bluuebunny/crossref_metadata_2025 huggingface dataset:
Complementary and alternative medicine in inflammatory bowel disease
Authors: Taylor Nicola S , Taylor Kirstin M
Published: May 2014

Complementary and alternative medicines are used by a significant proportion of patients with inflammatory bowel disease, often without the knowledge of their health-care team. In this review, Nicola Taylor and Kirstin Taylor provide an overview of the various therapies used, along with evidence supporting their use, where it is available. Although most of these therapies are safe, it is important to be aware that some may cause side-effects or interactions with other drugs. To date, there is no good evidence that any of these therapies can be used effectively in the place of conventional treatment in inflammatory bowel disease.
Travel and holidays: how best to advise ostomists
Authors: Williams Louise , Varma Sarah
Published: May 2014

Recommencing social activities is often a concern for patients who have undergone stoma formation. New ostomists will need to deal with the psychological aspects of the surgery as well as the practicalities of stoma care management. In this article, Louise Williams and Sarah Varma demonstrate how stoma care nurses can best advise new ostomates who are concerned about travelling with a stoma. The article will consider different types of travel and the problems they may present to the patient, and will provide evidence-based practical information so patients can plan and prepare for their trip to ensure an anxiety-free travel.
Pancreatic cancer: a whistle-stop tour
Authors: Gee Caroline
Published: May 2014

Each year in the UK, approximately 7500 people are diagnosed with pancreatic cancer. Patients usually present with inoperable disease, and are associated with a poor prognostic outlook. In this article, Caroline Gee provides a brief overview of how patients present and are diagnosed. The current trends in treatment options are examined; considering surgery, chemotherapy, biological therapies, stereotactic radiotherapy and palliative interventions.
Colonoscopy in surveillance of inflammatory bowel disease
Authors: Ahmad Saqib , Ragunath Krish
Published: May 2014

Patients with chronic colitis from inflammatory bowel disease (IBD), whether ulcerative colitis or Crohn’s disease, have an increased risk of colorectal cancer (CRC), which accounts for approximately 10–15% of all deaths among IBD patients. The risk of CRC increases with disease duration and is frequently preceded by the pre-cancerous histological stage called dysplasia. In an attempt to detect dysplasia and asymptomatic cancers in patients with IBD, most national gastroenterology societies recommend initiating colonoscopy surveillance after 8 to 10 years of diagnosis. The goal of surveillance is to reduce the risk of cancer and mortality due to CRC. Current studies of surveillance using chromoendoscopy (dye spray) have demonstrated improved detection of dysplasia compared to conventional colonoscopy surveillance and have changed the approach from random to targeted biopsies. In this article, Saqib Ahmad and Krish Ragunath aim to discuss chromoendoscopy in detail with brief discussion about management of dysplasia.
Anal dilatation in children with anorectal malformations
Authors: Orr Stephanie
Published: May 2014

Following a Posterior Sagittal Anorectoplasty (PSARP), infants require daily anal dilations to prevent stenosis of the new neoanus and obtain optimal width of the anal opening. In this article, Stephanie Orr looks at anorectal malformations, their classification, how they are surgically managed, and the role anal dilatation plays in the care of the infant post PSARP. As anal dilatation is widely performed throughout surgical centres in the UK and Ireland, the Paediatric Stoma Nurse Group (PSNG) have worked together to produce a comprehensive parent information leaflet to support parents who are carrying out anal dilatation on their child. This article will also examine the reasons why the leaflet was created and its benefits.
Colorectal service development audits within an enhanced recovery pathway
Authors: Brundrett Diane , Jenkins Ian , Kennedy Robin , Robinson Susheela , Rye Beth , Wright Steve , Burch Jennie
Published: May 2014

Three audits were undertaken in a colorectal service within an enhanced recovery programme. Each audit had a separate objective. Audit one examined actual theatre times against predetermined times. Audit two explored reasons for delay of discharge home and audit three surveyed the views of patients on postoperative supplemental drinks. The audits were retrospective, prospective and a survey respectively. The results from audit one showed that in general, the main predetermined theatre times were accurate. Results from audit two showed that the majority of delays were related to social reasons. Finally, audit three found that when patients were offered postoperative supplemental drinks, most were able to tolerate them. These audits, despite being small, have led to improvements in care.
Making sense of metabolites, azathioprine and allopurinol in IBD
Authors: Stansfeld Cath
Published: May 2014

Immunomodulating therapy, such as azathioprine and mercaptopurine is commonly used to control the symptoms of infammatory bowel disease. Over recent years, evidence has emerged to support the use of these drugs in conjunction with allopurinol. In this article, Cath Stansfeld discusses the use of azathioprine and allopurinol, and the role of metabolite monitoring in the care of patients receiving combination therapy and highlights the caution needed in caring for this group of patients with infammatory bowel disease.
Gum chewing as a strategy to reduce the duration of postoperative ileus
Authors: Lafon Caroline , Lawson Lauren
Published: May 2014

