bluuebunny/crossref_metadata_2025 huggingface dataset:
Enhanced recovery programmes in colorectal surgery: clinical implications
Authors: Barclay K , Williams A , Windsor A
Published: May 2014

Since the first successful colorectal resection in 1833 by Reybard of Lyons, surgeons have sought to improve technical and perioperative strategies to minimize morbidity and mortality in colorectal surgery. In the last 10 years, evidence-based medicine has questioned the routine use of mechanical bowel preparation, abdominal drains, nasogastric tubes and prolonged perioperative fasting. A greater understanding of the metabolic response to surgery has led to strategies to minimize the complex cytokine cascades and other neurohumoral factors. These concepts, with attention to social and medical factors within a multidisciplinary framework, are the foundations of enhanced recovery programmes.
Coarctation of the aorta, hypertension and associated features
Authors: Dubrey Simon W , Mittal Tarun K
Published: May 2014

A 17-year-old female athlete who had a black belt in Tai-Kwondo was discovered to be hypertensive (blood pressure recorded as 150/90 mmHg in both arms) when she was screened to join a new gym. Although able to perform physical contact sports to a competitive level without apparent symptoms, direct enquiry revealed that she had calf pain on jogging.

On examination a grade 4/6 systolic murmur was audible throughout the precordium. Femoral pulses were impalpable bilaterally. Routine blood tests including renal function were all normal as was a renal ultrasound and urine analysis for protein and catecholamines. The electrocardiogram showed sinus rhythm, a normal axis and satisfied voltage criteria for left ventricular hypertrophy. A transthoracic echocardiogram was normal, with no evidence of left ventricular hypertrophy and good biventricular systolic function. However, on examination of flow in the abdominal aorta there was continuous forward flow throughout the cardiac cycle.

The chest X-ray (Figure 1) showed rib notching as a result of erosive pressure on the ribs from collateral blood flow in large vessels derived from the subclavian, axillary, internal thoracic, scapular and intercostal arteries.

Cardiac magnetic resonance imaging confirmed the diagnosis of coarctation of the aorta (Figure 2), explaining the continuous abdominal aortic blood flow. The murmur was the result of turbulent blood flow through an isolated, typical post-ductus location, coarctation of the thoracic aorta. The diameter at its narrowest was 0.6 cm. The femoral pulses were impalpable as the flow at the femoral arteries was reduced and continuous in character (as demonstrated by the echo study) rather than pulsatile and palpable.
Anaesthetic rooms: luxury or necessity?
Authors: Sultan Pervez
Published: May 2014

Induction of anaesthesia in an anaesthetic room has been a feature of UK practice since 1860. In 2002 only 4% of UK anaesthetic departments routinely anaesthetized all patients in theatre (Broomhead and Jones, 2002). In most other countries, induction takes place on the operating table in theatre without any apparent disadvantage to the patient. £30 million has been spent equipping anaesthetic rooms in the UK since 1994 in order to comply with minimum standards of monitoring (Association of Anaesthetists of Great Britain and Ireland (AAGBI), 1994). There has been considerable debate over the past 15 years about the use of anaesthetic rooms particularly given the increasing costs of monitoring equipment. This article explores the use of anaesthetic rooms in modern clinical practice.
Non-invasive imaging of coronary artery disease
Authors: Stirrup Jim , Underwood S Richard
Published: May 2014

Non-invasive imaging of the heart is an expanding field in cardiology and appropriate test selection depends on the clinical question and test availability. This article reviews the role of single photon emission computed tomography myocardial perfusion scintigraphy, positron emission tomography and multi-detector computed tomography.
Cerebral venous sinus thrombosis in polycythaemia
Authors: Thomson D , Vyas P , Hammersley MS
Published: May 2014

A 50-year-old man was admitted as an emergency with severe bilateral headache. For 1 month he had felt unwell with a gradual onset, dull, throbbing headache that kept him awake at night. Admission to hospital was precipitated by an increase in severity of headache, associated with nausea and photophobia.

There were no exacerbating factors and the headache was not positional. He denied red eye, lacrimation, blurred vision or visual fortification, dizziness, weakness or change in sensation. He had no other past medical history. He was an ex-smoker with a 10 pack-year history. On examination, he was plethoric. He was afebrile and blood pressure raised at 160/120 mmHg. There was no meningism and fundoscopy was normal. The remainder of the examination was unremarkable. Urine dipstick demonstrated 3+ protein, an electrocardiogram showed T-wave inversion inferiorly, with no evidence of left ventricular hypertrophy by voltage criteria, and a chest radiograph was normal. The initial diagnosis was hypertensive headache, but the patient was found to be significantly polycythaemic.

His test results were haemoglobin = 21.2 g/dl (normal range 13.0−17.0 g/dl); haematocrit = 0.656 (normal range 0.4−0.5); red cell count = 7.72×1012/litre (normal range 4.5−5.5×1012/litre); white cell count = 11.0×109/litre (normal range 4.0−11.0×109/litre); platelets = 295×109/litre (normal range 150−400×109/litre); clotting profile was normal; biochemical profile was normal; PaO2 on room air was 10.8 kPa.

