bluuebunny/crossref_metadata_2025 huggingface dataset:
Pegs, sticks and pop-ups
Authors: Finlayson Keri
Published: May 2014

The third article in our short series exploring the use of puppets in the early years, looks at ways of creating characters using sticks of various sizes, wooden or plastic pegs, and various craft materials.
The lessons of Spanish Armada
Authors: Startup Julie
Published: May 2014

Helping year 6 children to investigate the significance of the Spanish Armada, by Julie Startup, a key stage 2 teacher from Alton, Hampshire.
Electrical circuits light up learning
Authors: Chilvers Clara
Published: May 2014

Encourage the children to think about just how electrical devices work. Get them to build and test a circuit, comparing their predictions with what actually happens. By Clara Chilvers, Charles Dickens Primary School, London.
Reliving the past with ballad opera
Authors: Scott Douglas M
Published: May 2014

Douglas M Scott, a former music teacher and a freelance writer from Perthshire, Scotland, sets out plans for the nonspecialist teacher to add some music to a history lesson.
Marching with Caesar to reclaim the curriculum
Authors: Berry Jon
Published: May 2014

Jon Berry, secretary, Hertfordshire NUT, explains how a local union branch has joined the fight against SATs. He can be contacted at secretary@hertfordshire.nut.org.uk
How history can make the past come to life
Authors: Chilvers Clara
Published: May 2014

Clara Chilvers, Charles Dickens Primary School, London, looks at how to teach history through a skills-based curriculum in the primary classrooom.
Identifying HEARING LOSS
Authors: Shulberg Adam
Published: May 2014

Hearing loss can be difficult to diagnose, which, at times, can have disastrous consequences. Adam Shulberg is a hearing aid audiologist at Cubex Independent Hearing Aid Audiologists, London.
A case of colour prejudice
Authors: Richardson Sarah
Published: May 2014

Sarah Richardson, an art and design consultant from London, looks at the rules and the fun of colour-mixing with paints. For more information call 020 7737 4545 or visit www.arttime.co.uk
How Teddy brings shades of light
Authors: Cooper Clare
Published: May 2014

Clare Cooper, ICT co-ordinator at Osbaston Infants School, Monmouth, Monmouthshire, looks at how ICT, and data logging in particular, can be used to help and inform on the scientific topic of finding the colour that makes the safest sunglasses for Teddy!
The jury is still out VALUE OF PLAY
Authors: Thornton Stephanie
Published: May 2014

Just what role does play have in children's development? Is it a waste of time and energy, merely a way to stave off boredom, or is it invaluable preparation for adult life?
Why size is important in fighting the class battle
Authors: Nash Sally
Published: May 2014

Sally Nash, a former teacher, examines the National Union of Teachers' policy of sending home pupils when the number of children in a class exceeds 26.
Let the force be with you
Authors: Smith Julie
Published: May 2014

The topic of forces provides an excellent opportunity to teach the elements of scientific enquiry. Julie Smith, a key stage 2 teacher from Alton, Hampshire, explains how.
Sculpting portraits in clay
Authors: Harris Katherine
Published: May 2014

Use clay to put emotion into the human face. Katherine Harris, a year 5 teacher and art co-ordinator at Sandfields Primary School, Port Talbot, South Wales, explains.
Money can solve many problems
Authors: Dabell John
Published: May 2014

Identifying redundant information and using a solving skills agenda gives children the confidence to calculate problems. By John Dabell, a maths coordinator at Derby High Junior School, Derby and series editor of The Mathematics Coordinator’s File, pfp publishing.
The deaf child in the classroom
Authors: Fox-Eades Jenny
Published: May 2014

Is your school a deaf-friendly school? Find out as Jenny Fox-Eades provides an overview of ways to support children and parents, ideal for the non-specialist
More than ticking boxes
Authors: Andrews Cristpin
Published: May 2014

If children are to fulfil their potential, assessment must be an enabling tool, as well as an indicator of performance, says Crispin Andrews
World poetry day
Authors: Hammond Paula
Published: May 2014

It is claimed that there has been a ′poetry day′ in some form since 1505. Paula Hammond suggests one way to get children excited about this day
Who are we kidding? Ourselves or our children?
Authors: RHODES LIZ
Published: May 2014

How about being realistic with children rather than being held to ransom by the perceived need to build self−esteem?
Maths with merry monsters!
Authors: Croft Sue
Published: May 2014

Look at this month′s poster. Make a copy of the words. Practise saying them. Start a steady pulse: four slaps on your thighs, then start the words. If you stand to do this, you can do alternate foot stamping to the pulse, in the manner of a merry monster! At the sixth line of each verse, stop slapping. Hold up the correct number of fingers, shaking your hands to the pulse. Say the last verse gradually quieter, as the monsters disappear into the distance.
The Calouste Gulbenkian Foundation Oil fuels the philanthropy
Authors: Maiden Andew
Published: May 2014

Continuing the series profiling grant-makers to schools, Andrew Maiden features the work of the Calouste Gulbenkian Foundation.
On the agenda: A scientific approach
Authors: Griggs Amy
Published: May 2014

As deadlines for applying for funding for National Science Week loom, Fundraising for Schools puts science in the spotlight and explores some of the ways schools can carry out innovative and exciting projects.
In your neighbourhood Funding on your doorstep
Authors: Maiden Andrew
Published: May 2014

