bluuebunny/crossref_metadata_2025 huggingface dataset:
Pre- and post-operative nursing considerations of bariatric surgery
Authors: Apau Daniel , Whiteing Nicola
Published: May 2014

Obesity is becoming a major health issue, and is putting significant pressure on NHS resources and the economy through direct medical and social care costs. Significant attempts to address obesity through lifestyle modification and pharmacological therapy has had little effect in addressing the problem. Since the National Institute for Health and Clinical Excellence (NICE) guidelines in 2002 , there has been an exponential growth in the number of people having bariatric surgery as a weight management treatment. In this article, Daniel Apau and Nicola Whiteing look at the prevalence of obesity and the types of bariatric surgery available as well as the nursing considerations before and after this procedure.
The way forward: the advanced endoscopy practitioner
Authors: Drew Kaye , E McAlindon Mark , Sidhu Reena , S Sanders David
Published: May 2014

In 2001, the British Society of Gastroenterology (BSG) described an increasing demand for all forms of endoscopy. To meet this demand, nurse endoscopists have been instrumental in providing the service delivery of diagnostic endoscopy. However, the cost effectiveness of this role has been questioned ( Richardson et al, 2009 ). It has been suggested that the advanced endoscopy practitioner may be a solution to this problem ( Chapman, 2009 ). There is evidence of overlap between advanced nursing and medical roles, with each group applying similar knowledge and skills in a different way ( Hunsberger and Mitchell, 1992 ). In this article, Kaye Drew, Mark E McAlindon, Reena Sidhu and David S Sanders describe initiatives to develop the advanced role within the capsule endoscopy speciality not just as the cheaper option but as a positive choice to enhance the quality of service delivery.
Meeting patient needs with a risk-stratified colorectal cancer follow-up
Authors: S.W.Samarasinghe Buddhika , Wiles Lilian
Published: May 2014

Managing the increasing numbers of colorectal cancer survivors with complex needs while minimizing recurrence or secondary cancer is bringing fresh challenges to healthcare providers. A baseline study completed in five counties in England with eight acute care organizations highlighted the importance of developing a risk-stratified follow-up pathway that goes beyond the traditional follow-up. In the absence of guidelines, this follow-up pathway was developed in consultation with the Network Site Specific Group consisting of specialist care clinicians from all the acute care providers. This comprehensive follow-up pathway encourages healthcare providers and clinicians to address complex patient needs by a process of shared decision making and holistic needs assessment (HNA), providing optimum surveillance testing combined with various coping and self-management strategies
IED: ‘improvised explosive device’ or an ‘inspirational and exceptional but disabled’ young soldier? The impact of blast injuries in a combat war zone
Authors: White Maddie , Leyland Annette
Published: May 2014

Coalition military forces are currently engaged in armed combat in Afghanistan. Young soldiers who are injured in battle may suffer extensive, debilitating injuries, which can have devastating consequences. The leading cause of death among troops is the increasing use of improvised explosive devices (IEDs). Gunshot wounds and IEDs both cause injuries which may involve the bowel. In this article, Maddie White and Annette Leyland discuss the care associated with these injuries, to provide nurses working in coloproctology with an insight into their complexity and management.
Body mass index as an independent predictor of postoperative complications following colorectal surgery
Authors: Fitzgerald Penny
Published: May 2014

In this article, Penny Fitzgerald describes a quantitative study to investigate whether or not a high body mass index (BMI) can be used to predict the risk of postoperative complications following colorectal surgery. Examining retrospective data from a 4-year period, 346 patients who had elective bowel surgery with a laparotomy incision for cancer at one centre in the north of England were divided into two groups according to BMI. A signifcant increase in postoperative complications was detected in patients with a BMI of 30 kg/m2 or more. However, the overall incidence of complications was very low—just 17.6% (n=61) had some type of complication following surgery, before being discharged home. This suggests that while a high BMI is associated with more complications, colorectal surgery is safe, regardless of BMI. Thus, a BMI of 30 kg/m2 or more should not be considered a contraindication to colorectal surgery.
Complicated skin problems in stoma patients: a case study
Authors: Jowett Annie
Published: May 2014

The Colostomy Association (2013) estimates that there are 120 000 ostomates living in the UK, of which 65 000 have colostomies, 45 000 have ileostomies and 10 000 have urostomies. Peristomal skin issues pose a significant problem to stoma patients, and as many as one-third the number of colostomy patients and more than two-thirds that of ileostomy and urostomy patients can be affected ( Lyon and Smith, 2001 ). Skin problems can arise from the frequent application and removal of stoma appliances or from allergic reactions to the products being used. At times, it can be difficult to ascertain the cause of the allergy or sore skin, and this results in a lengthy process of elimination and a distressing time for the patient ( Burch and Sica, 2008 ). Often the treatment can be simple and the skin will heal quickly. At other times, the skills of a specialist stoma nurse will be needed. The problems arising from sore peristomal skin can have a detrimental effect on a patient's emotional, physical, and sexual wellbeing.
ERCP: indications, complications and contraindications
Authors: Patel KV , Wong T
Published: May 2014

