bluuebunny/crossref_metadata_2025 huggingface dataset:
Administering rectal suppositories: Preparation, assessment and insertion
Authors: Bradshaw Elissa , Collins Brigitte , Williams Julia
Published: May 2014

This series is designed for the nursing professional as a review of the key clinical skills necessary for patient care, clearly presenting common clinical procedures and their rationale, together with the essential background theory. In this ninth article in the series, the use of suppositories as a method of administering other drugs rectally within a base preparation is considered (Homan, 2002). Rectal suppositories are ideal for local or systemic treatment as the rectal mucosa has a blood and lymph supply that is capable of systemic absorption (Kyle, 2009). Best practice in pre-administration digital rectal examination and insertion of suppositories will be outlined.
Globalization in gastroenterology
Authors: Hodson Rachael
Published: May 2014

The process of globalization is ongoing in the 21st century, with economies, societies and cultures continuing their integration through a globe-spanning network of communication and technology. Under globalization many barriers are removed, although successful globalization retains and defends uniqueness, individuality, and identity. These principles of globalization extend to endoscopy, with the Global Rating Scale (GRS) built around these principles to improve health care. Created in 2004 as a quality improvement and assessment tool for the gastrointestinal endoscopy service it assesses 12 key aspects relating to clinical quality and the quality of the patients′ experience of having an endoscopy (Global Rating Scale, 2008).
Oral feeding difficulties and dilemmas
Authors: Gordon Harriet
Published: May 2014

Oral feeding toward the end of life can be fraught with dilemmas for health professionals dealing with patients who cannot clearly give their views. On the one hand, is providing artificial feeding an essential requirement and failing to do this tantamount to manslaughter, or is it assaulting a frail and dying individual? In a protocol-driven medical environment, many frail and unwell patients may be placed ′nil by mouth′ and receive artificial feeding before full consideration regarding all their medical and social issues has taken place.
E-learning: The new panacea for nurses?
Authors: Harrison Penny
Published: May 2014

Penny Harrison, senior lecturer in adult nursing, De Montfort University, Leicester, argues that gastrointestinal nurses need to access new e-learning facilities and initiatives in order to fully engage in lifelong learning, and take advantage of the resources available in their area of professional practice.
Reassessing loop ileostomies
Authors: Perston Yvette
Published: May 2014

The last two decades have seen incredible advances in medicine, and the gastrointestinal (GI) speciality is no exception. We have seen improvements in diagnosis and treatment options for many of the diseases and disorders that affect our patient group. We have also seen the development and successful launch of the first whole population screening programme in the UK for bowel cancer. All these advances are to be applauded and celebrated but sometimes we need to reassess our practice.
Psychological interventions for irritable bowel syndrome: A nursing perspective
Authors: Smith Graeme D
Published: May 2014

Irritable bowel syndrome (IBS) is a common functional bowel disorder. It accounts for up to 50% of all referrals to gastrointestinal departments and to this day it remains a mysterious and poorly understood condition. IBS patients can suffer from abnormal bowel function and a range of unexplained abdominal symptoms, which can have a detrimental affect on their psychological wellbeing and health-related quality of life. In this article, Graeme D Smith outlines the psychological management of IBS from a nursing perspective.
Survivorship Care Planning Care for Colorectal Cancer Patients
Authors: Taylor Claire , Odey Kathryn
Published: May 2014

The completion of cancer treatment marks a new phase in cancer care delivery, as individuals are assisted in the transition from cancer patient into cancer survivor. This phase is described as survivorship care which involves addressing the physical, psychological, social and economical problems experienced after cancer in order to optimize individuals’ current health and future quality of life. In this article, Claire Taylor and Kathryn Odey discuss the implementation of a survivorship care plan and the benefits for both colorectal cancer survivors and the health professional.
Stoma care: creating a cutting template for correctly fitting a stoma pouch
Authors: Chandler Pip , Lowther Claire
Published: May 2014

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Ensuring effective placements for pre-registration nursing students on endoscopy units
Authors: Tremayne Penny , Harrison Penny
Published: May 2014

In this article, Penny Tremayne and Penny Harrison discuss how learning opportunities in the endoscopy unit can be maximised. Gastrointestinal (GI) nurses working in these busy, challenging, dynamic and evolving clinical environments are well-placed to act as clinical mentors for pre-registration student nurses and with the correct skills, qualities and preparation, as outlined by the professional regulator, are able to assist students to learn effectively. The mentor's acknowledgement of the student's previous nursing experiences, transferable skills from other placements, current level of study and preferred learning styles are all part of this equation.
Consultation and prescribing: a model for stoma care
Authors: Lowther Claire
Published: May 2014

Models of consultation are essential tools that doctors and nurses can use to base care when reviewing a patient. The type of model used ideally should be patient-oriented and specific to the needs of the individual and the speciality of nursing involved ( Fittock, 2010 ). A model should help a doctor or nurse gather relevant information to make an informed decision about the patient's problem. In this article, the author talks about the importance of models of consultation, discusses existing models and describes how her newly developed model of consultation can be used within stoma care and aid prescribing.
Using reflection to treat stoma patients with dementia
Authors: Powell Catherine
Published: May 2014