Schools have a wealth of fundraising possibilities within their local communities. How do you identify them? A community audit is the answer, writes Andrew Maiden.
Strategic thinking:Making friends with the media
Authors: Baker Shari
Published: May 2014

Shari Baker offers a few simple guidelines and discusses how to master the art of writing great press releases, and why!
Tips for developing a fundraising strategy
Authors: Bannister Nick , Smith Justin
Published: May 2014

Nick Bannister invites Justin Smith, Director of Enterprise and Community at Wymondham High Academy, to share five pieces of advice on developing a focused fundraising strategy for your school.
Advice on the leasing and procurement of tablets
Authors: Thompson Valerie
Published: May 2014

In 2012, the BBC's panorama exposed the leasing scandal affecting some schools. As new schemes are emerging, Valerie Thompson provides sadvice and outlines some of the risks.
School budget: Making sure you are in control
Authors: David Anthony
Published: May 2014

This month, Anthony David shows how your school's budget should serve your school's ambitions and not be controlled by it.
Factors affecting medication compliance in inflammatory bowel disease
Authors: Hall Alex , Porrett Theresa , Cox Carol
Published: May 2014

Inflammatory bowel disease (IBD) is a chronic disease, and for many people means taking medication indefinitely. The purpose of this research was to explore factors which influence and affect medication compliance in patients with IBD who attend a district general hospital. Data were collected by undertaking six in-depth interviews. Data were analysed through a combination of Miles and Huberman′s (1994) interactive model of data analysis and a modified version of Dey′s (1993) steps of analysis. Ten categories were developed to encapsulate the experiences of the participants and factors that affected compliance: beliefs regarding medication; side-effects; length of time and experiences since diagnosis; social support; regimen and routine; practicality of the administration of medication; prescriptions; healthcare provision; information resources and self-management and relapse. The categories discerned were those that affected compliance and therefore may have been methods of enhancing compliance or factors which had a detrimental effect on compliance. Factors that influence compliance are multi-factorial and patients are inconsistent in the way they view use of medication. The role of the nurse specialist is key in initiating new interventions and changes in a service to address the needs of IBD patients in relation to medication compliance.
Peri−anal disease: developing a nurse−led follow-up clinic
Authors: Hibberts Fiona
Published: May 2014

This article outlines the development of a nurse−led clinic for patients following surgery and conservative treatment for benign peri−anal disease. Outlining the patient′s pathway and identifying problems through a patient mapping excercise was conducted. A nurse−led clinic was then set up, outlining training and supervision needs, practical and management issues, and audit details. An audit and patient satisfaction survey was then completed and the outcome was very positive for the new service. Patient information was also developed to enhance the service. The article concludes that nurse−led services are beneficial to patients and can help reduce complications and further admissions.
Flexible sigmoidoscopy: Saving more lives
Authors: Alsina Deborah
Published: May 2014

Deborah Alsina, Chief Executive of Bowel Cancer UK, reports on the government's new approach to bowel cancer screening. The introduction of flexible sigmoidoscopy into the existing screening programme will help to save thousands of more lives every year.
Understanding eosinophilic oesophagitis: A rare form of dysphagia in adults
Authors: Boyer Anne
Published: May 2014

Eosinophilic oesophagitis (EO) is a rarely diagnosed chronic relapsing inflammatory condition of the oesophagus. Reports of EO have almost always related to paediatric populations but the condition is being increasingly recognized in adults. However, a diagnosis of EO may be missed due to the lack of general awareness of the condition and the reluctance of endoscopists to biopsy a normal-looking oesophagus. In this article, Anne Boyer provides an overview of research into the development of EO, the diagnostic pathway and treatment options that are available at the current time. It is important to raise awareness of this rare condition that may escape diagnosis when preliminary investigations show no mechanical obstruction to account for symptoms of dysphagia.
Leakage and ostomy appliances: results from a large-scale, open-label study in clinical practice
Authors: Porrett Theresa , Nováková Svatava , Schmitz Katrin , Klimekova Emilia , Aaes Helle
Published: May 2014

Leakage from an ostomy appliance impairs peristomal skin integrity and quality of life (QoL). The proportion of participants who reported that they ‘never’ had leakage increased from 13% at visit 1 (i.e. with their pre-study appliance) to 36% at visit 2 (i.e. after using the double-layer adhesive appliance, SenSura (Coloplast A/S)) (P<0.0001). The proportion of participants reporting that they ‘never’ had unplanned changes increased from 12% at Visit 1 to 34% at visit 2 (P<0.0001). The double-layer adhesive appliance, SenSura, in conjunction with advice/intervention from a stoma care nurse (SCN), was superior to the pre-study appliance across all performance parameters (P<0.0001), including adhesion, flexibility and erosion. Higher leakage frequency at baseline correlated with worse peristomal skin (P<0.0001). Peristomal skin improved from visit 1 to visit 2, across all leakage frequencies. The use of an appropriate double-layer adhesive appliance in conjunction with SCN intervention, reduced leakage and improved peristomal skin conditions.
Maintaining healthy skin around an ostomy: peristomal skin disorders and self-assessment
Authors: Martins Lina , Samai Oirda , Fernández Adelina , Urquhart Mary , Hansen Anne Steen
Published: May 2014

