014

A 61-year-old man presented acutely to hospital with respiratory distress. He had a background history of recurrent respiratory tract infections. Chest radiograph showed bilateral lower lobe air-space opacification. Subsequently the patient developed acute respiratory decompensation and respiratory arrest requiring endotracheal intubation.

The patient was admitted to the intensive care unit, and intensive care unit staff noted that unusually high positive end expiratory pressure values were required to maintain adequate oxygenation. Another notable finding was repeated reflux of air through the patient's oropharynx. The endotracheal tube was replaced with a larger calibre endotracheal tube without improvement. The possibility of tracheooesophageal fistula was considered and the patient underwent flexible bronchoscopy and contrast oesophagography, none of which showed a tracheo-oesophageal fistula. Clinical concern for tracheooesophageal fistula persisted and the patient continued to require mechanical ventilation.

Multi-detector computed tomography (Aquilion 4, Toshiba Medical Systems, Toshiba, Tokyo, Japan) extending from hyoid bone to lung bases was performed with the following technical parameters: 120 kVp, 225 mAs, 1 mm slice thickness in helical mode with table speed of 0.75 and pitch of 3, without intravenous contrast administration. An attending radiologist and intensive care physician were present during the examination and the images were reviewed and discussed during the study. A subtle, focal, ill-defined thinning of the trachea was identified at the level of the endotracheal tube cuff (Figures 1a and b). A decision was made to repeat the study following temporary deflation of the endotracheal tube cuff and advancement of endotracheal tube into the right mainstem bronchus. This demonstrated a posterior tracheal defect with oesophageal communication, confirming a tracheo-oesophageal fistula at the site of thinning on the earlier imaging phase. Multiplanar reconstructions in the sagittal plane (Figures 1b and 2b) and virtual bronchoscopy (Figure 3) (Vitrea workstation, Vital Images Minnetonka, Minnesota, USA) confirmed the presence of a tracheo-oesophageal fistula at the level of the endotracheal tube cuff.

Three days later, with the aid of multi-detector computed tomography and the multiplanar reconstructions, focused conventional bronchoscopy confirmed the presence of the tracheo-oesophageal fistula. The patient succumbed to overwhelming sepsis 2 weeks later.
Paediatric necrotizing pancreatitis
Authors: Sachiththanandan Sajitha , Rajendran Nirooshun , Rohatgi Ashish , Reddy Marcus
Published: May 2014

A 13-year-old boy was admitted with a 7-week history of worsening epigastric pain and vomiting. There was no prior history of similar episodes, jaundice or viral infection. There was no family history of hyperlipidaemia. His only comorbidity was obesity with a body mass index of 36.6 kg/m2. On examination he was tachycardic and tachypnoeic with a tender epigastrium. Blood results showed a leucocytosis, normal liver function tests and normal cholesterol, C-reactive protein and amylase levels.

An ultrasound scan was performed but did not reveal any detail because of his body habitus. A computed tomography scan showed a necrotic pancreas and that gallstones were present.

The patient deteriorated, becoming increasingly septic, and was transferred across to a paediatric intensive care unit. Initial management consisted of fluid resuscitation, intravenous protein pump inhibitors, intravenous antibiotics, parenteral nutrition and surgical review. He initially responded to treatment, but then deteriorated with worsening sepsis requiring readmission to the paediatric intensive care unit. The repeat computed tomography scan (Figure 1) revealed bilateral pleural effusions, free fluid in the abdomen and peripancreatic inflammation.

He showed signs of abdominal compartment syndrome and was taken to theatre for a laparotomy. The operative findings were a necrotic pancreas with over 5 litres of free fluid. A pancreatic necrosectomy and laparostomy was performed (Figure 2). Between 60 and 70% of his pancreas was involved and removed.

The rest of his postoperative course was uneventful. He was discharged on Creon supplements, insulin and an antihypertensive. His weight had dropped from 106 kg on admission to 84 kg. After further surgical and paediatric review as an outpatient he later underwent an open cholecystectomy with an ontable cholangiogram.
Sleep apnoea and sleep breathing disorders
Authors: O'Reilly John
Published: May 2014

Sleep apnoea and related sleep breathing disorders are a major cause of medical, social and occupational disability. Excessive sleepiness may be associated with respiratory failure, obesity, hypertension and insulin resistance in the cardiometabolic syndrome. This article reviews practical assessment and management.
Emerging therapies for sleep disorders
Authors: Wilson Sue
Published: May 2014

There has been an upsurge in interest in treatments for sleep disorders recently, as new discoveries in the physiology of sleep-related brain neurotransmitter systems have been made. New targets for therapies have been identified in the field of insomnia, and these will be described in this article.
Management of intracranial bleeding in anticoagulated patients
Authors: Thompson Andrew
Published: May 2014

