bluuebunny/crossref_metadata_2025 huggingface dataset:
Rivastigmine: a review
Authors: Sim Alasdair
Published: May 2014

The acetylcholinesterase inhibitors are the first useful and useable drugs for palliative treatment of dementia of the Alzheimer type. This article reviews the second-generation carbamate cholinesterase inhibitor, rivastigmine (EXELON®, Novartis, Basel) whose distinctive pharmacology is not only of immediate clinical relevance but also the key to some tantalizing therapeutic possibilities.
Prostate disease: an overview
Authors: Anderson John
Published: May 2014

Diseases of the prostate remain the Cinderella of medical practice in the UK as we approach the third millennium. Despite their high prevalence, disproportionately low levels of resources are provided to investigate, treat or promote research into this important cause of morbidity and mortality in men.
Interpretation of the neonatal chest X-ray
Authors: Barnes Nik , Pilling David W
Published: May 2014

Most neonatal X-rays are seen initially by a paediatrician without formal training in interpretation of chest X-rays. This article aims to help improve the information obtained from these X-rays which are often complex. Many factors affect accurate interpretation of the neonatal chest X-ray, including good quality radiographs, appropriate viewing conditions and thorough education.
Bias in surveys
Authors: Davies Huw TO
Published: May 2014

The simple survey is a regular tool in health services research. However, like any research method, surveys can be flawed in design, execution, analysis or interpretation. This short article outlines the basis of good survey design and advises how bias in published studies can be assessed.
Medical workforce and the gender shift
Authors: Clay Barbara
Published: May 2014

The future medical staffing for the NHS needs to take account of the demands of doctors for a humane lifestyle and the service demands of all groups of patients. The increasing numbers of female practitioners and the reduction in hours required by new legislation will be important influences. Suggestions are made about possible future working patterns.
An unusual cause of obstructive sleep apnoea
Authors: Chu CM , Ng PW , Ku PKM
Published: May 2014

Obstructive sleep apnoea is usually associated with obesity and is caused by recurrent collapse of the pharyngeal airway during sleep at multiple levels. Vocal cord paralysis is an uncommon cause of obstructive sleep apnoea. We describe a patient with obstructive sleep apnoea caused by idiopathic vocal cord paralysis. He also had features of autonomic failure including orthostatic hypotension and urinary retention.
Screening for genital Chlamydial infection
Authors: Catchpole Mike
Published: May 2014

Chlamydia trachomatis infection of the genital tract is the commonest sexually transmitted bacterial infection in the UK. Acute infection of the lower genital tract is frequently asymptomatic or associated with mild and nonspecific symptoms, and yet with the exception of HIV, this infection has been associated with higher economic costs than any other infectious disease in developed economies.
Flexible specialist training compared with full-time training
Authors: Goldberg Ilfra , Paice Elisabeth
Published: May 2014

The educational and training quality of flexible training posts compared very well and in some instances was better than that obtained in full-time training. The hours of work were fewer, but as a proportion not as small as is sometimes recognized by the Colleges and is comparable with many full-time training programmes in other European Union countries.
Tachycardia-induced cardiomyopathy caused by atrial flutter responding to DC cardioversion
Authors: Rinaldi Christopher A , Thompson David S
Published: May 2014

A58-year-old man presented in February 1996 to his local hospital with a true posterior myocardial infarction for which he received thrombolysis. He subsequently underwent exercise testing which was terminated because of chest pain and anterior ST depression of >2 mm after 6 minutes of a Naughton Balke protocol. He proceeded to coronary angiography which demonstrated severe triple vessel coronary artery disease. The left ventriculogram demonstrated posterior hypokinesis but overall left ventricular (LV) contractile function was well preserved with an ejection fraction (EF) calculated at 49%. He was in sinus rhythm and had chronic stable angina.

In September 1996 he underwent revascularization on prognostic grounds. Five days postoperatively he developed atrial flutter for which he was started on amiodarone 200 mg once daily and subsequently discharged. Two weeks later he was readmitted with progressive dyspnoea and peripheral oedema. He was found to be in clinical heart failure and atrial flutter with a ventricular rate of 150. He subsequently underwent a successful DC cardioversion reverting to sinus rhythm following a single 200J DC shock. He was discharged on amiodarone 200 mg once daily, frusemide 80 mg once daily, enalapril 10 mg once daily and aspirin 75 mg once daily.

In November 1996 he presented in atrial flutter with heart failure. An echocardiogram was performed showing a dilated hypokinetic left ventricle with an EF of approximately 20% (Table 1). He was anticoagulated and underwent a further DC cardioversion in February 1997 which successfully reverted him to sinus rhythm. Echocardiography was performed following reversion to sinus rhythm (Table 1) which revealed a dilated LV with global systolic dysfunction and functional mitral regurgitation (EF=30%). In April 1997 he reverted to atrial flutter and had significant effort dyspnoea with an exercise tolerance of 50 yards. He was again successfully cardioverted and commenced on sotalol 80 mg twice daily in an attempt to maintain sinus rhythm.