Problems affecting the peristomal skin are common in people with an ostomy and are an important area of stoma care nurse intervention. The DialogueStudy documented the experiences of more than 3000 people with an ostomy, with a focus on quality of life (QoL) and peristomal skin condition. These factors were assessed using the Ostomy Skin Tool. At visit 1, 60% of participants had a skin disorder, with irritant contact dermatitis (48%) and mechanical trauma (21%) being the most common causes cited. Only 53% of participants with a skin disorder were aware of it. The mean DET score had improved (decreased) from 2.5 (±2.8) at visit 1 to 1.6 (±2.1) at visit 2, 6–8 weeks later (P<0.0001). The factors affecting peristomal skin included age, time since surgery, ostomy type, choice of appliance and leakage. The results demonstrate that the combination of evidence-based nursing practices and the use of a double-layer adhesive, SenSura (Coloplast A/S) improved peristomal skin condition in people with an ostomy.
Endoscopy in children
Authors: Cullen Mick
Published: May 2014

The provision and governance of adult endoscopy services has changed greatly in the last 15 years. While paediatrics generally follows where adult practice leads, some aspects of paediatric endoscopy are unique to the discipline. In this article, Mick Cullen explores some of the differences between child and adult endoscopy and argues that paediatric endoscopies should be performed in a paediatric setting by practitioners who are proficient and experienced in looking after children. The use of sedation versus general anaesthesia is discussed, as is the practice of adult endoscopists performing child endoscopies in district general hospitals. To highlight some key concepts, the author outlines the support that children receive when journeying through the endoscopy service in his own practice.
Self-care and patient empowerment in stoma management
Authors: Di Gesaro Antonella
Published: May 2014

Research has shown that the early promotion of stoma management skills can signifcantly enhance the psychological adjustment of stoma patients post-surgery (O’ Connor, 2005). However, experiential evidence has shown that this does not always occur due to staff shortages and increased workloads. In this article, Antonella Di Gesaro aims to highlight the importance of teaching stoma patients to self-care. The author’s experiences on teaching stoma management skills will be deliberated and the effects this has on the enhanced recovery programme (ERP). Improving nurse documentation in order to enhance continuity of care will be discussed and the potential legal issues this could involve. Finally, the importance of effective communication, teamwork and effective practical teaching to empower patients to self-care will be reinforced.
Audit of an inflammatory bowel disease (IBD) telephone helpline set up and managed by IBD specialist nurses
Authors: Anderson Gill , Marsden Eliane
Published: May 2014

Gill Anderson and Eliane Marsden report on an audit of a newly set-up telephone helpline by inflammatory bowel disease (IBD) specialist nurses at Peterborough and Stamford Hospitals NHS Foundation Trust, which reviewed the service to see if its original aims were being met. These aims were to accelerate the treatment of patients with exacerbations of IBD and to provide support for these patients. Although a small cohort, the results were extremely positive. The audit showed that both aims were being clearly met and provided some very interesting data. For example, before the helpline, 77% of patients would contact their GP in the first instance, and of that 77%, only 19% had their problem resolved within one day; 31% of those had to wait 1–2 weeks for the resolution of their problem. As for the support provided by the service, one patient's comments sum up the helpline's success, ‘Before the phone service I felt that I was suffering in silence.’
Nutritional and fluid requirements: high-output stomas
Authors: Medlin Sophie
Published: May 2014

Based on the current available evidence, this article explores the nutritional management of those with a high-output stoma. The main alterations required to the intake of patients with a high-output stoma include the use of an oral rehydration solution to ensure optimum absorption of fluid and sodium, and a high-calorie, high-protein diet, with the aim of optimising nutritional status. Diet advice should be delivered by a dietitian with experience in managing these complex patients. Monitoring of electrolytes and micronutrients is essential, and long-term follow up from a multidisciplinary nutrition support team is invaluable in coordinating this. Patients with high-output stomas can enjoy good quality of life and long-term health if their condition is managed effectively by a well-organised multidisciplinary team.
The dilemma of choice: introduction to a stoma assessment tool
Authors: Buckle Nick
Published: May 2014

Providing a rationale for product solutions is becoming increasingly common as commissioners and additional stakeholders investigate the cost and practices of stoma care. In this paper, Nick Buckle introduces a stoma assessment tool that could provide expert health-care professionals with a framework to support clinical assessments and validate their product selection in a way that can be easily communicated to non-stomal experts, be they health-care professionals, commissioners or the patients themselves. The tool is designed for use in everyday practice and captures the experiential knowledge of the expert stoma care nurse in a concise and easy-to-interpret format.
Continuing need for Department of Health and UK government support for gluten-free staple food on prescription
Authors: Cuccu Zara , McGough Norma
Published: May 2014

A strict and lifelong gluten-free diet is the only available treatment for coeliac disease. Removal of gluten from the diet involves elimination of gluten-containing staple foods. Without appropriate replacement, this change can result in a person's restricted and unbalanced dietary intake and may affect nutritional status. Therefore, alongside dietetic referral and advice, access to gluten-free staples is vital. Although gluten-free substitute foods are available in supermarkets, the significantly higher cost and limited availability in some cases, necessitates a system of support to safeguard individuals with coeliac disease. More importantly, the prescribing of gluten-free staples has been shown to promote adherence to the gluten-free diet, which in turn helps to avoid associated health complications. Therefore, there is a continuing need for the Department of Health and UK government to support the prescribing of gluten-free staple foods.
Stigma, taboos, and altered bowel function
Authors: Chelvanayagam Sonya
Published: May 2014