The diagnosis was amended to headache secondary to hyperviscosity and an urgent computed tomography scan of the brain was arranged to rule out cerebral venous sinus thrombosis. The computed tomography scan of the brain confirmed subacute thromboses of the right transverse and sigmoid sinuses.

To manage hyperviscosity, the patient underwent isovolaemic venesection of 450 ml of blood. The venous sinus thrombosis was treated by anticoagulation with low molecular weight heparin and the patient was commenced on warfarin.

Subsequent investigations revealed a suppressed erythropoietin (0.88 mU/ml; normal range 5−25 mU/ml) and the presence of the JAK-2 chromosomal mutation, which confirmed a diagnosis of polycythaemia rubra vera. The patient was discharged and returned for day case venesection.
Francis Joseph Gall (1758–1828):false prophet of cerebral localization
Authors: Ellis Harold
Published: May 2014

The localization of function to different parts of the CNS has a long and fascinating history which, with modern radionucleotide techniques, is continuing to this day and which is still incomplete. For example, little is still known of the central connections of the olfactory tract. Thomas Willis (1621–75), in his Cerebri anatome published in 1664, suggested that the cerebrum controls voluntary, and the cerebellum involuntary movements, in what was probably an inspired guess. It was not until 1809 that Luigi Rolando (1773–1831) of Sardinia showed, by animal experiments in which he ablated one or other of these structures, that Willis's conjecture was correct.
Is cricoid pressure needed during rapid sequence induction?
Authors: Sultan Pervez
Published: May 2014

Mendelson (1946) was the first to report the risk of pulmonary aspiration of gastric contents during mask anaesthesia. Fifteen years after Mendelson's publication, Sellick (1961) reported the use of cricoid pressure to prevent gastric contents entering the pharynx and subsequent aspiration into the pulmonary tree. Cricoid pressure or Sellick's manoeuvre is the application of sustained digital pressure to the cricoid cartilage of the larynx pushing it backwards and thus compressing the oesophagus between the posterior aspect of the cricoid and the body of C5–6. The cricoid cartilage is used because it forms the only complete ring of the larynx and trachea. It has traditionally been considered an integral part of patient safety in rapid sequence tracheal intubation and emergency airway management. This article explores the arguments for the use of cricoid pressure, the concerns and its potential serious disadvantages.
Acute gastrointestinal haemorrhage: a rare presentation of aortic dissection
Authors: Salisbury EM , Ikin N , Bansi DS
Published: May 2014

A 72-year-old woman presented with a 24-hour history of severe upper jaw pain and more recent onset central chest pain. She denied difficulty breathing or nausea. Her ast medical history included cluster headaches, mild chronic obstructive airways disease and hypertension. She had been well on review in outpatient clinic the day before.

On examination, she was apyrexial, blood pressure 130/60 mmHg, pulse 95 beats per minute and regular, oxygen saturation 96% on room air. Clinical examination was unremarkable. There were no new electrocardiogram changes and a chest X-ray was reported as normal. Blood tests showed haemoglobin 9 g/dl, a 2 g/dl drop from the previous day in clinic. The remaining laboratory tests were normal. With no identified source of bleeding or associated rise in urea, her full blood count was repeated to exclude a spurious result.

Over the next 24 hours, her chest and jaw pain eased but she developed diarrhoea and tachycardia. Her blood pressure remained stable at 140/65 mmHg. The haemoglobin drop was confirmed with a repeat value of 8.7 g/dl but still no source of bleeding was identified. Over the course of the day, the patient's diarrhoea continued with increasing abdominal discomfort, until she suddenly passed fresh blood per rectum associated with a blood pressure drop to 70 mmHg systolic. She was resuscitated promptly and a decision made to manage her conservatively with oesophagogastroduodenoscopy and colonoscopy scheduled for 24 hours later, as it was the weekend and endoscopy services were limited.

However, she continued to pass fresh blood per rectum and suffer severe generalized abdominal pain, and so an urgent computed tomography scan with contrast was performed (Figure 1). This showed a type A aortic dissection extending from the left coronary artery to involve the carotid arteries and extend down below the renal arteries. The Stanford classification divides dissections into 2 types: A and B. Type A involves the ascending aorta, type B does not. The ascending and transverse colon appeared thickened and oedematous on the scan. The most likely cause of bleeding in this case was ischaemic colitis, secondary to aortic dissection impeding inferior mesenteric artery blood flow. Cardiomegaly raised the probability of pericardial involvement.

On the basis of these findings, the patient was immediately reviewed by the on-call vascular surgical team. Given the extent of the dissection, surgery was not felt to be an option. Shortly afterwards she became profoundly hypotensive and died. The most likely cause of death was cardiac tamponade, although an echocardiogram was never performed. The family declined a post mortem.
Electronic fetal heart rate monitoring
Authors: Gandhi Hina , Kean Lucy
Published: May 2014

Electronic fetal heart rate monitoring is a useful monitoring tool to assess intrapartum fetal wellbeing and has been shown to improve perinatal outcomes in at-risk fetuses. This article describes the benefits, criticisms of its use during labour, the pathophysiology and care pathway based on the cardiotocogram features.
Lisfranc injuries
Authors: Loveday David , Robinson Andrew
Published: May 2014