He subsequently remained in sinus rhythm with a marked symptomatic improvement (New York Heart Association Grade 1 dyspnoea and no clinical evidence of cardiac failure). Echocardiography in July 1997 demonstrated a significant improvement in LV dimensions and systolic contractile function (EF=50%) with values equivalent to pre-surgery.
Clopidogrel: a novel antiplatelet agent
Authors: D'Sa Shirley , Machin Samuel J
Published: May 2014

Clopidogrel is a novel antiplatelet agent that has a different mechanism of action to aspirin. Clopidogrel is chemically related to ticlopidine, both of which are more effective than aspirin in preventing some thrombotic events, but it has a safer sideeffect profile than ticlopidine. It is likely to add to the antithrombotic armoury and reduce vascular mortality and morbidity more than current therapies.
Right ventricular involvement in acute myocardial infarction
Authors: Burgess Malcolm I , Ray Simon G
Published: May 2014

The presence of right ventricular dysfunction in patients with acute myocardial infarction has important implications. It is a marker for inhospital mortality and failure to recognize it may lead to inappropriate treatment with serious consequences for the patient. Patients surviving the acute event do, however, have a relatively good long-term prognosis.
Clinical efficacy and antimicrobial pharmacodynamics
Authors: Wise Richard
Published: May 2014

Changes in the susceptibility of bacterial pathogens and the availability of new antimicrobial drugs mean that physicians need to understand the underlying pharmacodynamics of each antimicrobial therapy. Antimicrobial pharmacodynamics determine clinical efficacy and should therefore be carefully considered when selecting appropriate antibiotic agents in the therapeutic setting.
Sudden visual loss and headache: important symptoms of pituitary disease
Authors: Morris AHC , Anderson DF , Browning AC , Mandel CJ , Barker CS , Green WT
Published: May 2014

A63-year-old man presented to the ophthalmology department with a 24-hour history of loss of vision in the right eye and 3 days of severe frontal headache. Six weeks earlier a supero-temporal field defect was observed in the left eye during examination by his optician. A routine referral to the ophthalmology department for assessment of possible glaucoma was made.

On examination he was alert and orientated. The visual acuity was hand movements in the right eye and 6/12 in the left eye with a dense right relative afferent pupillary defect. Visual fields tested by confrontation demonstrated a bitemporal loss. This was confirmed by formal Goldmann visual fields (Figure 1). There was no papilloedema or external ophthalmoplegia and further ophthalmic examination was unremarkable. There were no focal neurological signs and his blood pressure was normal. Serum prolactin was 400U/litre (normal range: 100–500 mU/litre).

A computerized tomography scan (Figure 2) revealed an intrasellar mass expanding the sella turcica and extending into the suprasellar cistern. There were small high density foci suggesting a recent haemorrhage within a pituitary adenoma.

The patient underwent transphenoidal decompression of the pituitary tumour and histopathology confirmed haemorrhagic pituitary adenoma. Repeat visual fields within 1 week of surgery (Figure 3) illustrate dramatic recovery of visual function. Two weeks postoperatively, the patient's visual acuity had improved to 6/24 in the right eye and 6/9 in the left with continued improvement in the visual field. After 5 months his visual acuity was 6/18 right and 6/6 left with almost complete recovery of his visual fields and he was able to return to driving.
Neuropathic pain
Authors: Smith TE , Chong MS
Published: May 2014

Neuropathic pain is a distressing, poorly understood and under-treated condition. In this review we seek to examine the definition and classification of neuropathic pain, summarize clinically important underlying mechanisms, outline current management strategies and look at future directions for research and therapy.
The use of Scopoderm in palliative care
Authors: Spiller Juliet A , Fallon Marie
Published: May 2014

The drug hyoscine has several indications for symptom control for patients with end-stage disease. The transdermal preparation, Scopoderm, is most widely used to control excess salivary secretions but it can also have a role in the management of terminal secretions and in the control of nausea.
An unusual case of recurrent septicaemia
Authors: Robinson Catherine , Cole David , Chambers Stephen
Published: May 2014

A52-year-old farmer presented with a 1-week history of fever, rigors and myalgia. Three days before admission he had developed pleuritic left-sided chest pain. Clinical examination revealed a temperature of 38.4°C and bibasal pulmonary crepitations. Chest radiograph showed an area of patchy pulmonary opacity at the left lung base and a few small areas of opacity in the right lung. A presumptive diagnosis of pneumonia was made. Blood cultures subsequently grew Staphylococcus aureus and treatment with intravenous flucloxacillin was commenced. No other focus of infection was found, investigations included normal transthoracic echocardiogram and abdominal ultrasound scan.

The patient rapidly improved; however, 2weeks later he again became febrile. Further blood cultures grew Klebsiella pneumoniae. An abdominal computed tomography scan showed a high density linear structure straddling the second part of the duodenum and the inferior vena cava, representing a foreign body (Figure 1). Clot could be seen in the vena cava where it had been penetrated. Multiple ill-defined opacities seen in the lung base were consistent with embolization of the lungs. A plain abdominal radiograph showed the foreign body was a 4cm sewing needle (Figure 2). The needle and clot were removed surgically through an incision in the inferior vena cava and culture of specimens yielded both Staphylococcus aureus and Klebsiella pneumoniae (Figure 3) . The patient was treated with cefuroxime and made an uneventful recovery but had no recollection of having swallowed the needle.
Bias in cohort studies
Authors: Davies Huw TO , Crombie Iain K
Published: May 2014