Postoperative ileus is a common complication following surgery. Many pharmacological agents and surgical techniques have been proposed to influence the severity and duration of an ileus; however, no individual method has been shown to successfully influence its clinical course. Often, these techniques are used in combination to create a ‘fast-track’ recovery program. Current research has proposed gum chewing as a form of sham feeding that can be used as an alterative to early oral feedings. In this article, Caroline Lafon and Dr Lauren Lawson will review recent randomized controlled trials and meta-analyses studying the effects of gum chewing on gastrointestinal motility. Research suggests that gum chewing is a safe and cost-effective method that acts by stimulating the cephalic-vagal system, triggering the release of gastrointestinal hormones and juices, increasing salivation and pancreatic juice release, and ultimately promoting the return of normal bowel function. Gum chewing can be used as a component in a fast-track recovery program to reduce the duration of postoperative ileus and thereby reduce hospital length of stay and hospital costs.
Medical clearance of the gut in children
Authors: Gordon Morris
Published: May 2014

Whether for chronic constipation or preparation before an investigation or surgery, medical clearance of the gut in children is challenging. In this article, Dr Morris Gordon summarises the current state of the evidence base. Recent evidence-based guidance and systematic reviews have improved the professional's ability to select the safest and most effective therapies. There is a reasonable evidence base to support the use of polyethylene glycol (PEG) and mineral oil to manage childhood constipation and some evidence that rectal enemas can support impaction. The evidence base for bowel preparation prior to colonoscopy is poor, but sodium phosphate, sodium picosulphate plus magnesium citrate and PEG appear effective, although PEG is poorly tolerated. Further research is needed in all areas.
Uncovering anorexia nervosa in a biofeedback clinic for bowel dysfunction
Authors: Chelvanayagam Sonya , Duncan Julie , Collins Brigitte , O'Brien Lorraine
Published: May 2014

Biofeedback is a conservative treatment based on behavioural techniques, which can be used in the management of bowel dysfunction. This article reports the results of a retrospective review of the clinical notes of 87 female patients attending a biofeedback service at St Mark's Hospital, Harrow. The initial review was conducted to examine the incidence of polycystic ovary syndrome (PCOS) in patients attending this service. Seven percent were found to have PCOS, which is within the normal range. However, a signifcant proportion of patients (11.5%) had a current history of anorexia nervosa, a higher rate than in the general population, which prompted further investigation. In this article, Sonya Chelvanayagam, Julie Duncan, Brigitte Collins and Lorraine O'Brien report on the results of this review and discuss the signifcance of its fndings.
Prednisolone in the management of patients with Crohn’s disease
Authors: Cronin Elaine
Published: May 2014

Glucocorticoids, a type of steroid hormone, are widely used in the treatment of inflammatory bowel disease (IBD) in patients with Crohn’s disease or ulcerative colitis. Many patients with these conditions are managed conservatively outside hospital, with continued support from their gastroenterologist and occasional glucocorticoid medication. However, glucocorticoids are not a long-term solution for anyone with IBD, since they carry many unwanted side effects, and can damage body parts and function years after ingestion, particularly if the dose was high and for longer than 6 months. In the short term, glucocorticoids can produce some very impressive results, but patients need to know the facts about them and what they should and could expect from taking this medication. This article gives an outline of one of these drugs—prednisolone— what it is used for, and the side-effects that may arise.
Pathophysiology of pancreatic stellate cell fibrogenesis and the development of alcoholic chronic pancreatitis
Authors: Mayer Hedvika
Published: May 2014

In the late 1990s it was established that, once activated, pancreatic stellate cells (PSCs) transform into myofibroblast-like cells; a process termed ‘PSC activation’ ( Apte et al, 1998 ; Bachem et al, 1998 ). Researchers observed that in this process of activation PSCs proliferate, lose their retinol-containing lipid droplets, produce huge quantities of extracellular matrix (ECM) proteins and express α-smooth muscle actin (α-SMA). Jaster and Emmrich (2008) have more recently postulated that dysregulated tissue repair and uncontrolled PSC differentiation lead to pancreatic fibrosis, stirring-up discussion about links between PSC abnormalities and the development of chronic pancreatitis. However, the mechanism by which pancreatic fibrosis develops is yet to be elucidated at the cellular level. In this review, Hedvika Mayer examines the links between abnormalities of pancreatic cell function and the development of alcoholic chronic pancreatitis.
The role of the stoma nurse in providing culturally sensitive care for a Chinese child with a prolapsed loop colostomy
Authors: Chandler Pip
Published: May 2014

Paediatrics form a small part of the workload of the majority of community specialist stoma nurses. As with all patients, it is the nurses’s responsibility to ensure that a child’s stoma care plan fulfils their needs. When a child with a prolapsed stoma is from an ethnic minority, it may add to the complexity of care. Specialist stoma nurses need to be open to learning about each patient’s culture and adjusting their approach to meeting the family’s needs. In this article Pip Chandler reflects on how working within a multidisciplinary team, including education staff, and gaining an understanding of their roles and responsibilities, has helped to personalise her practice to support young people with a stoma from a variety of cultural backgrounds.
Online bowel cancer symptom checker to help determine need for GP visit
Authors: Thompson Michael , Porrett Theresa
Published: May 2014