Lisfranc injuries are fracture-dislocations of the tarsometatarsal joint. They are usually associated with high energy trauma and are regularly overlooked. An early diagnosis and urgent orthopaedic referral is required to minimize the long-term consequences.
'Idiopathic' torticollis: have you ruled out a spinal tumour?
Authors: Bhattacharya Debarata , Choudhari Kishor A
Published: May 2014

A 70-year-old woman presented with a 6-month history of progressive torticollis accompanied by low back pain and mild lower limb weakness (Figure 1). Apart from grade IV power and diminished reflexes in the lower limbs, her neurological examination was normal. Plain X-rays and magnetic resonance scan of the cranio-cervical junction and cervical spine did not detect any significant abnormality apart from age-related degenerative changes. The torticollis was thus thought to be idiopathic in aetiology. However, in view of her lower limb symptoms, a magnetic resonance scan of the lumbar spine was performed which revealed an intradural extramedullary tumour opposite the L1 and L2 vertebrae (Figure 2). Following excision of the tumour (schwannoma), her symptoms improved gradually. Nine months later, not only was she pain free and walking independently, but the torticollis had also reversed remarkably (Figure 3).
Thyroid surgery: what are the options for anaesthesia?
Authors: Cregg Roman , Raghuraman Thippa , Green David , Windsor Jeremy
Published: May 2014

A 29-year-old Afro-Caribbean woman delivered a healthy baby by vaginal delivery at 38 weeks following a pregnancy complicated by gestational diabetes. Three months later she returned to work and soon began to develop symptoms of lethargy, nervousness and palpitations. Following investigations she was diagnosed with Graves’ disease and commenced on propylthiouracil and propranolol.
Prevention of acute kidney injury
Authors: Brincat Stephan , Hilton Rachel
Published: May 2014

Acute kidney injury is common and carries a high mortality. Many drugs have been evaluated for their role in preventing acute kidney injury, of which some are of no benefit and others may be harmful. This review discusses current interventions to prevent acute kidney injury and reviews the evidence base for each.
Recurrent facial nerve palsy caused by a facial cyst
Authors: Michalopoulos Konstantinos , Bajaj Yogesh , Strachan David R
Published: May 2014

Mr B first presented to the authors' department in 2001 complaining of right-sided facial weakness. He was diagnosed with a grade 2 facial nerve palsy for which no obvious cause was identified. He was actively treated with aciclovir and steroids and his symptoms resolved completely. Over the next 2 years, he suffered two similar episodes that responded well to similar treatment.

One year later, he was referred to the clinic with a grade 3 facial nerve palsy. A computed tomography scan showed no abnormality along the course of the right facial nerve. Genetic tests showed no genetic cause for the recurrent facial nerve palsy. His symptoms initially resolved but 6 months later he was readmitted with a grade 4 facial nerve palsy. A magnetic resonance imaging scan showed inflammation of the tympanic and mastoid sections of the facial nerve and facial nerve decompression surgery was planned.

Intra-operatively, mild oedema was evident along the intratemporal course of the facial nerve. During decompression of the mastoid (horizontal) segment of the facial nerve (Figure 1), a significant amount of mucoid fluid in keeping with a benign cyst was drained (Figure 2). His facial palsy fully resolved and a magnetic resonance imaging scan performed 1 year after surgery showed no evidence of recurrence or other pathology. At 3-year follow up, there was no recurrence of symptoms.
HIV testing in dementia: clinical, ethical and patient safety implications
Authors: Collier A , Ghosh S , Dowie A , Walsh K , O’Leary C
Published: May 2014

This article presents patient safety issues along with the professional and ethical challenges in relation to UK guidelines on HIV testing in patients who are incapacitated as a result of dementia. Current protocols are designed to protect the patient, but may have undesirable consequences for patients, carers and doctors.
The cost of education: saving for school and university fees
Authors:   Wesleyan Medical Sickness
Published: May 2014

Having children can be an expensive business, not least when it comes to considering the costs of school and university fees. Most parents would agree that a good education is key to giving children the best start in life. This comes at a cost, however, especially for parents who choose to educate their children in private schools. As many young people continue their education into their early twenties, the financial cost to parents can continue for many years.
Making the most of theatre time
Authors: Heetun Mohammad , Gurjar Shashank
Published: May 2014

As part of their surgical teaching block, most medical students find that they have the opportunity to go to the operating theatre to assist or watch various surgical procedures. This can be a rewarding setting in which to learn about surgical and perioperative care, but many students do not take full advantage of the educational opportunities available and are often uneasy about being in a different environment within the hospital. However, with the right approach and a few useful tips, you can maximize your precious time spent here, and get to see and do more. This article gives a guide to making the most of your theatre time.
A survivors' guide to working in the intensive care unit
Authors: Darroch Ruth H , McCombe Kate
Published: May 2014

Foundation training seems to be here to stay and so doctors with significantly less experience than before will find themselves facing a training block on the intensive care unit (ICU). This is a daunting prospect for the uninitiated; the authors both left jobs as medical registrars to work on ICU, but despite these good foundations still found themselves near-paralysed with fear on their first mornings on the unit. The following tips are intended to help equip you and reduce your anxiety levels.
So you want to be … a chest physician
Authors: Apps Michael
Published: May 2014