The ability to self-care is of paramount importance when a patient has a stoma. However, this essential skill, which has to be learned, can be difficult to grasp if the patient has dementia. The incidence of dementia is ever-increasing ( Ferri et al, 2005 ) and affects all aspects of nursing. In this article, through a case study, the author describes the importance of reflection by nurses, which in turn will lead to improved stoma care for dementia patients and allow them to obtain appropriate treatments. Reflection is an important tool that can be used in the workplace as easily as within educational establishments, but it has little impact at ward level; moreover, there appears to be a lack of general nursing knowledge in the use of reflection when caring for dementia patients ( Esterhuizen and Freshwater, 2008 ). Therefore, this case study touches upon three issues in stoma care: pre-operative information, informed consent and dementia.
Compartment syndromes
Authors: Patel RV , Haddad FS
Published: May 2014

Compartment syndrome occurs when pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischaemia. Two distinct conditions are recognized: acute and chronic (exertional) compartment syndromes. Differences in aetiology, pathophysiology and management are elaborated on in this article.
Bite wounds of genitalia: clinical presentation and management
Authors: Nabi G , Mishriki SF
Published: May 2014

A27-year-old man presented with a swollen penis 1 week after being bitten by his girlfriend during a sexual act. There were no associated urinary symptoms. Examination under anaesthesia revealed a severe inflamed prepuce with ulcers on the undersurface of the prepuce and purulent discharge. After taking pus for culture and sensitivity, circumcision was carried out under antibiotic cover. Pus culture showed growth of mixed anaerobes. The patient made an uneventful recovery and was discharged after 48 hours. Histology revealed multiple ulcers with infiltration of acute and chronic inflammatory cells in subcutaneous connective tissue.
A case of ocular myasthenia gravis and Miller-Fisher syndrome
Authors: Mak W , Chan KH , Ho SL
Published: May 2014

A40-year-old Chinese man with myasthenia gravis presented to the emergency department with worsening of ocular symptoms and the authors were asked for an opinion. He first presented 7 years ago with diplopia and ptosis that were responsive to edrophonium. His acetylcholine receptor antibody titre was elevated at 0.8 optical density unit (ODU) (laboratory reference <0.43 ODU), although repetitive nerve stimulation study did not produce a significant motor potential decrement. He improved with regular pyridostigmine (40 mg three times a day) but there was still mild ptosis and limited abduction of his left eye.

His condition did not change in the last few years. For the current presentation, he had progressive deterioration of ocular movements over 1 week. Physical examination showed complete ophthalmoplegia bilaterally, partial ptosis of the left eye and absent pupillary light reflex in the right. Intravenous edrophonium 10 mg produced minimal improvement in right eye abduction.

On further questioning, he also complained of numbness of his extremities, difficulties in fine hand functions, and unsteadiness while walking. He recalled a flu-like illness 2 weeks before the neurological symptoms. All his tendon reflexes were unobtainable and he had an ataxic gait. There was no demonstrable limb or facial weakness. Cerebrospinal fluid analysis showed increased protein concentration at 1.33 g/litre (reference range 0.12–0.6 g/litre) with total cell count of <1×106/litre. Anti-GQ1b antibody level was elevated at 43 enzyme immunoassay (EIA) Units (reference range <10 EIA). Nerve conduction studies only showed marginal reduction of F-wave persistence in the upper limbs. Magnetic resonance imaging of his brain revealed no abnormalities.

Miller-Fisher syndrome (MFS) was diagnosed. He was treated with three sessions of plasmapheresis. His symptoms started to improve over the next week and he subsequently made a full clinical recovery. Moreover, he was completely free from his myasthenia gravis-related ophthalmoplegia in the following 2 months. Pyridostigmine was later recommenced when his baseline symptoms returned.
Choosing appropriate measures in inpatient rehabilitation
Authors: Sinnott Anne , Dean Sarah
Published: May 2014

This article aims to assist inpatient rehabilitation clinicians to choose appropriate measures. Emphasis is given to measurement processes and interpretation. The authors provide examples of measures commonly reported for five rehabilitation diagnostic groups: stroke, traumatic brain injury, spinal cord injury, multiple sclerosis and cardio-respiratory rehabilitation.
Management problems of spontaneous ICH
Authors: McNaughton Harry , Barber P Alan , Gommans John , Nowitz Mike
Published: May 2014

The management of spontaneous intracerebral haemorrhage (ICH) can be challenging for hospital doctors. Although the management of ICH is covered in stroke guidelines, many difficult clinical questions remain. In this article the authors suggest approaches to ten common and difficult questions.
Transforming learning: the challenge of interprofessional education
Authors: Ahluwalia Sanjiv , Clarke Robert , Brennen Maureen
Published: May 2014

Interprofessional education (IPE) is the foundation for collaborative practice. It is resource intensive because it requires a shift away from didactic teaching towards a model of facilitated small group learning. This article discusses the ways in which IPE is supported by educational theory and summarizes the increasing evidence for its effectiveness in transforming health-care organizations, leading to increased staff motivation and direct improvements in patient care.
Is the new White Paper for higher education feasible?
Authors: Roberts Trudie E , Boursicot Katharine
Published: May 2014