Public awareness campaigns to achieve early diagnosis of bowel cancer can result in large numbers of people worrying, many of who see their GP unnecessarily—the ‘worried well’. This can lead to over-referral and investigation of patients in hospital, and the inappropriate use of scarce clinical and financial resources with little evidence of benefit to those with cancer. There is a sound evidence base for a simple self-assessment by people with symptoms to stratify their risk of having bowel cancer. However, it is difficult to provide this sort of complex information in a way that is easy to understand and at the right time. The authors feel that online decision support could be the answer. This article describes the development of the first online, professionally endorsed bowel symptom checker for people in the community.
Verifying patient information in the colorectal family history clinic
Authors: Pettman Maria
Published: May 2014

The national colorectal family history screening guidelines categorise risk on the basis of the incidence of familial cancer, type of cancer, age, and genetic proximity. Appropriate assessment of risk involves obtaining detailed, relevant, and accurate family history information. An incorrect assessment can result in high- or medium-risk patients not receiving tests, or low-risk patients being subjected to unnecessary invasive and costly colonoscopies. The majority of asymptomatic referrals to nurse-led colorectal family-history screening clinics (CFHSC) are from primary care. Information provided by the GP is nonstandardised and can often be inaccurate. CFHSCs expend significant resources to improve the accuracy and relevance of family history information. This is done using a patient questionnaire and verifying the information against medical records and the Cancer Registry. This study aims to quantify the benefits of this verification process.
Endoscopic retrograde cholangiopancreatography (ERCP) performed under propofol sedation
Authors: Eykyn Felicity
Published: May 2014

Endoscopic retrograde cholangiopancreatography (ERCP) is an important technique that allows detailed visualisation of the bile and pancreatic ducts. ERCPs are indicated for persistent abdominal pain and malignancies obstructing the pancreatic and bile ducts. This article critically analyses the care given to a patient who underwent an ERCP. It demonstrates specialist nursing considerations by explaining the ERCP technique and the indications for this procedure, as well as discusses alternative diagnostic examinations and the introduction of propofol sedation. The article also explores the current practices in caring for patients undergoing an ERCP by critically analysing the literature that promotes best practice and identifying therapeutic techniques and the equipment used.
Patients’ knowledge of vaccines required when on immunosuppressive therapy
Authors: Slater Jayne
Published: May 2014

Nearly all patients with infammatory bowel disease will at some point in their disease process require immunosuppressive therapy to manage their symptoms, such as steroids, purines, thiopurines and biological agents. However, using two or more of these therapies together will increase the risk of the patient developing vaccine-preventable opportunistic infections. In this article, describes a small, prospective audit, which revealed that a signifcant proportion of patients were not aware of the vaccinations they required while receiving immunosuppressive therapy and of the need to avoid live vaccines.
Management of anal fistulas
Authors: Hammond Toby
Published: May 2014

Anal fistulas can significantly affect quality of life by either persistently discharging or intermittently occluding, causing recurrent abscess formation. They pass through the anal sphincter complex, which is responsible for maintaining continence of rectal contents (gas, liquid or solid stool). Treatment therefore aims to eradicate the fistula and preserve sphincteric function. To date, laying open the fistula (fistulotomy) is still the most effective treatment, but as it divides the sphincter muscle, it increases the risk of incontinence. For those in whom fistulotomy is not recommended, alternative strategies exist, including techniques aimed at minimising sphincter disruption, ‘sphincter-conserving’ methods or the placement of a long-term loose draining seton. This article reviews the literature on all aspects of anal fistulas, as well as their management and the requirements of postoperative care.
Nurse perspectives in ulcerative colitis: an approach to individualised care
Authors: Chadda Santosh
Published: May 2014

The most important goal when caring for patients with ulcerative colitis is to achieve and maintain remission, in order to minimise the impact this debilitating condition has on their quality of life. However, there is no single approach to achieve this goal, and what works for one patient may not work for another. Each patient's unique circumstance and attitude affect both the impact of the disease and the care they need. In this article, Santosh Chadda explores the importance of individualised care approaches and examines how evidence can be used to help set realistic expectations for both nurses and patients
Complications in acute liver failure: managing hepatic encephalopathy and cerebral oedema
Authors: Fullwood Danielle , Sargent Suzanne
Published: May 2014

Acute liver failure (ALF) is a term that first became established in the 1960s to describe a rare clinical syndrome that is characterised by severe hepatocyte injury, jaundice, and hepatic encephalopathy, usually in the absence of pre-existing chronic liver disease. ALF has a variety of aetiologies, and is associated with a high mortality and morbidity. While it is a disease of multiorgan failure, all patients with ALF will have some degree of hepatic encephalopathy, which when advanced, is associated with a high incidence of cerebral oedema and intracranial hypertension. When these symptoms are combined with other failing bodily systems, this group of patients is extremely challenging to manage. This article presents an overview of hepatic encephalopathy and the management of cerebral oedema in this group of patients, examining both current medical and nursing strategies.
NMC proposal for revalidation of nurses
Authors: Harrison Penny
Published: May 2014

Penny Harrison, Senior Lecturer in Adult Nursingt De Montfort University, Leicester, critically analyses the Nursing and Midwifery Council's revisions to the revalidation and regulation system for nurses
Metastatic prostate cancer presenting as diplopia with regression of signs with hormone manipulation
Authors: Kumar P , Duarte J , Pati J
Published: May 2014

A 73-year-old man presented with sudden onset diplopia. He was referred to the ophthalmology team who thought he had a VIth nerve palsy. He subsequently underwent computed tomography (CT) (Figure 1) and magnetic resonance imaging (Figure 2). These images revealed a mass occupying and expanding the sella with extension inferiorly to the sphenoid sinus. The clivus was almost completely replaced by tumour. The cavernous sinuses were involved bilaterally but the optic chiasm was not involved. It was thought that these finding were consistent with an unusual invasive pituitary tumour and surgical excision biopsy was undertaken. The histology was consistent with metastatic carcinoma of the prostate.