Respiratory problems cause 30–40% of acute medical admissions, and are important co-morbidities in many more. The respiratory physician needs a wide base of experience in general internal medicine, and also a full grasp of the speciality.
Addison's disease: a diagnostic challenge
Authors: Jones Daniel A , Miras Alex , Tringham Jennifer R
Published: May 2014

Primary adrenocortical insufficiency (Addison's disease) is a rare disorder in which destruction of the adrenal cortex results in reduced production of glucocorticoid, mineralocorticoid and androgens. Despite being over 150 years since Thomas Addison (1855) first described the clinical and pathological features of adrenal failure the disease remains under-diagnosed, leading to unnecessary morbidity and mortality. Finding adrenal insufficiency in a patient with a previously unknown adrenal disorder is a demanding diagnostic challenge, and the condition is life-threatening if not recognized and treated. However, once diagnosed, simple treatment results in the rapid recovery of a critically ill patient, making this one of the most rewarding diagnoses. This article highlights key features and raises awareness of the condition.
Time management: a guide for the foundation year doctor
Authors: Hooke Rachel , Trivedi Deepali , Trivedi Kinjal
Published: May 2014

Many junior doctors feel that there are never enough hours in the day to do all their jobs. They end up feeling obliged to stay late to finish off routine tasks, reluctant to hand them over to the doctor on the late shift.
Advice for junior doctors working in a trauma unit
Authors: Rogers Benedict A , Ricketts David M
Published: May 2014

At the start of a new post junior doctors' performance in certain key areas is important in creating a good impression and obtaining competencies. Before starting a new post any protocols and policy documents relating to clinical care or the logistics of that specific unit should be read. However, the aim of this short guide is to detail the skills required in four key areas for junior doctors working within a trauma unit. These are:
Dealing with complaints 2: a guide for the foundation year doctor
Authors: Hooke Rachel , Trivedi Deepali
Published: May 2014

In the first part of this article (Trivedi and Hooke, 2008), we looked at the reasons people complain and how to prevent complaints. In this part, we look at how to deal with a complaint involving you when it actually occurs.
Intravenous urogram interpretation
Authors: D'Sa Anthony , Hale Jemma , Pasha Yasmin
Published: May 2014

Renal colic is a common acute clinical presentation. Although computed tomography is recommended as the first-line investigation (Royal College of Radiologists, 2007), this is not always readily available especially out of hours, and in these instances an intravenous urogram (IVU) is often performed. IVUs are frequently requested in the emergency setting by accident and emergency doctors and they are also involved in the procedure (giving the contrast injection) and initial interpretation of the subsequent films. Additionally IVUs involve several radiographs with a typical radiation dose of 2.4 mSv (by comparison the UK background radiation dose is 2.2 mSv per year). It is therefore important to have a working knowledge of basic interpretation.
An unusual complication of an attempt to open the airway in a choking child
Authors: Gjoni D , Mbamalu D , Banerjee A , James KK
Published: May 2014

A 3-year-old boy was brought to the emergency department with bleeding from the throat. Earlier that day he had been given a boiled sweet by an older cousin. This was followed by an episode of choking and apnoea. His mother intervened, placing her finger into his mouth and attempting to extract the offending sweet. The sweet was delivered along with some fleshy tissue, followed by bleeding from the throat.

On arrival in the emergency department, the child was alert, with no evidence of respiratory distress at rest. Vital signs were: heart rate 120 bpm, blood pressure 108/70 mmHg, respiratory rate 20/minute, and oxygen saturation on 15 litres of oxygen (Fi02 85%) 100%. Bloody secretions were noted at the mouth. Airway patency was maintained.

Examination of the throat showed loss of the upper third of the right tonsil. There was no active bleeding, there being clotted blood in the tonsillar fossa. Respiratory and cardiovascular examinations was normal. The sweet and the missing part of the tonsil were available for inspection (Figure 1).

Initial management included intravenous access, venous blood testing, including blood grouping, and the provision of analgesia (rectal paracetamol). The child was taken to the operating theatre where loss of the upper third of the right tonsil was confirmed (Figure 2). The remainder of the tonsil was nearly completely detached from the tonsillar fossa, being attached only by a small mucosal pedicle. Bilateral tonsillectomy was performed, and the right-sided palatal laceration sutured. An uneventful recovery was followed by discharge the following day.
The future of trauma care in the UK
Authors: Willett Keith M
Published: May 2014

Addressing the care quality issues of two very different patient groups is the priority to improve trauma care in the UK: the older patient with a fragility fracture and the seriously injured patient. They have in common the challenge to provide multi-professional crossinstitution prompt treatment in services in which they have not historically been given primacy. Current deficiencies are borne of a lack of integrated services and designated facilities, competing priorities and, for the critically injured, a low incidence, high acuity, complexity and limited available expertise. There are abundant outcome data, published research, national reports and a contemporary professional consensus to rapidly move to efficacious and cost-effective local and national service redesign.
Slowing the progression of chronic kidney disease
Authors: Herrington William G , Mason Phil D
Published: May 2014

Progression of chronic kidney disease can be slowed by careful management of risk factors. The most effective treatments are aggressive blood pressure control, renin–angiotensin system inhibition in proteinuric patients and tight glycaemic control in diabetics. Patients should be educated to avoid nephrotoxins and maintain a healthy lifestyle.
Cutaneous Listeria infection
Authors: Gilchrist Mark
Published: May 2014

A 38-year-old farmer presented with a 3-day history of a pustular rash, originally affecting his hands and wrists (Figure 1), before ascending up his forearms. This was accompanied by progressively worsening systemic upset.

