bluuebunny/crossref_metadata_2025 huggingface dataset:
Coronary angiography in chronic aortic dissection
Authors: Rao Archana , Hakeem Abdul , Morrison Lindsay
Published: May 2014

A 67-year-old man was followed up by the thoracic surgeons with annual computed tomography (CT) scans for a chronic type B dissection of his thoracic aorta. He had medically treated hypertension and was a smoker. On the CT scan the descending aorta measured 6.4 cm and elective surgical intervention was planned. The patient was well and relatively asymptomatic with normal renal function. All peripheral pulses were present.

He was listed for a coronary angiogram preoperatively. The procedure was undertaken via the right femoral artery. Access was gained easily but it was not possible to advance the guide wire beyond the arch. An arch aortogram was undertaken (Figure 1) which confirmed that the guide wire was in the false lumen. The coronary arteries were intubated via the right brachial approach (Figure 2). It appears that coronary and upper limb perfusion was from the true lumen and the rest from the false lumen.
Doppler cardiac output monitoring: a tool for all physicians
Authors: Usher SM , Walker DA , Mythen MG
Published: May 2014

This article introduces Doppler ultrasound cardiac output monitoring and outlines its increasing utility for managing patients with critical illness in the hospital environment.
Detention on a general ward: understanding and applying the law
Authors: Schofield C , Holden N
Published: May 2014

From April 2007 there will be two acts of parliament that govern the legal detention of patients in hospital: the Mental Health Act 1983 and the Mental Capacity Act 2005. This article addresses common questions posed to liaison psychiatrists by hospital doctors: how to legally detain patients on general wards and how these Acts are applied.
Techniques used for assessing the sense of smell
Authors: Nik H , Arya AK , Swift AC
Published: May 2014

Assessment of the sense of smell is a challenging clinical investigation. Although a wide range of tests are available, many are modifications of tests designed more than 20 years ago. This article describes the smell tests that are available, and consider smell assessment after nasal surgery.
The management of olfactory disorders
Authors: Shetty Sandeep , Vishwanathan Harishnath , Carrie Sean
Published: May 2014

Disorders of olfaction affect quality of life and their significance are underestimated. Investigation and diagnosis can help in the early implementation of rehabilitative measures and also in recognizing those forms of olfactory disorders that are potentially treatable.
Effectively communicating a diagnosis of Parkinson's disease
Authors: Ford Steve
Published: May 2014

Each year approximately 10 000 people are diagnosed with Parkinson's disease in the UK. As Schrag et al (2000) have reported, one in every 20 of those diagnosed is under the age of 40 years.
Top-up insurance for cancer drugs
Authors: Sikora Karol
Published: May 2014

NHS patients lag behind those in Europe with regard to access to new cancer drugs. In a comparison of 19 countries, a study from the Karolinska Institute (Wilking and Johnson, 2006) showed that for several drugs licensed for use in cancer in the early part of this decade, the UK falls far behind our immediate neighbours and is on the level of Poland and Hungary. The combination of National Institute for Health and Clinical Excellence (NICE) delays and financial pressure on overstretched and poorly managed primary care trusts (PCTs) have created a powerful barrier to the ability of British oncologists to use novel agents.
Introductory teaching for intensive care residents: development and implications
Authors: Cosgrove Joseph F , Laws Philip , Nesbitt Ian D , Cressey David M , Kilner Andrew J
Published: May 2014

Within intensive care medicine there is a need to rapidly and safely integrate junior doctors into individual units with effective introductory training. Evolution of such training is influenced by pressures placed on clinicians to maintain standards of care.
Maximizing treatment outcomes in the depressed patient
Authors: Corcoran Ciaran , McAllister-Williams R Hamish
Published: May 2014

Depression is a serious illness associated with morbidity and mortality, but it is treatable. However, outcomes are often far from ideal with patients left with residual symptoms of depression. These are associated with poor social functioning and an increased risk of relapse.
Saving for school fees and university costs
Authors:   Wesleyan Medical Sickness
Published: May 2014

Few parents consider how much it will cost when they decide to start a family. That’s probably how it should be. Having children should not be a financial decision. And yet, once you do have them, it would be irresponsible not to start planning for the future costs that will arise.
Emphysematous cystitis
Authors: Casey Rowan , Stunell Helen , Torreggiani William C , Grainger Ronald
Published: May 2014

A 70-year-old poorly-controlled type 2 diabetic male presented with a 48-hour history of dysuria, frequency and frank haematuria. He described a 6-week history of worsening bladder outflow obstructive symptoms with nocturia and hesitancy. On examination he had a temperature of 37.5°C and tenderness in the left iliac fossa. Digital rectal examination revealed a tender, smoothly enlarged prostate gland. Blood glucose measurement was significantly elevated at 17 mmol/litre and serum white cell count was elevated at 19×109/litre, demonstrating a marked neutrophilia. A plain film of the abdomen demonstrated the presence of a well-defined area of lucency in the region of the bladder suggestive of air within the bladder wall. A large lucent area was also noted in the left lower quadrant suggestive of a large bladder diverticulum distended with air (Figure 1). Based on these findings, a diagnosis of emphysematous cystitis was considered likely and the patient was commenced on broad-spectrum intravenous antibiotics, intravenous fluids and subcutaneous insulin sliding scale.