Cohort studies allow an exploration of patient change over time. They can provide information on the incidence of disease, prognosis (including patient satisfaction) and likely health-care resource use. Nonetheless, bias can be present in cohort studies in the way patients are selected and followed-up, the way measures are taken, or the way data are analysed. This short paper explores ways in which such flaws can be uncovered in published studies, so that their findings can be interpreted appropriately.
Self-regulation in the independent sector
Authors: Hangartner Robert
Published: May 2014

Hospitals providing acute surgical and medical care in the independent sector are regulated with nursing homes through the Registered Homes Act 1984. That this legislation is inadequate is accepted within the sector, by Government, and the House of Commons Health Committee (1999a).
Chest pain in the emergency department
Authors: Cooper Angus , Hodgkinson David W , Oliver Richard M
Published: May 2014

The assessment of patients with chest pain is challenging for any emergency physician because of the spectrum of illness covered by this symptom. Patients may have a serious life-threatening condition or a trivial self-limiting illness. This article presents an approach to the assessment and early management of patients presenting with acute non-traumatic chest pain in the emergency department.
MADD or drunk? Adults have inborn errors too
Authors: Stojanovic N , Walker V , Gatling W , Coppini DV
Published: May 2014

Severe genetic enzyme deficiencies cause acute illness in early life and paediatricians are familiar with their presentation. Milder defects may present in adults under conditions of abnormal metabolic stress. Because of their rarity they may be missed.
Disaster medicine: an emerging specialty
Authors: Lumley John , Ryan James
Published: May 2014

The diverse nature of natural and man-made disasters demands a wide range of medical skills and resources from any attendant clinician. Working in a hostile environment may also require armed protection. This article considers the types of disasters, their medical requirements and the training of doctors wishing to be involved in this field of medicine. It includes a description of the Diploma in the Medical Care of Catastrophes.
Bias in case-control studies
Authors: Davies Huw TO , Crombie Iain K
Published: May 2014

Case-control studies are largely used to explore differences between groups of individuals. They can identify potential risk factors associated with disease, or they can investigate patient behaviour, such as why some people do not attend for services. As such, case-control studies are often used to generate or test hypotheses about causal factors. Nonetheless, bias is always a danger in case-control studies, arising especially from the way in which study samples are selected or from the collection of retrospective data. Confounding also remains a problem. This short paper explores ways in which such flaws can be uncovered in published studies.
HIV, childbirth and suicidal behaviour: a review
Authors: Green Lucinda , Ardron Caroline , Catalan Jose
Published: May 2014

Women who are both pregnant and HIV positive may be at particularly high risk of suicidal behaviour. This is important in view of recent guidelines recommending routine antenatal HIV testing. We present a case and review the relevant literature.
Atopic eczema and staphylococcal endocarditis: time to recognize an association?
Authors: Conway DSG , Taylor AD , Burrell CJ
Published: May 2014

An 18-year-old man presented with a 3-day history of malaise, pyrexia, confusion and left knee pain. He had a history of atopic eczema since the age of 6 months but was otherwise well. He had worn a dental brace for the past 2 years without complications and had no recent dental intervention. There was no history of intravenous drug abuse.

On examination he was pyrexial at 39.0°C, clinically dehydrated, with a sinus tachycardia of 100 beats per minute and a systemic blood pressure of 130/80 mmHg. He had eczematous lesions on his face, arms and legs. Auscultation revealed no cardiac murmurs and lung fields were clear. There were no stigmata of endocarditis. He was mentally obtunded with a Glasgow Coma Score of 14/15 but had no other neurological signs. The left knee demonstrated a full range of movement and no obvious effusion. Orthopaedic opinion was of a reactive arthritis.

Chest and left knee radiography was unremarkable. C-reactive protein (CRP) was elevated at 251mg/litre, haemoglobin was 12.4g/dl, leukocytes 11.7×109/litre (with 89% neutrophils) and platelets 26×109/litre. A screen for disseminated intravascular coagulopathy was negative. He was hyponatraemic (sodium 125 mmol/litre) and mildly uraemic (urea 7.8 mmol/litre, creatinine 91μmol/litre).

Blood cultures grew Staphylococcus aureus sensitive to flucloxacillin and gentamicin. Computed tomography (CT) of the brain showed generalized cerebral swelling with effacement of the basal cisterns, but no focal abnormality. Treatment was initiated with intravenous flucloxacillin, gentamicin and fluid replacement.

The following day he developed severe pulmonary oedema and haemodynamic compromise necessitating admission to the intensive care unit for inotropic support and ventilation. Urgent transoesophageal echocardiography showed a 2x2 cm vegetation on the anterior mitral valve leaflet (Figure 1) with marked prolapse and severe mitral regurgitation. There was systolic flow reversal in the pulmonary veins. Left atrial size was normal and left ventricular function good.