In 2003, the government published a White Paper, ‘The Future of Higher Education’ (Deparment for Education and Skills, 2003), which set out a number of major reforms for the higher education sector. The recommendations are due to be implemented by 2006. This editorial addresses issues raised by recommendations relating to the improvement of teaching quality which specifically state: ‘New national professional standards for teaching in higher education will be established as the basis of accredited training for all staff, and all new teaching staff will receive accredited training by 2006’ and that ‘from 2006 all new teaching staff should obtain a teaching qualification that incorporates agreed professional standards’(Deparment for Education and Skills, 2003).
The management of non-melanoma skin cancer
Authors: Campbell FA , Gupta G
Published: May 2014

Non-melanoma skin cancer is an increasingly common problem with a diversity of aetiologies as well as treatments. This article describes the clinical sub-groups and discusses potential management strategies as determined by best clinical practice and patients' individual needs.
Role of grand rounds in the education of hospital doctors
Authors: Myint Phyo , Sabanathan Kanagasabesan
Published: May 2014

The educational role of grand rounds in continuing medical education of junior hospital doctors is unclear. In this article, the authors examine the benefit for junior doctors of attending grand rounds by assessing a groups' knowledge a week before, and 4days after a grand round. The scores obtained were compared between pre- and post-grand round periods and between grand round attenders (fully or partly) and non-attenders.
Intrapulmonary shunting and hepatopulmonary syndrome
Authors: Cannon John , Usmani Omar , Chambers John , Thompson Richard P , Twort Charles
Published: May 2014

A57-year-old woman was referred for assessment of progressive dyspnoea, decreasing exercise tolerance and worsening bluish facial discolouration. She had congenital cirrhosis complicated by portal hypertension aged 4 years, for which she underwent a portacaval shunt. She was an exsmoker of 30 years. On examination, she was centrally cyanosed and clubbed. Her jugular venous pressure was not elevated, cardiac examination was normal and there were no focal chest signs. Spider naevi were noted, but no palpable organomegaly or ascites. Her oxygen saturation, however, was 88% breathing room air, which did not alter when recumbent or supine.

A chest radiograph showed normal lung fields and vasculature, and no effusions. Renal and liver profile blood tests and international normalized ratio were normal. Arterial blood gas analysis revealed: pH 7.43 (normal 7.35–7.45), Pa∘2 7.21 kPa (normal >10.6 kPa), PaC∘2 3.96 kPa (normal 4.6–6.0 kPa) breathing room air. Her AaPa∘2 was 7.8 kPa (predicted agecorrected AaPa∘2 2.10 kPa). Pa∘2 increased to 69.8 kPa breathing 100% inspired oxygen delivered using continuous positive airway pressure. Her calculated intrapulmonary shunt fraction was 7% (normal <5%). Pulmonary function tests showed normal spirometry and preserved lung volumes, however, carbon monoxide diffusing capacity was only 38% predicted, adjusted for haemoglobin 17.8 g/dl.

Transthoracic echocardiography demonstrated normal structure and function of all cardiac chambers. Contrast echocardiography established the presence of intrapulmonary shunting (Figure 1) and confirmed the diagnosis of hepatopulmonary syndrome. She was established on long-term oxygen therapy and is currently under consideration for a liver transplant.
Pancreatic and periampullary cancers: treatment and outcome
Authors: Spalding DRC
Published: May 2014

Periampullary cancers arise within 2 cm of the major duodenal papilla and include cancers of the head of pancreas, distal common bile duct, ampulla of Vater and duodenum. Their anatomical locations and clinical features are similar, as are the therapeutic approaches; however, their long-term outcomes vary.
Pancreatic transplantation for patients with type 1 diabetes
Authors: Hakim Nadey S
Published: May 2014

Pancreas transplantation aims to improve quality of life of patients with type I insulin-dependent diabetes mellitus and to ameliorate secondary complications by establishing an insulin-independent euglycaemic state. Transplantation can prevent secondary complications, prevent recurrence of diabetic nephropathy in a newly transplanted kidney, improve nerve damage and stabilize retinopathy caused by diabetes mellitus.
Current concepts in diagnosis and treatment of sialolithiasis
Authors: Iro H , Dlugaiczyk J , Zenk J
Published: May 2014

Sialolithiasis is one of the most frequent causes of inflammatory changes within the major salivary glands in Europe. Salivary stone formation affects the submandibular gland in 80%, the parotid gland in 20% of cases, and rarely the sublingual gland.
Spontaneous intracranial hypotension
Authors: Nour EM , Charles TJ , White RP
Published: May 2014

A 47-year-old woman presented with a 4-week history of headaches. These were present from waking, and the preceding night's sleep had been disturbed by a sudden popping sensation associated with tinnitus. She described pounding frontal headaches on sitting or standing which were associated with nausea and vomiting, but relieved with bed rest. She had a past history of migraine without aura, which were qualitatively different, lacking a postural component associated with sensory sensitivity (photophobia and phonophobia). There was no history of trauma.

Detailed neurological examination was normal. There was no evidence of nasal or auditory meatal CSF leakage. Magnetic resonance imaging of brain demonstrated bilateral subdural effusions and there was diffuse enhancement of the pachymeninges following gadolinium (Figures 1 and 2). Magnetic resonance imaging (MRI) of cervical spine showed a small extradural collection of CSF density at the level of C6.

The patient was treated with bed rest and intravenous caffeine sodium benzoate (500 mg). Her headaches reduced in severity post caffeine such that she was able to sit and mobilize. Caffeine gave immediate but temporary benefit. Her headaches resolved completely over a further 4 weeks and a repeat MRI showed resolution of her collections and gadolinium enhancement.

