bluuebunny/crossref_metadata_2025 huggingface dataset:
what the journals say
Authors: Williams Julia
Published: May 2014

This paper reports on a study of patients′ experiences of rehabilitation and highlights their self−reported need to assist their care. Rehabilitation is seen as a health seeking effort on the part of patients based on the attitude that recovery is possible. As nurses, we must to be able to recognise patient needs to plan effective and individualised care. The authors go on to recognise rehabilitation as a holistic, teamwork−oriented approach where patients and their needs are at the centre of the multidisciplinary team.
Prescribing methotrexate for patients with Crohn's disease
Authors: Stansfield Catherine , Tattersall Suzanne , Connell Fiona
Published: May 2014

Methotrexate is commonly used to manage Crohn's disease. This article discusses the use of supplementary prescribing to deliver a safe and efficent service for patients with IBD by a specialist nurse. Audit revealed that over a two−year period, 132 consultant clinic appointments were saved and clinical incidents were reduced. Patients positively reviewed the changes in the service, commenting upon regular contact with the specialist nurse, and mentioning improved continuity and reduction in delays in management decisions.
A guide to the management of incontinence in older people
Authors: Mangnall Joanne
Published: May 2014

Difficulties with bladder and bowel control have the potential to blight old age. Sadly, the prevalence of both urinary and faecal incontinence does rise in the older age groups; however, this rise should not be viewed as confirmation that incontinence is an inevitable consequence of ageing (Roe and Doll, 2000). This article aims to provide a brief overview of the prevalence of urinary and faecal incontinence in older people, the impact it has on the individual and those involved in their care, and what can be done to help.
Endoscope decontamination: would you pass a JAG visit?
Authors: Thomson Libby
Published: May 2014

Effective decontamination is the cornerstone of the endoscopy service and is essential in maintaining patient and staff safety. This article outlines the recommendations of the National Endoscopy Programme, which aimed to develop a document that would encompass all the current guidance on endoscope decontamination into a relevant and easy−to−use format. The article provides advice on aspects of infection control and important areas to address before an inspection, and describes some of the positive results of the project.
Colostomy cancers: a report of two cases
Authors: Rao PK Dhruva , Saklani AS , Perston Yvette
Published: May 2014

Carcinomas on ileostomies have been reported in patients who have undergone colectomy for ulcerative colitis, familial adenomatous polyposis and Crohn′s disease. Colostomy carcinomas are relatively rare, with only ten cases reported worldwide. This article describes two cases that we have recently seen and highlights the challenges, such as diagnosis, extent of excision, closure of defects, and siting of further stoma. In both cases, the presentation was to a specialist nurse−led clinic. Lesions around a stoma are relatively common and specialist nurses need to be aware of the possibility of cancer on a colostomy or ileostomy.
Addressing obesity
Authors: Coutts Alison
Published: May 2014

There should not be a problem: in the UK, around 37% of women and 18% of men are on a permanent weight-reducing diet. That corresponds quite nicely with Government figures, suggesting that one quarter of adults in the UK are obese (Butland et al, 2007). An optimist would conclude that those adults who are too big are taking action, and their health will benefit− if only.
Understanding the microbiology, prevalence and pathology of Clostridium difficile
Authors: Maggi Banning
Published: May 2014

Clostridium difficile was promoted as the bug of the 1990s due to its high rate of infection in older people and those exposed to colonization following a course of antibiotics. Infection with C. difficile follow two paths: either spontaneously resolve or progress to C.difficile−associated diarrhoea (CDAD). Management with fluids and antibiotics is the most common treatment plan. However, probiotics can also be beneficial and help to reduce relapse and re−infection. In hospitals, clean environments can reduce the incidence of C. difficile infection. Nurses working in gastroenterology need to be current in their practice and, therefore, knowledgeable about the benefits to patients of using alternative treatments, such as probiotics in the management of CDAD.
what the journals say
Authors: Williams Julia
Published: May 2014

High socio-economic status (SES) has been associated with an increased tendency to develop colorectal cancer, while low SES impacts on survival. The aim of this study was to investigate whether the social gradient could be attributed to other factors such as comorbidities, lifestyle or treatment.
New arrangements for the provision of stoma appliances: Appliance use reviews
Authors: Katt Carol
Published: May 2014

On 1 April 2010, new arrangements for the provision of stoma and urology appliances-and related services-in primary care come into force. With full compliance expected by 31 December 2010, it is crucial that stoma care nurses understand the aims, purpose and implications of the new arrangements, in particular the introduction of appliance use reviews (AURs) to be undertaken by dispensing appliance contractors and pharmacy contractors. Carol Katt′ argues that primary care trusts should seek to commission comprehensive stoma care services rather than pay for AURs which may have limited benefit and disrupt patient pathways.
Improving endoscopy
Authors: Thomson Libby
Published: May 2014