He underwent emergency mitral valve replacement with a St Jude mechanical valve (St Jude Medical Inc, St Paul, Minnesota, USA). At operation there was seen to be almost complete destruction of the anterior mitral valve leaflet. His postoperative recovery was good, completing 6 weeks of antibiotic therapy, and repeat CT showed resolution of the cerebral oedema. During the admission he experienced an exacerbation of his eczema and was treated with topical steroids and emollients by the dermatologists.
A case of intraoperative pyrexia
Authors: O’Brien B , Kamaraj T , Ormonde G
Published: May 2014

A 14-year-old boy was admitted via accident and emergency after a road traffic accident. Open fractures of his left radius and ulna required urgent fixation so he was assessed preoperatively. Previous surgery for correction of strabismus had been uneventful and he was otherwise well. He had eaten just before the accident and had suffered significant blood loss. Intravenous fluids and blood were infused to restore haemodynamic stability. Examination was otherwise unremarkable. His temperature was 36°C. Premedication with atropine was prescribed and rapid sequence induction planned using thiopentone and suxamethonium. Cefuroxime was given as an antimicrobial.
HIV resistance testing: value for money
Authors: Omrani AS , Pillay D
Published: May 2014

Human immunodeficiency virus (HIV)-related morbidity and mortality has declined dramatically with the introduction of highly active antiretroviral therapy (HAART) into routine HIV care (Palella et al, 1998). Nevertheless, many health authorities continue to struggle with the excessive health-care costs for HIV infection (Perdue et al, 1998). With the emergence of viral resistance testing as a potentially useful adjuvant to standard HIV care, budget pressures will certainly increase.
Post-intubation tracheal stenosis
Authors: Ahmad I , Pahor AL
Published: May 2014

A42-year-old insulin-dependent diabetic woman was admitted in the intensive care unit with aspiration pneumonia following an episode of hypoglycaemia. She was managed by mechanical ventilation with endotracheal intubation. During her stay she had a pulmonary embolism for which she was heparinized. Myocardial infarction further delayed her weaning from the ventilator. She remained intubated for 11 days. She was discharged after 3 weeks hospital stay, in a satisfactory condition.

After 3 weeks, she presented as an ear, nose and throat emergency with breathing difficulty. She was found to have biphasic stridor and arterial oxygen saturation concentration ranged from 70 to 80%. Flexible naso-laryngoscopy showed normal vocal cords. A plain X-ray lateral view of the neck showed narrowing of the air column in the upper trachea. Her flow–volume curve showed features of severe tracheal obstruction with a reduction in peak expiratory and inspiratory flow. All routine blood tests and chest X-ray were normal. She was managed by humidified oxygen, intravenous hydrocortisone (100 mg three times a day) and co-amoxiclav (1.2 g three times a day). She responded to this treatment very well.

A tomogram of larynx and trachea performed the next day showed a narrowing of theupper tracheal lumen (Figure 1). Flexible bronchoscopy showed a ring of granulations, resulting in a circumferential narrowing of the upper trachea of 2–2.5 cm in length.

She settled with conservative treatment. Serial flow–volume curve measurements also showed a significant improvement. She was discharged after a week and maintained on a reducing dose of oral steroids for 2 weeks. She is still under close follow-up.
The use of sildenafil in heart disease
Authors: Jackson Graham
Published: May 2014

Erectile dysfunction (ED) is common, affecting 30% of men between the ages of 40–70 years to some degree (National Institutes of Health Consensus Development Panel on Impotence, 1993). It increases in incidence with age as does coronary heart disease (CHD), and with an ageing population treating ED co-existing with CHD has become an increasing management challenge. As vascular diseases and diabetes are the major causes of ED, an asymptomatic male presenting with ED should be screened for evidence of occult vascular pathology (Jackson et al, 1999a), with one study identifying a 50% incidence of silent CHD (Pritzer, 1999).
How accurate is cancer scan reporting?
Authors: FitzGerald Richard , Mehra Rakesh
Published: May 2014

The wide recognition of advances in medical imaging need to be matched by an awareness of the significant error rates in radiological interpretation of cancer scans. Common errors, their aetiology and potential solutions are discussed. Internet awareness of these errors has appeared.
Arterial thoracic outlet compression syndrome: a differential diagnosis of painful right supraclavicular swelling?
Authors: Okereke Chikezie Dean , Mavor Andrew , Naim Mukarram
Published: May 2014

The narrow triangle described by the first rib inferiorly, the scalenus medius posteriorly and the scalenus anterior anteriorly confines the neurovascular structures of the upper extremities as they exit from the mediastinum and the spinal canal. In patients with cervical ribs or abnormal congenital fibrous connections between the cervical transverse process and the first rib, the base of the triangle maybe raised to the height of the vertebrae resulting in the angulation or compression of the neurovascular structures. This compression and angulation results in the syndrome known as thoracic outlet compression syndrome (TOCS) (Mann et al, 1995).
Acute medical emergencies: the physician's role
Authors: Winter Robert
Published: May 2014

Medical emergencies are an important and growing component of medical practice. The past 6 years have seen a year-on-year annual growth of 4.4% in non-elective admissions. Thus, in 1992–3, 3 577 266 patients were admitted to acute hospital beds, a number that rose in 1998–9 to 4 642 382 (excluding psychiatry and maternity) (NHS Executive, 2000).
An update on coeliac disease
Authors: Sen Sandip
Published: May 2014

This review article provides an overview of coeliac disease but also highlights its protean manifestations. These can often lead to a delay in diagnosis of this easily treatable condition.
Treating venous thromboembolism: enoxaparin
Authors: Perry DJ
Published: May 2014

This article reviews the developments that have occurred in the treatment of venous thromboembolism during the last decade, with emphasis on the establishment of low molecular weight heparin as a therapeutic agent of proven efficacy and examines the evidence that supports the movement from inpatient to outpatient hospital management of venous thromboembolism.
Atopic dermatitis in childhood
Authors: Lewis-Jones Sue
Published: May 2014