Three days before presentation the patient had delivered a stillborn calf as an emergency because of maternal distress. He had not had time to retrieve birthing gloves from the distant farmhouse. The delivery was physically difficult and the patient observed some minor soft tissue trauma to his hands at the time. Approximately 6 hours later he became aware of the rash on his wrists. This was accompanied by flu-like symptoms with myalgia, and followed by intermittent rigors and pyrexia. The rash began to ascend up both arms with the evolution of multiple large pustules (Figure 2).

On the third day he sought attention from his GP who commenced oral amoxicillin. Despite this the patient felt his symptoms becoming more pronounced and presented to the emergency department.

On admission he was pyrexial with a temperature of 40.8°C. His heart rate was 123 beats per minute with a blood pressure of 103/58 mmHg. Respiratory rate was 24 breaths per minute. His chest was clear to auscultation, heart sounds were normal and the abdomen was soft and non-tender. Inspection of his arms revealed a symmetrical erythematous rash with multiple well-demarcated, now ruptured, pustules, some of which had coalesced. Some smaller pustules remained intact. There was a 5 cm linear area of erythema consistent with ascending lymphangitis. There was no axillary lymphadenopathy, although both axillae were exquisitely tender on palpation. Two sets of blood cultures were taken. One of the few remaining pustules was aspirated and sent for culture. He was fluid resuscitated and commenced on high dose intravenous benzyl penicillin and gentamicin.

Within 12 hours he was symptomatically tremendously improved. He was apyrexial and his haemodynamic status had significantly improved. The rash had also begun to diminish dramatically. Two days later he was fit for discharge and went home with a 10-day course of oral co-amoxiclav.

The blood cultures taken on the night of admission plus two further sets taken the following day remained sterile. The sample from the pustules grew Listeria monocytogenes.
Surgery in safe hands: a manifesto for surgery
Authors: Black John
Published: May 2014

The current parliament will expire in 2010 and there will be a general election by June at the very latest. The UK is therefore set for a long and possibly increasingly bitter election campaign with health care prominent in the wrangling. Politicians of all parties are seeking to stake a claim with the electorate to be the best defenders of the NHS. With massive public spending cuts almost certain and likely budget restrictions for many years to come it is crucial to each of the party's chances how well they convince the public that health care is safe in their hands.
Update on liver transplantation
Authors: Millson Charlie
Published: May 2014

Indications for liver transplant are expanding and most patients can expect a long-term successful outcome. Who should receive this life-saving gift and how should they be managed in an era of diminishing donors and increasing demand?
Sleep-disordered breathing and heart failure
Authors: Bhatia Praveen , Abdelaziz Muntasir M , Katira Ravish
Published: May 2014

Sleep-disordered breathing is a spectrum of disorders. As our knowledge of sleep medicine is improving, the strong association of sleep-disordered breathing with cardiac disorders is being recognized. This article discusses the association of sleep-disordered breathing and heart failure.
Daniel John Cunningham: a distinguished teacher of anatomy
Authors: Ellis Harold
Published: May 2014

In October 1943, starting my medical school days at the University of Oxford, I was dispatched to the bookshop in Broad Street to purchase the three volumes of the 10th (1940) edition of Cunningham's Manual of Practical Anatomy. These were to become my constant companions during the next 2 years. I have them in front of me now as I write, their much-turned pages discoloured by the stains of various cadavers, the text underlined and annotated here and there with my unreadable writing. Even today, in my opinion, no other dissection guide gives such clear and helpful practical advice to the student and its illustrations cannot be bettered.
Self removal of unwanted tattoos
Authors: Sarraf KM , Atherton DD , Jones I , Jawad M
Published: May 2014

A 42-year-old man presented to the burns unit with full-thickness burns over the dorsal aspect of each of the proximal phalanges. These corresponded to the sites of a series of tattoos that had spelt out the name of his previous partner, and that were now a source of conflict in his current marriage. The quoted cost of private laser removal was prohibitively expensive. Eventually in desperation the patient resorted to using a lit cigarette to destroy the tattoos. When these wounds failed to heal by 2 weeks, he attended the authors' burns unit (Figure 1). The affected areas were tangentially excised to healthy subcutaneous fat or paratenon and the defects resurfaced with split-thickness skin grafts. All grafts went on to heal without incident and he retained a full range of motion in the hand and fingers.
Endovascular repair of infrarenal abdominal aortic aneurysms
Authors: Sadat Umar , Boyle Jonathan R , Gillard Jonathan H , Hayes Paul D
Published: May 2014