At 6-month review she remains free of postural headache.
Thoracic epidurals for on-pump cardiac surgery: a good or bad idea?
Authors: Sebastian J , Borra PJ
Published: May 2014

Thoracic epidural anaesthesia (TEA) is not widely used in patients undergoing on-pump cardiac surgery. The main concern is the risk of neuraxial haematoma and spinal cord injury associated with epidural instrumentation and subsequent anticoagulation for cardiopulmonary bypass (CPB). Cardiac patients are often on aspirin and other antiplatelet agents which may further increase this risk.
Foundation year 2 programmes in shortage specialities: implementation and early experience
Authors: Sharma Vishal , Treloar Adrian , Jarrett Peter , Patrick Hannah , Ghosh Koushik , Bahia Sandeep
Published: May 2014

In August 2005 the London Deanery implemented a pilot foundation year 2 programme in shortage specialties at Queen Mary's Hospital. This article discusses experiences of the foundation year 2 doctors in shortage specialty areas, and highlights the use of competency-based assessment tools in shortage specialty posts.
An unusual case of cardiomyopathy
Authors: Miller Christopher A , G Williams Simon
Published: May 2014

A 56-year-old man presented with a 3-week history of worsening dyspnoea and lethargy. Clinical examination revealed signs of marked congestive cardiac failure and hypotension with a systolic blood pressure (BP) of 70 mmHg. Laboratory investigations revealed a urea of 29 mmol/litre and a creatinine of 310 μmol/litre with normal liver function tests, apart from a bilirubin of 40 μmol/litre. Initial treatment included oxygen, intravenous diuretics and ionotropes although his BP remained low. Subsequently, an intra-aortic balloon pump (IABP) was inserted with 1:1 augmentation and his clinical picture improved gradually. Cardiac catheterization was performed which showed normal coronary arteries and high right-sided heart pressures with a right ventricular pressure of 58/14 mmHg, pulmonary artery pressure of 58/28 mmHg, and a mean pulmonary capillary wedge pressure of 29 mmHg.

His electrocardiogram (ECG) 1 year before his current admission is shown in Figure 1. This revealed an atrial tachycardia with a cycle length of approximately 320 ms with upright P waves in lead V1 and inverted P waves in the inferior leads. There was a left bundle–branch block morphology with a QRS duration of around 100 ms and relatively high degree atrioventricular block with a ventricular rate of around 60–70 beats per minute.

He had initially presented 5 years earlier in congestive cardiac failure. ECG at that time showed first degree heart block with a QRS duration of 100 ms. Transthoracic echocardiography revealed a dilated left ventricle at 6.1 cm in diastole and a left ventricular ejection fraction <20%. Viral serology at the time was negative, he did not drink alcohol and did not suffer from ischaemic heart disease. His only other medical history consisted of hypothyroidism for which he was treated with thyroxine. His brother had died at the age of 44 years suffering from liver cirrhosis, diabetes and heart failure, which raised the question of hereditary haemochromatosis (HHC). The diagnosis of HHC was confirmed by HLA testing showing he was homozygous for the C282Y mutation of the responsible gene, a raised serum ferritin at 900 mg/litre and a liver biopsy in keeping with HHC (increased iron deposition in the liver cells but with normal acinar architecture and no inflammation or cirrhosis).

After stabilization with an IABP, his treatment options for cardiogenic shock included either insertion of a left ventricular assist device to improve BP and renal function or cardiac transplantation. Unfortunately the patient became septic from his IABP insertion site and so neither were viable options. He died shortly afterwards.
Spontaneous rectus sheath haematoma in pregnancy
Authors: Banerjee AK , Waugh JJS
Published: May 2014

A 20-year-old, primiparous, Caucasian woman presented at 32 weeks and 6 days gestation with sudden onset severe left-sided abdominal pain. She denied any history of recent trauma, falls or vaginal bleeding. She had no history of previous abdominal pain in this pregnancy and had booked at 9 weeks gestation. Her booking weight was 96 kg with a body mass index of 39 kg/m2 and her booking haemoglobin was 13.6 g/dl. No relevant past medical or surgical history was noted and so far her pregnancy had been uneventful.

Clinically she was very distressed with the pain, was sweaty and had cold extremities. Her pulse was 130/minute, blood pressure was 130/87 mmHg and her temperature was 36.4°C. Abdominal examination revealed marked tenderness in the left upper quadrant of the abdomen over the upper pole of the uterus, which had a symphysiofundal height of 34 cm. Her haemoglobin was 8.8 g/dl, white cell count was 9.1×109/litre, and platelet count was 454×109/litre with a normal clotting screen. The cardiotocograph (CTG) was normal. On ultrasound scan a large haematoma was noted associated with the left uterine wall. This was directly associated with her tenderness. With a presumptive diagnosis of placental abruption a decision was made to perform emergency caesarean section delivery under general anaesthetic.