Endoscopic retrograde cholangiopancreatography has become an almost exclusively therapeutic procedure, indicated for choledocholithiasis, biliary and pancreatic neoplasms and postoperative biliary complications. In this review, KV Patel and T Wong give a detailed account of its indications, complications and absolute and relative contraindications. The safety and effcacy profle of this technique, when compared with other approaches, has been confrmed in a large, multicentred, comprehensive UK audit.
An overview of coeliac disease: patterns, causes, symptoms and management
Authors: Coutts Alison
Published: May 2014

Coeliac disease in an autoimmune disorder of the small intestine, which results in an unpleasant reaction to ingested gluten. Symptoms range from mild to severe and can include abdominal pain and bloating, chronic or occasional diarrhoea, tiredness, iron-deficiency anaemia, nausea or vomiting, and weight loss. The disorder has a complex genetic background, although additional environmental factors also need to come into play. Its treatment is solely dependent on the exclusion of gluten from the diet.
Obesity and coeliac disease: possible effects of the gluten-free diet
Authors: Whitehead Christine
Published: May 2014

Contradictory evidence exists as to whether patients with coeliac disease have a higher rate of obesity than other patient groups. The potential for weight gain following diagnosis of coeliac disease and commencement of a gluten-free diet exists. Christine Whitehead discusses difficulties experienced by patients who have coeliac disease, with regard to cost, availability and prescription of gluten-free food and practical considerations of maintaining a social life. She examines the incidence of obesity while on a gluten-free diet. The anatomy and physiology of coeliac disease is also outlined.
Psychosocial impact of chronic constipation
Authors: Woodward Sue
Published: May 2014

Constipation is a symptom-based disorder that affects a significant percentage of the UK population at some point in their life. The disorder is considered chronic if symptoms persist for longer than three months. Chronic idiopathic constipation most commonly affects women and has been shown to be associated with anxiety, depression and poorer quality of life. In this paper, Sue Woodward suggests that practitioners should make an assessment of the psychosocial impact of constipation on individuals under their care, which should include an assessment of the impact of constipation on relationships and quality of life. Successful treatment of constipation has been shown to improve symptoms of anxiety and depression as well as quality of life.
Hepatitis B virus part 2: treatment options and the role of the specialist nurse
Authors: Jack Kate , Cooper Joanne , Ryder Stephen
Published: May 2014

The management of chronic hepatitis B virus (HBV) infection is complex, both in terms of the terminology required to understand the virus and the drug treatments available. In this second article on HBV, Kate Jack, Joanne Cooper and Stephen Ryder outline the practical management of patients with HBV and clarify when to initiate antiviral treatment, how to choose the appropriate drug, frequency of monitoring and the aim of the treatment strategy. They emphasise that all nurses have a key role in supporting patients at the frontline of care.
The pathophysiology of hepatorenal syndrome
Authors: Gipson Anna
Published: May 2014

This article is the first of a two-part series focussing on hepatorenal syndrome. Understanding pathophysiological changes can enhance the nursing and medical care given. The article explains the pathophysiology behind this severe complication and demonstrates how abnormal effects from a damaged liver can affect renal function. The author analyses the changes in liver cirrhosis, portal hypertension and ascites to explain the developments that result in hepatorenal syndrome. The pronounced vasodilation of the splanchnic area together with the intense renal vasoconstriction in hepatorenal syndrome result from multiple factors and have caused differing pathological theories over time. This article highlights how the beginnings of liver disease provide a platform for hepatorenal syndrome.
Emerging pharmaceutical therapy for the treatment of ulcerative colitis
Authors: Cope Graham
Published: May 2014

Ulcerative colitis (UC) is a chronic relapsing and remitting inflammatory disease of the colon that generally requires lifelong treatment ( Mehta et al, 2013 ). Therefore, the therapeutic treatment for UC is complex and must be tailored to an individual's circumstances and degree of disease severity. The mainstay therapy has been treatment with systemic and local corticosteroids, but new treatments have been introduced, with new formulae available to affect novel elements of the chronic inflammatory process. This article is an update of a previous summary of this complex topic ( Fraser, 2008 ).
Group sessions: experimental approach to support patients using rectal irrigation
Authors: Lyons Monica
Published: May 2014

In 2008, group sessions were commenced at the Pelvic Floor Unit of St Thomas' Hospital, London. The aim of these sessions was to give patients the time to deal with the practical aspects of using rectal irrigation (also known as trans-anal irrigation or anal irrigation) and to provide them with a safe and confidential environment to share their experiences of living and coping with a functional bowel disorder. This article describes the group sessions and how the approach was developed such that patients learn from each other. In addition, it discusses the organisation of the group sessions together with the policy and etiquette that govern it, as well as the issues of constipation and faecal incontinence and how rectal irrigation can be part of selected patients' management options. Finally, the author presents anecdotal evidence of a patient's experience.
Reversal of Ileostomy following elective anterior resection for rectal cancer: a review of current practice
Authors: Jackson Claire , Barnwell Abby
Published: May 2014