Subsequent computed tomography of his abdomen and pelvis with intravenous and oral contrast confirmed the presence of emphysematous cystitis with a markedly abnormal, thick-walled bladder as well as air within the bladder wall (Figure 2). The large lucency seen in the left lower quadrant on plain film was shown on computed tomography to represent a 9.7 cm bladder diverticulum, also containing air within its wall (Figure 3). There was no evidence of a colovesical fistula. Urine culture demonstrated a significant growth of Escherichia coli. His clinical course was uneventful and he was discharged home well 7 days later on oral antibiotics for a total of 14 days. He is due for further investigation of his lower urinary tract symptoms with cystoscopy.
The Venturi mask: more than moulded plastic
Authors: J Adcock Christopher , S Dawson James
Published: May 2014

Supplemental oxygen therapy is central to the management of most acutely ill patients and many patients with chronic disease. Oxygen should be regarded as a drug and therefore be prescribed and administered with consideration. Fixed performance devices such as the Venturi masks and humidifier systems deliver a fixed fraction of inspired oxygen (FiO2) for a given oxygen flow rate. The indications, contraindications and hazards of oxygen therapy have been described by Booth (2006). This article aims to provide ammunition for the next ward round or clinical viva, by exploring both the physical principles behind these devices and celebrating the physicists whose names we use every day.
So you want to be… a rheumatologist
Authors: Farrow Sarah J , Kingsley Gabrielle H
Published: May 2014

Even in the 19th century, when rheumatoid arthritis, the most common of the serious rheumatic diseases, was first defined, sufferers moved inexorably towards life in a wheelchair. As late as the 1950s, the only widely available treatments were aspirin, which just produced symptom relief, and cortisone which had severe side effects. However, rheumatoid arthritis was one of the first fields in medicine where treatments were subjected to controlled trials. The benefits of injectable gold, the earliest disease-modifying drug, were demonstrated by Fraser in 1944–5, following which this treatment became widely available.
Spinal immobilization for the junior doctor
Authors: Hudson Benjamin J , Waller James R , Oussedik Sam
Published: May 2014

The early recognition and correct management of spinal injuries is vital to avoid serious, irreversible long-term consequences. In the 1970s the American College of Surgeons (ACS) devised the Advanced Trauma Life Support course. This was designed to give any doctor the basic knowledge to stabilize any trauma patient in a systematic fashion. These guidelines are still widely accepted as the gold standard for the assessment and initial management of trauma patients throughout the world.
Isaacs syndrome
Authors: Sharma Neel , Verma Surabhi , Yeung Michelle
Published: May 2014

A 57-year-old retired factory worker was admitted to the accident and emergency department complaining of a 3-month history of painful stiffness of his hands and toes. In addition he complained of generalized weakness, numbness and a tingling sensation of both his upper and lower limbs as well as weight loss. He was keen to mention that his stiffness had been long lasting and was even present during sleep. There was no significant past medical history. On general examination a mild weakness affecting the distal region of all four limbs were noted in addition to myokymia. He was also remarkably unsteady on his feet. There was no evidence of excessive perspiration or muscle wasting. A routine full blood count, urea and electrolytes, liver function and creatinine kinase were unremarkable.

The patient was referred for electromyography testing which demonstrated evidence of neuromyotonia and myokymia. Antibody testing to voltage-gated potassium channels was not performed. The patient was prescribed phenytoin 50 mg twice daily. After 1 week his symptoms had improved substantially and at 1-month follow up the patient was practically asymptomatic.
Bettertesting: putting laboratory test guidance on the web
Authors: Smellie WSA
Published: May 2014

This article describes a website ( www.bettertesting.org.uk ) which provides guidance on use of laboratory tests in common situations. It was constructed using a standard search strategy to identify the best quality guidance from the literature and will shortly include clinical self-assessment questions.
Perforation in pictures
Authors: Chew Ne Siang , Pasha Yasmin , Al-memar Maya
Published: May 2014

A 35-year-old woman presented with a 4-day history of sudden onset right-sided back pain radiating to the right flank and central abdomen. This was associated with nausea and relieved by lying still. The patient had a long history of back pain and had been self-medicating with non-steroidal anti-inflammatory drugs (NSAIDs). On examination, she was haemodynamically stable with tenderness and guarding over the epigastrium and right upper quadrant. A chest radiograph revealed free subdiaphragmatic air.
HIV and respiratory medicine
Authors: Mandal Swapna , Cooper Samantha , Lipman Marc
Published: May 2014

The end of the 20th century saw the start of an HIV pandemic that brought death and suffering to millions. Anti-HIV drug therapy has improved the lives of many, although HIV-related respiratory complications remain extremely common worldwide
Pitfalls in the diagnosis of hydrocephalus
Authors: Ambrose Tim , Butler Christopher , Myles Lynn , Zeman Adam
Published: May 2014

Hydrocephalus is a life-threatening condition presenting with a wide range of symptoms to a variety of specialties. Resulting delays in diagnosis can be hazardous. Doctors in all specialties should be familiar with the protean presentations of hydrocephalus.
Dressler's syndrome post-pacemaker insertion
Authors: Porter Gordon , Doherty John , Wong Roger
Published: May 2014

A 75-year-old man underwent placement of a dual-chamber pacemaker for symptomatic sinus node disease in a tertiary referral centre. Three days after the procedure, he presented to the emergency department in the same hospital with right-sided, pleuritic chest pain and a diagnosis of pulmonary embolus was considered, although excluded by investigations which included spiral computed tomography and d-dimer. He was discharged, only to return the next day with increasing dyspnoea, and a transthoracic echo confirmed the clinical diagnosis of a significant pericardial effusion with early signs of tamponade physiology. In the operating room 700 ml of blood-stained fluid was aspirated and the patient's symptoms improved dramatically. Chest X-ray and pacemaker interrogation did not necessitate re-positioning of the pacemaker leads.