Atopic dermatitis (eczema) is the commonest of the childhood dermatoses, accounting for 20% of all dermatological referrals with many cases continuing into adulthood. The morbidity and costs to society are high.
Nasogastric tube insertion using flexible fibreoptic nasendoscope
Authors: Karagama YG , Lancaster JL , Karkanevatos A
Published: May 2014

The insertion of a nasogastric tube, especially a fine bore feeding tube, can occasionally be problematic because of an anatomical variation or pathology. A method of passing an nasogastric tube under direct vision using a flexible fibreoptic nasendoscope introduced through the nostril is described, which is reserved for cases where traditional methods of insertion failed.
A political asylum seeker with an amoebic empyema in Birmingham
Authors: Banerjee Dev , Clamp Andrew , Stableforth David
Published: May 2014

A previously well 21-year-old male non-smoker from Afghanistan was admitted with a 5- week history of right-sided pleuritic chest pain, weight loss, fever and night sweats. Two days before admission he developed a productive cough with frank haemoptyses. He had arrived into the UK 6 months previously as a political asylum seeker. On examination, he was unwell with an oral temperature of 39.0°C and tachypnoeic at 20 breaths per minute. Respiratory examination revealed signs consistent with a right basal consolidation and an effusion. Cardiovascular and abdominal examinations were unremarkable.
Actos (pioglitazone): a new treatment for type 2 diabetes
Authors: Lawrence JM , Reckless JPD
Published: May 2014

Type 2 diabetes is increasingly common and can be difficult to control. By directly targeting insulin resistance, the thiazolidinediones offer a new mode of treatment. Here, the pharmacology, clinical trial evidence, side-effects and current clinical uses of pioglitazone are reviewed.
Handling clinical negligence claims: implications for the NHS
Authors: Panting Gerard
Published: May 2014

In May this year, the National Audit Office issued its latest report on handling clinical negligence claims in England (National Audit Office, 2001). It made chilling reading. As at 31 March 2000, the outstanding bill for negligence claims stood at £3.9 billion — £500 million up on the previous year.
Updated guidelines for the management of Parkinson's disease
Authors: Bhatia Kailash , Brooks David J , Burn David J , Clarke Carl E , Grosset Donald G , MacMahon Douglas G , Playfer Jeremy , Schapira Anthony HV , Stewart David , Williams Adrian C
Published: May 2014

New data on diagnosis, drug therapy, surgery and psychosocial concerns have emerged since the publication of the 1998 Guidelines for the Management of Parkinson's Disease. This article reviews new data and addresses issues left unanswered in the previous guidelines.
Recent advances in neuroanaesthesia
Authors: Matta Basil , Shankar Ravi
Published: May 2014

In order to provide optimum intracranial operating conditions for neurosurgery, anaesthetists must have a thorough understanding of brain physiology and how this is affected by pathology and anaesthetic drugs and techniques. This article discusses the current understanding of cerebral vascular physiology and how novel neuroanaesthetic drugs and techniques affect it.
Improving the management of chronic myeloid leukaemia
Authors: Neylon Annette , O'Brien Stephen
Published: May 2014

Until recently the therapeutic options available to patients diagnosed with chronic myeloid leukaemia hinged on their suitability for allogeneic bone marrow transplantation. With the advent of new agents targeting the specific molecular pathways involved in the disease, drug therapies may have an increasingly important role in improving outcome.
Why is xenon not more widely used for anaesthesia?
Authors: Meeder Han , Lachmann Burkhard , Tenbrinck Robert
Published: May 2014

Many authors write favourably about the use of xenon as an anaesthetic, but the clinical use of xenon is still limited to a small number of patients.
A training programme for refugee doctors
Authors: Cheeroth Sheila , Ambrose Lucy
Published: May 2014

Apart from the difficulties of being refugees in a foreign land, refugee doctors face complex difficulties in re-entering their medical career in the UK. All must pass the International English Language Testing System with high scores as specified by the General Medical Council, and the vast majority must pass the Professional and Linguist Assessments Board (PLAB) test before they are permitted to practice.
An endocrine potpourri
Authors: Devendra D , Marshall R , Wilkin TJ
Published: May 2014

A 77-year-old woman presented as an emergency with a 1-week history of increasing lethargy, confusion, drowsiness and anorexia. She was known to have active acromegaly, having undergone a transsphenoidal resection of a pituitary adenoma 6 years previously, and a course of radiotherapy 2 years later. She had subsequently developed post-hypophysectomy hypothyroidism, and her acromegaly was known to be still active: a recent insulin-like growth factor (IGF-1) was 49.2 nmol/litre (normal range (NR) 26—29 nmol/litre). Her current medication comprised thyroxine 100 µg daily, bromocriptine 40 mg daily, co-amilofruse 5/40 one tablet daily and aspirin 75 mg daily.
Patients' right to refuse treatment
Authors: Sedgwick Emma
Published: May 2014

The recent decision by the High Court to allow a woman paralysed from the neck down to end her life by refusing treatment upholds a competent patient's right to decline treatment, even if this would lead to his or her own death [Re B v NHS Trust 2002].