Endovascular repair of abdominal aortic aneurysms significantly reduces early mortality and morbidity, although long-term benefits appear to be equal to those of open repair in elective cases. This article summarizes the key aspects of endovascular aneurysm repair and different techniques of endovascular stenting.
Optimal dose and timing for perioperative morphine after remifentanil-based anaesthesia
Authors: Carle C , Goodall J
Published: May 2014

The dose and timing of perioperative morphine following remifentanil-based anaesthesia varies widely in clinical practice.
Palliation of nausea and vomiting
Authors: Mannix Kathryn
Published: May 2014

Nausea is often unrecognized or poorly managed. Understanding the central pathways involved in nausea enables clinicians to choose anti-emetics with a higher likelihood of successful symptom management.
Symptom control and palliative care: management of breathlessness
Authors: Oxberry SG , Lawrie I
Published: May 2014

Breathlessness remains a common and significant problem in palliative care. This article reviews the most commonly used interventions and discusses strategies to improve this symptom.
Management of delirium
Authors: Nicholson Timothy RJ , Henderson Max
Published: May 2014

Delirium occurs in up to 50% of general hospital inpatients and is even more common in terminal illness. It is associated with a high morbidity and mortality, regularly missed and importantly is often either preventable or treatable.
UK guidelines for the systemic treatment of renal cell carcinoma
Authors: Nathan Paul , Wagstaff John , Porfiri Emilio , Powles Tom , Eisen Tim
Published: May 2014

There have been recent significant improvements in treatment options for patients with advanced renal cell carcinoma. This article presents UK consensus guidelines on the use of systemic therapies for this poor prognosis disease.
Abraham Flexner (1867-1959): pioneer of modern medical education
Authors: Ellis Harold
Published: May 2014

Today, medical education in the UK is in a state of flux, so it is comforting to look back on the life and work of a pioneer in this field, who is recognized as having had a profound effect for good on the standards of medical training throughout the western world and who died half a century ago.
Sleep violence
Authors: Shneerson John M
Published: May 2014

Violence during sleep is more common than is usually thought and has characteristic clinical features. These reflect the altered cerebral activity during sleep as well as the specific pathophysiology of the underlying sleep disorder. There are often forensic as well as clinical implications of violence during sleep which need careful assessment.
Assisted dying is not the solution
Authors: Grogan Eleanor , Beattie Rosaleen , Campbell Colin , George Rob , Harlow Tim , MacGregor Beth , Oliver David
Published: May 2014

A modern fallacy is that we can either have our own way without cost to society or someone else, or that our desires always trump another's need or freedom. This is none clearer than in the area of wanting to be killed.
Treatment of dementia: where is it going?
Authors: Fox Chris , Boustani Malaz , Moniz-Cook Esme
Published: May 2014

Global levels of dementia are escalating but alongside this new innovations and service models are developing to improve outcome and the patient journey. This article describes some of the current and horizon issues in dementia care.
Can computed tomography improve outcomes in acute coronary syndrome?
Authors: Boxt Lawrence M , Lipton Martin J
Published: May 2014

Each year, six million patients in the USA visit the emergency department for acute chest pain. Many patients are hospitalized because immediate discharge of those suspected of acute coronary syndrome could be disastrous. This review looks at whether patient outcomes could be improved by coronary computed tomography angiography.
Improve your lecturing
Authors: Held Sam , McKimm Judy
Published: May 2014

Lecturing remains the mainstay of many university courses and conference programmes and when done well it can be an extremely effective large group teaching technique.
Managing alcohol withdrawal syndromes: the place of guidelines
Authors: Walker L , Brown P , Beeching NJ , Beadsworth MBJ
Published: May 2014

Alcohol misuse poses a significant problem in terms of morbidity, mortality and cost. Alcohol detoxification and treatment for associated vitamin deficiency syndromes is simple and saves lives. This article discusses the reasons for poor guideline adherence and the current evidence base behind the formulation of these guidelines.
Achilles tendinopathy: pathology and management strategies
Authors: Abbassian Ali , Khan Rashid
Published: May 2014

As patient expectation is rising, surgery is being considered more frequently for Achilles tendinopathy. Traditional open interventions have a significant morbidity, rising interest in less invasive techniques. This review discusses some of the current concepts and controversies in the management and pathology of tendinopathy of the Achilles tendon.
Ovarian pregnancy: report of three cases and review of the literature
Authors: Yang Jing , Yin Tailang , Xu Wangming
Published: May 2014

A 29-year-old woman presented 77 days after she had undergone in-vitro fertilization and embryo transplantation with a 15-day history of vague pain in the hypogastrium which had increased over the last 8 days. Her pulse rate was 75 bpm and blood pressure was 100/70 mmHg. Abdominal examination revealed tenderness of the hypogastrium and rebound in the left lower quadrant. A routine blood test showed her haemoglobin levels were 79 g/litre. Transvaginal sonography revealed an enlarged uterus with evidence of intrauterine pregnancy and a complex 10.4×5.5 cm mass in the left adnexal region (Figure 1).