One month later he returned to his local hospital complaining of increasing dyspnoea and a chest X-ray (Figure 1) demonstrated a large right pleural effusion and a smaller effusion on the left. There was a moderate pericardial effusion without tamponade (Figure 2). The larger of the pleural effusions was aspirated with improvement in the patient's symptoms, but recurrence of the fluid, persistent symptoms, a low grade fever and a high erythrocyte sedimentation rate, led to consideration of Dressler's syndrome. The patient was commenced on prednisolone 60 mg daily and both his symptoms and the pleural effusion resolved.
Elongated styloid process or Eagle's syndrome
Authors: Vaidhyanath R , Kenningham R
Published: May 2014

A 39-year-old woman presented to the maxillofacial clinic of the authors' institution with a 2-year history of pain in the right side of the throat radiating to the right face and ear.

On clinical examination, there was scarring in the anterior pillar of the fauces, more prominent on the right side. There was no ulceration or palpable neck mass. The temporomandibular joints were normal. The patient gave a history of tonsillectomy 19 years ago.

An orthopantomogram (Figure 1) demonstrated elongated styloid processes bilaterally, measuring 4.4 cm on the right and 4 cm on the left. Palpation of the styloid process following review of the orthopantomogram resulted in exacerbation of the patient's symptoms on the right side. Unenhanced computed tomography (Figure 2) of the neck confirming the clinical diagnosis of elongated styloid process or Eagle's syndrome.

The patient underwent right-sided styloidectomy through an intra-oral approach. She was symptom free at 1 year follow-up.
The importance of information for frontline nurses
Authors: Negus Jennie
Published: May 2014

Back in the days of eusol and liquid paraffin when I was a new staff nurse, other than the ubiquitous ‘Kardex’, fluid balance and various observation charts there was little other paperwork to do – you just got on with the job of nursing. Nowadays it is different. There are times when I wonder how on earth we would have coped with the new technologies in information, let alone in patient care, but on the other hand I also have moments wishing I had had access to such innovation.
Silent sinus syndrome: a cause of enophthalmos
Authors: Vaidhyanath R , Kenningham R
Published: May 2014

A 66-year-old woman presented to the ophthalmology unit with a 3-month history of a 'receding right eye'. The patient noted occasional drooping of the right upper eyelid but no disturbance of vision. Clinical examination revealed deep right superior sulcus. Hertel ophthalmometry confirmed enophthalmos of 3 mm on the right side. Visual acuities were 6/6 bilaterally, eye movements were normal and visual fields were normal on testing by confrontation. There was no history of previous orbital trauma or significant sinus disease, particularly recurrent acute sinus disease. Computed tomography of the orbits was requested to exclude orbital disease.

Computed tomography findings were complete opacification of the right maxillary sinus with occlusion of the maxillary ostium, downward displacement of the floor of the right orbit and enlargement of the right middle meatus. Mucosal thickening is noted in the left maxillary sinus (Figure 1). The right maxillary sinus volume was reduced with inward bowing of its walls (Figure 2).

Thre patient underwent a right middle meatal antrostomy. Three months after surgery the patient's symptoms had improved and hence an orbital floor repair was not considered
Why inflation matters
Authors:   Wesleyan Medical Sickness
Published: May 2014

Inflation, a word barely heard over the past 10 years, is once again rearing its ugly head. Official figures put inflation at an annual rate of 3.3% and it is expected to rise to 4% by the end of 2008. The official target which the Bank of England is charged to maintain is just 2%.
Atrial pacing wires: an uncommon cause of postoperative hiccups
Authors: Doshi H , Vaidyalingam R , Buchan K
Published: May 2014

A 60-year-old man was admitted to the cardiac intensive care unit following elective coronary artery bypass grafting. His past medical history included ischaemic heart disease and hypertension. Persistent bradyarrhythmias had necessitated temporary pacing before termination of cardiopulmonary bypass. This was achieved using right atrial epicardial pacing wires.

On admission to the unit he was being paced at 80 beats per minute with a blood pressure of 132/68 mmHg, central venous pressure of 9 mmHg and an arterial oxygen saturation of 98%. The immediate postoperative period was uneventful and he was weaned off ventilatory support as per departmental protocol.