Intracranial haemorrhage is a life-threatening complication of anticoagulation. When the anticoagulation is for a mechanical heart valve the risks of further bleeding on warfarin need to be balanced against the risks of thromboembolism from an unprotected valve.
Venous thromboembolism: a UK perspective
Authors: Kakkar Ajay
Published: May 2014

Venous thromboembolism remains a significant cause of morbidity and mortality in the UK, and its dangers, particularly in hospitalized patients, have long been recognized. Recent measures to tackle this problem and new treatments should alleviate the burden of venous thromboembolism for patients, their families and hospital services.
The emperor's new clothes: workwear and uniforms guidelines undressed
Authors: Williams Geraint , Jarvis Neil
Published: May 2014

This article summarizes patient and physician opinions of what constitutes appropriate attire in the clinical environment. It evaluates the Department of Health workwear and uniforms policy, including the evidence and inconsistencies which underlie these guidelines, and attempts to predict future trends.
Managing the appraisal
Authors: Parkin Doug , McKimm Judy
Published: May 2014

Appraisal is a formal process for doctors at all levels, including doctors in training, which supports professional development and stimulates improvements in clinical practice. Appraisal skills are fundamental to the process of educational supervision.
A neonate with fetal distress and anaemia
Authors: Pugalenthi A , Sridhar AV , Fisher R
Published: May 2014

A baby girl was delivered by emergency caesarean section for fetal bradycardia at 37 weeks' gestation. The 20-week fetal anomaly antenatal scans had showed no obvious abnormalities. At birth the baby looked pale and floppy, needing resuscitation with bag and mask. The Apgar scores were 6 and 8 at 1 and 5 minutes respectively. The baby weighed 1.98 kg.

On examination she was noted to be pale with an abdominal mass extending from the left hypochondrium to the right iliac fossa. The initial blood results showed a low haemoglobin of 9.9 g/dl with normal white cell and platelet count. The urea, creatinine, electrolytes, C-reactive protein and liver functions tests were in the normal neonatal range. The Coombs test was negative. There was no evidence of haemolytic anaemia. She received packed cell transfusion for correction of anaemia.

An abdominal X-ray showed a paucity of gas in the lower abdomen (Figure 1). Ultrasound of the abdomen and pelvis showed a large pelvic mass with numerous irregular fluid-filled spaces. The liver, biliary tree and the kidneys were normal. A computed tomography scan of the abdomen and pelvis (Figure 2) with contrast showed a 7×5×5 cm low attenuation mass arising from the pelvis and extending into the abdomen, most likely to be right ovarian in origin.

Laparotomy showed a large right-sided ovarian cyst with haemorrhagic areas. She underwent right oopherectomy which on macroscopic examination showed multiple blood-filled cysts. Histopathology of the mass suggested a luteinized follicular cyst with no malignant features. She made good postoperative recovery and on follow up at 5 months of age, she was growing and developing normally with no ongoing problems related to the ovarian cyst.
So you want to be … an oral medicine physician
Authors: Hegarty Anne M , Mighell Alan J
Published: May 2014

The British Society for Oral Medicine ( www.bsom.org.uk ) defines oral medicine as ‘the specialty of dentistry concerned with the oral health care of patients with chronic recurrent and medically related disorders of the oral and maxillofacial region, and with their diagnosis and non-surgical management.’
Ocular emergencies 1: traumatic
Authors: Sallam Ahmed , Taylor Simon
Published: May 2014

This pair of articles aims to familiarize physicians with acute ophthalmic conditions requiring urgent referral and attention. It therefore primarily focuses on conditions that pose a direct threat to patients' vision and/or life, as well as on problems seen frequently in clinical practice.
Ocular emergencies 2: non-traumatic
Authors: Sallam Ahmed , Taylor Simon
Published: May 2014

This pair of articles aims to familiarize physicians with acute ophthalmic conditions requiring urgent referral and attention. They primarily focus on conditions that pose a direct threat to patients' vision and/or life, as well as on problems seen frequently in clinical practice.
The doctor-nurse relationship: time for change?
Authors: Ahmad Ahmir
Published: May 2014

As members of the health profession, our relationship with patients is at the heart of everything we do. But what about our relationship with members of our own team? How can enhancing these improve patient care? This article explores the doctor–nurse relationship, how it has changed over time, the current situation and how we can make things better.
Research governance: a guide for the foundation year doctor
Authors: Andreatta Walter , Kothari Alka , Trivedi Deepali , Hooke Rachel
Published: May 2014