After admission, the patient was prescribed antibiotic (penicillin) and antihaemorrhagic (aminomethylbenzoic acid and Dicynone) medication, but her symptoms did not improve. On the 85th day of pregnancy, the patient complained of severe and persistent hypogastric pain. Ultrasound showed that the complex structure was now 12.6×10.5 cm. Immediate laparotomy revealed 700 ml haemoperitoneum, 300 ml of sludgy blood in the rectouterine pouch, a normal pregnant uterus, a dark smooth left ovary with a crevice on the back and the left fallopian tube adherent to the abdominal membrane. Pathology showed ovarian pregnancy with bleeding. After ovary wedge resection the patient felt better and the intrauterine pregnancy continued.

To the authors' knowledge, this is the first reported case of ovarian pregnancy along with intrauterine pregnancy after in-vitro fertilization and embryo transplantation. In this case, the transferred embryo moved from the uterus into the ovary.
Confidence and performance: a guide for foundation year doctors
Authors: Hooke Rachel
Published: May 2014

It is common to feel under-confident when you first start as a foundation doctor. After all, you are not automatically omniscient just because you have gained your medical degree. Some people hide their emotions better than others. Many appear confident but, if asked, would claim they are not really underneath. Building confidence comes with time and experience. However, even top consultants will admit that they are sometimes flummoxed. The key is to know when you need help and to be able to ask for it appropriately from the right person. However, you should have some faith in your own ability. Some people under-estimate theirs.
The unwell patient on haemodialysis: what you need to know on an acute medical take
Authors: Hinchliffe WT , Murray JS , Kanagasundaram NS
Published: May 2014

In the UK, approximately 300 people per million population require maintenance haemodialysis for end-stage renal failure. Although haemodialysis prevents death from overt renal failure, 4-year survival remains poor at only 48%, falling to 24% in those aged ≥65 years (Levy et al, 2004).
Good medical records: a guide for the foundation year doctor
Authors: Singisetti Kiran , Staley Helen
Published: May 2014

Maintaining good medical records is essential for providing safe and effective patient care. The General Medical Council (2006), in Good Medical Practice, suggests that doctors should ‘keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed’. While good medical practice is necessary throughout one's medical career it is important to develop good qualities early in the training.
Preoperative assessment
Authors: James Alex , Abbott Joy
Published: May 2014

Preoperative assessment of patients scheduled for surgery aims to improve patient care and safety while making the most efficient use of theatre resources and ward beds (Roizen, 1997). Foundation doctors often play a key role in this process. This article summarizes the principles of preoperative assessment and offers clear advice about how to perform well in this role.
Japes and jackanapes: on being a junior hospital doctor in the 1970s
Authors: Waxman Jonathan
Published: May 2014

It is all such a long time ago. In two twinkles of time, 30 years have gone by. And it was such fun. I went to medical school at 17 years of age and, after going to a number of parties, reading a few novels, learning to play the mouth organ badly, and participating in some desultory training, I was released. But this liberation coincided with a prison sentence which confined my freedom to one night in two for a whole year, and two nights in three until I was a consultant. Time off was so special that I would work hard to fill it with the glitter of entertainment, and this set in stone sleeping habits for a lifetime, where I always get up early to enjoy, or try to enjoy, the day.
So you want to be … an ophthalmologist
Authors: Hale Sarah L , Lightman Sue
Published: May 2014

Ophthalmology deals with the diseases of the eye and their treatment. The word ophthalmology comes from the Greek root ‘ophthalmos-’ meaning ‘eye’; ophthalmology literally means ‘the science of eyes’.
So you want to be … an orthopaedic surgeon
Authors: Haddad Fares , Hudson Ben
Published: May 2014

Orthopaedics is a flourishing and ever-expanding specialty which encompasses a variety of subspecialists – many orthopaedic surgeons only focus on one or two joints at the very most. In addition to trauma surgery and fracture management, the sub-specialties include spinal surgery, which crosses over with neurosurgery; shoulder and elbow surgery; hand surgery which crosses over with plastic surgery; hip surgery, knee surgery, and foot and ankle surgery. There is also expanding interest in sports orthopaedic surgery.
So you want to be … a specialist in HIV/AIDS medicine
Authors: Jones Rachael , Pozniak Anton
Published: May 2014

There is no single speciality called ‘HIV/AIDS’ (human immunodeficiency virus/acquired immune deficiency syndrome) – physicians with a major interest in this field tend to progress via alternative routes in terms of training and accreditation.
Inflammatory markers
Authors: Reynolds Tim M
Published: May 2014

Before considering markers, it is first appropriate to consider inflammation (Latin, inflamatio, to set on fire). Inflammation is a complex response by an organism to injury, either resulting from invasion by pathogenic organisms, traumatic cell damage or irritants. Inflammation is essential for tissue repair and without it, wounds would not heal but instead would continue to expand. It can be either acute (the initial response to the harmful stimulus) or chronic (a prolonged process involving continued healing and cell damage occurring simultaneously).
The art of the ward round
Authors: Ahmed Alia , Rutter Peter , Neequaye Simon
Published: May 2014

Ward rounds are an essential part of hospital practice, providing regular contact between doctors, nurses and their patients. The ward round allows evaluation of the patient and planning of his/her care as well as valuable social interaction. The most valued trait of a foundation doctor is organization, and this is most applicable in the planning and execution of the ward round. The following gives undergraduates or newly qualified doctors a taster of what to expect, as well as some advice on how to be prepared.
Managing your pay: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Being paid is a pleasant monthly experience. However, you need to understand how your pay is calculated and be able to spot any discrepancies. You should always be polite when questioning perceived errors.
Thyroid surgery
Authors: Gill Jasper , Agrawal Avi
Published: May 2014