Welcome to this special issue of GIN to mark the annual conference of the British Society of Gastroenterology (BSG) in Liverpool between 22–25 March 2010. The BSG conference is an excellent platform for continued professional development and networking in endoscopy and provides a fitting conclusion to a busy year for training and improving standards for the specialty. In England, the first round of accreditation visits by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) is coming to an end while the rest of the UK is busy preparing for the full visit process to be rolled out. All the regions have started or are about to start bowel cancer screening and I am delighted with JAG′s success in making the Gastrointestinal Endoscopy for Nurses (GIN) training programme available to all endoscopy staff across the UK.
Complementary and alternative therapies in Crohn's disease and ulcerative colitis
Authors: Hawthorne AB
Published: May 2014

Complementary and alternative medicines (CAM) are treatments that fall outside conventional science and medicine. Users of these therapies may consider them more ′wholesome′ than modern pharmaceuticals, and relevant to approaches of holistic and individualized care. While up to half of inflammatory bowel disease (IBD) patients use CAM, the number of high-quality trials of CAM in IBD is extremely limited. Alternative therapies cannot be ignored, explains AB Hawthorne, as patients will continue to use them in chronic conditions such as IBD which are difficult to control through conventional drugs. Health professionals should be well informed about available CAM, and the evidence (if any) of benefit or harm.
Is rectal transplantation possible to save lives and improve quality of life?
Authors: O'Bichere Austin , Peck Jacquie
Published: May 2014

Experiments have shown rectal transplantation to be technically feasible, although there remain obstacles such as returning physiological function and immunological considerations.Austin O'Bichere and Jacquie Peck argue that further interest in this novel method of restoring normal anal defaecation after excision of the rectum will be driven by the desire to restore quality of life by transplantation of non-essential organs.
Rebranding to connect with the public
Authors: Clark Suzi
Published: May 2014

After 30 years of being known as the National Association for Colitis and Crohn's Disease, the charity has rebranded with a new working name, Crohn's and Colitis UK. This is a brave move during a recession and at a time when branding and fundraising are even more critical than ever.
what the journals say
Authors: Coutts Alison
Published: May 2014

Alison Coutts, senior lecturer in applied biological sciences, City University, London, provides a brief overview of recently published nursing and health articles. A reference is provided for further information.
Managing passive incontinence and incomplete evacuation
Authors: Collins Brigitte , Norton Christine
Published: May 2014

Both passive faecal incontinence and evacuation difficulty are distressing and demoralising conditions, resulting in physical and psychological problems including social restrictions, loss of self-esteem, altered body image and loss of skin integrity. Conservative management and biofeedback therapy have been shown to help by creating a manageable situation that can significantly improve quality of life. However, some patients may not improve their symptoms and would require alternative measures. In this article, Brigitte Collins and Christine Norton report an audit of the use of the Qufora mini irrigation system in 50 patients (48 female, 2 male) with passive faecal incontinence and/or evacuation difficulty, who had failed to respond to conventional biofeedback. In all, 70% found the irrigation comfortable and 74% rated the system as good or acceptable. Moreover, two thirds believed that the symptoms improved and would wish to continue using the system. Prospective studies are needed to confirm which patients would respond well to the irrigation.
H2RBs vs PPIs part 2: histamine-2 receptor blockers as a first-line agent for peptic ulcer disease prophylaxis
Authors: Regidor Ronnell
Published: May 2014

In the first part of this two-part series, the author reviewed several studies assessing the clinical scenarios in which histamine-2 receptor blockers (H2RBs) and proton pump inhibitors (PPIs) should be used. Although H2RBs and PPIs have been used extensively in the treatment of peptic ulcer disease (PUD), little is known about which should be the initial medication for PUD prophylaxis. PPIs tend to be stronger than H2RBs and are therefore more frequently prescribed in hospitals; however, their overuse can be detrimental to healthcare outcomes. Since H2RBs have evidenced themselves to be on par with PPIs, but with fewer side effects, in the second part of this two-part series, Ronnell Regidor explains why HR2Bs should be considered as the initial treatment for PUD prophylaxis.
Early identification of patients with psychological distress: the role of inflammatory bowel disease nurses
Authors: Swart Nicholas , Friedli Karin , Price Tracey , Johnson Matthew W , Wood Greg
Published: May 2014

Psychological complications in patients with inflammatory bowel disease (IBD) reflect the complexity of coping with a chronic disease. Roughly 30% of patients with IBD have symptoms of psychological distress ( Mikocka-Walus et al, 2007 ). Such distress often goes unidentified, although the effect on disease severity, management, and patients’ use of hospital services can be profound. Even though nurses often feel they do not have the training or skills to identify and deal with patients with psychological problems, yet they find that giving psychological and social support to patients forms a key part of their daily routine. This article provides a simple and straightforward explanation of psychological distress, and provides brief and practical screening tools that can be used in everyday settings to help identify patients in distress.
ERCP and diagnosis of unexplained hyper-bilirubinaemia
Authors: Tiwari Alok , Hussain Musurat , Coker Julian B , Jacob Sabu , Bettany George EA
Published: May 2014

A 72-year-old man presented with a 2-day history of malaise, rigors, shortness of breath, delirium and a dry cough. He was dehydrated, pyrexial (39°C), tachypnoeic and jaundiced. He had bibasal crepitations and right upper quadrant tenderness with mild hepatomegaly. Blood tests showed him to be anaemic with mild neutrophilia, lymphopenia, hyponatraemia and raised urea and creatinine. His bilirubin was 65 (<17mmol/litre). Chest radiograph showed basal reticulonodular shadowing. A preliminary diagnosis of Legionella pneumonia was made and antibiotics were commenced.
An unusual presentation in the emergency department with ‘hands up’ posture
Authors: Sharma H , Lindsay JR
Published: May 2014