Anterior resection for rectal cancer is typically performed with a covering temporary loop ileostomy. The authors carried out a review of practice to assess the timing of ileostomy reversal following anterior resection to determine if the patient information was accurate. Although the review was small, the findings correlated to those of previous larger studies. The median length of time for reversal was 5 months, which was longer than expected, and 9 months if patients required chemotherapy However, 11% of patients were found not to have their temporary ileostomy reversed. Fewer patients—28.6%—had an ileostomy than previously thought following anterior resection. This review has resulted in a change of practice, with patients being offered reversal in 3–4 months following anterior resection or on completion of chemotherapy. Patients are now contacted by their clinical nurse specialist before their reversal and provided with pre- and postoperative information, advice, and support to manage the effects of bowel dysfunction.
The IBD Registry: a patient management system to improve practice
Authors: Munro Claire
Published: May 2014

In recent months, a database has been launched that, for the first time, allows clinicians to collect UK-wide information on inflammatory bowel disease (IBD), thus driving improvements in care and standards. A patient management system (PMS) has also been created to support IBD clinical teams in providing high quality care and to allow easy input of information at the time of a consultation. The system then feeds data into the registry automatically. This article reviews the database and PMS, which are known as the IBD Registry. During the pilot phase, both clinical teams and their patients found the PMS to be beneficial, since all the relevant patient information is summarised in one place and is easily accessible. Local management reports can also be generated for service planning/monitoring, as well as patient summaries and GP letters.
Pilot study of a multitiered psychosocial support framework for inflammatory bowel disease patients
Authors: McDonnell Emma , Forry Mary , O'Raghallaigh Jennifer Wilson , Kelly Orlaith , Patchett Stephen , Ruane Ailbhe
Published: May 2014

The need for a comprehensive psychosocial support framework for patients living with inflammatory bowel disease (IBD) was recognised by a multidisciplinary team working in a tertiary referral teaching hospital. The team developed a three-tiered structure of psychosocial support for patients with IBD: a half-day IBD workshop for patients and their families, 6-week Chronic Disease Self-Management Programme (CDSMP), and bimonthly IBD patient support group. Following overwhelmingly positive feedback from the half-day workshop, with patients requesting a more in-depth programme, the CDSMP was offered to participants because it is an internationally recognised model of psychosocial intervention for chronic disease. A pilot study of the CDSMP for IBD patients was undertaken with a waitlist control group. CDSMP participants had reduced levels of anxiety and improved levels of health-related quality of life variables at follow-up when compared to the waitlist controls. A bimonthly patient-led support group developed from the CDSMP.
Liver transplantation for viral hepatitis
Authors: McCaughan Geoffrey W , Koorey David J , Strasser Simone I
Published: May 2014

Viral hepatitis is associated with two forms of liver failure that may require liver transplantation: fulminant hepatic failure associated with all forms of acute viral hepatitis and chronic liver failure as a result of chronic hepatitis B and C infection (or both). This review briefly discusses liver transplantation for fulminant hepatitis but focuses on transplantation for hepatitis B- and hepatitis C-associated cirrhosis.
Congenital cardiac emergencies
Authors: Brierley Joe
Published: May 2014

Cardiac emergencies are rare in children in comparison to adults. The pathophysiology differs; ischaemic heart disease is virtually unknown, whereas most congenital cardiac emergencies occur secondary to structural heart disease. Of the myriad lesions many decompensate in the perinatal period, usually in association with arterial duct closure. Subsequent rapid haemodynamic deterioration may lead to a moribund infant in extremis at presentation and with more home deliveries and early discharges such infants may present not only to paediatricians, but to accident and emergency departments, GPs and community midwives.
Dysphagia: an unusual orthopaedic cause
Authors: Indar R , Jacob J , Aldam CH , Hussein AA
Published: May 2014

A61-year-old man presented with a 3-year history of progressive dysphagia. This resulted in regurgitation of ingested food contents, resulting in weight loss of 25 kg despite a good appetite. He also reported hoarseness of voice and vertigo, as well as mild neck stiffness.
The levonorgestrel-releasing intrauterine system in modern gynaecology
Authors: McGavigan C Jay , Owen Philip
Published: May 2014

The levonorgestrel-releasing intrauterine system was initially developed for contraception but is now widely used for a variety of gynaecological conditions. Compliance can sometimes be hampered by troublesome side effects (principally breakthrough bleeding) but appropriate counselling can reduce unnecessary discontinuation.
Craniectomy for middle cerebral artery infarction
Authors: St George EJ , Weatherby S , Bhangoo R , Heafield T
Published: May 2014

Acute occlusion of the major intracerebral arteries produces brain ischaemia and cerebral oedema with an attendant rise in intracranial pressure producing an intracranial compartment syndrome (‘malignant’ stroke). Over the course of 2003, three patients referred to the authors' unit underwent craniectomy for space-occupying malignant cerebral oedema following acute middle cerebral artery infarction. Each case deteriorated acutely following the initial event. Details regarding each patient’s initial clinical state, mode of deterioration and clinical outcomes are briefly described. On each occasion the preoperative computed tomography (CT) scan showed signs of a large middle cerebral artery territory infarction and was consistent with space occupation and mass effect. The postoperative CT scans demonstrated evidence of expansion of the oedematous brain tissue, most pronounced in case 2. These findings are illustrated in Figures 1a and b.
Hot or cold? In support of cold
Authors: Tisherman Samuel A
Published: May 2014