Following extubation the patient complained of hiccups. On examination he had diaphragmatic contractions only on the right side synchronous with the pacing rate. At this point, as his heart rate had increased the pacing rate was reduced. This reduced the frequency of hiccups and switching off the pacemaker lead to the resolution of hiccups.
Understanding insulins: new developments
Authors: Robertson Doug
Published: May 2014

Diabetes is a disease known from antiquity, rediscovered in the modern era (von Engelhart, 1989) (Table 1). As populations across the world live longer and become more overweight, the incidence of type 2 diabetes (which represents 90% of all cases of diabetes) is increasing. This is true for both the developed and developing world – especially places like India where epidemiological evidence suggests that a diabetes epidemic is underway (Hossain et al, 2007). The World Health Organization estimates that there will be about a 25% increase in diabetes cases in the UK by 2030 (Wild et al, 2004). Management of diabetes and its complications will, therefore, become an ever more common part of the physician's job over the coming years.
Assessing risk and managing patients who deliberately self harm
Authors: Ganeshalingam Yogesh
Published: May 2014

Deliberate self-harm is one of the most frequent reasons for general hospital admission. It is estimated that about 150 000 cases present to accident and emergency departments in the UK annually (Hawton and Fagg, 1992; Hawton et al, 1998). Most cases are associated with a psychiatric disorder. A large proportion of cases involve an overdose of commonly available drugs such as aspirin, paracetamol, antidepressants and minor tranquillizers, often in conjunction with alcohol (Hawton et al, 2004). Selfharm is a high risk factor for future suicide. Individuals who have deliberately harmed themselves have a 100-fold greater risk of suicide than the general population (Hawton and Fagg, 1992). Hence it is essential that assessments are thorough and management is planned appropriately.
The radiology request form: a guide for the foundation year doctor
Authors: Andi Allan , Howlett David
Published: May 2014

The walk to the radiology department with a paper or electronic request in mind may make the junior doctor apprehensive. This scenario may begin on a busy ward round during which multiple requests for imaging are made. By the time one patient plan has been documented, a correct request form found and the notes frantically arranged to an up-to-date entry point, your team have moved on. You may then receive a secondary history for the initial request while simultaneously writing a new set of notes. Invariably you are left asking ‘What should I write on the form?’, ‘How much do I write?’, ‘Do I arrange it now or later?’, ‘Can we all go to the department and get this investigation organized?’, echoing distant memories of your first week as a new trainee.
A guide to organizing FY2 training in Australia
Authors: Vamadeva Sarita
Published: May 2014

After 6 months of fantastic experiences as a houseman at a London teaching hospital, I was thrust into the new foundation year two (FY2) job application process. While struggling through the application form I decided it was time for a change. The North West Thames Foundation School offered their FY1 trainees the opportunity to train abroad for FY2. They stipulated that the year abroad should be structured in a similar way to UK-based FY2 jobs and include completion of all necessary assessments such as mini-clinical evaluation exercises and directly observed procedural skills.
Ultrasound imaging of the kidneys
Authors: Niewiarowski Sylwia , Lloyd Claire , Hart Jonathan , Harvey Chris
Published: May 2014

A wide range of disorders affect the kidneys and ultrasonography is often the modality of choice in the initial assessment. This article reviews the ultrasound appearances of some common adult kidney disorders encountered in daily practice.
Acute skin conditions in children
Authors: Gait Rosalind C , Johnston Graham A
Published: May 2014

This article covers four acute skin conditions seen in children. Early recognition and appropriate prompt treatment is important as significant morbidity may ensue.
Tips on giving a good handover
Authors: Heetun Mohammad , Chalmers Ritchie
Published: May 2014

The introduction of the European Working Time Directive has sought to protect health-care workers from the potentially damaging effects of working excessive hours and ensure that there are adequate rest periods between shifts (Department of Health, 2007). For doctors, this has led to a move away from the traditional on-call pattern of work, where individuals were previously working for longer continuous hours, to a more coordinated shift pattern with continuity of care being transferred to a different team. This often means different individuals will be looking after the same patients in any given day and therefore an effective handover is essential between these teams.
Cardiovascular therapeutics
Authors: Shakur R , Cockrum E , Scott D
Published: May 2014

Cardiology is an expanding area, with a strong evidence base for many of the interventions used. When prescribing for a patient with cardiovascular disease, it is essential to check the diagnosis (several drugs can be used for multiple indications but will be dosed differently) and to check the patient's drug history. When doing this, do not rely upon a previous discharge letter alone nor on a GP letter alone; always use the documents available but also ask the patient what he/she is actually taking. The patient may have varied the dosage, with or without medical advice, and it is crucial to know this to make appropriate adjustments.
Zenker's diverticulum
Authors: Amerasekera Steve
Published: May 2014

A 78-year-old man presented with a 6-month history of dysphagia, regurgitation of food and weight loss. Nasal endoscopy and plain chest radiography were unremarkable. However, a single contrast barium swallow demonstrated the classical appearances of a Zenker's diverticulum (also known as pharyngeal pouch) (Figures 1 and 2).
Lethal cause of abdominal pain: a diagnosis not to be missed
Authors: Durai Rajaraman , Ruhomauly Sha-Nawaz , Kerwat Rajab , Hoque Happy
Published: May 2014

A 77-year-old woman was brought to the accident and emergency department with a 11-day history of abdominal pain. She was in shock and required resuscitation. She had attended the accident and emergency a few days before and had been discharged home with a diagnosis of non-specific abdominal pain. The previous abdominal X-ray is shown in Figure 1. Her past medical history included bilateral below knee amputation for peripheral vascular disease, pacemaker for heart block and hypertension. On examination, post-resuscitation, she was confused and apyrexial with a heart rate of 100 beats/minute and a blood pressure of 110/70 mmHg. Her abdomen was diffusely distended with minimal tenderness in the epigastrium and supra-umbilical region. There was no rigidity or guarding. Bowel sounds were normal. Digital rectal examination showed soft faeces. Blood test showed a haemoglobin of 6.6 g/dl (down from 11 g/dl during her previous accident and emergency visit). There was slight impairment of renal function with a urea of 11 mg/dl and creatinine of 160 mg/dl. The rest of the blood tests were within normal limits. Arterial blood gases showed metabolic acidosis with a pH of 7.2 and lactate of 3 mmol/litre. A computed tomography scan of the abdomen was performed.