A75-year-old right-hand dominant woman attended the emergency department with both arms locked in the erect position. She had fallen off a ladder and had landed vertically down on both outstretched hands. Her past medical history was unremarkable. She had had no previous shoulder trauma. On examination, both humeral heads were palpable in the axillae, lying against the lateral chest walls. On neurological assessment of the extremity, paraesthesia in the regimental badge area with deltoid weakness was noted, affecting the left shoulder. Bilateral inferior shoulder dislocations, with no associated bony injuries, were confirmed on a chest X-ray (Figure 1). A closed manipulation was successfully performed under sedation in the emergency department (Figures 2 and 3).
Histopathology training schools 4 years on
Authors: Giles Tom , Griffin Nick , Leonard Niamh , McGregor Angus
Published: May 2014

The initial three pilot histopathology senior house officer schools have improved training efficiency and effectiveness. Additional schools have been established to develop a national network of histopathology training schools. Their success provides lessons for the organization and delivery of structured training in other medical specialties.
The intensive training and assessment programme in histopathology
Authors: Bharucha Hoshang , Coles Colin , Foria Vipul , Gallagher Patrick J , Mountford Brenda
Published: May 2014

A large number of experienced overseas graduates are attracted to the UK and form a significant proportion of applicants for training positions in histopathology. An individually tailored 3-month post can be used to evaluate the overseas doctor's abilities and assess his/her suitability for higher specialist training.
Non-pharmacological treatment of arrhythmias
Authors: Kiistler Peter M , Schilling Richard J
Published: May 2014

This article reviews the role of electrophysiological study and catheter ablation for the management of supraventricular and ventricular tachycardias. Catheter ablation is playing an increasingly important role in the management of patients with cardiac arrhythmias.
General practice in the foundation programme: evaluation of a brief embedded experience
Authors: Swanwick Tim , Firth-Cozens Jennifer
Published: May 2014

Modernising Medical Careers aims to provide an experience in general practice for all doctors in the foundation programme. Is this desirable, and what constitutes a meaningful experience in primary care? This evaluation of a brief embedded attachment reports on an alternative to the 4 months in general practice which will be on offer to the majority of trainees in 2006.
Treatment for heart failure: good news and bad
Authors: Assomull Ravi , Elliott Perry M
Published: May 2014

Heart failure is a common disorder associated with significant morbidity, mortality and financial burden to health services. The pharmacotherapy of heart failure, including new treatments, will be discussed.
Does prolapse surgery address the symptoms that concern women?
Authors: Radley Stephen , Brown Oliver
Published: May 2014

Clinicians are constantly being challenged to improve services and the care provided for individual patients. This article looks at the current approach to the management of uterovaginal prolapse in women and explores new developments in the assessment of prolapse and related pelvic floor disorders.
Cavitating lung disease in ankylosing spondylitis may have other causes
Authors: Nour EM , Taylor KJ
Published: May 2014

A 64-year-old man, who was an ex-miner with a 15-year history of ankylosing spondylitis was admitted with cough, purulent sputum and shortness of breath. He was a smoker with a 20 pack-year history. His lung function tests showed mainly restrictive disease but clinically there was an element of chronic obstructive pulmonary disease (COPD).

Physical examination showed him to be cachectic, afebrile, there was no finger-clubbing or lymphadenopathy. Chest examination showed reduced expansion and scattered wheezes. There was marked kyphoscoliosis of the dorsal spine and limited cervical spine movement. While his chest X-ray in 1994 was normal, subsequent chest X-rays showed progressive fibrocystic disease with extensive changes in the right side (Figure 1). His thoracic computed tomography scan showed bilateral fibrobullous disease and the right cavities were thick-walled with at least one fluid level, suggesting active disease, and there was marked pleural thickening over both apices (Figure 2).

Radiograph of the spine showed typical changes of ankylosing spondylitis with complete bony bridging of sacroiliac joints and ankylosing of the spine. Full blood count was normal; there was no evidence of eosinophilia. Tuberculin test was negative. Sputum smear and culture for acid-fast bacilli were negative. He was treated for exacerbation of COPD and his condition improved with a course of antibiotic and he was discharged home. He was readmitted a few months later with type 2 respiratory failure but, despite treatment, died. A post-mortem macroscopic examination showed severe bilateral apical pleural fibrous adhesions, severe emphysematous changes and marked scarring with fibrosis in the upper lobes and a 5 cm cavity in the right upper lobe. Histological examination showed caseating granuloma (Figure 3), indicating active tuberculosis but no acid-fast bacilli were seen.
What do specialist registrars know about clinical governance?
Authors: Beavan JR , S Briggs , Corrado OJ , Turnbull CJ
Published: May 2014