Two recent studies (Bernard et al, 2002; Hypothermia After Cardiac Arrest (HACA) Study Group, 2002) demonstrated that mild hypothermia (32–34°C) improves survival and neurological outcome following cardiac arrest, leading to recommendations that comatose survivors of resuscitation from cardiac arrest should be cooled to 32–34°C for 12–24hours (Nolan et al, 2003).
Endotracheal intubation in the field: pro position
Authors: Floccare Douglas J , Cushman Jeremy T
Published: May 2014

Airway, breathing and circulation will continue to be the top priorities of emergency medical care for the foreseeable future. Correction of hypoxia by bag-valve mask ventilation in the prehospital environment is problematic. It is difficult to obtain a mask seal, challenging to assist patients who have increased work of breathing or a clenched jaw, and essentially impossible to use end-tidal carbon dioxide (CO2) as a gauge of ventilation. Bag-valve mask ventilation does not facilitate tracheal suctioning or protect the airway, and it increases the risk of regurgitation by causing gastric insufflation.
Unusual foreign body in the soft palate
Authors: D'souza Derick
Published: May 2014

I would like to report a patient with an unusual airway foreign body that I recently encountered. A 38-year-old male, intoxicated with alcohol, presented to the accident and emergency department with a 30cm-long barbecue skewer sticking out of his mouth. The sharp pointed end of the skewer was sticking out of his mouth and the curved end was inside the mouth.There were pieces of meat still attached to the skewer.
Paediatric sepsis and multiple organ failure
Authors: Tibby Shane M
Published: May 2014

Mortality from paediatric sepsis and multiple organ failure has fallen over the last half century, but both remain significant causes of death and morbidity among children and infants in the intensive care unit. This article provides a basic guide for front-line clinicians involved in paediatric resuscitation, addressing nomenclature, epidemiology and suggestions for early treatment.
Managing acute cardiac patients in and out of the hospital setting
Authors: Willoughby Maria , Williams Jason , Proctor Donna , Lovley Janine , Hall Mark , Shaw Rebecca , Nyman Cyril , Morley Davies Adrian , Hassan Hussain , Boulton John , Read Donna , Collins Margaret , Hill Linda
Published: May 2014

The National Service Framework (NSF) for Coronary Heart Disease (CHD) (Department of Health, 2003) sets the standard of treating eligible acute myocardial infarction (AMI) patients within 60minutes of a call for help in order to improve survival rates and long-term quality-of-life for heart-attack patients.
Forward thinking in orthopaedic surgery prophylaxis
Authors: Pownall Mark
Published: May 2014

Inadequate prophylaxis after orthopaedic surgery continues to put patients at risk of life-threatening thrombosis, Professor Simon Frostick, Professor of Orthopaedics at the University of Liverpool, warned at a debate at the Royal Society of Medicine, London, 3 February 2005.
Paediatric airway disorders
Authors: Bull PD
Published: May 2014

Impairment of the airway in infants and children causes anxiety to the patient, the parents and the health-care staff responsible for the child. This article outlines and explains paediatric airway impairment and aims to improve understanding of the various diseases.
Autonomic dysreflexia: the forgotten medical emergency
Authors: Cherian Jacob , Thwaini Ali , Rao Amrith , Arya Neehar , Shergill Iqbal S , Patel Hitendra RH
Published: May 2014

Autonomic dysreflexia (AD) is a potentially dangerous complication of spinal cord injury (SCI). In AD, an individual's blood pressure may rise to dangerous levels and, if not treated, can lead to stroke and possibly death. All medical personnel, especially those interacting with SCI patients, must have a good understanding of its aetiology, complications and emergency management.
Partial dopamine agonists in schizophrenia
Authors: Launer Mike
Published: May 2014

The emergence of partial dopamine agonists reinforces the argument for the dopamine hypothesis of schizophrenia. Aripiprazole (Abilify®) is the first of these compounds for the treatment of schizophrenia to be launched in the UK. Aripiprazole has a promising efficacy and favourable tolerability profile that suggests it has a significant role to play in the management of schizophrenia.
The role of flumazenil in self harm with benzodiazepines: to give or not to give?
Authors: Tote S , Mulleague L
Published: May 2014

Flumazenil competitively inhibits the activity of the benzodiazepine (BDZ) at the GABA/BDZ receptor complex. This property allows its use as an antagonist for the effects of BDZs in certain clinical situations. There is, however, continuing contention in one area – its use in patients having taken, or suspected to have taken, an excessive quantity of BDZ, with a low Glasgow Coma score.
Payments by results: what does it mean?
Authors: Gainey Beverley
Published: May 2014

Payment By Results (PBR), first discussed in 2002 and to be fully implemented by 2008, is the most radical and fundamental restructuring of health finance that we shall see in our lifetimes. PBR offers benefits, but carries risks.
Alcohol consumption and the outcomes of pregnancy
Authors: Fraser R
Published: May 2014

The consumption of alcohol offers no benefits in relation to the outcomes of pregnancy and alcohol is both teratogenic and feto-toxic in the human.
Management of craniofacial abnormalities
Authors: Woolley Emma J , Richardson David , May Paul
Published: May 2014