His prostate-specific antigen (PSA) taken post-histology was 382 μg/litre and a bone scan confirmed metastases in the ribs, thoracic and lumbar spine, sacrum, left sacroiliac joint, ilium, ischium and pubis. He was subsequently started on luteinizing hormone-releasing hormone analogues which brought about a resolution of his diplopia. Follow-up CT of the head revealed regression of the skull base mass. At 18-month follow-up he remains well with no visual impairment, the PSA having decreased to >0.2 μg/litre.
Age-related macular degeneration
Authors: El-Amir Ahmed N , Sagoo Mandeep S , da Cruz Lyndon
Published: May 2014

Age-related macular degeneration is the leading cause of irreversible loss of vision in the west, accounting for up to 50% of all blind registrations. With an ageing population age-related macular degeneration will have a discernible impact on society and the NHS. This article outlines our current level of understanding of age-related macular degeneration and treatment strategies.
PRHO views on the usefulness of a pilot ward simulation exercise
Authors: Ker Jean , Hesketh Anne , Anderson Fiona , Johnston David
Published: May 2014

There are concerns that pre-registration house officers (PRHOs) lack the expertise to initially manage acutely-ill patients. Simulation can support them in this role by providing a safe yet authentic setting. This paper shares PRHOs' views of a ward simulation exercise. The positive feedback has resulted in further development of the exercise to support PRHOs who have given cause for concern in their practice.
Sub-specialization in general surgery – the end of the ‘general’ surgeon?
Authors: Rajan Prabhakar , Din Nasim A
Published: May 2014

As general surgeons in the UK National Health Service (NHS), we are operating in a time of uncertainty as a result of the debate on centralization and sub-specialization of our profession. The impetus for change (Expert Advisory Group to the Chief Medical Officers of England and Wales, 1995), exemplified by vascular and breast, is improvement in outcome; the rationale is that surgeons with large single-procedure workloads yield better results. However, this controversial process, together with proposed senior house officer reforms (Department of Health, 2003), has major implications on the provision of elective and emergency services.
Giant cell arteritis presenting as painful third nerve palsy with normal erythrocyte sedimentation rate
Authors: Madge Simon N , Klys Howard , Twomey John M
Published: May 2014

An 80-year-old man was referred to hospital with a 2-week history of headache and 1 day of vertical diplopia, but was systemically well with no symptoms of giant cell arteritis (GCA). Past medical history included right central retinal vein occlusion, for which he had previously received panretinal photocoagulation. His full blood count and blood glucose were normal, erythrocyte sedimentation rate (ESR) 24 mm/hr and C-reactive protein (CRP) 34 mg/litre. Two days later, an ophthalmological review was requested.

The visual acuity was 6/36 right eye and 6/9 left. There was a moderate exotropia with diplopia and a left ptosis with restriction of both elevation and adduction of the left eye; depression of the left eye was normal. The left fourth nerve appeared intact. Neither optic disc appeared swollen. In view of the painful left partial third nerve palsy, urgent magnetic resonance angiography was performed but showed no significant abnormality, suggesting a microvascular cause. A Fresnel prism was fitted to his spectacles with resolution of diplopia.

Three weeks later, his symptoms had resolved. Although he remained well and had no symptoms of GCA, his left superficial temporal artery was markedly swollen, albeit non-tender. His ESR was 25 mm/hr and CRP 30 mg/litre. In light of his unusually rapid recovery, a diagnosis of atypical GCA was made and prednisolone started. Temporal artery biopsy confirmed GCA (Figures 1 and 2).
Femoral nerve injury following oophorectomy
Authors: Kumar B , Chandra K , Kapoor Tina
Published: May 2014

A 46-year-old woman attended the gynaecology clinic complaining of right iliac fossa pain and dyspareunia of 18 months duration. Her symptoms were gradually worsening. She had a history of hysterectomy and left salpingoophorectomy for menorrhagia caused by fibroids.

The patient had a body mass index of 29. Bimanual pelvic examination revealed right adnexal fullness which was confirmed on ultrasound scan to be an ovarian cyst. After appropriate counselling a right oophorectomy was planned. The procedure was performed through a transverse suprapubic incision. During the operation the abdominal wall was held apart with a self-retaining retractor. It was not necessary to open the retroperitoneal space because the ovary was lying adherent to the vaginal vault peritoneum. The procedure was uneventful.

In the immediate postoperative period she complained of pain in the right anterior and medial aspect of the thigh. She also showed signs of significant intraperitoneal bleed and developed mild haematuria.