This article discusses the concepts of stigma and taboos and their relevance to bowel function and gastrointestinal disorders. The author debates the definitions regarding the concepts of stigma and taboos and considers the effects of stigma on the stigmatised and non-stigmatised person. The types of stigma experienced by individuals with chronic illness are examined and the effect of stigma in specific gastrointestinal disorders is reviewed. The interventions to try to reduce the stigma associated with bowel function and gastrointestinal disorder are also explored. It is hoped that this article will contribute to a debate on addressing the issue of stigma in the UK.
Genetically predisposed to obesity? Avoid fried foods
Authors: Welyczko Nikki
Published: May 2014

Nikki Welyczko, Senior Lecturer and Academic Lead for Adult Nursing at De Montfort University, briefly reviews recently published articles
Prostate cancer: screening approaches
Authors: Donovan JL , Martin RM , Neal DE
Published: May 2014

Introducing screening for prostate cancer requires evidence that this would do more good than harm. Current evidence about the impact and natural history of prostate cancer, screening and diagnostic tests, and the effectiveness of treatments is reviewed below.
The use of the cell saver in obstetrics
Authors: Wylie Sandi , Stockton Emma
Published: May 2014

The most recent Confidential Enquiry into Maternal Deaths cited haemorrhage as the second most common cause of death, killing 17 parturients, two of whom refused donated blood (Lewis, 2005). Cell-saved blood is used routinely in other specialities where massive haemorrhage is common, yet this is not the case in obstetrics, mostly because of the concern over possible iatrogenic amniotic fluid embolism.
Evidence for inpatient rehabilitation as an effective intervention
Authors: Thomson Tom , Taylor William
Published: May 2014

Rehabilitation in inpatient settings is expensive and staff-intensive. It is necessary for such services to demonstrate effectiveness to justify this. In contrast to popular notions, evidence for the effectiveness of inpatient rehabilitation does exist and is reviewed in this article. In particular, there is very good evidence for specialized inpatient stroke care and rehabilitation.
Preoperative evaluation of cardiac risk
Authors: Older Paul , Hall Adrian
Published: May 2014

Ventricular function is the most important predictor of cardiac risk for non-cardiac major surgery. There is now good evidence that patients with coronary artery disease without cardiac failure are at no higher risk for postoperative cardiac events than the general population.
Strategies and tactics for effective prescribing during the foundation year
Authors: McGavock Hugh
Published: May 2014

About 5% of all emergency admissions to hospital are the result of prescribed drugs, rising to 10–12% in the elderly (>70 years old) (Pirmohamed et al, 1998; Kohn et al, 2000; Baijer and de Blaey, 2002; Huang et al, 2002). These relate to drugs prescribed in general practice, some on specialist advice. More worrying, from the house officer's point of view, prescription-related illness is also common in hospital (Dean et al, 2002) and 18% of elderly deaths in hospital are the result of hospital medication, half of which are preventable (Ebbeson et al, 2001).
NICE guidelines for the management of depression
Authors: McAllister-Williams R Hamish
Published: May 2014

The National Institute for Health and Clinical Excellence (NICE) published depression guidelines in December 2004 (NICE, 2004). Given that depression has a point prevalence in the population of somewhere between 5 and 10% (Katon and Schulberg, 1992), with rates of 30% or more in medical and surgical clinics (Kroenke et al, 1997), and that the illness is the leading cause of disability world wide (Murray and Lopez, 1996), the guidelines are relevant to all doctors. This editorial focuses on the implications of the guidelines for nonmental health specialists.
Arterial dissection and cerebral venous thrombosis in sickle cell trait
Authors: Cardenas Doris , Ovbiagele Bruce
Published: May 2014

A 26-year-old African-American male with no significant past medical history first presented in 1994 to another hospital with sudden onset headache, right-sided weakness, and language expressive difficulties 3 days after mild and otherwise uneventful head trauma while playing football. Magnetic resonance imaging (MRI) of the head and neck demonstrated a large left middle cerebral artery territory infarct and a left internal carotid artery mass interpreted as a pseudoaneurysm suggestive of arterial dissection. Workup at that time included evaluation for protein C/S, antithrombin III, antinuclear antibody, lupus anticoagulant, the factor V Leiden mutation and erythrocyte sedimentation rate levels, all of which were negative or within normal limits. A transoesophageal echocardiogram did not show a thrombus or a patent foramen ovale. Haemoglobin electrophoresis, however, showed that the patient was a carrier of the sickle cell trait (haemoglobin A1 = 61%, haemoglobin A2 = 3%, haemoglobin S = 36%). He was discharged from the hospital on an antiplatelet agent.