A number of congenital and acquired conditions can affect the skull, face and jaws resulting in a wide range of craniofacial abnormalites that commonly present at birth or in early infancy. This article aims to outline the aetiology, pathogenesis, diagnosis and principles of management of those conditions that commonly present to a craniofacial unit namely the craniosynostoses.
Aorto-caval fistula
Authors: Geoghegan Tony , Persaud Thara , O'Grady Helen , Tierney Sean , Torreggiani William C
Published: May 2014

A 62-year-old male patient was referred with a 6-hour history of abdominal pain and a palpable abdominal mass consistent with an aortic abdominal aneurysm, which had been demonstrated by grayscale ultrasound at another hospital.
Perioperative beta-blockade: does it improve outcome?
Authors: Foë Pierre
Published: May 2014

The use of beta-blockers in the management of patients with coronary artery disease, arterial hypertension and cardiac failure suggests that they should offer significant protection against perioperative cardiac events. Initiating or continuing beta-blockade in patients presenting for surgery may be regarded as offering protection with no need for further assessment of investigations. However, data do not support this and appropriate investigations are needed.
Succinylcholine vs rocuronium for intubation in the intensive care unit
Authors: Regan Kathryn
Published: May 2014

Rapid sequence induction (RSI) of anaesthesia followed by tracheal intubation is the gold standard technique for securing the airway during emergency care. This was originally developed for the operating theatre, but has been used successfully in the emergency department and intensive care unit (ICU). Succinylcholine has been the muscle relaxant of choice owing to its rapid onset and short durationof action, but side effects have led to suggestions that its use in the ICU is now obsolete (Reynolds and Heffner, 2005). This article examines the evidence for this and compares it with the main alternative, rocuronium.
Interpretation of the chest radiograph in the casualty department
Authors: Harvey Chris , Allen Steve , O'Regan Declan
Published: May 2014

The chest X-ray (CXR) is the most common radiograph requested in casualty departments. However, all too often relatively junior doctors, who have not been formally trained in interpretation of emergency radiographs, have to make instant decisions that profoundly affect patient management. In the space available here it is not possible to cover the numerous medical and surgical emergencies that may be encountered. This article provides a systematic approach to interpreting the chest film and describes the common emergency conditions requiring CXRs along with radiological signs.
How to intubate
Authors: de Beer JMA , Homewood J
Published: May 2014

Modern endotracheal anaesthesia and intubation was developed by Magill and Rowbottom after the First World War. Since then tracheal intubation has become an essential part of airway management in elective and emergency acute medicine.
Clinical governance: what foundation doctors need to know
Authors: Schofield Helen
Published: May 2014

The recently published curriculum for the foundation years put patient safety and care within the framework of clinical governance at its centre. It not only included clinical skills, but also formalized the development of generic skills, such as communication and team working. This article defines clinical governance and discusses its components in relation to the foundation years curriculum.
So you want to be … a cardiologist
Authors: Holdright DR
Published: May 2014

Cardiovascular disease accounts for nearly 40% of all deaths in the UK. Major government initiatives, most notably the National Service Framework in 2000, have served as a catalyst for the provision of more accessible and comprehensive cardiac services in the 21st century. This has paralleled advances in the investigation and treatment of heart disease such that many subspecialty skills are used in district general hospitals as well as tertiary centres. This sets the backdrop for those considering a career in cardiology.
Interpretation of the abdominal radiograph: 2
Authors: Harvey Chris J , Allen Steve , O'Regan Declan
Published: May 2014

This article discusses important emergency conditions that may be diagnosed on the abdominal radiograph highlighting the key radiological signs that should be recognized.
An evaluation of four foundation programme pilots in the Kent Surrey and Sussex Deanery
Authors: Dewhurst Graeme , Shaw Pam , Wood David
Published: May 2014

The authors discuss the outcomes of four pilot foundation programmes in terms of the trainees' experience, that of their educational supervisors and ask what made foundation placements good learning opportunities. The authors conclude that trainees' learning needs to be embedded in a learning community.
Achieving fasting and postprandial blood glucose control in type 2 diabetes
Authors: Robertson Douglas
Published: May 2014

Until the availability of glycated haemoglobin, laboratory fasting plasma glucose was the measurement against which insulin doses were most commonly titrated. More recently, evidence has accumulated that self-monitored postprandial blood glucose may be at least as useful in adjusting treatment.
Glycaemic control in south Asian patients during feasting and fasting
Authors: Asghar Omar , Greenstein Adam , Malik Rayaz A
Published: May 2014

In the UK, type 2 diabetes is at least four times more common in the south Asian community than the Caucasian population. The vast majority of south Asians in the UK are Muslims, Hindus or Sikhs. Fasting and feasting are an integral part of these faiths, so these patients expose themselves to an increased risk of hyperglycaemia and hypoglycaemia. This article provides advice on adjusting both oral medication and insulin during fasting.
Stroke: improving outcome through better diagnosis and treatment
Authors: C Pereira Anthony
Published: May 2014

High quality stroke management is based on doing the simple things well and may greatly improve long-term patient outcome. This article provides a straightforward approach to managing stroke patients.
Who needs an implantable cardioverter defibrillator?
Authors: Behan MWH , Gill JS , Rinaldi CA
Published: May 2014