These negative feelings may account for the authors' finding that, except for audit which has generally been accepted, SpRs are taught less about other areas of clinical governance by their supervisors. It is important that the positive benefits and outcomes of clinical governance are emphasized to SpRs during their training.
Pitfalls in recurrent varicose vein surgery
Authors: Cheung KS , Khan SM , How P , Hamilton HEC
Published: May 2014

A 62-year-old lady previously had a left sapheno-femoral ligation with stripping of the long saphenous vein and multiple avulsions 10 years ago. The pre-operative duplex scan, performed by an experienced vascular technologist, showed a patent and competent deep venous system with no evidence of previous deep vein thrombosis. The sapheno-femoral junction (SFJ) was shown to have been surgically ligated but a small tortuous recurrence was noted to fill the groin varices. It was evident that the proximal long saphenous vein had been stripped. The residual mid-thigh long saphenous vein was significantly incompetent and filled by the sapheno-femoral junction recurrence and by a large atypical incompetent branch that coursed medially and proximally to the sapheno-femoral junction. The duplex report was reviewed by the surgeons and operative religation of the SFJ with avulsion of the new varicose veins was considered the best management.

The patient had no clinical episode of deep venous thrombosis before surgery, but the large medial thigh varicose vein appeared to be unusual. Chase Farm Hospital have a policy of performing on-table varicogram for all atypical veins because a significant proportion could be a result of ovarian vein incompetence (Giannoukas et al, 2000) and the source may not be detected by duplex imaging (Urigo et al, 1993).

Peri-operatively, a tributary of the atypical large medial thigh varicose vein was cannulated and an on-table varicogram was performed (Figures 1–3). It showed the absence of the ipsilateral left femoral vein with the contrast draining across the pubis into the contralateral femoral vein. The left groin was explored surgically to verify the varicogram findings and the surgeons were expecting to find an SFJ recurrence. The left femoral vein was found to be a thin solid cord structure with no doppler signal audible. This was presumed to have become fibrotic either from previous sapheno-femoral ligation or from previously unknown deep venous thrombosis prior to surgery.

It was therefore decided that the SFJ recurrence should be left alone as the only venous outflow for the left leg was via these upper medial thigh recurrent varicose veins and the superficial collaterals that had developed across the pubis. The latter was recognized as being exactly the superficial venous reconstruction described by Palma (1976) for iliac venous obstruction. This phenomenon occurred naturally in our patient as a consequence of an unrecognized deep venous thrombosis in the left common femoral and external iliac veins (auto-Palma phenomenon) (Figure 4 (iv)).
The importance of sleep
Authors: Cummin Andrew RC
Published: May 2014

‘Welcome little stranger’ wrote my grandmother when I was born. But I was not welcome for long. I was a ‘difficult baby’, as I was reminded half a century on. The problem was that I would not sleep. Keeping your mother awake is not the best start to a relationship. We all know the importance of sleep. Or do we?
Hepatic hydrothorax
Authors: Awasthi AK , Cramp ME
Published: May 2014

A 67-year-old man was admitted with a 1-week history of shortness of breath. He was a heavy smoker with alcohol consumption exceeding 40 units per week. On examination he was apyrexial and had signs of a right-sided pleural effusion. His liver was enlarged 3 cm below the costal margin. There was no ascites or splenomegaly. His jugular venous pressure was normal and there was no pedal oedema. On his initial investigations, he had normal urea and electrolytes and normal liver function tests except for a low albumin level of 28 g/litre.

The chest X-ray confirmed a large right-sided pleural effusion. The pleural fluid had a low protein/albumin content (pleural fluid albumin 8 g/litre), but in view of the history of heavy smoking, large pleural effusion and hepatomegaly, a diagnosis of possible bronchogenic carcinoma with liver metastasis was made. The computed tomography (CT) scan of the chest failed to reveal a cause for the pleural effusion. The pleural fluid cytology, bronchoscopy and echocardiogram were normal. An ultrasound of the abdomen showed an irregular liver with possible single metastasis and minimal free fluid in the abdominal cavity.

He had a chest drain inserted which continued to drain more than 3 litres of fluid daily for 5 days. A thoracoscopy and pleural biopsy were normal. He had two attempts at pleurodesis with talc and tetracycline both of which failed to stop fluid from reaccumulating. He then had a tunnelled pleural drain inserted. This still continued to drain large amounts of fluid for the next 8 days. Therefore a parietal pleurectomy was carried out.

A repeat ultrasound at this stage showed no ascites but an irregular liver suggestive of cirrhosis and a possible malignant lesion within the liver. He had a modestly raised alpha-fetoprotein level of 65 ng/ml (normal range 0–10 ng/ml). He was referred to the authors and a diagnosis of hepatic hydrothorax was made. He was treated with salt restriction and spironolactone. He responded well to treatment and stopped reaccumulating fluid.