He presented 10 years later to the authors' emergency room with 2 days of left frontal headache accompanied by nausea, vomiting and photophobia. Days before this headache there were no other precipitating factors such as illness, trauma or obvious dehydration. His general exam was unremarkable. Pertinent findings on neurological exam were non-fluent speech, mild right upper extremity distal weakness and brisk right-sided reflexes. All of these findings were unchanged from the prior stroke per previous medical records. An MRI of the brain done 2 days after symptom onset demonstrated the old left middle cerebral infarction without evidence of a new ischaemic or haemorrhagic lesion but with increased signal in the superior sagittal (Figure 1) and transverse sinuses. Computed tomography (CT) angiogram of the brain revealed enlargement and hyperdensity involving the superior sagittal, transverse and sigmoid sinuses consistent with widespread thrombosis. CT angiogram of the neck showed focal stenosis (about 40%) of the high cervical internal carotid artery, and a more proximal thrombosed pseudoaneurysm (Figure 2), all likely residual from his prior arterial dissection. New laboratory workup included the anticardiolipin antibody, beta-2-glycoprotein, factor VIII, activated protein C resistance, prothrombin 20210A mutation, homocysteine and alpha-1- antitrypsin, all of which were either negative or within normal limits. The patient was started on anticoagulation 3 days after symptom onset and within 1 week experienced complete resolution of his headache.
Goodpasture's syndrome, haemodialysis and pregnancy
Authors: Shah Alpa , Bailey Elizabeth , Hughes Sean
Published: May 2014

A 29-year-old Caucasian woman had been diagnosed with Goodpasture's syndrome 12 months previously. Her renal function did not recover, she required haemodialysis and was put on the transplant list. She developed amenorrhoea on haemodialysis. She was seen at 22 weeks gestation in her second pregnancy. She was counselled regarding the high risk of fetal and maternal complications. She was offered medical termination of pregnancy but decided to continue.

management plan was devised aiming to maintain the health of the mother, allow growth of the fetus and to support the patient and her partner.

The plan included referral to a specialist obstetric unit. All drugs were evaluated and potentially dangerous medication, i.e. losartan, was stopped. Her haemodialysis was increased to six times a week (at least 24 h/week) to maintain a pre-dialysis urea of less than 16 mmol/litre. Her dialysate bicarbonate levels were reduced to prevent the usual post-dialysis alkalosis and avoid pre-dialysis acidosis. Intradialystic hypotension was avoided by careful fluid balance assessment and low ultrafiltration rates on dialysis, and post-dialysis hypercalcaemia was avoided by adjusting the dialysate calcium concentration. Hypocalcaemia was avoided by close monitoring of calcium and vitamin D levels and ensuring adequate doses of calcium and alfacalcidol. Hypertension was controlled with a safe antihypertensive (methyldopa), her haemoglobin was maintained between 10 and 11 g/dl with iron and erythropoietin and adequate nutrition with increased calorie and protein intake, water-soluble vitamins (B and C), and folic acid. Fetal growth and liquor volumes were monitored by regular ultrasound scanning.

At 24 weeks methyldopa 250 mg twice a day was started to control her blood pressure. Her growth scan at 24 and 26 weeks was satisfactory. At 27 weeks and 2 days she was admitted with severe epigastric pain. There were no other features of pre-eclampsia. She was given a course of betamethasone for fetal lung maturity. Two days later tests revealed a low platelet count (67×109/litre; normal value 150–400×109/litre) and high alanine aminotransferase (ALT) levels (113 iu/litre; 0–40 iu/litre). The next day a repeat test showed platelet count of 47×109/litre and an ALT level of 415 iu/litre. A working diagnosis of HELLP (haemolysis, elevated liver enzyme and low platelet) syndrome was made. The multidisciplinary team decided to deliver her electively by caesarean section the next day. A healthy baby boy weighing 540 g was delivered without any difficulty. She recovered well after the operation and was back on haemodialysis three times a week. The baby was doing well at 6 months of age.
Fraud and deceit in medical research
Authors: Ramnarain Nishan , Kirk Paul
Published: May 2014

Fraud and deceit in medical research is a serious issue that may be more prevalent than currently thought. This article examines the extent and history of medical research fraud and looks at the current and future mechanisms for detection and prevention.
A swallowed toothbrush causing perforation 2 years after ingestion
Authors: Cox David , Donohue Peter , Costa Vanda
Published: May 2014

A 33-year-old woman presented with a 3-day history of abdominal distension, ten-out-of-ten abdominal pain and rigors. She had had her bowels open every day since the onset of the pain, and her stools were normal. She had vomited once on the day of presentation. She mentioned she had been in a tussle with another person 3 days previous, and her pain had come on after this.

She looked unwell, and was found to be hypotensive and tachycardic. Abdominal examination showed generalized tenderness and a tightly distended abdomen. There was no overt guarding and bowel sounds were normal. There was a palpable hardness in the right upper quadrant, which the patient identified as a toothbrush which she had swallowed 2 years previously as a suicide attempt. She said that it often gave her some discomfort but never anything like the pain she was experiencing at presentation. She had refused intervention to remove it at the time of ingestion and ever since.

Erect chest radiography (Figure 1) revealed a large amount of free gas under both hemidiaphragms, and the bristles of a toothbrush to the right of the midline below the diaphragm. Arterial blood gas sampling showed a profound acute metabolic acidosis.