The ruling, that a woman known as Miss B could have a ventilator keeping her alive switched off, reinforces a doctor's duty to respect a competent patient's wishes. However, doctors facing difficult decisions such as this often need to seek clarification from the High Court before acting.
Unusual causes of severe orthostatic hypotension
Authors: Nasar M Abu , Murty Shaku
Published: May 2014

Two elderly female patients presented with severe refractory orthostatic hypotension, one of which was an isolated case and the other as a part of multisystem atrophy (MSA; Shy-Drager syndrome). Both patients showed significant improvement in blood pressure (BP) and postural symptoms following administration of midodrine, a peripherally acting a-adrenergic agonist.
Balance disorders in adults: an overview
Authors: Palaniappan R
Published: May 2014

Dizziness is a common and potentially disabling complaint. A multitude of medical and otological conditions may manifest as disequilibrium. Symptomatic improvement in peripheral vestibular lesion is the result of central compensation and not restoration of normal labyrinthine function.
Intestinal ischaemia
Authors: Shetty S , Morris-Stiff G , Lewis MH
Published: May 2014

Over the past three decades major advances have been made in the diagnosis and management of mesenteric ischaemia. Early identification and treatment of this condition has reduced its mortality and morbidity. This review discusses the causes, preliminary and definitive investigations, and treatment protocols relating to gut ischaemia.
Using ‘citizenship’ to deal with feelings of hate in psychiatry
Authors: Ikkos George
Published: May 2014

Clinicians' feelings of hate towards their patients may contribute to adverse clinical outcomes through unintended harm or intended abuse. Ideas of ‘citizenship’ may assist psychiatrists and other mental health professionals to deal with naturally arising feelings of hate, through engagement in dialogue with patients and colleagues, in a spirit of ethical encounter and fellowship.
Giant lipoma of the descending colon
Authors: Lyburn Iain D , Wallace Deborah , Birch Philip , Thomson W Hamish , Shepherd Neil A , Torreggiani William C
Published: May 2014

Lipomas are relatively rare in the gastrointestinal tract. About two thirds occur in the colon, most frequently in the caecum (Taylor et al, 1990). Most lipomas are found incidentally. Larger tumours may cause intermittent episodes of intussusception (Liessi et al, 1996). Radiological investigation can make the diagnosis. The authors present the barium enema and computed tomography findings of a large lipoma in the descending colon.
Are we going to do a rapid sequence on the next patient, doctor?
Authors: McCorkell Stuart
Published: May 2014

As an anaesthetic senior house officer, when asked this question by my operating department practitioner I would invariably know the answer immediately (and often so did they).
Reappraising first-line treatment in glaucoma management
Authors: Phelan Peter
Published: May 2014

Despite treatment, glaucoma patients may still suffer vision loss because of inadequate control of intraocular pressure or late presentation. This article reviews the latest evidence supporting a reappraisal of first-line treatment in the management of glaucoma, including a review of latanoprost, recently approved for first-line treatment of glaucoma and ocular hypertension.
Factors influencing teaching and learning in the preregistration year
Authors: Brown Jeremy , Graham David , Chapman Tom
Published: May 2014

Preregistration training is a transitional period in the career of new medical graduates as they complete their final year of basic medical education in practice settings. This study gathered the views of both preregistration house officers and their educational supervisors on preregistration training in the Mersey Deanery between August 2000 and August 2001.
Oxygen delivery and venous oxygen saturation monitoring
Authors: Singh Sukhbinder
Published: May 2014

Maintenance of adequate oxygen delivery is essential to ensure survival from shock, critical illness and major surgery. Impaired oxygen delivery can result in tissue hypoxia, anaerobic metabolism, lactic acid production and oxygen debt. If sustained, this sequence of events can lead to multiorgan failure and death.
Brain-gut interaction in irritable bowel syndrome
Authors: Harris ML , Aziz Q
Published: May 2014

Abdominal pain occurs commonly in irritable bowel syndrome. The mechanism of pain is likely to be either peripheral or central sensitization of gut nerves or aberrant brain processing. Functional brain techniques are now allowing the study of brain–gut interactions.
The role of the nurse in colorectal cancer follow up
Authors: Fitzgerald-Smith Angela M , Srivastava Pankaj , Hershman Michael J
Published: May 2014

The follow up of patients after colorectal cancer surgery remains controversial. It may be intensive or minimal. The authors describe an intensive follow-up regimen and discuss the leading role of the colorectal specialist nurse. In the absence of evidence from randomized trials, the most persuasive arguments for routine follow up are patient support and audit.
Vitreous haemorrhage in the diabetic eye
Authors: Towler Hamish MA
Published: May 2014

Vitreous haemorrhage is a serious sign indicating significant intraocular pathology in the diabetic eye and warranting prompt referral to an ophthalmologist for further assessment and management.
Diabetic retinopathy: medical management and assessment
Authors: Delli Castelli M , Leslie RDG
Published: May 2014

Diabetic retinopathy is a common and potentially devastating complication. This review discusses the practical assessment and management of retinopathy, focusing on the treatment of concomitant systemic disorders that influence the development and progression of this complication.
Laparoscopic surgery in urology: nephrectomy and prostatectomy
Authors: Joseph Jean V , Madeb Ralph , Leung Yuk-Yun , Erturk Erdal , Patel Hitendra R
Published: May 2014

Urological laparoscopic techniques have received great attention in the past decade. With the development of improved laparoscopic instrumentation, approaches to kidney and prostatic diseases have been successfully performed. Laparoscopic nephrectomy and prostatectomy are discussed. Awareness of these evolving technologies is critical for all surgeons with an interest in laparoscopy.
Chronic appendicitis diagnosed incidentally by colonoscopy
Authors: Courtney Edward DJ , Melville David , Leicester Roger J
Published: May 2014