1. What is the differential diagnosis?

2. What can you find in the abdominal X-ray?

3. What can you find in the computed tomography scan?

4. What is the treatment?

5. What is the prognosis of this patient?

The differential diagnoses in this case are peritonitis from hollow viscus perforation, ischaemic bowel and leaking abdominal aortic aneurysm. The abdominal X-ray (Figure 1) shows minimal dilatation of the right and transverse colon and a tortuous calcified aorta. However the upper aortic calcification is not obvious. Computed tomography scan shows an abdominal aortic aneurysm which commences immediately distal to the origin of the right renal artery with not involving the bifurcation. There is leakage from this aneurysm (Figure 2b arrow) which has a maximum diameter of 5 cm. There is a periaortic haematoma which extends anteriorly to displace the loops of bowel anteriorly (Figure 2b). There is free fluid in the peritoneal cavity (Figure 2a). The right kidney is well perfused but the left kidney shows no evidence of perfusion (Figure 2c). There are some calculi in the left pelvis. In this patient, palliation was felt to be the most appropriate treatment option (her case was discussed with the on-call vascular surgeons). The patient died a few hours after her hospital admission. In a relatively fitter patient, open surgery is the treatment of choice.
The use of neuromuscular blockers to facilitate mechanical ventilation in severe asthma
Authors: Jones C , Mulleague L , Jankowski S
Published: May 2014

Ensuring adequate oxygenation and ventilation in patients with severe asthma can be challenging. Although no randomized trials have been performed, neuromuscular blockade is a useful adjunct in the care of severe life-threatening asthma with respiratory failure. Neuromuscular blockers can prevent respiratory dysynchrony, help lower peak pressures and allow longer expiratory times to reduce dynamic hyperinflation and its attendant risk of barotraumas and pneumothorax. Patients with severe life-threatening asthma and respiratory failure are often young, male and can be difficult to sedate.
Glucocorticoid therapy in acute respiratory distress syndrome
Authors: Gibbs RH
Published: May 2014

Acute respiratory distress syndrome is an important cause of mortality and morbidity in the critically ill. Despite advances in ventilation strategies and organ support, mortality remains at around 30%. Persistent functional disability and neuropsychiatric disorders, such as cognitive dysfunction and depression, can exert a profound effect on quality of life in the months or years following discharge in patients diagnosed with the syndrome.
Introduction to teaching for junior doctors 2: collecting feedback and developing expertise
Authors: Cook Vivien , Sharma Anita , Alstead Elspeth
Published: May 2014

Doctors are likely to be involved in teaching activities and need to show evidence of their practice. For junior doctors this means gaining an understanding of educational principles and practice. This second of a two-part article focuses on how to collect feedback on teaching and develop educational expertise immediately and over the longer term.
Unusual presentation of renal calculous disease
Authors: Campbell Naomi , Barrett Sarah , Stunell Helen , Torreggiani William C
Published: May 2014

A 79-year-old woman was transferred to the authors' institution with resolving urosepsis and acute-onchronic renal failure after two related intensive care unit admissions during the previous 3-month in-hospital stay elsewhere. She had a medical history of hypertension, chronic obstructive pulmonary disease and limited mobility as a result of osteoarthritis.
Liver transplantation for liver disease caused by hepatitis C virus infection
Authors: Shankar Arun , Alexander Graeme
Published: May 2014

Hepatitis C is an important problem that often requires liver transplantation. However, outcomes have not improved in line with liver transplants for other indications. This article explores the issues surrounding this difficult area of transplant hepatology.
Ephraim McDowell and the first successful elective laparotomy
Authors: Ellis Harold
Published: May 2014

I occasionally carry out the interesting exercise of asking a group of my medical students if they can guess the date of the first successful elective laparotomy, the name of the surgeon who performed the procedure and where it took place. After a long and profound silence, someone might suggest ‘around 1870 or 1880’, guess at some well-known name, such as Joseph Lister (who, in fact, never performed a laparotomy), and opine that the venue must have been one of the great British teaching hospitals or a famous continental clinic. None of these could be further from the truth – the place was Danville, Kentucky, the surgeon Ephraim McDowell and the date 1809 – just 200 years ago.
A review of endovascular management of abdominal aortic aneurysm
Authors: Collin Neil , Haslam Elizabeth , Fay Dominic , Hardman John , Horrocks Michael
Published: May 2014

Abdominal aortic aneurysm is a common finding in older men and is often asymptomatic, either being found incidentally or presenting with acute rupture. This article will discuss the current indications for treatment and the clinical evidence behind the options currently available.
Palliative sedation therapy
Authors: Hulme Bill , Campbell Colin
Published: May 2014