At laparotomy a large rectus sheath haematoma (RSH) was noted. There were no signs of intraperitoneal bleeding and the uterus was 32 weeks in size. Both tubes and ovaries appeared normal. Caesarean delivery was not performed. About 400 ml of blood clot was evacuated from the left rectus muscle. No active bleeding vessels were noted. The peritoneum was closed followed by the rectus sheath after leaving a sub-rectus drain in the haematoma cavity. Postoperatively fetal CTG monitoring remained normal. She did not require blood transfusion. On her second postoperative day her haemoglobin was 9.7 g/dl and the abdominal drain was removed. She was allowed home on the fifth postoperative day on oral ferrous sulphate. At 34 weeks sonographic fetal biometry was on the 50th centile, liquor volume was normal and the haematoma was resolving (size 72 mm × 60 mm × 35 mm). She was seen again at 36 and 38 weeks. At 39 weeks and 2days she presented in spontaneous labour and proceeded to a forceps delivery, for failure to progress, of a 2.81 kg healthy baby. Her 6-week postnatal follow-up scan showed complete resolution of the RSH.
Ageism in medicine: a problem for all
Authors: Rhind George , Macphee Graeme
Published: May 2014

Ageism was first coined as a term by an American physician, Robert N Butler, who defined it as: ‘A deep and profound prejudice against the elderly which is found to some degree in all of us. Ageism allows the younger generations to see older people as different from themselves; thus they subtly cease to identify with their elders as human beings’.
Understanding and managing Achilles tendinopathy
Authors: Sharma Pankaj , Maffulli Nicola
Published: May 2014

Achilles tendinopathy is common among athletes participating in racquet sports, track and field, volleyball and soccer. Greater participation in recreational and competitive sporting activities has lead to an increased incidence of Achilles tendinopathy in recent years. However, Achilles tendinopathy does not exclusively affect athletes. This article reviews the aetiology and management of Achilles tendinopathy
Stroke in pregnancy
Authors: Hender J , Harris DG , Bu H , Richard B , Khanna PB
Published: May 2014

The incidence, causes and optimum management of stroke in pregnancy are poorly understood, which largely reflects the inconsistency and limitations of the published data available. Women who have had a stroke in pregnancy are anxious about subsequent pregnancies, particularly as there is a lack of definitive information and guidance that general physicians and obstetricians are able to provide.
Recent advances in adult cardiac surgery
Authors: Chikwe Joanna , Athanasiou Thanos , Casula Roberto
Published: May 2014

Cardiac surgery remains the definitive therapy for severe heart disease despite being the most invasive and expensive of the available therapeutic options. This article describes the most important of many recent advances in the field.
Should I wheel out the Heliox with non-invasive ventilation?
Authors: Downie Paul
Published: May 2014

Heliox is a mixture of helium and oxygen; the most common combination in the UK is oxygen 21%, helium 79%. The substitution of helium for nitrogen produces a gas that is significantly less dense than air; this provides improved gas flow characteristics when turbulent flow might be encountered. Gas flow is said to be turbulent only in the larger airways and thus there is a logical use for heliox in upper airway obstruction.
Rheumatoid arthritis: acute presentations and urgent complications
Authors: Scott David L
Published: May 2014

Rheumatoid arthritis is a common chronic disorder. Its many complications, comorbidities and adverse effects of treatment often involve general physicians. Particular risks are septic arthritis, systemic infections, upper gastrointestinal ulcers and systemic vasculitis. Delayed diagnosis will result in poor outcomes.
Percutaneous coronary intervention for revascularization of the diabetic patient
Authors: Butts Jeremy , Morgan Kenneth P , Beatt Kevin J
Published: May 2014

The field of interventional cardiology has progressed rapidly in recent years with the advent of new technology and expanding role of adjunctive pharmacology. This article provides an overview of both current and historical approaches to treating coronary artery disease in the diabetic patient.
Psoriasis: a general overview
Authors: Burd Robert M
Published: May 2014

Psoriasis is a common inflammatory dermatosis which affects 1.2 million people in the UK. Psoriasis is a chronic relapsing, remitting disease that varies in severity from relatively mild localized disease, to patients who have all their skin involved. With adequate treatment the signs and symptoms of psoriasis can be relieved. Newer therapeutic options are offering improvements in care for sufferers.
Perioperative beta-blockade: beyond myocardial ischaemia
Authors: Ackland Gareth
Published: May 2014

Although perioperative beta-blockade is recommended for patients at higher risk of myocardial ischaemia (Eagle et al, 2002), adoption of such guidelines is limited. Concerns over clinical trial data, plus the safety of perioperative beta-blockade, persist. Since preoperative revascularization does not reduce mortality, a very large, increasingly elderly patient population will present major challenges for the anaesthetist.
The value of ovarian cancer screening
Authors: Sharma Aarti , Menon Usha
Published: May 2014

Ovarian cancer is the commonest cause of death from a gynaecological malignancy. Diagnosis of the disease at an early stage is associated with significantly improved survival rate. This suggests that screening may impact on disease mortality. This review addresses the current methods of screening, the ongoing trials and future of screening for ovarian cancer.
Persistent neonatal hypoglycaemia as a result of hypoplastic pituitary gland
Authors: Yong Sin-Chuen , Boo Nem-Yun , Wu Loo-Ling
Published: May 2014

An Indonesian female infant developed hypoglycaemia shortly after delivery by lower segment caesarean section. Following admission to the neonatal intensive care unit, she continued to have episodes of hypoglycaemia despite adequate glucose intake of up to a maximum of 12 mg/kg/minute.

During the episodes of hypoglycaemia, repeated measurement of her blood samples revealed persistently low levels of serum insulin of <2 IU/ml, serum free thyroxine of 4.78 pmol/litre, thyroid stimulating hormone of 0.31 uIU/ml and growth hormone of 0.27 mIU/litre, all suggesting a diagnosis of hypopituitarism.