The patient was taken to emergency theatre for a laparotomy. In theatre a 1.5 cm prepyloric anterior ulcer was found, and the toothbrush was removed, head-first, having been lying transversely in the stomach.

The patient made a slow recovery and was discharged from hospital a month after initial admission, having suffered episodes of adult respiratory distress syndrome and hypoalbuminaemia-related pleural effusion before discharge.
Buprenorphine in the treatment of opioid dependence
Authors: George Sanju , Day Ed
Published: May 2014

Methadone has been the mainstay of pharmacological management of opioid dependence since the 1960s but buprenorphine is fast gaining acceptance among addiction specialists and patients. This article provides an overview of buprenorphine, its pharmacology, clinical efficacy and role in the treatment of opioid dependence.
Out-of-hours work: what is the training value for paediatric senior house officers?
Authors: Onyon Clare , Wall David , Goodyear Helen
Published: May 2014

Out-of-hours work is needed for recognition of training posts. This article looks at the opinions of paediatric senior house officers on the training value of this work. Although senior house officers felt out-of-hours work was important for training, suggested improvements are discussed.
Coma cocktail: a role for flumazenil?
Authors: Carvalho Clarissa , Walker David A
Published: May 2014

A common clinical scenario in the emergency department is a patient with a presumed drug overdose. Patients are often unresponsive with respiratory depression and hence unable to give a clear history. When the culprit toxin is known, rapid reversal with administration of the relevant antidote may be life saving. The empirical administration of a ‘coma cocktail’ consisting of naloxone, glucose and thiamine is common in many emergency departments. It is tempting to add flumazenil to this cocktail if there is a suspicion of benzodiazepine misuse; however, the possibility of mixed overdose or any suggestion of long-term benzodiazepine use should influence management choices.
Ambulatory cardiac rhythm monitoring
Authors: Rao Archana , Lomax Sue , Ramsdale Kathryn , Ramsdale David
Published: May 2014

Cardiac arrhythmias may cause palpitations, dyspnoea, angina pectoris, dizziness or even syncope and sudden death. This article will review the indications for investigation, the novel devices that are available for investigating patients with suspected cardiac dysrhythmias and the new technology available for analysis and reporting.
Principles and procedures of medical ethics case consultation
Authors: Banerjee Dipanjan , G Kuschner Ware
Published: May 2014

Ethical conflicts are common in hospital medicine. This article reviews core medical ethics principles, describes models for conducting hospital-based ethics case consultations, and highlights the contributions of hospital ethics committees to high quality patient care.
Psoriasis: maximizing topical treatment concordance
Authors: Gupta Girish , Bhattacharya Susmita
Published: May 2014

Psoriasis is one of the most commonly occurring skin conditions in the UK. It is a chronic inflammatory disease and therefore psoriatic patients are predisposed to developing other inflammatory conditions such as cardiovascular disease. The management of such patients increasingly involves other specialties. A basic knowledge of available topical treatments is essential in improving overall patient concordance.
Bacterial meningitis resulting in visual impairment and panhypopituitarism
Authors: Lynch Ceri , Fish Mark
Published: May 2014

A 30-year-old man presented to his local district general hospital with a week-long history of headache, cough and coryzal symptoms, followed by 24 hours of fever, neck stiffness, photophobia, confusion and agitation. He had no significant previous medical history. Examination revealed a Glasgow Coma Score of 11 (E4, M5, V2), stiff neck, tachypnoea and tachycardia. There were no localizing neurological signs. Mucus was crusted around the nose.

The patient was sedated and ventilated in intensive care and given intravenous benzylpenicillin and cefotaxime. He then underwent a computed tomography (CT) head scan, which suggested fluid in the paranasal sinuses and pus filling the maxillary antrum.

CSF was turbid, containing 16 000 white cells/mm3 (97% polymorphs), protein 3.22 g/litre and glucose 0.1 mM although no organisms were seen on Gram stain. At this point the patient was transferred to a tertiary neurology centre, where a repeat CT after 3 days showed further fluid and oedema in the paranasal sinuses. Sinus washout was performed and nasal decongestants prescribed. Initial attempts at extubation led to repeated seizures. Blood tests performed included assessment of pituitary profile, which was unremarkable.

Sedation was withdrawn 10 days after admission and the patient extubated; once awake it became clear that he was blind. The patient was pyrexial (38°C), agitated and hallucinating. It was thought that he had Anton's syndrome (cortical blindness and poor awareness of blindness). He was transferred to a neurology ward and a low-dose antipsychotic was started. The patient became more alert and orientated, and able to cooperate with ophthalmological examination, which established healthy optic discs, no intraocular abnormality, no papilloedema and no afferent papillary defect, supporting the diagnosis of cortical blindness.

A repeat CT scan to investigate his continuing headache demonstrated loss of radiolucency of all the paranasal sinuses and the patient underwent functional endoscopic sinus surgery; this involved bilateral eithmoidectomy, sphenoidectomy and insertion of stents into both frontal sinuses. An audiogram demonstrated high frequency sensorineural deafness.

The patient's condition improved and his eyesight partly recovered (visual acuity 6/60 right eye and 6/24 left eye). Further ophthalmology examination revealed bilateral disc pallor and optic atrophy was diagnosed.