It is sometimes not possible to relieve symptoms adequately in dying patients. When all other remedies have failed, sedation can be a useful means to relieve terminal suffering. When used appropriately, palliative sedation does not, and should not, shorten life.
Leopold Auenbrugger, father of the clinical examination of the chest
Authors: Ellis Harold
Published: May 2014

I am writing this contribution having, only this morning, taken a group of students from Guy's Hospital, in the first week of their clinical introduction course, through ‘examination of the chest’. Of course, they were excited as I demonstrated the art of ‘inspection, palpation, percussion and auscultation’. I showed them the old trick of practicing ‘dullness to percussion’ by using the side of the examination couch and ‘resonance to percussion’ by using the mattress.
Automatic generic substitution: losing the right medication for the right patient
Authors: Solanki T
Published: May 2014

Traditionally, doctors have been encouraged to prescribe drugs using their generic names. Increasing cost constraints in both primary and secondary care have resulted in the Department of Health considering the introduction of ‘automatic generic substitution’ from 2010. Thus pharmacists receiving a prescription for a brand-named drug would automatically substitute it for a generic preparation where that was available. It is unlikely that the prescribing clinician would be notified of the substitution, and the patient would not be able to choose to receive his/her original medication.
Basic statistics: a guide for the foundation year doctor
Authors: Andreatta Walter , Kothari Alka , Trivedi Deepali , Hooke Rachel
Published: May 2014

Statistics encompasses the methods of collecting, summarizing, analysing and drawing conclusions from data (Petrie and Sabin, 2005; Greenhalgh, 2006).
Applied anatomy of cricothyrotomy and tracheostomy
Authors: Ellis Harold
Published: May 2014

Doctors in training are called upon to perform many practical procedures – often under emergency conditions. All of these depend on a knowledge of their anatomical basis. All too often, the complications which occur, some serious and even life-threatening, are the result of failure to appreciate these anatomical facts. Arterial injury following ‘venous’ cannulation, damage to the liver or stomach after insertion of a chest drain, pneumothorax consequent on the insertion of a subclavian line – the list can go on and on.
Managing personal communication: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Everyone conducts private communication during work time at some point. This may be purely personal, such as with:
Theory and practical application of blood-based renal replacement therapy
Authors: Murray JS , Hinchliffe WT , Kanagasundaram NS
Published: May 2014

The term renal replacement therapy incorporates three modalities that control or correct biochemical and fluid disturbances of renal failure. Peritoneal dialysis and renal transplantation are two forms of renal replacement therapy that are outside the remit of this article. This review focuses upon the third group which are bloodbased and involve direct treatment of a patient's blood in a closed, extracorporeal circuit. They provide renal replacement for end-stage renal failure and during periods of severe acute kidney injury, and also for non-renal indications such as the management of drug overdoses. Blood-based renal replacement therapies are often loosely referred to as ‘haemodialysis’, although this is only one of a range of treatments. This article outlines the theory and practical applications of these treatments.
Percutaneous renal biopsy
Authors: Joseph Joble , Chowdhury Paramit
Published: May 2014

Percutaneous renal biopsy allows a small sample of kidney tissue to be obtained via a relatively minor procedure. Subsequent histological analysis of this tissue can help with making the diagnosis, providing prognostic information and guiding the management of many renal diseases, both in native and transplanted kidneys. In fact many renal conditions are classified on the basis of the histopathological appearances seen in biopsy samples (Figures 1 and 2). The diagnostic potential of a renal biopsy has also increased with advances in immunofluorescence and electron microscopy.
So you want to be … a cardiologist
Authors: Velmurugan S , Holdright DR
Published: May 2014

Cardiovascular disease accounts for 40% of all deaths in the UK. This has led to the development of a highly structured approach, both in the hospital setting and in the community, to the investigation and treatment of common cardiac conditions. These changes have resulted in tremendous opportunities for trainee cardiologists.
One size fits all: palliative care for people with learning disabilities
Authors: Matthews Dorothy , Gibson Lynn , Regnard Claud
Published: May 2014

The End of Life Care Strategy takes as inclusive an approach as possible, but can it make a difference for people with learning disabilities who are dying? Therefore we must ask ourselves ‘Does one size fit all?’
Alcohol and the pancreas
Authors: Williamson JML , Williamson RCN
Published: May 2014

Alcohol abuse predisposes to acute and chronic pancreatitis, both of which carry a substantial risk of serious complications and even death. The various hypotheses for pancreatic damage are discussed, together with the management of alcoholic pancreatitis and the role of operative intervention.
Naltrexone in the treatment of opioid dependence
Authors: George Sanju , Ekhtiari Hamed
Published: May 2014

Naltrexone is an opioid antagonist that acts by preventing the reinforcing effects of addictive opioids. This article provides an overview of naltrexone, its pharmacology, treatment effectiveness and role as a relapse prevention agent in the treatment of opioid dependence.
Developmental coordination disorder
Authors: Kirby Amanda , Sugden David A
Published: May 2014

