bluuebunny/crossref_metadata_2025 huggingface dataset:
Consultation skills training for hospital doctors: an evaluation of a pilot workshop for ophthalmology
Authors: Mohammed BR , Patwary S , Perry SR , Wilkie V
Published: May 2014

Good quality doctor–patient communication is fundamental in the modern health-care era. This pilot study describes the design and evaluates the outcome of a consultation skills workshop for hospital doctors that incorporates participants' real video consultations.
The patient who threatens to self-discharge
Authors: Justin M , Zaman S
Published: May 2014

Patients who take the hospital discharge decision into their own hands, leaving against medical advice, are familiar to all doctors. No data exist on precise numbers – but as most selfdischarges are not logged on any hospital database, there is no way to know. From the author’s personal experience, the vast majority of patients who self-discharge tend to be those seen acutely as emergencies and most of these patients only see doctors-in-training as opposed to a consultant. These patient episodes are often only witnessed by one doctor and a handful of agency nursing staff at night. Thus, no large studies have been published containing detailed clinical information to help doctors and hospital managers to determine the predictors of such discharge. Furthermore, as such data are lacking, the incidence of potentially dangerous outcomes is difficult to assess.
Cancer-related breakthrough pain
Authors: Davies Andrew N
Published: May 2014

Breakthrough pain is a common problem in patients with cancer, and is associated with significant morbidity among this group of patients. This review examines the different types of breakthrough pain, and the various options for the management of breakthrough pain.
Foundation training: first experiences
Authors: Black David
Published: May 2014

Foundation training is the first step in the delivery of Modernising Medical Careers. Significant changes are occuring in the first year of foundation compared with previous preregistration house officer training. Career planning, new academic programmes, changes in general practice and interprofessional learning are all areas of real change. Some trusts are also developing innovation and creativity in the way that the curriculum is being delivered.
Tube thoracostomy: how to insert a chest drain
Authors: Gareeboo Shafick , Singh Suveer
Published: May 2014

Chest drain insertion (tube thoracostomy) is an essential skill for hospital doctors dealing with certain pleural diseases. While aspiration may be appropriate in spontaneous pneumothorax and uncomplicated pleural effusions, it is often inadequate. In such cases, and for other indications (Table 1), it may be necessary to insert a chest drain. Traditionally, this is inserted in the pleural space percutaneously through blunt dissection and connected to a drainage device with an underwater seal. The procedure may be image-directed. Newer chest drains based on a guide-wire technique have been developed with the dual aims of safety and ease of appropriate placement.
Withdrawal of treatment in children
Authors: Vince T , Petros A
Published: May 2014

With advances in medical technology, many critically ill children will die following withdrawal of treatment rather than failed resuscitation attempts. Legally the parents are surrogate decision makers. The authors review the ethical, legal and practical aspects of withdrawal of treatment and the complex interactions between them.
The radiological investigation of subarachnoid haemorrhage
Authors: Williams Marc , Kasznia-Brown Jo
Published: May 2014

Subarachnoid haemorrhage is an important condition with a high mortality, so prompt diagnosis is essential. This article will review the investigation of subarachnoid haemorrhage with a radiological bias. Appropriate clinical correlation will be included and it will look at some of the more interesting areas in the investigation of this condition.
The legacy of a critical illness
Authors: Sukantarat Kannika , Williamson Robin
Published: May 2014

Improved management of the acute phase of a critical illness ensures that approximately two in three patients will eventually leave hospital, yet survival does not necessarily mean a return to full health. The more widespread use of follow-up clinics in patients discharged from an intensive care unit (ICU) has shown a substantial legacy in terms of physical, cognitive and psychological dysfunction. Problems are all too common during early convalescence from a life-threatening illness, and recovery can be slow and incomplete thereafter. The recognition and management of persisting disability among ICU survivors formed the subject of a meeting held at the Royal Society of Medicine in November 2006, and these topics are covered in the six articles that follow this editorial.
Injuries to the clavicle and acromioclavicular joint
Authors: Oussedik Sam
Published: May 2014

The clavicle is a doubly-curved long bone which acts as the only osseous strut connecting the trunk to the shoulder and arm (Figure 1). Medially the clavicle articulates with the manubrium of the sternum at the sternoclavicular joint, while laterally it articulates with the acromion of the scapula at the acromioclavicular joint. Trapezius and deltoid muscles attach to the flat outer third, as do the acromioclavicular and coracoclavicular ligaments. The tubular medial third is a boundary of the cervicoaxillary canal, and as such affords protection to the neurovascular bundle supplying the upper limb, including the brachial plexus, subclavian and axillary vessels. The junction between these two different crosssectional configurations occurs in the middle third, which constitutes an area vulnerable to injury.
Gestational diabetes mellitus
Authors: Theodoraki A , Baldeweg SE
Published: May 2014

Gestational diabetes is glucose intolerance first recognized in pregnancy. Its prevalence is rising. There are well-recognized associations between gestational diabetes and increased risks to the fetus and the mother. This review looks at the presentation, risks and management of gestational diabetes including recent guidelines.
Neck lumps and head and neck tumours in children
Authors: MacGregor FB , McAllister KA
Published: May 2014