The implantable cardioverter defibrillator has been shown to be the optimal treatment for both primary and secondary prevention in patients with previous aborted sudden death and with life-threatening cardiac arrhythmias. This article reviews the latest evidence and guidelines supporting implantable cardioverter defibrillator use.
Evidence-based management of epistaxis in adults
Authors: I Trotter Matthew , De Ranit , Drake-Lee Adrian
Published: May 2014

Epistaxis is a common complaint presenting to both hospital doctors and GPs, the management of which is often suboptimal. This article gives an evidence-based review of the non-surgical management of this common condition.
Waking up to sleep disorders
Authors: Olson LG , Ambrogetti A
Published: May 2014

Sleep disorders are very common. Prevalence estimates vary widely because of variable case definitions, but roughly 25% of adults have insomnia, 20% have troublesome snoring, and 3% have obstructive sleep apnoea syndrome (OSAS) – repetitive apnoea during sleep and daytime sleepiness. That is a lot of people: insomnia is about as common as hypertension, and sleep apnoea is about as common as diabetes mellitus.
Flexible training: how do trainees perceive the application process?
Authors: Goodyear Helen , Wall David
Published: May 2014

The application process for flexible training is often perceived as being complex. This article looks at flexible trainees' views on the application process. Although there is general satisfaction, suggested improvements are discussed.
Biological therapy for psoriasis
Authors: Clements Suzanne E , Abdul-Ghaffar Sharizan , Griffiths Christopher EM
Published: May 2014

Psoriasis is a common, chronic immune-mediated skin disorder. Recent advances in the understanding of the immunopathogenesis of psoriasis have led to the development of biological agents designed to target the molecular mechanisms of the condition. These provide new and effective treatments for patients with moderate to severe psoriasis.
Chromobacterium violaceum infection
Authors: Tee Hoi-Poh , Francis Alex L , How Soon-Hin
Published: May 2014

A 22-year-old Indonesian oil palm plantation worker presented with a 1-week history of fever associated with severe headache, pain in the right upper abdomen and seizure a day earlier. He had a cough with expectoration but no bowel symptom. There was no history of injury reported before the present illness.

The patient was febrile, dehydrated and drowsy on admission, with Glasgow coma score of 14/15. His blood pressure and pulse rate were 100/60 mmHg and 96/min respectively. Lung examination showed right-sided crackle, with no neck stiffness or any signs suggestive of immunocompromized state. Abdominal examination revealed tender hepatomegaly of 10 cm in length.

The initial chest radiograph showed opacity in the right middle lobe. Total white cells count was 11.1 × 109/litre. Platelet count was 100 × 109/litre with normal haemoglobin. Random blood glucose and renal profile were normal. Coagulation profiles were deranged with international normalization ratio of 4.5 and activated partial thromboplastin time ratio of 3.4. Liver function tests revealed alanine aminotransferase of 446 U/litre, aspartate aminotrasferase of 253 U/litre and albumin of 30.5 g/litre.

The patient was given empherical intravenous ceftriaxone, metronidazole and acyclovir for possibility of meningo-encephalitis. Despite fluid resuscitation, he remained hypotensive and required inotropic support. On the second day, multiple pustular skin lesions (Figure 1) were noted on the patient's trunk, upper and lower limbs. Aspiration of the pustules revealed pus that contained gram-negative bacilli. Lumbar puncture was done and cerebrospinal fluid was normal. He required multiple platelet concentrates and plasma transfusions for disseminated intravascular coagulation. Abdomen ultrasound revealed multiple liver abscesses (Figure 2). He was intubated and ventilated for worsening respiratory failure. Samples of pus and blood cultures were positive for Chromobacterium violaceum. Intravenous imipenem 500 mg four times daily and ciprofloxacin 400 mg twice daily were administered. However, he died the same evening.
Barium appendicitis
Authors: Srinvas Gandrapu N , Sinha S , Houghton PWJ
Published: May 2014

A 57-year-old man presented with lower abdominal pain and diarrhoea. Clinically there was evidence of localized peritonitis in the lower abdomen. A plain film of the abdomen showed normal bowel gas pattern and the presence of barium in the diverticula of the colon. In addition, the appendix was seen delineated with the barium and few filling defects caused by faecoliths (Figure 1).
Tuberculosis of the prostate
Authors: Rachapalli V , Natale S , Awasthi R
Published: May 2014

A 45-year-old man of South Asian origin was referred with urinary symptoms of urgency, dysuria and a feeling of incomplete bladder emptying and one episode of macroscopic haematuria. He had no other symptoms apart from an unexplained 2 stone (12.6 kg) weight loss with occasional evening temperature rise. He had lived in the UK for the past 25 years and his mother had recently visited him from his home country.

A digital rectal examination demonstrated an enlarged non-tender right prostatic lobe with a craggy consistency. Prostatic specific antigen level was 2.6 ng/ml (normal level ≤2.5 ng/ml). Ultrasound of the renal tract and kidney, ureter and bladder imaging were normal. Flexible cystoscopy showed a diffusely red oedematous bladder and he underwent a transrectal ultrasound-guided prostate biopsy. Histological assessment showed chronic inflammation associated with multiple non-necrotizing epitheloid granulomas with acid-fast bacilli on Ziehl Nielsen staining. Culture of mid-stream urine demonstrated Mycobacterium tuberculosis.