A biphasic CT of the abdomen and hepatic angiography confirmed the diagnosis of multifocal hepatoma. His liver biopsy was consistent with cirrhosis secondary to alcohol.
Injuries to the distal radius
Authors: Oussedik Sam
Published: May 2014

The distal radius includes the metaphysis, formed mainly of cancellous bone, supporting the articular surface (Figure 1). This articular surface is biconcave, allowing articulation with the proximal carpal row (the radio-carpal joint) and has a sigmoid notch for articulation with the distal ulna (the distal radio-ulnar joint (DRUJ)).
Supraventricular or ventricular tachycardia?
Authors: Lambiase Pier
Published: May 2014

A 30-year-old Bosnian man presented to casualty with a 24-hour history of persistent palpitations. He had no significant past medical history and was not taking any non-prescription medication. On arrival in accident and emergency his pulse was 130/min and his blood pressure was 120/80 mmHg. He was initially administered intravenous (IV) adenosine up to a dose of 24 mg which had no effect on the tachycardia. IV lignocaine 200 mg failed to cardiovert the patient. Therefore, three attempts at DC cardioversion were made to a maximum of 360 J delivered anteroposteriorly. This was ineffective. What is the diagnosis on the electrocardiogram (ECG) in Figure 1 and what drug would successfully cardiovert this patient?
Injuries around the elbow
Authors: Jenabzadeh AR , Haddad FS
Published: May 2014

The elbow joint is a complex hinge which is important for the range of motion and mobility of the upper limbs. Injuries of the elbow fall into two groups: those of children and those of adults. This article offers an overview of common elbow injuries.
Injuries of the humeral shaft
Authors: Young Claire F
Published: May 2014

The humeral shaft is triangular in cross section and runs from just proximal to the insertion of pectoralis major to the metaphyseal flare and supracondylar ridge distally. It is the long bone of the arm co
How to perform an arteriovenous fistula
Authors: Hakim Nadey S
Published: May 2014

Endogenous arteriovenous fistula (AVF), first described in 1966, remains the optimal vascular access for chronic dialysis. An internal AVF avoids the disadvantages of an external appliance, such as frequent septic and clotting problems. In spite of surgical innovations, such as autogenous vein interpositional grafts, bovine heterografts, expanded polytetrafluoroethylene (ePTFE) grafts and permanent indwelling silastic central venous catheters, the Brescia–Cimino fistula has remained the best access for maintenance haemodialysis because of its low incidence of complications and high long-term patency rate. The 1- and 3-year cumulative patency rates are 85–90% and 60–85% respectively.
So you want to be … an orthopaedic surgeon
Authors: Haddad Fares
Published: May 2014

The increasing pressures of the medical curriculum lead to a relative underexposure of most undergraduates to orthopaedic surgery. Nevertheless orthopaedics is a flourishing and ever expanding specialty as a result of remarkable developments in the past 50 years and increasing need in an ageing population. A worldwide initiative, the bone and joint decade, has already seen a massive expansion in the numbers applying for registrar and consultant posts in orthopaedic surgery and this trend is going to increase.
Medical regulation: promoting excellence and safety
Authors: Gupta Romesh , Singh Iqbal , Vaidya Abhay
Published: May 2014

The report Good Doctors, Safer Patients (Department of Health, 2006), recently published by Sir Liam Donaldson, Chief Medical Officer of England, has generated a great deal of interest and debate in the General Medical Council (GMC) and the medical profession at large. Sir Liam has made 44 recommendations and consults on key changes in medical education and regulation. This editorial reflects on some of these recommendations regarding medical education and regulation in order to take it forward to produce excellent doctors working in an environment where patients are assured of safe and quality health care.
Facial flaps for facial skin lesions
Authors: Snow David
Published: May 2014

This article covers basic surgical principles for the use of local flaps in facial skin reconstruction. Some surgical details of commonly used flaps are included, but detailed classification of facial flaps is not covered. Readers are referred to standard texts for more detail of individual flap design and use.
Evaluation of the chest X-ray: a pictorial review
Authors: Kasznia-Brown Joanna , Cooke Chris
Published: May 2014

This article aims to provide the reader with a step-by-step guide to the accurate interpretation of the chest radiograph. It begins by discussing the importance of patient and radiographical features, and then describes the main anatomical structures that can be seen on the chest radiograph.
Educational strategies for the foundation years: developing teamwork, communication and teaching
Authors: C Stewart Moira , L Morison Susan , Moriarty Paul
Published: May 2014

This article considers how the requirements of the new curriculum for the foundation years to develop teamwork, teaching and communication skills can be met by involving trainee doctors in the development and implementation of interprofessional education for undergraduate students.
Diffuse cerebral oedema mimicking subarachnoid haemorrhage on computed tomography
Authors: Vaidhyanath R , Khan MA , Messios N
Published: May 2014

A 62-year-old man with a history of petrol consumption was admitted to the accident and emergency department of an adjacent district general hospital by paramedics. He complained of headache and difficulty in breathing. On admission his Glasgow Coma Scale was 10/15 which rapidly deteriorated to 4/15. An unenhanced computed tomography (CT) scan was performed immediately which showed obliteration of basal cisterns consistent with brainstem oedema. He was mechanically ventilated with inotropic support and then transferred to the intensive care unit of the authors' institution. Relevant past history included alcohol abuse, manic depressive psychosis and carbamazepine overdose.

Following transfer, sedation was withdrawn and the patient reassessed. He had fixed dilated pupils, no respiratory effort, absent gag reflex and response to pain. He was also hypernatraemic with a serum sodium level of 170 mmol/litre (normal range 133–144 mmol/litre). Toxicology for paracetamol and salicylates was negative.