This article discusses the presentation, investigation and treatment of both benign and malignant lumps encountered in the head and neck region in children.
Assessment and management of post-traumatic haemarthrosis of the knee
Authors: Shaerf Daniel , Banerjee Ashis
Published: May 2014

Traumatic haemarthrosis of the knee poses significant diagnostic difficulty in the acute phase. Orthopaedic follow up is essential. An update of current recommended practice is provided, and the pros and cons of arthroscopy and magnetic resonance imaging are discussed.
Preoperative skin preparation: a historical perspective
Authors: Crosby CT , Elliott TSJ , Lambert PA , Adams D
Published: May 2014

The incidence of health-care-associated infections has reduced since skin antisepsis was introduced in the 19th century. Despite this, health-care-associated infections, including post-surgical sepsis, continue to cause significant morbidity and mortality. This article reviews the evidence for the use of preoperative skin preparations.
Monitoring and management of heparin-induced thrombocytopenia
Authors: Rogers BA , Little NJ , Jones C
Published: May 2014

Low molecular weight heparins have been used to reduce thromboembolic risk for at least 20 years, but their use is not without risk. This article considers the incidence, monitoring, treatment and lack of insight about heparin-induced thrombocytopenia – a potentially fatal complication of low molecular weight heparin use.
Decision making about reproduction and pregnancy by women with cystic fibrosis
Authors: Simcox AM , Duff AJA , Morton AM , Edenborough FP , Conway SP , Hewison J
Published: May 2014

With significant improvements in longevity, women with cystic fibrosis are increasingly likely to consider pregnancy and parenthood. This article reviews the literature relating to medical and psychosocial research that informs the decision-making process these women undertake.
Why we need a national strategy for liver disease
Authors: Moore Kevin , Sheron Nick
Published: May 2014

For the last 10 years the British Association for the Study of the Liver and the British Society of Gastroenterology Liver Section have been campaigning for greater recognition of liver disease as an important priority for the NHS. Deaths from liver disease are escalating at a frightening rate (Figure 1) (British Association for the Study of the Liver, 2009). Based on current trends, the death rate from liver disease will exceed cardiac deaths by 2030. This needs to be reversed before we get to this ridiculous scenario – over 95% of all liver diseases are entirely preventable or treatable, and deaths from liver disease occur at an average age of 55 years rather than ∼82 years for cardiac disease or stroke. To stop this we need to reduce the rising tide of alcoholic liver disease and fatty liver disease, and actively treat the increasing number of patients with chronic hepatitis B and C.
A rare cause of small bowel obstruction
Authors: Delia Etienne Cassar , Hallan Rodney
Published: May 2014

An 83-year-old man was admitted with a 1-day history of worsening, colicky central abdominal pain associated with vomiting and abdominal distension. A suprapubic catheter had been inserted under cystoscopic vision 4 years previously for a hypotonic, trabeculated bladder complicating long-term bladder outlet obstruction as a result of benign prostatic hyperplasia. The catheter was changed every 8 weeks without the need for any further surgical intervention.

On this admission, physical examination revealed a grossly distended abdomen with central and left upper quadrant tenderness. He also had a left inguinal hernia, which was easily reducible. The suprapubic catheter was placed two fingerwidths above the upper border of the pubic bone.

A chest radiograph was normal while a plain abdominal film showed dilated small bowel (Figure 1). A computed tomography scan of the abdomen showed the suprapubic catheter passing through the mesentery of the small bowel with dilated small bowel loops proximal to it (Figure 2). An urgent lower midline laparotomy was performed. The suprapubic catheter passed transperitoneally through the mesentery of the distal jejunum, very close to the bowel, before entering the bladder. The suprapubic catheter acted as a sling, kinking the jejunal loop, which looked discoloured (Figure 3). The suprapubic catheter tract within the mesentery and the short segment of ischaemic jejunum were resected and anastomosis performed. Another suprapubic catheter was inserted extraperitoneally inferior to the laparotomy wound. The postoperative period was uneventful apart from a wound infection, which was treated with antibiotics.

Histological examination of the resected specimen showed a strictured inflamed segment of jejunum about 20 mm wide. Sections from this area showed an actively inflamed granulation tissue-lined tract within the subserosa and muscularis propria, consistent with the tract formed by the suprapubic catheter.
Giving effective feedback
Authors: McKimm Judy
Published: May 2014

Feedback is a vital part of education and training which, if carried out well, helps motivate and develop learners' knowledge, skills and behaviours. It helps learners to maximize their potential and professional development at different stages of training, raise their awareness of strengths and areas for improvement, and identify actions to be taken to improve performance.
Post-concussion syndrome
Authors: Foy Kevin , Murphy Kieran C
Published: May 2014

Post-concussion syndrome is common after head injury. It consists of a triad of physical, cognitive and psychological symptoms that occur after a head trauma and cause significant social and occupational disability. This article examines the clinical features, epidemiology, aetiology and treatment of the condition.
Acute management of croup in children
Authors: Syed Irfan , Tassone Peter , Sebire Peter , Bleach Nigel
Published: May 2014