The primary aim of research is to understand the aetiology and pathogenesis of disease and to improve prophylactic, diagnostic and therapeutic procedures. Continuous research is necessary for improvement of efficiency, effectiveness and accessibility of pre-existing procedures. Biomedical research has transformed medicine from a simple caretaking role to that of curing serious lifethreatening diseases. Medical progress is based on research involving experimentation with human subjects (Schucklenk and Ashcroft, 2000; Beauchamp and Childress, 2001).
Calcium and phosphate testing
Authors: Smellie WSA
Published: May 2014

Calcium and phosphate usually form part of a ‘bone’ profile of tests that also includes measurement of serum albumin and alkaline phosphatase levels. Most laboratories report total calcium concentration in serum. This is influenced in particular by serum albumin concentration, and the total calcium is therefore also adjusted for the serum albumin concentration (ACa = serum Ca + (0.02(40–alb) (g/litre))). However, the adjustment is an approximation which may be inaccurate, particularly at extreme albumin concentrations.
How to insert a central line
Authors: Rajan Jonny , Bajaj Sanjay , Kaur Navkiran , Stephens Robert CM
Published: May 2014

The ability to insert a ‘central line’ (a catheter into a large central vein) is an essential skill for many physicians. This is a riskprone procedure and is now subject to National Institute for Health and Clinical Excellence guidance (National Institute for Clinical Excellence, 2002).
Should cell salvage be used in oncological surgery?
Authors: Bouras Irene , Mingo Olivia
Published: May 2014

Cell salvage, the process whereby blood is suctioned from the surgical site then filtered, centrifuged and washed before being transfused, was first developed in 1974. Since then it has become a widely used technique which reduces the need for allogenic blood transfusion. Cell salvage was initially considered to be contraindicated in obstetrics, because of the risk of amniotic fluid emboli, in potentially ‘dirty’ surgical sites and in oncological surgery because of concerns about re-transfusion of malignant cells. However, cell salvage is now routinely used in obstetrics, particularly in massive haemorrhage, and in elective bowel resection. The potential use of cell salvage in oncological surgery has been highlighted following the National Institute for Health and Clinical Excellence (NICE, 2008) guidance sanctioning (although not specifically recommending) cell salvage during radical prostatectomy and cystectomy. This leads to the question of whether cell salvage is safe to use in these and other types of oncological surgery.
Medicine and management: crossing the divide
Authors: Patel Shelain , Babaei-Mahani Amir , Haddad Fares S
Published: May 2014

There is great managerial hierarchy within the NHS. Doctors play a key role in this although it may not be stated as such. This article examines the history of management in the NHS and key management skills that can be adopted by doctors to deliver effective health care.
Jean Henri Dunant: father of the Red Cross and Nobel laureate
Authors: Ellis Harold
Published: May 2014

Today, the International Red Cross is the largest humanitarian organization in the world. This year marks the 100th anniversary of the death of its founder, Jean Henri Dunant. The details of his life and achievement are both incredible and sad.
Delayed diagnosis of blunt traumatic diaphragmatic hernia
Authors: Jones C , Dawson S , Badger SA , Epanomeritakis E
Published: May 2014

A 52-year-old man presented with a 3-day history of left shoulder-tip pain and shortness of breath, in the background of abdominal pain for 3 weeks. The patient had been admitted 4 months previously following a fall onto his left posterior chest wall, when he sustained a left-sided pneumothorax and fractures of the left 6th, 7th and 8th ribs posteriorly. At that time a computed tomography scan showed a left-sided pneumothorax with associated basal atelectasis and consolidation.

On this, the second admission, initial observations were stable, apart from a mild tachypnoea. Abdominal examination was normal, but respiratory auscultation revealed bowel sounds in the left hemithorax. The chest radiograph showed a new left-sided pneumothorax and large bowel in the left chest (Figure 1). Abdominal radiography confirmed this, with some mildly dilated loops of bowel. A computed tomography scan demonstrated a left diaphragmatic rupture with associated intra-thoracic incarcerated large bowel, a left hydropneumothorax and mediastinal shift to the right (Figures 2 and 3). Subsequently, the patient underwent a transverse colectomy with colostomy formation, along with diaphragmatic repair through a left thoraco-abdominal approach. Gastrointestinal continuity was later restored electively.
Current applications of interventional radiology
Authors: Shaw Aidan , Speirs Archibald JD , Howlett David
Published: May 2014

Interventional radiology uses a range of radiological techniques to precisely and accurately diagnose and treat pathologies. This article discusses patient preparation and selection and highlights its strengths and weaknesses as well as introducing its use in each of the systems of the body.