Developmental coordination disorder affects the motor functioning of 5–6% of children in the population. While other disorders have been given a greater focus by clinicians and researchers, increasing knowledge of this condition is now seeing greater prominence and recognition in both child and adulthood.
The acute medical abdomen: Henoch–Schönlein purpura presenting with peritonitis and nephritis
Authors: Sritharan Kaji , Karim Ahmed , Ijaz Samia , Raymond Sebastian
Published: May 2014

A 41-year-old man presented with a 6-day history of worsening generalized, colicky abdominal pain associated with fever, non-bloody diarrhoea, vomiting and joint swelling. This was preceded by an upper respiratory tract infection for which he was prescribed antibiotics. On examination, the patient was febrile with generalized abdominal tenderness and peritonitis localized to the right iliac fossa. Investigations revealed an elevated white cell count of 14.0×109/litre (neutrophils 11.0×109/litre) and a C-reactive protein of 120 mg/litre. Abdominal X-ray (Figure 1) showed a decreased bowel gas pattern. An initial diagnosis of antibiotic-related colitis was made.

The patient's symptoms did not resolve and computed tomography scanning of the abdomen was performed and revealed focal jejunal thickening with associated mesenteric inflammation and free fluid within the pelvis (Figure 2). This suggested either inflammatory bowel disease or focal bowel ischaemia, and since the clinical picture favoured the former, broad spectrum intravenous antibiotics and steroids were commenced.

The patient later developed generalized peritonitis and underwent laparotomy. At surgery, a large amount of serosanguinous free fluid was found, a 30 cm segment of jejunum was thickened and inflamed and the small bowel mucosa was congested. The abdominal cavity was washed out and a jejunal biopsy was performed which demonstrated vasculitis (Figure 3).

Two days post-laparotomy the patient developed a polyarthritis and a purpuric rash over the limbs. Blood tests revealed an erythrocyte sedimentation rate of 65 mm/hour; rheumatoid factor, anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies, complement C3 and C4 levels were unremarkable. The rash and arthritis improved, but 2 weeks later the patient developed macroscopic haematuria. Urinalysis demonstrated proteinuria; serum albumin was 20 g/litre and serum urea and creatinine were 8.4 mmol/litre and 135 μmol/litre respectively. A 24-hour urine collection showed a protein loss of 0.5 g/24 hours and a creatinine clearance of 53 ml/min. Core biopsy of the renal cortex and medulla revealed focal, segmental proliferative glomerulonephritis, consistent with an immunoglobulin A nephropathy. The patient was managed with an angiotensin-converting enzyme inhibitor, aspirin, furosemide, prednisolone and mycophenolate and made a full recovery.
Should patients routinely be visited by the anaesthetist once they have left the recovery area?
Authors: Krzanicki Dominik , Burdett Ed
Published: May 2014

An anaesthetic preoperative assessment for all patients is the standard of care in UK hospitals, but guidance from the Royal College of Anaesthetists (Curran and Rowbotham, 2009) states that a postoperative visit by an anaesthetist is only recommended in certain circumstances, such as those patients graded American Society of Anesthesiologists (ASA) physical status 3, 4 or 5, or patients discharged from recovery with invasive monitoring in situ. There are a number of potential advantages of a routine postoperative visit by the anaesthetist, so why is this not performed? This article examines the arguments for and against a routine postoperative visit by an anaesthetist.
So you want to be … a gastroenterologist
Authors: Kelly Sean
Published: May 2014

Of the medical specialities gastroenterology offers the most varied mixture of day-to-day work – from busy, interesting, clinics to the management of sick inpatients and on to the endoscopy suite. Gastroenterologists manage a wide variety of conditions encompassing the whole of the gastrointestinal tract.
Echocardiography in acute medicine: a clinical review
Authors: Potter Andy
Published: May 2014

As a result of developments in portable and hand-held devices, transthoracic echocardiography can now be brought to the patient. There is the opportunity for acute physicians to exploit the benefits of echo in the assessment and management of acutely unwell patients in a variety of settings.
Carotid artery disease and stroke during coronary artery bypass surgery
Authors: Curry Philip , Berg Geoff , Butler John
Published: May 2014

Stroke is a devastating complication during coronary artery bypass grafting. Screening may identify patients at highest risk. Surgical timing, sequence strategies and carotid stenting remain unresolved. Selective use of techniques could prevent adverse neurological sequelae while achieving complete myocardial revascularization.
A current perspective on a moving target: clinical leadership in postgraduate medical education
Authors: Hadley Lindsay , Penlington Clare , Black David
Published: May 2014

Clinical leadership is now part of the curriculum for all doctors in training. This article describes one deanery's approach to the development of clinical leadership.
Mandibular coronoid process hyperplasia causing restricted mouth opening
Authors: Vaidhyanath R , Raj V
Published: May 2014

A 52-year-old Caucasian woman underwent pre-anaesthetic evaluation before myomectomy for uterine fibroids. She had limited mouth opening of 10 mm (intra-incisal) and her lateral excursive movements were poor. There was no history of trauma or known temporomandibular dysfunction. The patient had not previously undergone surgery under general anaesthesia. She was not concerned about her limited mouth opening and had not sought medical help for it.

Orthopantomogram (Figure 1) and unenhanced computed tomography of the mandible in the closed (Figure 2a) and open mouth (Figure 2b) positions were performed. The orthopantomogram and computed tomography showed bilateral mandibular coronoid process hyperplasia. In the open mouth position, the elongated coronoid processes impinge on the zygomatic arch, limiting the mouth opening.