The expiratory wheeze of an obstructing lower airway in acute severe asthma is a common presentation in the emergency department and most physicians are well versed with the basic principles of initial assessment and management.
Acquired small bowel diverticular disease: a review
Authors: Bosanquet DC , Williams N , Lewis MH
Published: May 2014

Acquired diverticular disease, common in the large bowel, can also occur throughout the small bowel. This article reviews the prevalence, various presentations and management options for acquired small bowel diverticular disease.
Alcohol and the central nervous system
Authors: Imam Ibrahim
Published: May 2014

Alcohol has a significant and widespread effect on the central nervous system ranging from intoxication to neurodegenerative dementia. This article reviews these effects and summarizes their management.
Attention deficit hyperactivity disorder
Authors: Ather Muhammed , Salmon Gill
Published: May 2014

Attention deficit hyperactivity disorder is a highly heritable medical condition which mainly affects school-aged children although it is increasingly being recognized in adults. The exact cause remains unknown, but the condition responds well to evidence-based interventions.
Renal amyloidosis
Authors: Lachmann Helen J , Gillmore Julian D
Published: May 2014

Renal amyloid deposition is common in systemic amyloidosis. Presentation is usually with proteinuria renal impairment. With effective treatment of the underlying amyloidotic condition and good supportive care renal function can stabilize or improve but many patients still progress to end-stage renal failure.
Modernising Medical Careers and the British surgeons of the future
Authors: Chand Manish , Faruque Mohammed , Dabbas Natalie , Nash Guy F
Published: May 2014

The Modernising Medical Careers reforms in medical training have led to significant changes in the way junior doctors are trained. However, not all these changes have been welcomed by both trainees and trainers. This article seeks to examine some of the issues regarding training in surgery.
Using simulation in clinical education
Authors: Forrest Kirsty , McKimm Judy
Published: May 2014

Patient simulation in all its forms is widely used in clinical education with the key aims of improving learners' competence and confidence, improving patient safety and reducing errors. Understanding its benefits, range of uses and limitations will help clinical teachers improve the learning experience.
Psychiatric side effects of non-psychiatric drugs
Authors: Holvey Carl , Connolly Anne , Taylor David
Published: May 2014

Psychiatric side effects of non-psychiatric drugs are poorly studied. This article describes how to identify and manage the psychiatric side effects of some commonly prescribed medicines that are known to cause such problems.
The clinical anatomy of the great veins of the neck
Authors: Ellis Harold
Published: May 2014

Central venous pressure measurement, prolonged intravenous nutrition, massive and rapid fluid replacement, infusion of hypertonic and cytotoxic solutions, and the use of percutaneous pacemakers have all made catheterization of the great veins of the neck and superior mediastinum a common hospital procedure. A detailed knowledge of the internal jugular, subclavian and brachiocephalic veins is therefore of considerable importance – especially their surface markings and the position of adjacent structures which may inadvertently be damaged in these procedures.
Dysphagia
Authors: Berber O , Joshi JR
Published: May 2014

The term dysphagia is defined as difficulty in swallowing and originates from the Greek words dys, with difficulty, and phagia, to eat. Dysphagia should be distinguished from ‘odynophagia’ or painful swallowing, although both may appear together. Dysphagia is a distressing symptom and can have serious effects on a patient's health. The main concern is airway obstruction and the risk of aspiration. Suspicion of a swallowing difficulty should lead to accurate assessment and patient precautions must be taken. Furthermore, the physician should always suspect a malignant cause of dysphagia.
Disproportionate elevation of jugular venous pressure in pleural effusion
Authors: Jolobe Oscar MP
Published: May 2014

Constrictive pericarditis is characterized by elevation in jugular venous pressure disproportionate to the severity of concurrent breathlessness. As pleural effusion may be an associated feature it is recommended that jugular venous pressure should be documented in all patients who present with pleural effusion.
The eye in renal disease
Authors: Muthusamy Kirithika , Lightman Sue , Taylor Simon RJ
Published: May 2014

This article summarizes the ocular pathology that can be seen in conjunction with renal disease. Both the eye and the kidney can be the target of systemic disease processes, but the eye can also be affected as a consequence of either renal disease or its treatment.
The intensive care management of common and uncommon drugs of misuse
Authors: Watson Christine , Wilkinson Jonathan
Published: May 2014

With an ever-expanding field of illicit drugs available, doctors working in the acute specialties will inevitably be involved in the management of the serious and life-threatening side effects of drug misuse, as outlined in this article.
The athlete's heart
Authors: Zaidi Abbas , Sharma Sanjay
Published: May 2014

The deaths of a number of high-profile athletes within the sporting community have focused attention on the phenomenon of ‘the athlete's heart’. This review highlights the electrical and morphological changes observed in the hearts of athletes, and provides practical methods for differentiating physiology from disease.
Radiological investigation of acute stroke 1: non-enhanced computed tomography
Authors: Pearce Tim , Ngan-Soo Eleanor , Bradley Marcus
Published: May 2014

Radiology plays a central part in the acute stroke management pathway, with its role now widened beyond establishing the diagnosis. This article reviews the role of the non-enhanced computed tomography brain scan, particularly focusing on the hyper-acute presentation of stroke from a radiological perspective.
Advance care lanning:ethical and clinical implications for hospital medicine
Authors: Randall Fiona
Published: May 2014