A repeat unenhanced CT scan was performed at this stage. This showed high attenuation in the tentorium (Figure 1a), basal cisterns (Figures 1b and c) and in the sylvian fissures (Figure 1d). There was no history of injection of intravascular or intrathecal iodinated contrast media. This was initially interpreted as subarachnoid haemorrhage. On subsequent review, the diagnosis was changed to diffuse cerebral oedema.

In view of a failing brainstem and after discussion with the patient's family, treatment was withdrawn. A post mortem examination performed by the coroner showed no evidence of subarachnoid haemorrhage.
Hyperhidrosis: current management
Authors: Jaffer Usman , Cameron Alan
Published: May 2014

Hyperhidrosis can be a distressing problem for the afflicted patient and is commonly encountered by both primary care and hospital physicians. This article reviews the essentials of diagnosis and current treatment modalities available for various forms of hyperhidrosis.
Different diagnosis for two decades of dysphagia
Authors: Parr J , Macdonald CE
Published: May 2014

A 76-year-old man was referred in 2004 for assessment of longstanding dysphagia. His symptoms had changed slightly in that he had been experiencing some regurgitation of food up to 24 hours after a meal. He had first presented in 1984 with a complaint of food sticking on the way down, at the level of the epigastrium, which was intermittent in nature and worse with meat and bread. He had a 15-year history of indigestion at that time and was investigated with a barium meal and a gastroscopy (OGD), both of which were normal. As his symptoms were not progressive or troublesome he was discharged from follow up.

He was referred again in 1996 with similar symptoms. The dysphagia had been well controlled by avoiding foods that worsened his symptoms. OGD at that stage proved normal and the patient had settled. He was discharged with a diagnosis of mild motility disorder and advice to re-refer should things change. He attended in 2004 with a change in symptoms – he felt food now seemed to get stuck higher up with regurgitation of contents of previous meals. No worrying symptoms were noted and physical examination was normal.

The patient was booked for further OGD and oesophageal manometry to take place on the same day. The OGD was carried out first and it became apparent he had developed a pharyngeal pouch, which was later confirmed on barium swallow (Figure 1). The rest of the examination was normal. He also underwent manometry with the probe being placed over a guidewire. This revealed the presence of incoordination of peristaltic waves with simultaneous pressure rises in the lower oesophagus (Figure 2). It also showed a hypertensive lower oesophageal sphincter (max pressure 53 mmHg) that relaxed appropriately (Figure 3). The patient was referred to the ear, nose and throat surgeons for further management as the pouch was the main contributing factor in the new symptoms. He underwent an uncomplicated endoscopic stapling diverticulotomy with a return to previous level of function.
The audit cycle: a guide to success
Authors: Brown Peter M
Published: May 2014

Audit is an ongoing process that few achieve properly. Audit should be a catalyst for improvement in practice.This article will explain how to ensure a successful audit that may be accepted for presentation or for publication.
Treating learned helplessness in hospital: a reacquaintance with self-control
Authors: Lawrence-Smith Geoff , Sturgeon David
Published: May 2014

The concept of learned helplessness has been applied successfully to psychological interventions for the elderly and outpatients with chronic illness. However, learned helplessness goes largely undetected in general hospital inpatients. This article addresses this and outlines simple techniques for treating learned helplessness on the ward.
Sir David Bruce, a pioneer of tropical medicine
Authors: Ellis Harold
Published: May 2014

November 27 2006 marks the 75th anniversary of the death of Sir David Bruce at the age of 76 years. He was one of a distinguished group of British physicians, mostly serving in the Royal Army Medical Corps (RAMC) or the Indian Medical Service (IMS), who made enormous contributions to the knowledge of the aetiology, spread and control of a number of important tropical diseases.
Realizing the research potential of the NHS
Authors: O'Toole Liam
Published: May 2014

The NHS is a unique institution globally, providing a gateway to the largest single pool of patients in the world, and caring for those patients from ‘cradle to grave’. The NHS should provide the perfect environment in which to carry out high quality clinical research for the benefit of patients and, while a large amount of good research does take place, conducting clinical research in the UK is much harder than it need be.
Treatment of rare cancers: gastrointestinal stromal tumours
Authors: Cowie Fiona
Published: May 2014

Gastrointestinal stromal tumour, the most common mesenchymal malignancy of the gastrointestinal tract, is a rare cancer that until recent years had severely limited therapeutic options. This article looks at its epidemiology, aetiology, pathophysiology, diagnosis, current treatment and potential new treatment options on the horizon.
Modernising Medical Careers and the career framework
Authors: Heard Shelley
Published: May 2014

Postgraduate medical training in the UK is undergoing a major change in focus and direction, reflecting in many ways the changes taking place in the NHS. The impetus for this change was the publication of Unfinished Business (Department of Health, 2002), a review by the Chief Medical Officer originally designed to consider the senior house officer (SHO) grade of postgraduate training, but ultimately taking a wider view of the structure and purpose of postgraduate training overall.
Tonsillar haematoma presenting as a large oropharynx mass caused by toothbrush trauma
Authors: Leong Samuel C
Published: May 2014

A 43-year-old man was referred urgently by his GP with a large mass at the back of his throat. The patient had complained of a mild foreign body sensation for the past 3 days, but was distraught to see the mass in the mirror while he was flossing. On further questioning, he recalled brushing his teeth too vigorously and having injured himself. He reported spitting out some blood into the sink but not being unduly distressed. He was a non-smoker and was had no significant past medical history.