Empirical replacement therapy with hydrocortisone (10 mg four times daily) was started at 26 days. However, her hypoglycaemic attacks ceased only with commencement of additional hormone replacement therapy of growth hormone (0.1 mg once daily for 6 days per week) and thyroxine (50 μg once daily). The hydrocortisone dose was gradually tailed to a maintenance dose of 2.5 mg twice daily. Stimulatory tests such as adrenocorticotropic hormone and luteinizing hormone-releasing hormone tests and posterior pituitary function were not performed at that time as the infant developed Klebsiella pneumoniae and coagulase negative staphylococcus sepsis which may have affected the test results.

A magnetic resonance imaging (MRI) scan of her brain at 1 month of age showed a hypoplastic pituitary gland with a shallow pituitary fossa (Figure 1). The posterior lobe of the gland was undescended, lying ectopic at the base of the third ventricle with an absent pituitary stalk (Figure 2). The rest of the MRI was normal with no associated anomalies of the midline forebrain structures. No abnormalities were detected in detailed opthalmological examination of her eyes excluding the possibility of septo-optic dysplasia.

When followed up at 8 months of age, she remained well with improved hormonal profiles and normal levels of serum urea and electrolytes. Her weight, height and occipito-frontal circumference were all below the third percentile.
The vanishing twin: a major determinant of infant outcome in IVF singleton births
Authors: Pinborg Anja , Lidegaard Øjvind , Andersen Anders Nyboe
Published: May 2014

This article attempts to assess the frequency of vanishing twins in assisted reproductive and spontaneously conceived pregnancies, including in-vitro fertilization (IVF), and its impact on the live-born surviving twin.
Cholecystocolonic fistula: an unusual cause of large bowel obstruction
Authors: Sinha S , Pullan RD
Published: May 2014

A 70-year-old woman was admitted to the emergency department with a 2-week history of pain in the upper abdomen, vomiting, fever and jaundice. She was also complaining of pale stool and dark urine. Subsequently she developed abdominal distension with colicky pain and absolute constipation. There was no history of previous biliary symptoms. On examination she was pale and tachycardic with a fever of 37.9°C. Abdominal examination revealed generalized abdominal distension with a tender mass at right upper quadrant and hyperactive bowel sounds on auscultation. Laboratory examination showed a white blood cell count of 15 600/mm3 (neutrophil 85%), bilirubin of 47mmol/litre, alkaline phosphatase of 220 U/litre with normal liver enzymes and amylase. Plain abdominal X-ray demonstrated pneumobilia and dilated small and large bowel loops suggestive of intestinal obstruction (Figure 1). An unprepared barium enema showed a large smooth filling defect in sigmoid colon with large bowel obstruction (Figure 2). A diagnosis of large bowel obstruction presumably caused by a gall-stone was made. Surgical treatment followed a period of physiological optimization.

At laparotomy the abnormalities were large bowel obstruction caused by an impacted gall-stone in a section of sigmoid diverticular disease plus right upper quadrant mass. A sigmoid colectomy with removal of diverticular disease and the stone, then a primary anastomosis was performed. Exploration of right upper quadrant mass revealed an inflamed friable gall bladder with a fistula between its fundus and the transverse colon. A partial cholecystectomy was performed, the cystic duct closed in-situ and the defect in transverse colon was brought out as a loop colostomy. Her postoperative course was uneventful. Closure of colostomy was performed 3 months later and she made a full recovery.
Autologous gastrointestinal reconstruction for short bowel syndrome
Authors: Bianchi A
Published: May 2014

Parenteral nutrition-dependent patients with short bowel can realistically hope for a return to enteral autonomy on their own bowel, and with a full good quality of life. Autologous bowel reconstruction (including expansion, lengthening and reversed segments) enhances the natural adaptive process towards increased absorption.
Surgical management of enterocutaneous fistula
Authors: Datta V , Windsor ACJ
Published: May 2014

The surgical management of enterocutaneous fistulae is centred on teamwork. Restoration of deranged physiology with aggressive treatment of sepsis, early and adequate nutrition, followed by delayed but planned surgery are key steps in the care of these complex patients. This article will explore these issues in greater detail.
Preoperative cervical spine X-rays for patients with rheumatoid arthritis
Authors: Arawwawala D , Morgan P
Published: May 2014

Cervical joint destruction in rheumatoid arthritis may lead to vertebral instability. The incidence of cervical instability is 5–7% (Campbell et al, 1995; Riise et al, 2001), being more severe in those with erosive disease (Oda et al, 1995). The atlanto-axial joint is more prone to subluxation (AAS), most commonly in an anterior direction. Of patients with AAS only 25% have symptoms or signs (Marshall, 2006). Symptoms range from initial neck pain radiating to the occiput to painless sensory loss in the extremities and a slowly progressive quadraperesis. Sudden death may also occur.
Testosterone replacement therapy
Authors: Jones TH
Published: May 2014

Hypgonadism has important adverse effects on the health and quality of life of affected men, but remains underdiagnosed in clinical practice. This article reviews the physiology, causes and diagnosis of hypogonadism and the potential benefits of treatment with testosterone replacement therapy
Health and health care in south Asian communities in the UK
Authors: Singh Iqbal , Ayyar Anita , Ahmed Rizwan Yahya , Rashid Sheikh Tamir
Published: May 2014