The patient was subsequently referred to the respiratory physicians who diagnosed him with pulmonary tuberculosis and treated his condition with anti-tuberculous therapy.
Acute manifestations of autoimmune connective tissue diseases
Authors: Bontas Ecaterina , D'Cruz David P
Published: May 2014

Autoimmune connective tissue diseases are common conditions that often present non-specifically. Clinicians in emergency departments and acute medical assessment units may face these patients. This article provides an overview for the non-specialist clinician on the acute manifestations that may occur in these patients.
Purtscher's retinopathy after a rally-driving accident
Authors: Williams Michael A , Sinton Janet E
Published: May 2014

A 31-year-old man was a driver in a rally when his car hit a concrete block at approximately 100 km/h. He lost consciousness for an unknown number of minutes. His helmet was split. He had no external signs of injury; his Glasgow Coma Scale was 15 and computed tomography of the brain was normal. His vision gradually deteriorated over the following 6 days. He had no history of ophthalmic problems, including ambylopia. His best corrected visual acuities were hand movements in each eye. There was no relative afferent pupillary defect but dilated fundal examination revealed multiple, almost confluent, cotton wool spots around both optic discs with some slivers of retinal haemorrhage (Figure 1). Purtscher's retinopathy was diagnosed and the patient was counselled regarding the uncertain visual prognosis. His vision improved; 18 days later his visual acuities were 6/9 unaided in each eye, and the cotton wool spots were reducing (Figure 2).
New treatments for joint disease: what the future may bring
Authors: Oussedik Sam , Haddad Fares
Published: May 2014

Degenerative joint diseases are exerting an increasingly heavy burden on the ageing global population. Over the last 50 years the approach to managing these conditions has greatly evolved. The days of routine arthrodesis or excision arthroplasty are thankfully now behind us. Joint replacement, which was initially successfully developed by Charnley in the 1950s, has now become a routine procedure, carried out all over the world with great success. However, concerns remain regarding implant longevity, loss of bone surrounding the implants and restrictions placed on patients following surgery. Less invasive methods of managing joint disease are therefore constantly being sought.
Cartilage transplantation
Authors: Gupta A , Bhosale A , Balbouzis T , Smith HJ , Richardson JB
Published: May 2014

Chondral injuries are common sequelae following musculoskeletal trauma. This article reviews different techniques of cartilage regeneration undertaken in the past, and focuses on the recent advances in the field of tissue engineering.
The role of superficial venous operations for leg ulceration
Authors: Bicknell C , Cheshire NJW
Published: May 2014

Venous ulceration is a common clinical problem with high recurrence rates. The role of operative treatment to correct superficial reflux in venous ulceration remains unclear. This review reports current evidence for superficial surgical procedures in the treatment of venous ulceration.
On-the-job assessment of practical skills performance: experiences from a feasibility study
Authors: Anderson Fiona , Hesketh E Anne
Published: May 2014

A pilot exercise throughout one deanery during a whole training year has shown that the on-the-job assessment of practical skills is both feasible and acceptable to the wider health-care team. There was, however, a lack of exposure by trainees to a small number of specific procedural skills.
Manometry and 24-hour pH monitoring in diagnosis and management of GORD
Authors: Evans David F
Published: May 2014

Gastro-oesophageal reflux disease (GORD) is mainly diagnosed on symptoms and endoscopy findings. At least 50% of patients with GORD will have a normal oesophagus at endosopy. Twenty four-hour ambulatory pH monitoring together with manometry offers an accurate objective diagnosis of GORD and is helpful in directing appropriate treatments including surgery.
Subependymal nodular heterotopia
Authors: Larner AJ
Published: May 2014

29-year-old woman complained of episodic dizziness with a feeling of unsteadiness. She was referred to the ear, nose and throat clinic. Examination was normal and a pure tone audiogram was within normal limits. Although her symptoms improved with vestibular rehabilitation exercises, they did not resolve entirely and so magnetic resonance (MR) imaging of the brain was requested. Imaging changes (Figure 1a) prompted an urgent referral to the neurology clinic.

In her past medical history, the patient had developed seizures at the age of 5 years, initially brief ‘absences’ (eye blinking, head nodding, mouth twitching) with very occasional generalized tonic-clonic seizures. She was the product of a normal full-term vaginal delivery, with normal developmental milestones. There was no family history of seizure disorder. Formal testing at the age of 7 years showed that she was of average intellectual ability and above average ability on the arithmetic subtest. An electroencephalogram showed right temporal slow and sharp wave features. A diagnosis of ‘idiopathic’ temporal lobe epilepsy was made and she was commenced on carbamazepine with reduction in seizure frequency. A computed tomography brain scan performed at the age of 13 years after a further generalized seizure was reported to show a large cerebellar cistern but was otherwise normal. Family history was negative for seizure disorder. Her neurological examination was normal.