Repeat exploratory laparotomy was performed to stop haemorrhage. On the fourth postoperative day she fell down when attempting to walk. She described pain and numbness in the right anterior thigh extending from the inguinal crease and distally to the knee and slightly below the knee on the lateral border.

Following recovery from surgery a specialist neurological examination showed weakness of right hip flexion and knee extension, absence of the right knee jerk, and anaesthesia over the anterior and medial aspects of the right thigh. A right femoral neuropathy, presumed secondary to the surgical procedure, was diagnosed. Peripheral neurophysiological studies showed acute denervation of the right vastus lateralis with a marked loss of motor units confirming the clinical diagnosis. The patient started physiotherapy and was treated with amitryptiline and tramadol for her pain. After 8 months there was appreciable improvement in her symptoms. She was started on gabapentin and remains under follow up in a pain clinic.
Symptom management in palliative care: optimizing drug treatment
Authors: Wilcock Andrew , Twycross Robert
Published: May 2014

This article provides an approach to symptom management and highlights how good prescribing is one of the essential skills required for the provision of optimal holistic palliative care.
Managing critically ill patients with a pulmonary artery catheter
Authors: Harvey Sheila , Singer Mervyn
Published: May 2014

No monitoring device has polarized opinion as much as the pulmonary artery catheter. This review will describe the history and the reasons for much of the controversy surrounding this device, and then go on to discuss the available evidence.
Cerebrospinal shunt malfunction: recognition and emergency management
Authors: Khan Arshad Ali , Jabbar Abdul , Banerjee Ashis , Hinchley Geoff
Published: May 2014

Indwelling shunts to divert CSF flow are essential in treating hydrocephalus. There is a high incidence of shunt malfunction, which accounts for the increasing popularity of endoscopic third ventriculostomy. Failure to recognize and act on symptoms and signs of shunt malfunction may lead to loss of life or to permanent neurological dysfunction. This review provides the basis for assessment and management based on updated clinical knowledge.
The management of constipation in hospital inpatients
Authors: Greenfield Simon M
Published: May 2014

This article reviews the causes of constipation in hospital and how it can be prevented with simple measures. A review of laxatives available on hospital wards is provided for the reader and recommendations are made.
Breast abscess
Authors: Dixon J Michael
Published: May 2014

Inappropriate antibiotics continue to be prescribed for breast infection. Optimal management of breast abscesses consists of repeated aspiration or mini incision and drainage combined with appropriate antibiotic therapy.
Should non-steroidal anti-inflammatory drugs be given to orthopaedic patients with fractures?
Authors: Williams Andrew
Published: May 2014

Non-steroidal anti-inflammatory drugs (NSAIDs) are useful adjuncts in perioperative pain relief. They act by inhibiting the activity of the enzyme cyclooxygenase (COX) which catalyses the formation of prostaglandins from arachidonic acid (Peck and Williams, 2000). COX exists as two isoenzymes, COX-1 and COX-2. COX-1 is responsible for the production of prostaglandins that form the protective gastric mucosal barrier, help maintain renal perfusion and regulate haemostatic function. COX-2 facilitates the inflammatory response. The beneficial actions of NSAIDs are associated with inhibition of COX-2 while the adverse effects re associated with inhibition of COX-1. NSAIDs are sub-divided into three main groups: non-specific COX inhibitors, preferential COX-2 inhibitors and specific COX-2 inhibitors. COX-2 is also responsible for the production of prostaglandins by osteoblasts which are essential for bone repair (Raisz, 2001). NSAIDs are therefore implicated in delayed fracture healing or non-union of fractures.
How to insert a temporary pacing wire
Authors: Ahmed Akbar K , Lambiase Pier D
Published: May 2014

Temporary pacing is indicated in emergency situations for treatment of bradyand tachyarrhythmias. Frequently these patients are haemodynamically unstable and so competency in temporary wire insertion is vital as immediate intervention is frequently required. Temporary pacing should form part of the procedural capabilities of any medical specialist registrar undertaking acute medical on call, especially those working in emergency medicine. F1 and F2 doctors should have be able to recognize a patient with indications for temporary pacing (Table 1) and diagnose complications of the procedure.
Giant cell arteritis: not just a stroke in the eye
Authors: Borg Frances A , Dasgupta Bhaskar
Published: May 2014

Giant cell arteritis is a large vessel vasculitis with predilection for the cranial arteries. However, as illustrated by two case reports in this month's issue (p. 650 and 651), involvement of large vessels, such as the aorta, is increasingly recognized. It is the commonest systemic vasculitis of the elderly, almost exclusively seen in those of over 50 years of age. There is a female preponderance and geographical variation in prevalence, with higher frequency in Caucasians than in other ethnicities. The incidence in the UK is 2.2/10 000 person-years.
Stents and stentability: treatment for malignant bowel obstruction
Authors: Turner Jeff , Cummin Tom , Bennett Adam , Swift Gillian , Green John
Published: May 2014