In the 2001 census the population of the UK was estimated to be around 59 million, of which the ethnic minorities comprised just over 4.5 million (Office of National Statistics, 2001). People from India, Pakistan and Bangladesh (the south Asian communities) made up nearly 2 million or 4% of the total UK population. The health-related problems of this section of the population are in many ways different from the native Caucasian population. Moreover, this section of the population is itself heterogeneous, with different cultural and religious beliefs and varying dietary and lifestyle habits.
Dipeptidyl peptidase-IV inhibitors: fixing type 2 diabetes?
Authors: McIntyre Hugh F , Grant Paul
Published: May 2014

The optimal treatment of type 2 diabetes is currently uncertain. This article reviews a new class of oral hypoglycaemic agents: dipeptidyl peptidase-IV inhibitors. By potentiating the action of incretins they offer a more ‘physiological’ control of blood sugar with fewer side effects, and the possibility of ameliorating the decline in beta cell function.
Subcutaneous immunoglobulin for patients with antibody deficiency
Authors: Helbert Matthew , Farragher Alex
Published: May 2014

This article provides an overview on the management of primary immunodeficiency, and discusses the pharmacokinetics of subcutaneous and intravenous immunoglobulin and the relationship between blood levels and therapeutic effects in both treatments. The article will further highlight both treatments' efficacy in preventing infections and the risk of systemic side effects with each treatment.
Management of acute urinary retention
Authors: Aning JJ , Horsnell J , Gilbert HW , Kinder RB
Published: May 2014

Acute urinary retention is a common urological emergency that may present to any practitioner. This article provides guidance for the initial and ongoing management of this condition and looks at the evidence base supporting it.
James Blundell, pioneer of blood transfusion
Authors: Ellis Harold
Published: May 2014

This year marks the 130th anniversary of the death of a remarkable, yet somewhat forgotten, pioneer of clinical blood transfusion – the first to perform a series of cases with some successes.
Recognition and early management of the critically ill ward patient
Authors: Frost Paul , Wise Matt P
Published: May 2014

The management of general ward patients who develop critical illness is often suboptimal. There are many reasons for this including a lack of a systematic approach to these patients (Cullinane et al, 2005), over-burdened ward staff and deficiencies in medical training (Smith et al, 2007). Cardiac arrests occurring in ward patients are often preceded by many hours of untreated physiological deterioration (Franklin and Mathew, 1994). In addition up to 25% of admissions to intensive care from the ward have deteriorated to the point of cardiorespiratory arrest (Goldhill and Sumner, 1998). Knowledge of a simple practical approach to these patients can be life saving.
Applied anatomy of abdominal incisions
Authors: Ellis Harold
Published: May 2014

Opening the abdomen is the essential preliminary to the performance of a laparotomy. A correctly performed abdominal exposure is based on sound anatomical knowledge. The surgeon needs direct access to the organ(s) requiring investigation and surgical treatment and must provide adequate room for the safe performance of that surgery. If possible, the incision should be capable of easy extension to allow for any enlargement of the scope of the operation, and it should interfere as little as possible with the strength and function of the abdominal wall.
Maintaining an effective medical training portfolio
Authors: Ogundipe Olayinka A
Published: May 2014

Postgraduate medical trainees are often required to maintain a training portfolio, but lack formal instruction on how to do this. This article draws upon adult learning theories and the best available evidence from medical education, to give practical tips on maintaining an effective medical training portfolio.
Scrotal cystocele: a surgical pitfall
Authors: Angus LD George , Cardoza Supriya
Published: May 2014

A 91-year-old male nursing home patient with numerous medical problems was admitted to the medical service with rapid atrial fibrillation and congestive heart failure. A large scrotal hernia was noted and surgical consultation obtained. His past urological history was significant for chronic urinary retention secondary to benign prostatic hypertrophy, intermittent haematuria and recurring urinary tract infections. Given his overall poor general health, his outlet obstruction had been managed with an indwelling Foley catheter.

Examination of the scrotum revealed a large, oedematous left hemiscrotum that could not be transilluminated. Scrotal content was not reducible and no bowel sounds were audible. A computed tomography scan of the abdomen revealed herniation of bladder into the left scrotal sac (Figure 1). Owing to persistent swelling and drainage from the scrotum, retrograde cystography was performed and demonstrated massive herniation of the bladder through the inguinal canal and into the scrotum (Figure 2). Given his overall general condition, a decision was made to manage the herniation non-operatively.
Bisphosphonate-related osteochemonecrosis of the jaws
Authors: Hegarty Anne , Georgakopoulou Eleni , Porter Stephen
Published: May 2014

Osteochemonecrosis of the jaws is now a well-known complication of bisphosphonate use. It can present management difficulties for doctors and dentists alike. All doctors prescribing bisphosphonates have a responsibility to patients to inform them of the risks of this complication no matter how small.
Current management of varicose veins
Authors: Sadat Umar , Gaunt Michael
Published: May 2014

There has been an increasing trend towards less invasive methods of treating varicose veins, e.g. foam sclerotherapy, radiofrequency ablation and endovenous laser ablation, which has led many to question the more conventional methods of treating varicose veins. This review focuses on current techniques of managing varicose veins.
Epidemiology of severe sepsis in the intensive care unit
Authors: Vincent Jean-Louis , Atalan Hakan Korkut
Published: May 2014