Advance care planning takes place ‘in advance of’ anticipated loss of capacity with the aim of informing the best interests judgments required when capacity is later lost. It is an ethically and clinically distinct subset of general care planning.
Place of death: is home always best?
Authors: Macleod Una
Published: May 2014

Place of death is now a quality marker of end of life care. Decisions around place of death are complex. This article considers the extent to which place of death is an appropriate way to determine good end of life care.
Medical management of renal stone disease
Authors: Xu Gang , Iyasere Osasuyi , Al-Jayyousi Reem
Published: May 2014

Nephrolithiasis can cause significant morbidity in affected individuals. Recurrent stone disease can be prevented through a multidisciplinary approach to management.
Clinical leadership: a role for students?
Authors: Cosway Benjamin , Carson-Stevens Andrew , Panesar Sukhmeet
Published: May 2014

Since the publication of the ‘To Err is Human’ report, patient safety and quality improvement has been an increasingly important agenda in health care. This article explores the role that students can play in leading change in health-care systems.
Medical education and the Apothecaries
Authors: Beedham Trevor
Published: May 2014

In 1815 the Society of Apothecaries, which had already produced the first general medical practitioners, became the first regulator of medical practice throughout England and Wales. Now the Society focuses its expertise on important niche areas of medicine and is responsible for eight unique qualifications.
Sudden sensorineural hearing loss
Authors: Stew BT , Fishpool SJC , Williams H
Published: May 2014

This article highlights the importance of recognizing sudden onset sensorineural hearing loss and summarizes the key diagnostic and management points. There is much to learn about its pathogenesis, and more trials are needed to establish evidence-based management.
Platelet-rich plasma in sports medicine: hot favourite or non-starter?
Authors: Jassim S , Haddad FS
Published: May 2014

Platelet-rich plasma is not a new therapy – it is has been used in clinical medicine for almost 30 years. However, it has only recently come to prominence in the world of sports and musculoskeletal medicine with use in high profile sporting cases. This article examines the basic science and current evidence behind its use.
Common prescribing errors in renal patients
Authors: Dunleavy Aileen D
Published: May 2014

This article will outline some of the common prescribing errors that occur and how to avoid them when prescribing for renal patients including patients with chronic kidney disease, established renal failure and transplant patients.
Role of tapentadol in pain management
Authors: Mendis Victor
Published: May 2014

This article reviews tapentadol, a novel centrally-acting opioid analgesic that exerts its analgesic effects through mu-opioid receptor agonism and additionally via noradrenaline reuptake inhibition.

This potentially gives it a role in the treatment of both nociceptive and neuropathic pain.
Congenital hand anomalies and reconstruction
Authors: Smith Gillian D
Published: May 2014

The management of congenital hand deformities encompasses the care of the family from infancy, through childhood, to produce a well-adjusted adult who can function physically, socially and psychologically to the highest level that their anatomy will allow. It requires teamwork by all involved for this to be successful.
Heart disease in pregnancy
Authors: Vause Sarah , Clarke Bernard
Published: May 2014

In women with cardiac disease physiological changes in the cardiovascular system associated with pregnancy may precipitate decompensation. Heart disease is the commonest cause of maternal death. Close multidisciplinary working is important to ensure the best care possible for pregnant women with heart disease.
Trainee doctors with learning difficulties: recognizing need and providing support
Authors: Shrewsbury Duncan
Published: May 2014

Specific learning difficulties affect medical students and trainee doctors. These conditions impact on processing and learning skills, and are associated with positive attributes. Having an awareness of these is key for successful and effective medical educators.
Meticillin-resistant Staphylococcus aureus pneumonia
Authors: Edwards B , Gould IM
Published: May 2014

Meticillin-resistant Staphylococcus aureus causes an evolving clinical presentation of pneumonia. Health-care-acquired infection differs from community-associated disease, with important implications for treatment. Current antibiotics are less than ideal, and broader management strategies are crucial to prevent complacency.
Diabetic gastroparesis: pathophysiology, evaluation and management
Authors: Farmer Adam D , Kadirkamanathan Sri S , Aziz Qasim
Published: May 2014

As the incidence of diabetes mellitus inexorably rises, the burden of its complications is becoming increasingly problematic. Among the most bothersome, but often under-recognized, inadequately investigated and poorly managed, is diabetic gastroparesis.
Echocardiography and the non-cardiac anaesthetist
Authors: Peck MJE
Published: May 2014

Echocardiography is destined to revolutionize perioperative and intensive care medicine, as it has already in cardiac anaesthesia. This article reviews the evidence underlining why now is the time for general anaesthetists to get involved in this rapidly evolving field.
Evaluation of array comparative genomic hybridization in recurrent miscarriage
Authors: McNamee K , Dawood F , Farquharson RG
Published: May 2014

Chromosomal analysis of a failed pregnancy following the diagnosis of recurrent miscarriage is not standard practice yet an abnormal karyotype is one of the commonest causes. Array comparative genomic hybridization heralds a new and improved era of cytogenetics, which may prevent unnecessary interventions for patients.
Resuscitation beyond Advanced Trauma Life Support: damage control
Authors: Kaczynski Jakub
Published: May 2014