Colonic stents offer a palliative treatment for patients with malignant bowel obstruction otherwise requiring surgery and possible stoma, or as a bridge to surgery for potentially curative malignant disease. This article reviews the indications, risks and benefits of stent insertion.
Cerebrospinal fluid: the role of biochemical analysis
Authors: Srivastava Rajeev , Murphy Michael J , Jeffery Jinny
Published: May 2014

Biochemical analysis of cerebrospinal fluid may provide answers to important clinical questions. This review summarizes these questions and outlines the value and limitations of cerebrospinal fluid analysis.
Management of osteoarthritis of the glenohumeral joint
Authors: Sinha Ian , Lee Marcus , Cobiella Carlos
Published: May 2014

The National Institute for Health and Clinical Excellence will this year publish general guidelines for the management of osteoarthritis. The surgical management of shoulder arthritis has been an area of marked activity in the last decade. This article reviews current trends in the management of glenohumeral osteoarthritis.
Junior doctors' ability to interpret lateral soft tissue neck X-rays: is there a training issue?
Authors: Prasai Amit , Jaberoo Marie-Clare , Conboy Peter J
Published: May 2014

In light of the introduction of the European Working Time Directive and Modernising Medical Careers initiative, this article reports the results of a study to see whether junior doctors possess adequate skills to correctly interpret lateral soft tissue neck X-rays and if they receive adequate training.
Practical prescribing of intravenous unfractionated heparin
Authors: Sado Daniel M , Price Dallas , Sarvananthan Sajiram
Published: May 2014

Intravenous unfractionated heparin is sometimes poorly managed in NHS hospitals. This article investigates why this is so and reviews the evidence for optimal unfractionated heparin prescribing, using it to make some suggestions as to how doctors can improve this.
Non-invasive ventilation for acute exacerbations of COPD
Authors: Reinhardt Alistair K
Published: May 2014

Acute exacerbations of chronic obstructive pulmonary disease (COPD) causing respiratory failure are associated with mortality rates of up to 26%. A new Royal College of Physicians guideline aims to impart standards and practical advice to those providing a non-invasive ventilation service for these patients. This article examines the guideline.
e-learning in clinical teaching
Authors: Doherty Iain , McKimm Judy
Published: May 2014

Clinical teachers teach diverse groups of learners who are increasingly familiar with learning through an online environment. e-learning provides huge opportunities for enhancing clinical teaching and facilitating communication. However, to be effective, e-learning must be grounded within sound educational approaches.
Colorectal cancer: a decade of progress
Authors: Ormerod Nooreen , Sheikh Hamid , Saunders Mark
Published: May 2014

Over the last decade there has been considerable improvement in the management of metastatic colorectal cancer. Like other cancer patients, people with colorectal cancer have benefited from service reorganizations that have lead to more rapid referral and diagnosis, and enabled more patients to benefit from recent advances in treatment.
The journey of care for the frail older person
Authors: Ayyar Anita , Varman Surendra , De Bhaldraithe Sorcha , Singh Iqbal
Published: May 2014

The elderly have diverse health-care needs and the frail elderly, because of associated co-morbidities, carry a significantly high mortality during their journey of care. Adequate planning and coordination between teams and an accessible and flexible interface between services will help ensure a safe, smooth journey for these people.
Broken heart syndrome
Authors: Alrubaiy Laith KQ , Rehman Habib
Published: May 2014

A 56-year-old Asian woman presented with severe shortness of breath and chest tightness for 4 days. Her past medical history included well-controlled type 2 diabetes mellitus and hypertension. She was a non-smoker. On examination, she was afebrile with a blood pressure of 160/90 mmHg, a pulse of 90 beats per minutes, and a respiratory rate of 30 breaths per minutes with a PaO2 of 7.4 kPa on air. Auscultation of the chest revealed bi-basal crackles and expiratory rhonchi. Cardiac examination was normal. Chest radiograph showed pulmonary congestion with normal heart size. Electrocardiogram (Figure 1) showed deep T-wave inversions in the anterolateral and inferior leads. Her troponin T level was raised at 0.243 ng/ml (normal <0.03 ng/ml).

The patient was treated as having an acute coronary syndrome with supplemental oxygen, low molecular weight heparin, aspirin and clopidogrel. She was referred to a tertiary cardiothoracic centre for percutaneous coronary intervention. Bedside echocardiography showed reduced ejection fraction. Angiogram showed normal coronary arteries (Figures 2 and 3), and left ventriculography showed extensive anterior and inferio-apical areas of dyskinesia (Figures 4 and 5), consistent with Tako–Tsubo syndrome. With supportive therapy (aspirin, nitrate and diuretics), she made a good recovery. Her left ventricular function was normal on follow-up echocardiography 6 weeks later.
Should epidural analgesia be used in free flap transfer?
Authors: Ahmed-Nusrath A , Nusrath MA , Aziz AR
Published: May 2014

Afree flap is a composite block of tissue transferred from a donor site to a distant recipient site, where its circulation is restored by microvascular anastomosis of the artery and vein in the vascular pedicle to vessels at the recipient site. Indications for free flap transfer are trauma with soft tissue loss, e.g. lower third tibulo-fibular compound fractures, and reconstruction of complex defects following oncological surgery and burns. Free flaps allow better matching of resected tissue and provide more even cover of the defect with superior aesthetic and functional results, making them the preferred option for reconstruction. Adequate microvascular perfusion is vital for flap survival and decreased blood flow with consequent ischaemia is one of the main causes of flap failure.
Trampolining injuries
Authors: Sukeik Mohamed , Haddad Fares S
Published: May 2014