Severe sepsis affects large numbers of intensive care unit patients and is associated with high mortality rates. Understanding the epidemiology of sepsis is important to effectively allocate adequate resources. However, differences in definitions and in studied populations must be taken into consideration when interpreting and comparing the available epidemiological data.
Using assessment to drive learning by linkage to foundation year 2 appointment
Authors: Palmer Robert G , Howes Jonathan , Whitehouse Andrew
Published: May 2014

The premise of this study is that engagement with assessment, and doing well in it, will drive education itself. Engagement and success with assessment during foundation year 1 training was therefore used to allocate foundation year 2 posts to 440 trainees. A web-based system was used, with all contacts being on-line only.
Portfolio-based appraisal: superficial or useful?
Authors: Chamberlain John Martyn
Published: May 2014

A portfolio is a ‘dossier of evidence collected over time that demonstrates a doctor's education and practice achievements’ (Wilkinson et al, 2002). In addition to annual NHS appraisal, paper-based and electronic portfolios are now used within medicine to support performance appraisal throughout medical school and the foundation programme as well as higher specialist training. Portfolios will also play a role in revalidation as it is gradually rolled out across the UK over the next 2 years.
John Stough Bobbs: father of gall bladder surgery
Authors: Ellis Harold
Published: May 2014

This year marks the 200th anniversary of the birth of John Stough Bobbs (1809–1870), who was the first surgeon to carry out an elective operation on the gall bladder for gall stones.
Pathophysiology of autism: evidence from brain imaging
Authors: Deeley Quinton , Murphy Declan
Published: May 2014

Autism spectrum disorders involve pervasive developmental abnormalities in social communication, socio-emotional reciprocity, and restricted and repetitive interests. They are likely to be caused by abnormalities in multiple brain regions, including ‘underconnectivity’ between components of networks subserving a variety of cognitive functions.
The last year before the dawn of antibiotics
Authors: Ellis Harold
Published: May 2014

Pick up any bound volume of a general medical journal of 1934 (75 years ago – within the memory of old members of the profession), and there are likely to be papers concerning the dreaded effects of the Gram positive cocci. The pneumococcus, causing often fatal lobar pneumonia in previously fit young people, and the beta-haemolytic streptococcus, producing erysipelas, septicaemia and puerperal sepsis, were especially dangerous. Volume one of the Lancet for that year, for example, contains no less than four papers on different trials of treatment for streptococcal infection as well as a long and learned leading article.
Full blood count
Authors: Dillon Richard , Harrison Claire
Published: May 2014

The full blood count is a fast readily available investigation which adds essential information to clinical assessment of a patient. Interpretation of the blood count is an important skill, requiring knowledge of causes of individual abnormalities and the ability to recognize patterns associated with certain conditions.
Extending palliative care to patients with heart failure
Authors: Johnson Miriam J
Published: May 2014

The pathophysiology and targeted management of heart failure is now well understood. However, patients may live for some years with significant symptoms and resultant reduced quality of life. Good supportive care and access to specialist palliative care is important for optimum care for patients living and dying from heart failure.
Congenital clubfoot: a review
Authors: Colaço Henry B , Patel Shelain , Lee Marcus H , Shaw Olivia Malaga
Published: May 2014

Congenital clubfoot is a relatively common lower limb deformity that is increasingly managed by non-operative methods of serial manipulation and immobilization. This review looks at aetiology, examination techniques and severity scoring, and provides an overview of operative and non-operative methods of treatment.
Primary venous aneurysm of the long saphenous vein: an uncommon case
Authors: Syed Abdul , Bhagat Tasnim , Bradpiece Howard
Published: May 2014

A generally well 82-year old man presented to a general surgical outpatient clinic with a swelling of the medial aspect of his left thigh. It started as a small lump which grew quickly over a few weeks to approximately 6 cm. There was no history of trauma or thromboembolic complication and the patient was asymptomatic. On examination, there was a firm round swelling which was non-tender and non-pulsatile. It did not seem to be attached to deeper structures and was not anatomically related to the nervous system.

The patient was reviewed by a consultant – the diagnosis of a chronic sebaceous cyst was considered and he was offered an excision biopsy under local anaesthetic. Postoperatively, the patient had an unremarkable recovery but presented with a localized haematoma (Figure 1) on routine follow up, which was managed conservatively. Histology revealed the mass was in fact a venous aneurysm of the long saphenous vein.
Peripheral muscle dysfunction and chronic obstructive pulmonary disease
Authors: Breunung Lea , Roberts Mike
Published: May 2014

Chronic obstructive pulmonary disease is a systemic disease that includes significant adverse effects on muscle function, with varied changes to the structure and metabolism of the peripheral muscles. This review evaluates the evidence for the mechanisms that mediate these changes and the significance of the diminished muscle function.
Gilles de la Tourette syndrome: the complexities of phenotype and treatment
Authors: Robertson Mary M
Published: May 2014

Tourette syndrome is a chronic motor and vocal tic disorder, which is common (1%). The aetiology is complex (mostly genetic) and 90% of people have co-morbid psychiatric disorders and reduced quality of life. Management includes reassurance, education, behavioural treatments and medications for tics and psychopathology.