This article describes the general principles of the damage control concept in the management of the haemorrhaging multiply injured patient in a civilian setting. Military practice, head injuries and burns as well as trauma in paediatric and elderly patients and pregnant women will not be covered.
Cardiac resynchronization therapy
Authors: Cobb V , Thomas M
Published: May 2014

This article provides an overview of cardiac resynchronization therapy. At the end of the article, the reader should be familiar with the indications, risks and complications of cardiac resynchronization therapy and important areas of debate.
How to appraise a systematic review
Authors: Taylor Paul , Hussain Jamilla A , Gadoud Amy
Published: May 2014

Systematic reviews are a vital tool in evidence-based practice, allowing a comprehensive synthesis of research evidence. This article provides guidance for appraising systematic reviews and resources for more detailed assessments.
Specialty choice, stress and personality: their relationships over time
Authors: Firth-Cozens Jenny , Lema Victoria Caceres , Firth Robert A
Published: May 2014

A longitudinal questionnaire study of 314 medical students followed up as preregistration house officers (PRHOs) and again 7 years later showed laboratory-based doctors were the least happy with their choice of career and were the most stressed now, while surgeons were the most happy with their choice and the least stressed. These differences were apparent 10 years earlier. The study also describes perceived influences on specialty choice and explores how earlier factors, such as personality as students and stress in the PRHO year, may also have influenced specialty choice.
Current practice in thoracic sympathectomy
Authors: Chaudhuri Nilanjan , Birdi Inderpaul , Ritchie Andrew J
Published: May 2014

Thoracic sympathectomy has been performed for many years. With the recent development of video assisted thoracic surgical techniques the indications for surgery have increased, and the outcome is much better.
Catatonia 2: diagnosis, management and prognosis
Authors: Clark T , Rickards H
Published: May 2014

This is the second of two articles reviewing catatonia. In the first, catatonia was described as an under-recognized syndrome with a potentially fatal outcome. It was suggested that treatment with neuroleptics may exacerbate the syndrome. The differential diagnosis, management and prognosis of catatonia are reviewed below.
Folie à deux in a Seychellois mother and adult son
Authors: Christopherson Thereza , Robertson Mary M
Published: May 2014

Folie à deux, a French term which literally means psychosis of two, was first coined by Lasegue and Falret in 1877 to describe a rare clinical syndrome in which delusions are shared by two or more people who have a close and intimate relationship and are often isolated from the outside world. The phenomenon was later defined by Gralnick (1942) in his classic review of 103 cases as
Radiological features of non-accidental injury
Authors: Duncan Andrew W
Published: May 2014

Non-accidental injury is not uncommonly met in clinical practice. One should be aware of its presentation, the radiographic signs suspicious of abuse and the appropriate further imaging assessment to confirm or refute the diagnosis. Erroneous diagnosis can have grave consequences.
Postpartum haemorrhage
Authors: Jackson Nikki , Paterson-Brown Sara
Published: May 2014

Postpartum haemorrhage can be either primary (within 24 hours of delivery) or secondary (within the following weeks). This article reviews the factors that may help anticipation of postpartum haemorrhage, and looks at issues involved in the management and treatment of women with this condition.
Clinical governance and revalidation
Authors: Thomas Hilary
Published: May 2014

The quality agenda in the NHS has many parts. For the medical profession the means of enhancing standards and consistency will be revalidation. This article outlines progress to date in defining how doctors will demonstrate they are ‘up to date’ and ‘fit to practice’.
A pilot internet teaching project to support specialist medical training
Authors: Simpson A , Weist A , Reading NG , Roberts CM
Published: May 2014

Regional training programmes involving specialist medical trainees at geographically separate sites lend themselves to distance learning methods. This paper describes the setting up and early evaluation of an internet-based project designed to support regional study days across North East Thames for respiratory medicine.
Acute adrenocortical crisis and an abnormal electrocardiogram
Authors: Bhattacharyya Arpandev , Jagadeesan Subramaniam , Wolstenholme Roger J , Tymms D James
Published: May 2014

Acute adrenocortical crisis is often the first presentation of Addison's disease. The combination of pigmentation, peripheral circulatory failure and the electrolyte abnormality usually lead to suspicion and early treatment with corticosteroids is the key to the success in such cases. Failure of response to the standard treatment should highlight the possibility of a coexisting condition. We report a case where the patient did not respond to the treatment until such a condition was recognized.
Improving senior house officer training in accident and emergency medicine: the benefits of a diploma
Authors: Varghese D , Grocutt M
Published: May 2014

Accident and emergency is a fascinating specialty providing exposure to a wide range of acute and chronic conditions from all branches of medicine. To ensure a minimal standard of training nationally we propose the introduction of a diploma for junior doctors.
Cervical spine infection presenting as angina
Authors: Gadour M , Rajbhandari SM , Tesfaye S
Published: May 2014

The exact diagnosis for the cause of chest pain is not always straightforward as some unusual conditions may present with this symptom. We report one case of ‘cervical angina’ where a diabetic patient with infective discitis presented with a pain mimicking anginal chest pain.
A rare cause of tracheal obstruction unrelieved by tracheal intubation
Authors: Phillips JAJ , Cohen J
Published: May 2014