Trampoline-related injuries have increased dramatically over the last few years. This article presents a review of the literature summarizing the different types and mechanisms of sustaining such injuries and looks at current recommendations to prevent them.
Management of the hyperthermic patient
Authors: Calvello Emilie JB , Hu Kami , Khoujah Danya
Published: May 2014

Undifferentiated body temperature of greater than 38°C can herald a number of important clinical syndromes essential to diagnose besides just infectious aetiologies. This review examines the pathophysiology, clinical features and approach to the management of hyperthermia that will lead to appropriate diagnosis and treatment.
Preventing fractures in the elderly
Authors: Walker-Bone Karen
Published: May 2014

Fractures in the elderly are devastating, causing premature death and compromised independence among survivors. With demographic changes, their occurrence is expected to double. Given their crippling consequences, the identification and treatment of osteoporosis and prevention of falls are priorities.
Allocation of kidney transplants in the UK
Authors: Newstead Charles
Published: May 2014

Live and donation after cardiac death has increased markedly recently. The allocation system for donation after brain death reserves the least mismatched organs for young people. Live donors most often donate to relatives but a scheme tries to ‘exchange’ live donor kidneys when direct transplantation is not possible.
Surgery: a stressful business
Authors: Kelliher Leigh , Jones Chris
Published: May 2014

Over the years the surgical stress response and the efforts to modify it have been the subject of a great deal of research. Most recently this has led to the development of ‘enhanced recovery’ programmes which are revolutionizing perioperative patient care across the UK.
Entitlement to hospital treatment in the UK: qualifiers, challenges and comment
Authors: Dubrey Simon W , Mehta Paresh A , Sharma Ritu , Shah Sheila
Published: May 2014

Entitlement to NHS care is in some cases complex. Regulations include inter-country reciprocal agreements and specific categories of individuals who qualify. This article describes the current, albeit fluid, situation with discussion around some of the more contentious areas.
Acute aortic syndrome: surgical, endovascular or medical treatment
Authors: Anagnostakou Vania , Nenekidis Ioannis , Ashrafian Hutan , Kokotsakis John , Athanasiou Thanos
Published: May 2014

Acute aortic syndrome encompasses classic aortic dissection, intramural haematoma, penetrating aortic ulcer, and iatrogenic or traumatic transection of the aorta. These acute aortic pathologies present with characteristic ‘aortic pain’, and are managed by several operative and endovascular techniques.
Measurement and implications of postural changes in blood pressure
Authors: Banerjee Ashis , Weerasinghe Asoka , Mbamalu David , Weerasinghe Chisha
Published: May 2014

Postural changes in blood pressure are a commonly elicited vital sign. It is important that the measurements are reproducible in order to be clinically meaningful. This article makes recommendations about how and what to document as part of the technique of recording, on the basis of the literature.
Biological therapy for rheumatoid arthritis: where are we now?
Authors: Horton Sarah C , Emery Paul
Published: May 2014

Since the introduction of targeted biological therapies, the implications of a new diagnosis of rheumatoid arthritis have changed dramatically. There are now several therapeutic options available for these patients and the target of treatment – remission – is now a realistic goal.
Use of bevacizumab in the treatment of metastatic colorectal cancer
Authors: Raouf Sherif , Bridgewater John , Ellis Richard , Ferry David , Hill Mark , Wasan Harpreet
Published: May 2014

The Cancer Drugs Fund may allow more patients in England access to clinically effective cancer therapies. In this article oncologists already familiar with the clinical evidence, and experienced in treating with bevacizumab, share practical recommendations on optimal first-line use of this treatment for metastatic colorectal cancer.
Choanal atresia
Authors: Syed Irfan , Jephson Christopher
Published: May 2014

Choanal atresia is a congenital narrowing of the nasal airway at the posterior choanae. Early diagnosis is important for prompt treatment as this may be protracted, involving multiple surgical procedures. This article discusses the presentation, assessment and management of the child with suspected choanal atresia.
Hepatic encephalopathy
Authors: Patel D , McPhail MJW , Cobbold JFL , Taylor-Robinson SD
Published: May 2014

Hepatic encephalopathy is a serious complication of both acute and chronic liver failure. It manifests as a spectrum of neuropsychiatric symptoms which are associated with significant morbidity and mortality. This review discusses salient underlying pathogenic mechanisms and highlights diagnostic paradigms and management strategies.
Will telemedicine facilitate access to hyper acute stroke care across the UK?
Authors: Hargroves David
Published: May 2014

Delayed and inconsistent adoption of telemedicine among many acute stroke services is undermining recent advances in acute stroke care. Widespread use of telemedicine will be required for stroke care to achieve the standards demanded by the National Stroke Strategy.
Adult urinary tract infection
Authors: Schollum John BW , Walker Robert J
Published: May 2014