A57-year-old woman attended the endoscopy unit for a colonoscopy for polyp surveillance. For the previous 2 weeks she reported experiencing intermittent pain in her lower right abdomen without any systemic upset. On examination she was apyrexial with a soft, nontender abdomen. Colonoscopy revealed diverticular disease affecting the entire colon and a 3 mm tubular adenoma in the transverse colon. The caecum appeared normal but the appendiceal orifice was found to be oedematous and inflamed (Figure 1). No pus could be seen emerging from the appendiceal orifice. Given that the patient was systemically well with no abdominal tenderness it was thought she may have a low-grade appendicitis and allowed home with a 7-day course of metronidazole.
Small bowel perforation caused by an ingested foreign body masquerading as acute appendicitis
Authors: King NKK , Coggins RP , McCloy RF
Published: May 2014

Aman aged 45 years presented with a 9-hour history of lower abdominal pain, which was worse in the right iliac fossa. The pain was sharp in nature and worse with movement. There was no nausea or vomiting. He had previously been well and healthy. On admission, he was apyrexial (37.0°C), had a normal pulse rate (75 beats/min) and was normotensive (120/80 mmHg). Clinical examination was significant for right iliac fossa tenderness but there was no guarding or rebound. There was no blood on urinalysis. His blood tests revealed a raised white cell count (12.4×109/litre), a normal neutrophil count (7.40×109/litre), a raised C-reactive protein (122 mg/litre) and a normal serum amylase (33 U/litre). Erect chest X-ray and plain abdominal X-ray were normal. On re-examination, his pain had worsened and he had increasing peritonism in his right iliac fossa, so he was listed for an urgent appendicectomy.
Laryngeal mask or tube for tonsillectomy?
Authors: Bishop Peter , Patel Anil
Published: May 2014

Anaesthesia for ear, nose and throat (ENT) surgery poses a number of unique challenges for the anaesthetist. For many years airway management in ENT surgery required tracheal intubation. However, the advent of the laryngeal mask airway (LMA) provided anaesthetists with an alternative. So, LMA or tube for tonsillectomy?
Subfascial endoscopic perforator surgery: a review
Authors: Anwar S , Shrivastava V , Welch M , Al-Khaffaf H
Published: May 2014

Approximately 1–2% of the UK population suffers from venous ulcers. Incompetent perforator leg veins are thought to be a major contributory factor. Subfascial endoscopic perforator surgery treats incompetent perforators in a minimally invasive fashion with significant improvement in wound healing and reduction in ulcer recurrence rates.
DXA scanning and its interpretation in osteoporosis
Authors: Blake Glen M , Fogelman Ignac
Published: May 2014

The recent growth in the clinical use of bone densitometry began with the introduction of the first dual X-ray absorptiometry (DXA) scanning systems in the late 1980s. Today, scans to measure bone mineral density are seen as having an essential role in the evaluation of patients at risk of osteoporosis.
A diagnosis not to miss
Authors: Garside Maria , James Rebecca , Cooper Nicola
Published: May 2014

A 45-year-old woman attended accident and emergency after fainting and feeling unwell with a fever. Blood and protein were noted in the urine. A diagnosis of urinary tract infection was made and she was sent home with antibiotics. She became increasingly unwell with fever, headache and confusion before collapsing the following day.

On examination her Glasgow Coma Score was 7/15, with a fever of 38.2° C, respiratory rate of 35/minute, pulse of 120/minute and blood pressure of 160/95 mmHg. She had a widespread petechial rash. Tone was increased in all four limbs and she had extensor plantar responses. There was no neck stiffness. Her pupils were equal and reactive, but her gaze deviated to the right. Soon afterwards she had a focal fit involving the left side of her body. Her blood results were: sodium 142 mmol/litre, potassium 2.8 mmol/litre, urea 9.1 mmol/litre (blood urea nitrogen 25.3 mg/dl), creatinine 120 mmol/litre (1.44 mg/dl), glucose 12.5 mmol/litre (208 mg/dl), haemoglobin 7.7 g/dl, total white cells 21.8 × 109/litre (neutrophils 14.2 × 109/litre), platelets 8 × 109/litre. Arterial blood gases and coagulation studies were normal. A contrast computed tomography scan of the brain, performed under general anaesthesia, was normal.
Discitis
Authors: Lam Khai S , Webb John K
Published: May 2014

Discitis is not an uncommon condition and can be potentially life threatening if diagnosed late. This article reviews recent publications and discusses the clinical presentation, pathoaetiology, diagnosis, treatment and pitfalls.
Adhesions: the early history
Authors: Ellis Harold
Published: May 2014

Intra-abdominal adhesions following tuberculous and other peritoneal inflammatory diseases were well recognized by early pathologists, but it was not until the advent of abdominal surgery in the late 19th century that postoperative adhesions, and thus the complication of small bowel obstruction, became common. The first recorded operation for this condition is described.
Intravenous urography and imaging of the urinary tract
Authors: Costello CH , Cook CKL
Published: May 2014

This article briefly reviews the commonly used radiological investigations of the renal tract. The intravenous urogram (IVU) is a widely available imaging technique and one of the first-line investigations, yet is often poorly understood by junior medical teams. This article therefore discusses the IVU in detail, and reviews the common pathologies seen using this technique.
Deciphering data protection laws
Authors: Williamson Paula
Published: May 2014