A 50-year-old man presented with a 4- day history of cough on eating and drinking. He was known to have an oesophageal carcinoma for which he had received chemotherapy and radiotherapy initially and latterly dilatation and laser therapy. Oesophagoscopy revealed the tumour to be at 20–25 cm with a 6–8 mm tracheoesophageal fistula at 22 cm, which was treated by insertion of a Celestin oesophageal stent under sedation with midazolam and pethidine. Insertion of the stent was uncomplicated, but immediately afterwards the patient experienced severe dyspnoea and stridor so emergency anaesthetic assistance was sought.
Pruritus in pregnancy and obstetric cholestasis
Authors: Clark T Justin , Dwarakanath Linga , Weaver Judith B
Published: May 2014

Pruritus is often considered a common but minor symptom of pregnancy. However, pruritus caused by obstetric cholestasis is increasingly being recognized as a cause of so-called ‘unexplained’ stillbirths. This article reviews recent literature and outlines possible management strategies with the aim of reducing maternal morbidity and improving perinatal outcome.
Asthma management with HFA-BDP (Qvar™)
Authors: Davies Robert , Leach Chet , Lipworth Brian , Shaw Rory
Published: May 2014

This report reviews the role of hydrofluoroalkane-beclomethasone dipropionate (HFA-BDP; Qvar™, 3M, Loughborough) in the management of asthma, based on pharmacokinetic, efficacy and safety clinical trial data presented at a satellite symposium to the European Respiratory Society in 1998. Qvar provides equivalent efficacy and safety to chlorofluorocarbon-BDP at about half the dose.
Giant cell arteritis as a cause of intermittent claudication
Authors: Desmond J , Hussain ST , Colin JF
Published: May 2014

A 57-year-old lady who works in the post office presented initially in May 1994 with a 5- month history of left calf claudication at 50 yards.

Six months previously she had also complained to her GP of joint pain, tiredness, and muscle aches. Rheumatoid factor was negative and erythrocyte sedimentation rate was elevated at 102. A diagnosis of polymyalgia rheumatica was made and she commenced a course of low-dose steroids, from which she gained dramatic relief. However, the pain in her legs continued and 6 months after the onset it caused sufficient handicap to interfere with her lifestyle.

At presentation to the vascular clinic, she was no longer on steroids. She smoked ten cigarettes per day and had no other atherosclerotic risk factors. On examination she had palpable femorals with no pulses distally. An arteriogram was arranged, which showed bilateral femoropopliteal occlusions with both popliteal arteries being patent above the knee, with poor run off. A diagnosis of peripheral vascular disease was made and confirmed by ankle:brachial pressure indices of 0.7 and 0.76 for the dorsalis pedis arteries on the right and left side respectively. She was advised to stop smoking and was put on an exercise regime. An outpatient review was to be carried out in 2 months time.

Her joint and muscle symptoms returned, so she was referred to the rheumatologist. A temporal artery biopsy was arranged. This showed multi-nucleated histiocytes consistent with giant cell arteritis. She was subsequently started on prednisolone 60 mg and methotrexate 10 mg.

Three weeks after commencement of treatment she made a dramatic improvement in her symptoms of joint pains and muscle aches. Unexpectedly, the claudication disappeared, despite the continuance of her smoking habit. Her claudication symptoms were therefore attributed entirely to large vessel vasculitis as a result of giant cell arteritis. Her ankle:brachial pressure indices improved to 0.89 and 0.92 for the right and left side respectively.
Central venous catheter placement
Authors: Vrazas John I
Published: May 2014

Central venous access has become a vital element of medical care. Fraught with significant complications, traditional surgical approaches have yielded imageguided techniques. This article reviews clinical aspects and devices used, and compares surgical and interventional radiological approaches. It also looks at complications and their management, and aspects of patient care.
Immunosuppressive agents in organ transplantation
Authors: Magee Colm C , Denton Mark D , Milford Edgar L
Published: May 2014

This article reviews current and future immunosuppressive strategies in organ transplantion. Recently introduced drugs are lowering the rates of acute rejection and allowing more individualized management of transplanted patients.
The changing face of endocarditis: report of a series of cases
Authors: Brydie Alan D , Clark Andrew L
Published: May 2014

A 67-year-old man presented with a sudden onset right homonymous hemianopia associated with a swinging pyrexia and a new early diastolic parasternal murmur. He had had a Bjork–Shiley aortic valve replacement 2 years previously for symptomatic aortic stenosis with a transvalvular gradient of 80 mmHg and had been well thereafter.

Computed tomography scan of the brain showed a left occipital infarct (Figure 1), C-reactive protein was 51 mg/litre (normal <10 mg/litre), blood cultures consistently grew Candida parafilaris, and treatment with intravenous liposomal amphotericin and flucytocine was started the day the first positive culture was obtained. Transoesophageal echocardiography did not demonstrate vegetations, but did show a periprosthetic aortic incompetent leak.