On examination, there was a 3 cm smooth mass in the right orophapryx (Figure 1). The mass was soft and attached to the right tonsil via a pedicle. Flexible nasendoscopy was normal and there was no evidence of airway obstruction by mass effect. Under local anaesthesia, the mass was removed with the use of a snare. Full blood count and coagulation studies were entirely normal. Follow-up outpatient clinic at 4 weeks was unremarkable. The tonsillar remnant had healed completely and there was no suspicion of any underlying pathology. Histopathology was consistent with that of infarcted tonsillar tissue.
Thyrotoxic hypokalaemic periodic paralysis
Authors: Balami Joyce , Jones Hywel , Newey Paul , Seymour Jonny
Published: May 2014

A 24-year-old male Chinese student from southern China presented with sudden onset of generalized weakness. The evening before admission he had played football for 3 hours, and eaten a Chinese takeaway plus two hamburgers. He awoke in the early hours of the following morning unable to move his arms or legs. There was no history of any recurring illness and in particular there were no symptoms suggestive of hyperthyroidism.

On examination the only abnormality was a profound symmetrical muscle weakness more marked proximally than distally (Medical Research Council (MRC) classification grade 1–2). Sensation to light touch and pinprick was normal. There were no signs of thyrotoxicosis.

Laboratory investigations revealed the following (normal values in parentheses): serum potassium 1.2 mmol/litre (3.5–5.0); urinary potassium 14 mmol/litre (20–60); phosphate 0.18 mmol/litre (0.8–1.45); sodium, urea, and creatinine levels were normal. Electrocardiogram showed first degree atrioventricular block, prolonged QT interval and right axis deviation.

He was given 120 mmol of intravenous potassium supplement over 12 hours. Over the next 24 hours his serum potassium returned to 4 mmol/litre, with complete resolution of the weakness.

Subsequent investigations showed the following thyroid hormone measurements: thyroid-stimulating hormone (TSH) <0.08 mU/litre (0.5–6.0), triiodothyronine (T3) 3.7 nmol/litre (1.0–2.5), free thyroxine (T4) 53.7 pmol/litre (9.0–25.0), and thyroid peroxidase antibodies 124 IU/ml (0–75). He was HLA B46 and D9 positive. Ultrasonography of the thyroid gland revealed a mildly enlarged, heterogeneous thyroid with no discrete nodules and increased vascularity throughout.

He was started on treatment with propranolol and carbimazole and returned home to China to seek further medical treatment.
Interpretation of ankle and foot radiographs
Authors: Allen Steve D , Harvey Chris J , O'Regan Declan
Published: May 2014

Lower limb trauma is extremely common, with foot and ankle radiographs frequently simultaneously requested, as clinically it is often difficult to elucidate the exact site of trauma. Careful clinical assessment is imperative to minimize the amount of unnecessary radiographs. Plain radiographs remain the first-line investigation, but interpretation can be difficult because of the variety of possible injuries, and their sometimes subtle appearances. Understanding of normal anatomy is key to avoiding errors in the management of these injuries. This article provides a systematic approach to interpreting ankle and foot radiographs and describes the common conditions requiring these X-rays along with radiological signs.
Hind foot fractures of the calcaneus and talus
Authors: De Medici Aklbar , Oussedik Sam , Haddad Fares
Published: May 2014

The foot has two vital functions, first to support the body while standing or walking and second to act as a lever in propelling the body forward. Hence any damage to the structures that make up the foot will have a significant impact its function. Fractures of the hind foot are not uncommon and make up 2% of all fractures seen in adults. They are frequently missed, especially osteochondral fractures and fractures of the lateral and posterior processes of the talus which are radiographically difficult to detect. Controversies remain over the ideal management of these fractures and no one surgical strategy has eliminated the often significant long-term disability associated with these injuries. These difficulties make hind foot fractures an area of potential disaster, both for the patient and doctor.
Phlebotomy tips for junior doctors
Authors: Dandapani Madhumita , Rajagopalan Sriram
Published: May 2014

The term phlebotomy refers to the ancient practice of blood letting, which involved the withdrawal of large amounts of blood in an attempt to cure illnesses and disease. This practice has been virtually abandoned but the term phlebotomy is still widely used for the withdrawal of blood from a vein, artery, or the capillary bed into blood specimen collection tubes for laboratory analysis or blood transfusion.
Electrocardiographic changes in acute coronary syndromes
Authors: Pandya Bejal , Strike Philip C
Published: May 2014

Acute coronary syndromes (ACS) remain one of the greatest global causes of mortality and morbidity. Rapid diagnosis and treatment are paramount. Despite scientific advances, the electrocardiogram (ECG) remains the cornerstone of ACS diagnosis, classification, risk stratification and management. In 2002, an expertcommittee of the American College of Cardiology and the European Society of Cardiology redefined ACS. The new definition incorporated the new diagnostic markers of myocyte necrosis, troponins, and also redefined the electrocardiographic criteria for ACS diagnosis (Alpert et al, 2000).
Foundation programme assessment: the trainee's guide
Authors: Dolphin Tom
Published: May 2014