Bacterial infection of the urinary tract is one of the most common medical conditions resulting in significant morbidity and occasional mortality. Epidemiology, pathogenesis, investigation and management of adult urinary tract infection are reviewed.
Stress echocardiography vs nuclear stress imaging in clinical cardiology
Authors: Magri Caroline J , Xuereb Robert G
Published: May 2014

Stress echocardiography and nuclear stress imaging are important non-invasive tools in clinical cardiology. This review discusses the uses, strengths and limitations of these imaging modalities and looks at whether stress echocardiography can actually replace nuclear stress imaging.
Structured airway intervention improves safety of endotracheal intubation in an intensive care unit
Authors: Flavin Kate , Hornsby Jamie , Fawcett Jennifer , Walker David
Published: May 2014

Each year the Royal College of Anaesthetists undertakes a national audit project of procedures and practices within the specialty that have the potential to be associated with significant morbidity and mortality. The fourth National Audit Project (NAP4), endorsed by the Difficult Airway Society, audited advanced airway management and its complications in general theatres, labour wards, critical care units and emergency departments. The NAP4 data allowed the authors to benchmark their own practice against national standards. Using the recommendations in NAP4 they developed a quality improvement intervention to improve airway assessment and tracheal intubation procedures. The authors used a multidisciplinary team approach to training, improving resources and adopting new working practices, which resulted in improved endotracheal intubation technique, and embedded new practice and a new departmental training programme.
Combustion-derived air pollution and cardiovascular disease
Authors: Hunter Amanda L , Mills Nicholas L , Newby David E
Published: May 2014

Air pollution is a modifiable risk factor for cardiovascular disease that affects the entire population and is thus a major public health concern. It is important to understand how air pollution increases cardiovascular risk to develop strategies to protect susceptible individuals and reduce the effect of air pollution on cardiovascular health.
Audit of audit: review of a clinical audit programme in a teaching hospital intensive care unit
Authors: Anderson Peter , Fee Peter , Shulman Rob , Bellingan Geoffrey J , Howell David CJ
Published: May 2014

Objective:

A comprehensive review of the clinical audit programme in a teaching hospital intensive care unit.

Design:

A retrospective analysis of the clinical audit projects undertaken within the intensive care unit over the preceding 2 years and compared with published national guidelines for clinical audit.

Setting:

A 27-bedded teaching hospital intensive care unit in the UK.

Measurements:

Each audit project was reviewed independently by two assessors. The following questions were assessed: 1) Were the projects true audits? 2) Were they prospective or retrospective? 3) Did the projects have input from appropriate members of the multidisciplinary team? 4) How many of the audit projects were re-audits? 5) Of the re-audits how many showed evidence of service improvement? Each audit project was also scored against the Audit Project Assessment Tool produced by the UK Clinical Governance Support Team.

Results:

Of the twenty five audit projects reviewed twenty two were considered to be true audits. All of the projects used only retrospective data. Audit projects were contributed from all sections of the multidisciplinary critical care team but there were few truly multidisciplinary projects. Four of the audit projects were re-audits, of these three showed service improvement and one showed deterioration. Of the twenty two true audit projects reviewed, eleven were classified as good quality projects using the Audit Project Assessment Tool.

Conclusions:

Despite the clinical audit programme being active and well supported, objective evidence of clinical governance benefit was lacking. The overall clinical audit programme has been revitalised by a series of improvements since undertaking this review and this approach is recommended to other organizations who are interested in improving their clinical audit performance.
Current management of parathyroid tumours
Authors: Rafferty Amy , England James
Published: May 2014

Most parathyroid tumours are benign causing primary hyperparathyroidism. The number of patients diagnosed has risen significantly with routine biochemical testing. This review discusses the management of these and other parathyroid tumours.
The fairness, effectiveness and acceptability of selection for specialty training in the UK
Authors: Thomas Hywel , Davison Ian , Gee Harry , Grant Janet , Taylor Celia
Published: May 2014

This article examines the fairness, effectiveness (validity and reliability) and acceptability of the 2009 selection processes for 10 hospital specialties, using data from a nationwide evaluation of 33 selection processes across the UK.
The role of neurosciences intensive care in trauma and neurosurgical conditions
Authors: Sadek Ahmed-Ramadan , Eynon C Andy
Published: May 2014

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.
Nasal obstruction in children
Authors: Leong Samuel C , Swift Andrew C
Published: May 2014

Nasal obstruction is a common complaint in children. It usually is a self-limiting condition and resolves without treatment. Diagnosis is predicated on detailed history and a systematic clinical examination of the child. This article reviews the common causes of nasal obstruction encountered in children.
Pre-excitation on the electrocardiogram: what next?
Authors: Leong Kevin MW , Kelland Nicholas F
Published: May 2014

Ventricular pre-excitation, or a delta wave, on the electrocardiogram in an asymptomatic individual is frequently encountered in clinical practice. Management remains challenging and practice currently varies. This article reviews the evidence and suggests an approach to such patients.
Maternal Critical Care: Who Cares?
Authors: Sloan Brendan , Quinn Audrey
Published: May 2014

With rising birth rates, and greater numbers of increasingly challenging mothers, the need for maternal critical care is rising. In the light of several major reports, this article looks at current provision, as well as areas for future development.