Is your school meeting its obligations under the Data Protection Act? Law expert Paula Williamson looks at the new tougher penalties for breaching data protection law and what schools need to do to get compliant
London: leading the way
Authors: Lepkowska Dorothy
Published: May 2014

The London Leadership Strategy – born out of the London Challenge – is working to spread best practice across the capital and beyond. Dorothy Lepkowska explains
Closing the poverty- attainment gap
Authors: Monk Heath
Published: May 2014

The Future Leaders charity works to develop outstanding school leaders in challenging secondary schools. It is now expanding its work to the primary sector and is appealing for applicants. Heath Monk explains
Free schools: one term down
Authors: Lepkowska Dorothy
Published: May 2014

Since the government announced its policy on free schools there has been plenty of speculation in the press about how they will operate. Dorothy Lepkowska talks to headteachers who took the plunge in September about how the first term has gone
Pupil wellbeing and attainment
Authors: Bryant Giles
Published: May 2014

Wellbeing activities such as yoga, music, breathing techniques and good nutrition can help create pupils who are ready to learn. Giles Bryant explores the link between wellbeing and attainment and looks at case studies of wellbeing practices in action
Six aspects of effective CPD
Authors: Weston David
Published: May 2014

Deciding how to focus your school's CPD can be difficult. David Weston lists six key areas.
The necessity of 2-hour pre-operative fasting for patients
Authors: Mclauchlan Rita , Patton Niall
Published: May 2014

Aim: The paper discusses the findings of an audit carried out at Manchester Royal Eye Hospital. Its focus was to explore whether it was necessary for patients to fast 2 hours prior to undergoing surgery (including vitreoretinal) under local anaesthetic.A total of 67 patients were included in the audit (27 female (40%), 40 male (60%)}.

Results: Average age was 68 years (range 31-98 years). 60/67 had sub-Tenon's local anaesthetic (90%), 5/67 (7.5%) had peribulbar anaesthetic and 2/67 (3%) had topical anaesthetic. Results show that over an 8 month window of prospective audit on vitreoretinal patients who had undergone surgery for a variety of indications and with different diagnoses typical of a tertiary vitreoretinal service, both by retinal fellows and consultants, with a time on average of over an hour per case, there were no reported clinical incidences 0/67 (0%) that were either caused by a lack of fasting, or exacerbated by a lack of fasting.

Discussion: As a result of this audit we recommended that for all patients undergoing local anaesthetic (excluding sedation) vitreoretinal procedures, and because cataract surgery is usually of a significantly shorter duration, fasting for 2 hours is unnecessary. The standard for best practice policy is now embedded in practice within the ophthalmic division in Central Manchester Foundation Trust.
Nurse practitioner management of patients with retained contact lens
Authors: Gwenhure Tendai , Gibbons Helen
Published: May 2014

Attendance to the ophthalmic accident and emergency department with a retained contact lens is not uncommon. The patient's management involves thorough assessment, examination, treatment and health education.

This article provides an overview of the assessment, diagnosis and management of patients presenting to the ophthalmic accident and emergency department with retained contact lenses. Case presentations will be used to analyze causes, signs and symptoms and treatment modalities for retained contact lenses. The nurse's attention is drawn towards:

Significance of a comprehensive history and visual acuity assessment Recognition of clinical signs and symptoms Full anterior segment examination Importance of lid eversion and subtarsal examination Treatment modalities Health promotion.
Supporting children and families through enucleation
Authors: Reynolds Laura , Shea Tara
Published: May 2014

Enucleation (removal of an eye) is one of the most common treatment modalities for retinoblastoma. There is very little research into the impact of this type of treatment on the child and their family; however, it is thought to be a life-changing event. The Royal London Hospital retinoblastoma service has developed a model of care to support families during this time. Adequate support before and after enucleation is crucial in helping to decrease psychological trauma and increase acceptance and coping. This article will outline the model of care and supportive teaching materials that the multidisciplinary team use to help this patient group through enucleation surgery and at different points in the child's development.
Haematological disease: disorders of erythrocytes, leucocytes and platelets
Authors: Shalchi Zaid , Taylor Simon RJ , Lightman Sue
Published: May 2014

The eye allows living, functioning blood vessels to be observed and is thus ideal for the study of haematological disease. Disorders of the blood have significant ocular manifestations and pose a real threat to vision, making knowledge of the subject essential to ophthalmologists, haematologists, oncologists and general physicians.
Palliative care nursing research trends from 1987 to 1996
Authors: Wilkes Lesley
Published: May 2014

Nursing research in palliative care is becoming ever more important as cost-effectiveness and evidence-based practice become mandatory in the workplace. A search of Cinahl and Medline databases and the content pages of the International Journal of Palliative Nursing, Palliative Medicine and the Journal of Palliative Care provided 180 articles relating to nursing research in palliative care over the past decade. On reviewing the abstracts emerging trends show that nurses are becoming more focused on service delivery and there is evidence of their participation in particular aspects of patient and family care. In particular they are conducting more quantitative research on patient outcomes especially in areas where nurses can have an effect on care outcomes, e.g. complementary therapies, psychosocial support and non-pharmaceutical symptom control. These trends must continue in order to cement the nurse’s place in palliative care.