It was noticed that this patient's skin had become soft, pale and wrinkled and he was shaving less frequently than usual. On the basis of his skin appearance, a diagnosis of possible hypopituitarism was made, and pituitary hormone profile was assessed. This revealed panhypopituitarism and magnetic resonance imaging confirmed the presence of gross inflammation in the optic chiasm and around the pituitary, although the pituitary gland itself appeared intact (Figure 1). The patient was discharged home on pituitary replacement therapy with planned regular follow-up.
Renal replacement therapy in acute kidney injury: an overview
Authors: Kanagasundaram N Suren
Published: May 2014

Renal replacement therapy plays a key role in the management of acute kidney injury – a devastating condition in the critical care setting. This article reviews current evidence and provides a template to inform routine practice.
Practical management of common atrial arrhythmias 4: persistent atrial fibrillation
Authors: Williams Paul , Fitzpatrick Adam P , Earley Mark , Petkar Sanjiv , Diab Ihab , Fox David
Published: May 2014

This is the last in a series of four practical articles highlighting the important management steps for noncardiologists and non-cardiac electrophysiologists dealing with patients with atrial fibrillation and common atrial flutter. This article will deal with care pathways and management principles for persistent atrial fibrillation.
Use of an endotracheal tube or LMA Flexible in nasal surgery
Authors: Moloney Claire
Published: May 2014

Nasal surgery includes short procedures such as reduction of nasal fractures and antral washouts, or longer procedures such as septoplasty, turbinate surgery, functional endoscopic sinus surgery and nasal polypectomy.
Training: what went wrong? Where do we go now?
Authors: Bayne Louise , Jameson Evans Matthew , King Judy , Marks Richard , McCullough Chris , Shaw Matthew
Published: May 2014

When Sir Liam Donaldson wrote Unfinished Business: proposals for reform of the senior house officer grade in 2002 (Donaldson, 2002), only the most cynical of minds could have predicted the quagmire that we lie in today. On the contrary, there was an atypical professional consensus on the need for improvements to be carried out. The Sysiphean task of sending off hundreds of CVs for 6 months of poorly regulated training with no continuity and scant supervision was just one element of a system ripe for improvement. And so Modernising Medical Careers (MMC) was born – a 21st century training system that ould streamline medical training and bring us in line with our European counterparts. This shining new system would also herald the ‘consultant-led health service’ promised in the NHS Plan (Department of Health, 2000).
The consultants' contract: is it value for money?
Authors: Taylor Karen , Fisher Andy
Published: May 2014

The NHS Plan (Department of Health, 2000) outlined the Department of Health’s vision for a health service designed around the patient, with more and better paid staff working differently. Central to the plan was the need to modernize NHS pay, including the need for a new consultant contract to reward consultants more appropriately for their NHS work while improving the way they are managed.
Inversion of Meckel's diverticulum causing gastrointestinal bleeding and small bowel obstruction
Authors: Andrabi SIH , Spence GM , Clements Mr WBD
Published: May 2014

A 35-year-old man presented with vomiting, mid-gut colic, intermittent passage of fresh blood per rectum and a haemoglobin level of 8.0 g/dl. Clinical examination was unremarkable and initial investigation with abdominal sonography revealed no abnormality. Computed tomography of the abdomen demonstrated a thick-walled loop of small bowel in the region of the terminal ileum (Figure 1). A differential diagnosis of ileo-ileal intussusception, Crohn's disease and Meckel's diverticulitis was considered.

The patient proceeded to exploratory laparotomy, which revealed inversion of a Meckel's diverticulum causing incomplete small bowel obstruction. Segmental ileal resection and primary anastomosis was performed without incident. Recovery was uneventful. Histopathological examination showed a 15 mm submucosal nodule with associated ulceration of the overlying mucosa in the base of the diverticulum (Figure 2). Microscopy confirmed that the nodule contained heterotopic pancreas with lobules of ductal and acinar epithelium.
Cognitive dysfunction in intensive care survivors
Authors: Chapman RJ , Brett SJ
Published: May 2014

Cognitive dysfunction is increasingly recognized as a common, often prolonged and potentially disabling complication of critical illness. While demonstrable in patients who have survived a variety of both medical and surgical conditions, its causes remain unclear. Screening of patients in intensive care units and at follow up may help identify those who could benefit from cognitive rehabilitation.
The law, negligence and sick doctors
Authors: Corfield Lorraine
Published: May 2014

Doctors often come to work when they are too unwell to care for patients adequately. Should a negligent error occur, sickness provides no legal defence. Doctors and trusts must recognize this and take appropriate action.
So you want to be… an obstetrician
Authors: Rajasingam Daghni
Published: May 2014

The most fascinating, versatile and challenging of all specialities – that's obstetrics and gynaecology. It takes you from conception to the cradle and even to the grave. This unique specialty encompasses embryo research, fertility treatment, miscarriage, childbirth, laparoscopy, oncology, palliative care, endocrinology, infectious diseases and family planning.
Ultrasound imaging of the carotid arteries
Authors: Hart Jonathan L , Lloyd Claire , Niewiarowsk Sylwia , Harvey Chris J
Published: May 2014