MR brain imaging (Figure 1b) showed multiple bilateral subependymal nodules of grey matter, lining both lateral ventricles, appearances diagnostic of subependymal nodular heterotopia. No other cerebral or cortical malformation was seen.
Gabapentin for postoperative pain relief
Authors: Varadan Rama , Holding James
Published: May 2014

Gabapentin was developed 20 years ago to treat muscle spasms but has since been found to be useful in both the treatment of epilepsy and also increasingly in the management of chronic pain, especially neuropathic pain. There has been a recent flurry of articles describing the use of gabapentin for acute pain. This article discusses the case for and against its use as a postoperative analgesic.
How should postoperative pain in patients on long-term opioids be managed?
Authors: James Catherine , Williams John E
Published: May 2014

Management of patients on long-term opioids (LTOs) with acute or postoperative pain presents a number of problems. Such patients will need higher doses of opioids postoperatively than the general population; they are also more likely to need surgery. Managing the challenge of acute pain control in this group requires being able to identify which patients are at risk, and understanding the physiological basis for the problems that may arise from LTO dependence.
An avoidable antiarrhythmic side effect
Authors: Pandya Bejal , Lambiase Pier D
Published: May 2014

65-year-old woman with a known history of arrhythmia, who was receiving regular oral flecainide, presented to the accident and emergency department with severe palpitations, shortness of breath and chest pain. She remained haemodynamically stable. Her electrocardiogram (ECG) is shown in Figure 1. What is the underlying initial arrhythmia and what is the explanation for the response to flecainide? How could it be avoided?
Cardiotocograph interpretation
Authors: K Whitworth Melissa , Bricker Leanne
Published: May 2014

Cardiotocographs (CTGs) are a form of electronic fetal monitoring (EFM) used both in the antenatal period and during labour to provide a guide to fetal wellbeing. CTG traces are a continuous recording of fetal heart rate (FHR) combined with a recording of uterine activity. The basic principle of EFM is to detect developing fetal hypoxia with the aim of preventing subsequent acidaemia and cell damage.
Should junior doctors be obtaining consent?
Authors: Siddiky Abul
Published: May 2014

It's been a year since I became one of the latest additions to the medical profession and it's only now that I'm getting to grips with what to do. However, at the back of my mind throughout this year, I have never really been confident with one particular task – the issue of consent and who was expected to obtain it.
Part 1: medical resources
Authors: Leon Rebecca , Bayat Ardeshir
Published: May 2014

The publication and circulation of many medical journals each year provides the reader with up-to-date information and thereby improves communication of key messages. Without a way of critically appraising the information they receive, clinicians are relatively helpless in deciding what new information to incorporate into their practice (Anonymous, 1981).
So you want to be…a gynaecologist
Authors: Annan Henry
Published: May 2014

As a consultant gynaecologist for over 20 years I have had the privilege of training doctors from over 40 countries. My own professional development has taken me to several countries including Cyprus and Sweden. Gynaecology is hard work and challenging but the rewards in terms of satisfaction and contributions to women's health are immeasurable.
How to perform a lumbar puncturewith the patient in the seated position
Authors: Allen Samuel H
Published: May 2014

The main advantage of performing lumbar puncture with the patient seated is that it is technically easier since the anatomical landmarks are less ambiguous. The main disadvantage is that the opening pressure can not be accurately measured (Table 1).
Interpretation of wrist and hand radiographs
Authors: Harvey Chris J , Allen Steve D , O'Regan Declan
Published: May 2014

Wrist and hand injuries account for approximately 15% of casualty department attendances. Recognition of injuries in this area is important as apparently minor injuries can result in significant loss of function. Early detection and appropriate management usually results in full recovery of normal function.
So you want to be … a medical oncologist
Authors: Gore Martin
Published: May 2014

We are all influenced in our choice of career by senior doctors that we come into contact with as medical students or junior doctors. I had such an influential encounter as a student at Barts. Professor Gordon Hamilton-Fairley was a new breed in a fledgling specialty which was burgeoning in the USA as a result of dramatic advances in the treatment of patients with haematological malignancies, especially Hodgkin's disease. His appeared to be a rather maverick world, the treatments could not be found in any textbook and patients were scattered the length and breadth of the hospital.
So you want to be … a medical microbiologist
Authors: Smith Grace
Published: May 2014

Training doctors may have had little contact with medical microbiologists in their undergraduate years, but will inevitably have grappled with some aspect of the investigation, management and prevention of infections in their patients that is the specialist field of the medical microbiologist.
Interpretation of pelvis and hip radiographs
Authors: O'Regan Declan , Harvey Chris , Allen Steve
Published: May 2014

Fractured neck of femur is an important cause of morbidity and mortality in the elderly (Lyons, 1997). For a variety of medical and social reasons falls are common in this age group and this is compounded by the presence of age-related osteoporosis. Leg shortening and external rotation of the hip are the classical findings but are not invariably present.
Small bowel transplantation in children
Authors: Millar AJW , Gupte GL
Published: May 2014

Small bowel transplantation is no longer experimental, but is now a well established option for children with complications related to intestinal failure. Advances in surgical techniques along with the availability and a better understanding of immunosuppressive drugs have, in the last decade, resulted in a greatly improved outcome.
Systemic lupus erythematosus: diagnosis for the non-specialist
Authors: Suresh Ernest
Published: May 2014

This review discusses the pitfalls in placing too much reliance on an antinuclear antibody test result for the diagnosis of systemic lupus erythematosus, outlines a practical approach to patients in whom this illness is suspected, and gives guidance on how to request these tests sensibly.