On day 11 the aortic prosthesis was removed and replaced because of worsening aortic incompetence. Direct inspection of the prosthesis demonstrated a vegetation on the sewing ring. The immediate postoperative recovery period was complicated by complete heart block requiring insertion of a permanent pacemaker after an initial phase of pericardial pacing.

The intravenous antifungals were discontinued after 37 days of treatment and the patient commenced on lifelong oral fluconazole. At discharge on day 42 the patient was well and apyrexial with C-reactive protein less than 10 mg/litre.
Twin-twin transfusion syndrome
Authors: Brackley KJ , Kilby MD
Published: May 2014

Twin–twin transfusion syndrome is a complication of monochorionic twin pregnancies associated with extremely high perinatal morbidity and mortality. This article describes the ultrasound features associated with this condition and possible pathophysiological mechanisms. Management options are outlined, including recent developments such as laser ablation of placental vascular communications.
Perioperative management of the elderly trauma patient
Authors: Dickson RE , Patey RE
Published: May 2014

This article reviews the physiology and pathology associated with ageing and the impact these may have on the perioperative and anaesthetic care of the elderly trauma patient. The current literature on this subject is summarized and, based on this, recommendations are made for perioperative management.
Pantoprazole, Prout and the proton pump
Authors: Playford Raymond J , Podas Theo , Modlin Irvin
Published: May 2014

Pantoprazole is a proton pump inhibitor which has recently had its clinical license extended to include maintenance therapy for the treatment of reflux oesophagitis, Helicobacter pylori eradication and short-term intravenous administration. This article reviews the history of gastric acid secretion and examines the role of proton pump inhibitors, particularly pantoprazole, in the treatment of acid-related disorders.
Levomepromazine (methotrimeprazine) and the last 48 hours
Authors: O'Neill Joseph , Fountain Averil
Published: May 2014

Levomepromazine (previously known as methotrimeprazine) has a broad range of beneficial effects in the terminal phase of many illnesses, resulting from its combined antipsychotic, anxiolytic and sedative actions. Levomepromazine can safely be administered in a continuous subcutaneous infusion with most other commonly used drugs in palliative care.
The mysterious case of the lost pituitary: amiodarone-induced hypothyroidism
Authors: Weston SN , Weston CFM
Published: May 2014

A60-year-old man with a history of ischaemic heart disease, myocardial infarction and previous coronary bypass grafting was admitted to hospital with sustained monomorphic ventricular tachycardia. He was treated with intravenous amiodarone and was later discharged on oral amiodarone 200 mg once a day in addition to his usual antianginal therapy, angiotensin-converting enzyme inhibitor and diuretic.

Approximately 6 months afterwards, he presented with profound tiredness, somnolence, weight gain constipation and fluid retention. He described fluctuating disorientation in time as well as vivid visual hallucinations of people and animals. He had also experienced auditory hallucinations of the voices of his relatives conversing with him in the second person.

Transient secondary delusions were evident. In particular, on the night before his readmission he became convinced that he had lost his pituitary and enlisted his wife to help search for it in the bed.

Thyroid function tests (TFTs) revealed a free thyroxine level of 2 pmol/litre (normal range 11–25 pmol/litre) and markedly raised thyroid-stimulating hormone (TSH) of more than 150 mU/litre (normal range 0.35–5.00 mU/litre). Microsomal thyroid antibodies were present — 670 IU/ml (normal range 0–200 IU/ml). Amiodarone was stopped and he was given thyroxine, with gradual dose titration up to 150 μg per day.

On reviewing his medical notes it was discovered that a diagnosis of hypopituitarism was made in 1984, and he had briefly been treated with steroid, testosterone and thyroxine replacement therapy. This diagnosis had later been refuted. Of relevance is that a thyrotropinreleasing hormone test was normal at this time. Plain X-ray of the skull showed an asymmetrical sella, and a diagnosis of ‘empty sella syndrome’ was made. There was no previous psychiatric history. Interestingly his basal TFTs at the time of amiodarone initiation showed a normal thyroxine level of 16 pmol/litre but TSH was not measured. A month later his free thyroxine was still 16 pmol/litre and TSH was noted to be elevated at 8.9 mU/litre. He appeared euthyroid and no changes were made to his treatment.

Following the treatment of his hypothyroidism his angina worsened, while his psychiatric symptoms settled within a matter of weeks and his TFTs showed adequate replacement after 5 months. To date there has been no recurrence of his arrhythmia.
Management of oesophageal varices
Authors: Dagher Lucy , Patch David , Burroughs Andrew
Published: May 2014

Beta-blockers are the treatment of choice to prevent the first episode of variceal bleeding and further rebleeding episodes. In acute bleeding all patients should receive pharmacological treatment with vasoconstrictors and endoscopic treatment. Failure of therapy should lead to consideration of transjugular intrahepatic portosystemic shunting.
Treatment of paediatric cerebral palsy with Dysport
Authors: Ubhi Tim
Published: May 2014

Dysport® (Clostridium botulinum type A toxin-haemagglutin complex) has had its licence extended to include treatment of children aged 2 years and over with dynamic equinus foot deformity, caused by spasticity associated with cerebral palsy. Dysport® reduces muscle tone, thus improving function, relieving pain, and facilitating physiotherapy, application and tolerability of splints.
The risks of clinical practice
Authors: Reyes Rick , Davidson Tim
Published: May 2014