Stroke remains a leading cause of death in developed countries. Most are the result of atherosclerotic disease, usually involving the carotid arteries. A significant number of all strokes (10–20%) are caused by internal carotid artery stenosis. Carotid Doppler ultrasound (CDUS) is a commonly requested investigation, principally performed to assess the carotid arteries for the presence and extent of atheromatous plaque. Atheroma in the carotid arteries is typically localized to the carotid bifurcation and may give rise to microemboli causing transient ischaemic attacks in the contralateral limbs or amaurosis fugax in the ipsilateral eye.
Breast abscess
Authors: Agrawal Avi , Kissin Mark
Published: May 2014

The management of breast abscesses has continued to evolve over the last decade despite its decreasing frequency in developed countries. A breast abscess can occur at any age although is seen most commonly in adult premenopausal women. It may be difficult but should be distinguished from mastitis where there is inflammation without pus. Appropriate management is needed to provide symptom control and minimize long-term complications including chronic infection, recurrence and scarring.
Duplex ultrasound for diagnosis of deep vein thrombosis
Authors: L Hart Jonathan , Lloyd Claire , Niewiarowski Sylwia , Harvey Chris J
Published: May 2014

Deep vein thrombosis (DVT) is a common clinical condition, which may cause pulmonary embolus in as many as 20% of those affected (Baxter, 1997). The evolution of real-time venous ultrasound in the 1980s provided a rapid, non-invasive and relatively cheap alternative test for DVT. Such techniques now have a reported sensitivity and specificity in detecting femoral or popliteal vein thrombus of >95% and >98% respectively. Other indications for venous ultrasound are included in Table 1.
Managing low self-esteem: a guide for the foundation year doctor
Authors: Trivedi Deepali , Hooke Rachel
Published: May 2014

The word ‘esteem’ is derived from a Latin word which means ‘to estimate’. So, selfesteem is how you estimate yourself. It is only your personal opinion about yourself. Most of the time, we try to estimate ourselves based on our successes or failures, or sometimes comparing ourselves with others.
Junior doctors' hours and pay: a guide for foundation year doctors
Authors: Hooke Rachel
Published: May 2014

Before 1991, there was no statutory limit on the hours that doctors in training could be contracted and compelled to work. Then the now incongruously-named New Deal was brought in (NHS Management Executive, 1991).
Surviving shift systems: a guide for the foundation year doctor
Authors: Hooke Rachel , Trivedi Deepali
Published: May 2014

Shifts are relatively new for junior doctors. Until the first phase of the Working Time Directive (WTD) was brought in for this group in August 2004, they were less widespread. Even now, junior doctors still talk about being on call, although the old concept of being asleep, waiting to be called occasionally, has long since gone for most.
The applied anatomy of examination of the knee
Authors: Ellis Harold
Published: May 2014

Injuries of the knee are common. Accurate diagnosis of the precise site of structural damage entirely depends on a clear knowlege of its anatomy.
An introduction to fluid therapy
Authors: Woo Adam , Sutton Hannah , Stephens Robert
Published: May 2014

Most hospital inpatients will need intravenous fluid therapy as a result of altered intake, extra losses and dynamic shifts within the body. This simple and basic therapy is often overlooked but can cause significant morbidity if neglected as organ perfusion, electrolyte balance and acid base equilibrium may be compromised.
Abdominal injuries
Authors: Davenport Ross , Walsh Mike , Tai Major Nigel
Published: May 2014

This article will give an overview of abdominal trauma and provide a broad framework for the initial management of injuries to the abdomen. Abdominal injury carries a high morbidity and mortality in all age groups, therefore a sound understanding of the patterns of injury, examination, investigations and resuscitation procedures is vital to the trauma surgeon's armamentarium.
Publish or perish: how to secure your first publication
Authors: Williams Gwyn S , Singh Talvinder
Published: May 2014

With the advent of Modernising Medical Careers (MMC) and the piloting of the medical training application service (MTAS) already upon us, there has never been such pressure for junior doctors to ‘tick all the boxes’ when filling out the all important online form. Every word potentially carries a score, and with the punishing 150-word limit to every answer, every word does truly count. With one or two points making the difference between being shortlisted for an interview and leafing through BMJ Careers for opportunities abroad, it is more important than ever for juniors to grasp the nettle that has traditionally been the preserve of more experienced doctors, and get published (Williams, 2006).
Soft tissue knee injuries
Authors: Patel RV , Haddad FS
Published: May 2014

The knee is the largest joint in the body. It is a synovial joint of the modified hinge (condyloid) type between the distal end of the femur, the patella and the proximal end of the tibia. The femoral articular surface is formed of three surfaces: a middle concave surface for the patella (trochlea), and medial and lateral condylar surfaces for the tibia which are markedly convex. The upper surface of each tibia is oval and slightly concave (Figure 1).
Dealing with colleagues: a guide for the foundation year doctor
Authors: Trivedi Deepali , Hooke Rachel
Published: May 2014

Learning science and medicine are the main priorities for medical students, along with patient communication. However, less time has traditionally been devoted to preparing newly-qualified doctors for getting on with colleagues.
Controversies in chronic kidney disease, anaemia and cardiovascular disease
Authors: Fluck Richard
Published: May 2014

Inclusion of chronic kidney disease within the primary care Quality and Outcomes Framework recognizes that most patients are diagnosed and managed in general practice. However, improved identification of patients with renal impairment also has important – and controversial – implications for hospital doctors.