The enormous process of reforming the training grades is described in the Department of Health document, Modernising Medical Careers (Department of Health, 2003). The changes are being made in sequential order, with the preregistration house officer (PRHO) and first senior house officer (SHO) year being the first to change. These 2 years have been combined into one foundation programme (FP), intended to produce doctors with a range of generic core competencies (Department of Health, 2005) (i.e. skills and knowledge common to all doctors completing their FP) that match the areas covered by the General Medical Council's Good Medical Practice (General Medical Council, 2001).
Taking a psychiatric history
Authors: Ali Afia , Hassiotis Angela
Published: May 2014

This article is part of a series on psychiatry aimed at providing a framework for the diagnosis and management of common psychiatric disorders.
So you want to be … a vascular surgeon
Authors: Bicknell Colin , Hussain Tahir
Published: May 2014

For those who are dedicated to a career in a surgical specialty, vascular surgery is attractive for many reasons. There is close patient contact that is rarely achieved in other surgical specialties, elegant surgical operations that can often make the difference between life and death, and exciting new developments in the field of endovascular surgery. Many are put off, however, by common misconceptions of vascular surgery borne out in terms such as the ‘fem-dismal’ operation, ‘salami slicing amputations’ and ‘ascending chiropody’.
Conducting a mental state examination
Authors: Ali Afia , Hassiotis Angela
Published: May 2014

The mental state examination begins as soon as the patient walks into the consultation room, and describes the symptoms experienced or exhibited at the time of the examination. It serves the purpose of confirming or supporting the diagnosis suggested by the history. The mental state examination can be divided into the following categories: appearance and behaviour, speech, mood, thought content, perceptions, cognition, and insight.
Medical students' attitudes to Modernising Medical Careers: will it affect training or career choice?
Authors: Nixon MF , Wordsworth DR , Wallis DD
Published: May 2014

August 2005 was a landmark in medical education in the UK as this is when the changes suggested in the 2004 Department of Health white paper Modernising Medical Careers (MMC) were implemented. MMC is a bold attempt to address the conflicting demands of the European Working Time Directive, the educational needs of junior doctors, and quality service delivery to patients.
Managing the violent patient
Authors: Ali Afia , Hassiotis Angela
Published: May 2014

Managing the violent or acutely disturbed patient can be a difficult and stressful task. Most doctors are likely to encounter such patients in the emergency department or in inpatient psychiatric settings, but such patients may also present on medical or surgical wards. The principles outlined below relate predominantly to the accident and emergency (A&E) setting, but they may be applied to other settings. If the patient presents to A&E or a medical ward, the mental health liaison team should be consulted immediately for a psychiatric assessment of the patient.
Assessment of capacity to consent to medical treatment
Authors: Ali Afia , Hassiotis Angela
Published: May 2014

In England, every adult has the right to make decisions regarding their medical care, even if the reasons appear irrational and the outcome of the decision is likely to be detrimental. Therefore, for example, a Jehovah's witness can refuse a blood transfusion, even if the outcome of refusal is fatal. However, the individual must be well informed, have the ability or capacity to make that decision and should be able to decide without coercion. The Mental Capacity Act 2005, which will come into effect in 2007, states that all adults should be assumed to be capable of making decisions unless proven otherwise, which includes giving or withholding consent to medical intervention (Table 1).
Managing parenteral nutrition at home
Authors: Clare AM , Shaffer JL
Published: May 2014

Home parenteral nutrition is increasing in prevalence and doctors in other specialities may be called upon to treat such patients. This review outlines the practical management of these patients as well as potential pitfalls.
Referrals from GP with special interest clinics should be adequately evaluated
Authors: Rogers Benedict A , Bradley Neil
Published: May 2014

With the goal of improving the provision of accessible services for patients and reducing the demand on secondary care it was intended that by 2006 ‘at least 1 million more outpatient appointments will take place in the community rather than hospital’ (Department of Health, 2002).
Are psychiatric wards becoming safer?
Authors: Swinson Nicola , Kapur Navneet , Hunt Isabelle M
Published: May 2014

Recent increasing recognition of the global burden and extent of suicide has led to worldwide suicide prevention strategies, such as the National Suicide Prevention Strategy for England (Department of Health, 2002). This identified those in contact with mental health services as a priority group and evidence indicates that psychiatric inpatients are at particular risk (Qin and Nordentoft, 2005). Inpatients have been identified as a priority group by the National Confidential Inquiry (Appleby et al, 2006). Given the close proximity to services, they are clearly a group who are potentially amenable to intervention.
Clinical challenges of bipolar depression
Authors: Pandarakalam James Paul
Published: May 2014

The observation that atypical antipsychotic drugs have some role in treating bipolar disorders has revived interest in the management of bipolar disorder. Given the prevalence of and the disability associated with bipolar depression, current medication is inadequate and new research to help patients with this condition is overdue.