Most specialist endocrine surgeons in general surgical units see, manage and operate on patients with thyroid disease. Knowledge of the conditions encountered, preparation for surgery, operations performed, postoperative care and potential complications is essential in the management of these patients.
The survivors' guide to working in plastic surgery
Authors: Singisetti Kiran , Staley Helen
Published: May 2014

Starting any new training block can be a daunting experience, more so following the introduction of foundation training. It is now not uncommon for foundation year and core trainee doctors to rotate through specialist fields of medicine and surgery, such as plastic surgery. This often increases anxiety levels as only a few medical students rotate through plastic surgery. As with any other specialty, time spent preparing yourself for the new job will go a long way in building up your confidence.
Parathyroid surgery
Authors: Cowie Andrew , Agrawal Avi
Published: May 2014

Prolonged exposure to raised parathyroid hormone and serum calcium can lead to a multitude of systemic symptoms (Table 1). It is important to consider hyperparathyroidism in the differential diagnosis of patents with hypercalcaemia. Parathyroid surgery can cure patients with primary hyperparathyroidism and lead to prolonged life expectancy. Surgery can be challenging but safe, with low morbidity and mortality when undertaken by surgeons who specialize in parathyroid surgery.
The Integrated Research Application System: an introduction
Authors: Yewlett Alun , Tufail Sabeen , Whitaker Matthew , Manohar Sushil , Stew Ben
Published: May 2014

‘I don't care if you can put a chest drain in blindfolded, or if you can cannulate an intravenous drug user with your hands tied behind your back – what have you done in the way of research during the past 6 months?’
So you want to be … an otorhinolaryngologist
Authors: Swift Andrew C
Published: May 2014

Ear, nose and throat surgery (ENT), now referred to as otorhinolaryngology, head and neck surgery, offers a multitude of opportunities and has been described as having all surgical skills under one umbrella. Open surgery of the salivary and thyroid glands, reconstructive surgery and free flap surgery following excision of head and neck cancer, skull base surgery, microsurgery of the middle ear, endoscopic sinus surgery, facial plastics, functional and aesthetic nasal surgery, phonosurgery and the advances of lasers and navigational surgery are all included within otorhinolaryngology, head and neck surgery. There are approximately 565 consultants and 337 specialist registrars in the UK.
Extending palliative care to patients with respiratory disease
Authors: Cartwright Yvonne , Booth Sara
Published: May 2014

This article describes the importance of improving access to palliative care services of patients with advanced chronic respiratory disease. It outlines their needs, the challenges involved in meeting them and ways in which current models of care may need to be modified to increase access.
Palliative care in multiple sclerosis and motor neurone disease
Authors: Barnes Julia , Campbell Colin
Published: May 2014

The general physician can help patients and families living with advanced multiple sclerosis and motor neurone disease in a number of practical ways. The key areas requiring a palliative approach are the management of physical symptoms, psychosocial support, decisions around potentially life-prolonging treatments and end-of-life care.
The role of embolization in the management of tumour recurrence after radical nephrectomy
Authors: Akhtar Kashif , Lee George , Khan Masood , Mitchell Adam , Livni Naomi , Christmas Timothy
Published: May 2014

A 56-year-old Caucasian female underwent left thoraco-abdominal radical nephrectomy with excision of the regional lymph nodes for a 10 × 11 cm mass in the upper pole of the left kidney. Histology confirmed a Fuhrman grade 4 clear cell renal carcinoma, pT2 NoMx, with microscopic venous invasion. All 11 lymph nodes were negative for metastatic disease as were the staging scans.

A follow up computed tomography scan at 3 months revealed bilateral small pulmonary metastases with no evidence of renal bed recurrence. Bone scan was also negative. However, a further computed tomography scan 6 months after the nephrectomy demonstrated a 3.8 × 2.6 cm mass in the left renal bed with enlargement of the left gastric lymph nodes. In addition, there was a mass in the fundus of the stomach and the size of the pulmonary lesions had increased. The patient therefore started three cycles of chemotherapy (interferon-alpha, interleukin-2 and 5-fluorouracil, experimental arm of the MRC RE04 protocol) with an excellent response seen on subsequent imaging with complete resolution of the renal bed mass.

A repeat computed tomography scan 16 months after surgery showed significant disease progression with a 6 × 7 cm mass in the left renal bed. The patient was admitted to hospital soon after this with a haemoglobin of 6.0 g/dl following several episodes of fresh rectal bleeding, requiring a 7-unit blood transfusion.

Colonoscopy revealed a polypoid tumour in the proximal descending colon which was felt to be extrinsic in origin. Angiography revealed a number of sources of blood supply to the retroperitoneal mass, the largest from the T11 and T12 intercostal vessels (Figure 1). These were embolized satisfactorily with no further bleeding (Figure 2). The patient subsequently underwent a resection of the renal bed mass and a left hemicolectomy (Figure 3).