The hospital workplace is changing dramatically, moulded in part by the need to protect medical staff from the increasing physical and mental risks of medical practice today. This article examines the risks and look to the future.
Management of flail chest
Authors: Sivaloganathan M
Published: May 2014

Flail chest continues to be a significant injury with serious complications. Controversy exists as to the optimal treatment. The principal dilemmas are whether the patient should be managed conservatively without mechanical ventilation, with ventilation, or via operative chest wall stabilization. This article illustrates a case of flail chest and summarizes the evidence for current treatment options.
Finding health information on the Internet: health consumers
Authors: Kiley Robert
Published: May 2014

The quality of health information on the Internet is extremely variable. This article highlights some of the problems consumers encounter when searching for health information and suggests ways in which these can be overcome.
The use of patient information leaflets in surgery
Authors: Goldie Boyd
Published: May 2014

The vast majority of patients want to know more about their condition, the treatment and the prognosis. The fact that the second most searched for topics (after sex) on the Internet are medical supports this proposition. Some patients are inhibited from asking questions of their surgeon by a combination of factors that may include fear of wasting the doctor's time, fear of appearing ignorant or ill informed, and simply not thinking of questions at the time that they have the opportunity to ask them. Some ask their GP as an alternative to asking the specialist.
A mentorship scheme for senior house officers
Authors: Beckett Michael
Published: May 2014

Many junior doctors are unsure as to how their aspirations and developing abilities will match up to the demands of specialty training. They need sensitive and realistic guidance if they are to make the right career choice in a highly competitive market.
Surgical treatment of epilepsy resistant to medical therapy
Authors: Ellamushi H , Kitchen N
Published: May 2014

Epilepsy is a chronic brain disorder characterized by the spontaneous occurrence of seizures, the clinical characteristics of which depend on the regions of the brain involved at the beginning of, during and after the ictal event. The prevalence of epilepsy in UK ranges between 0.5 and 1% and of these about 20% are considered to be refractory to pharmacotherapy.
Surgical correction of congenital uterine anomalies
Authors: Matts SJF , Clark TJ , Khan KS , Gupta JK
Published: May 2014

Congenital uterine abnormalities have been associated with poor reproductive outcome. Anatomical corrections utilizing open or endoscopic surgery has been recommended to improve these outcomes. This article assesses the available evidence.
Intestinal perforation as a presentation of Wegener's granulomatosis
Authors: Skaife P , Lee S , Maitra D , Edwardson KF , Ramadwar M
Published: May 2014

Wegener's granulomatosis is a necrotizing vasculitic disease principally affecting upper and lower airways and commonly the kidneys. The disease process may, however, manifest itself in any organ system and cases continue to be reported to substantiate this (Hoffman et al, 1992).
Neurological manifestations of malignant disease
Authors: Rees Jeremy
Published: May 2014

Neurological complications of cancer are some of the most feared manifestations of malignant disease. Their frequency is increasing with improvements in the treatment of primary systemic disease. This article discusses the approach to patients with neurological complications of cancer and reviews some of the most common causes.
Branch retinal artery occlusion: a case complicating acute rheumatic fever and dental abscess
Authors: Tillett A , Edelsten C
Published: May 2014

A15-year-old boy presented with a 2-month history of lethargy, weight loss and migratory arthralgia following an episode of pharyngitis while on holiday in the Mediterranean. Examination revealed the murmurs of mitral and aortic regurgitation which were confirmed on echocardiogram. The serum C-reactive protein (CRP) was high at 124 mg/litre and the streptococcal antibody titre markedly elevated at >1440 units. A diagnosis of acute rheumatic fever was made and penicillin commenced in addition to aspirin for joint pain. Three months after diagnosis he was asymptomatic, the CRP was normal and aspirin was discontinued.

Six weeks later he presented with sudden onset of blurred vision in the right eye with a visual field defect in the nasal upper quadrant. There was no history of migraine and fundoscopy revealed an embolus at the disc with severe oedema below the macula consistent with occlusion of the inferotemporal branch of the retinal artery (Figure 1). Warfarin was commenced pending further investigation. Subsequent transoesophageal echo showed mild mitral regurgitation and minimal aortic regurgitation with no vegetations or thrombus. There was no evidence of arrhythmia and brain magnetic resonance imaging was normal. His protein C activity was transiently low at 64% (normal range 70–130%) and his CRP rose to 36 mg/litre. Aspirin was therefore substituted for warfarin. Three days later he presented with two dental abscesses requiring extraction. Fourteen months after presentation the superior altitudinal scotoma has improved and the retinal oedema resolved. Mild mitral valve regurgitation persists but aortic valve function appears normal. He continues on low dose aspirin and penicillin.
The dangerous needles in the haystack of sore throats
Authors: Gant Vanya
Published: May 2014

The two reports of patients with sore throat published this month (p. 435, 436) highlight life-threatening aspects of that condition. Such rare but clinically highly significant entities remain buried among the far more common sore throats usually associated with the cold and wet British winter; but just because they are rare manifestations of a common disease leaves no room for complacency when assessing the patient with pharyngitis.