The patient underwent bilateral mandibular coronoidectomy (Figure 3). Intra-incisal opening improved to 28 mm following surgery and she subsequently underwent myomectomy.
Cardiac amyloidosis: non-invasive diagnosis and current treatment strategies
Authors: Lodge FM , Dubrey SW , Collinson J , Prasad SK
Published: May 2014

A 70-year-old Irish man presented with several months of breathlessness and lethargy, which had become acutely worse over the preceding week. Exercise tolerance had decreased to around 40 yards, having previously been unlimited. Other symptoms included episodes of dizziness on standing and an occasional cough productive of small amounts of white sputum. There was no previous history of cardiac disease or any regular medication.

Examination revealed pitting oedema up to the mid-thigh and a grade 4 pansystolic murmur consistent with mitral regurgitation. There was decreased air entry and dullness of both lung bases. The abdomen was mildly distended with ascites and there was non-tender, smooth hepatomegaly extending to 4 cm below the costal margin that had been documented 2 years previously.

A 12-lead electrocardiogram (Figure 1) demonstrated atrial fibrillation with right bundle–branch block and complexes of less than 0.5 mV in amplitude in the limb leads. Echocardiography showed a left ventricular wall thickness of 16 mm (normal range 7–12 mm), but with preserved left ventricular function. There was mild mitral and aortic regurgitation. Myocardial perfusion imaging demonstrated normal resting left ventricular function with no evidence of inducible ischaemia and an ejection fraction of 60%. A thickened myocardium was noted, as well as mild irregular areas with reduced uptake throughout the myocardium in a non-coronary distribution, that was presumed to be artefact.

Subsequent to these investigations, it was found that echocardiography had been conducted in 2000 after two siblings had been diagnosed with hereditary amyloidosis caused by a mutation in the transthyretin gene. The patient was positive for the mutation, but had no evidence of amyloid disease at this time. The family was part of a large West Irish pedigree with an autosomal dominant alanine substitution in the gene at position 60. The diagnosis was subsequently confirmed using cardiac magnetic resonance scanning (Figure 2).
Rheumatic mitral valve disease in pregnancy
Authors: Dubrey Simon W , Kohli Sanjay K , Grocott-Mason Richard , Dhanjal Mandish K , Punjabi Prakesh P , Nihoyannopoulos Petros , Nelson-Piercy Catherine
Published: May 2014

A 32-year-old Nepalese woman with known rheumatic mitral valve disease presented 17 weeks into her first pregnancy with exertional breathlessness and wheezing, leading to expectoration of foamy pink liquid. Her history included percutaneous balloon mitral valvotomy at the age of 25 years, after which she had remained asymptomatic and fully active. She had three episodes of acute pulmonary oedema and was transferred to a tertiary centre for further management. An echocardiogram suggested severe mitral stenosis (mitral valve area 1.0 cm2) and pulmonary hypertension (mean pulmonary artery pressure 87 mmHg). She had further episodes of pulmonary oedema despite maximal medical therapy with diuretics, cardioselective beta blockers (dose limited because of systolic hypotension), digoxin, nitrates and anticoagulation. At 21 weeks' gestation, an emergency St Jude metallic valve was implanted. Unfortunately, intrauterine death occurred 2 days postoperatively, likely caused by pre-eclampsia or haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome.

The patient recovered well and continues on warfarin and a small dose of beta blocker.
Transition: the cancer perspective
Authors: Riley Vikky , Hough Rachael , Whelan Jeremy
Published: May 2014

There is an ever-increasing number of cancer survivors entering adult life. Health-care professionals in this field must ensure that there is seamless transition through paediatric, teenage and young adult and adult services such that an individual patient is able to achieve his/her maximum potential and enjoy a quality, ‘cancer-free’ future.
Critical care management of obstetric emergencies
Authors: Watson Christine , Wilkinson Jonathan N , Ali Nazrudeen
Published: May 2014

Obstetric cases are normally well managed on the labour suite. However, emergencies are not uncommon, and when they occur, they can be major. It is vital that rapid assessment and management are put in place. Critical care doctors are often called upon to do so.
Business intelligence and capacity planning: web-based solutions
Authors: James Roger
Published: May 2014

Income (activity) and expenditure (costs) form the basis of a modern hospital's ‘business intelligence’. However, clinical engagement in business intelligence is patchy. This article describes the principles of business intelligence and outlines some recent developments using web-based applications.
The cutting edge of medicine a century ago
Authors: Ellis Harold
Published: May 2014

What were the exciting topics in the wide field of medicine 100 years ago? An interesting way of judging this is to glance through the detailed reports in the Lancet of 1910 of the British Medical Association Congress in London, held in the July of that year, with reviews of its 21 sectional meetings.
Iatrogenic urethrovaginal fistula from catheterization in labour
Authors: Thrumurthy Sri G , Hill Simon R , Islam Shahid
Published: May 2014

Mild urethral trauma is a widely recognized sequela of urethral catheterization but the formation of urethrovaginal fistulae from inserting standard urethral catheters has never previously been reported. This article discusses a healthy young woman in whom catheterization during labour resulted in an iatrogenic urethrovaginal fistula.