bluuebunny/crossref_metadata_2025 huggingface dataset:
Tips for the final FRCA examination
Authors: Benington Steve , de Mello Winston F
Published: May 2014

The final Fellowship of the Royal College of Anaesthetists is a demanding written and oral examination requiring 6 months of dedicated preparation. The syllabus is large, and few candidates can hope to learn everything. The key to success is to practice as many written and viva questions as possible, focusing revision on areas of weakness identified in the process.
Rudolph Matas, pioneer of arterial surgery
Authors: Ellis Harold
Published: May 2014

Fifty years ago, on 23 September 1957, Rudolph Matas, one of the early pioneers of modern vascular surgery, died at the great age of 97 years. His name and reputation may now be little known to younger clinicians but he is remembered by the ‘old guard’ with great affection.
Spontaneous rupture of an umbilical hernia
Authors: Shrestha DB , Tsang A , Courtney ED , Pittam M , Ravichandran D
Published: May 2014

A 51-year-old man with decompensated liver cirrhosis and ascites was admitted as an emergency following spontaneous rupture of a previously asymptomatic umbilical hernia. Following initial loss of a large amount of fluid at home, he was having intermittent discharge of fluid from the umbilical hernia at an area of skin breakdown which later became much larger with evisceration of omentum (Figure 1). Following resuscitation he underwent uneventful mesh repair of the hernia with excision of the protruded omentum.
Characteristics, diagnosis and treatment of bone and soft tissue sarcomas
Authors: Dadia Solomon , Grimer Robert
Published: May 2014

Bone and soft tissue sarcomas are rare, representing around 1% of all adult cancers. They mostly affect the musculoskeletal system but can metastasize, often to the lungs. Treatment involves the concerted application of surgery, radiotherapy and chemotherapy in an integrated manner to maximize survival and quality of life.
A practical guide to building a national curriculum
Authors: Evans Dason E , Estcourt Claudia S
Published: May 2014

The clinical specialities are under-represented in local and national undergraduate curricula that are too generic to guide student learning adequately. This article gives practical advice, grounded in the published literature, on how to develop a speciality-specific national curriculum.
CORRESPONDENCE
Authors: Koulaouzidis Anastasios
Published: May 2014

I read with great interest the article ‘Paracentesis in the management of ascites’ by Mittal and Dangoor (vol 68(9), 2007, p. M162).
Admiral Nelson's amputation
Authors: Ellis Harold
Published: May 2014

5 here is no doubt that the most famous amputation in British history was that performed on Horatio Nelson. This year marks its 210th anniversary.
Traditional rapid sequence induction for caesarean section is outdated
Authors: Mingo Olivia
Published: May 2014

3apid sequence induction (RSI) with succinylcholine has been the mainstay of obstetric general anaesthetic practice for over 40 years. This aims to provide rapid intubating conditions in patients at risk of regurgitation. Failed intubation in obstetrics is ten times more common than in the general population although most parturients do not have a predicted difficult airway. This article explores whether traditional RSI with succinylcholine is still the method of choice for caesarean section.
The medical impacts of climate change
Authors: Montgomery Hugh
Published: May 2014

Carbon dioxide captured in fossil fuels over some 410 million years has been released in decades, and the earth is warming as a result. This threatens not just our health, but our very survival as a species.
Medical management of obesity
Authors: Kopelman Peter G
Published: May 2014

Primary intervention in the medical management of obesity is dietary restriction and physical activity with additional benefit gained from behaviour therapy. Subsequent use of anti-obesity drugs depends on unsatisfactory weight loss in a patient at medical risk from obesity. All treatment programmes must include long-term follow up.
Interpersonal performance
Authors: Haynes Keith
Published: May 2014

International research reveals that impaired performance in doctors is as much to do with behaviour, attitudes and communication skills as clinical skills (Levinson et al, 1997; Bunting et al, 1998). It is estimated that at any one time about 5% (6000) of UK doctors experience performance problems (General Medical Council, 2005). The personal and economic consequences of ‘poor performance’ are significant. The National Audit Office estimates the full cost of excluding a consultant to be £180 000 per annum (National Audit Office, 2005).
Physician test thyself
Authors: Goodman Neville
Published: May 2014

BBC4's Medical Mavericks (Wednesdays in February) told of scientists who experimented on themselves. The series started with anaesthesia. The narrator, Michael Mosley, was described as a ‘former doctor’; in the course of the programme he inhaled nitrous oxide, in the footsteps of Humphry Davy, and got quite merry.
Smell disorders and dysosmia
Authors: Koo FS , Arya AK , Swift AC
Published: May 2014

Disorders in olfaction are common, yet poorly understood. This article explains the mechanism of the olfactory system and the pathogenesis of dysosmia, along with current trends in management and treatment.
A perspective on the current issues in the diagnosis of Parkinson's disease
Authors: Worth Paul F
Published: May 2014

The National Institute for Health and Clinical Excellence published guidelines for the management of Parkinson's disease in 2006. This article summarizes the key diagnostic recommendations of the guidelines, and gives a personal view of current barriers to their implementation and how these might be overcome.
Tuberculosis: combating a growing problem
Authors: Johnson Norman
Published: May 2014

In the past few years there has been much concern over the resurgence of tuberculosis (TB) which has lead to initiatives from the chief medical officer, much press coverage in the lay press, National Institute for Health and Clinical Excellence (NICE) guidance, the setting up of an All-Party Parliamentary Group and most recently a large meeting in London addressed by the chief medical officer and the director of public health for the London Strategic Health Authority to which all chief executives were invited, emphasizing the priority that control of TB now has within the capital.
Interferon-induced depression: mechanisms and management
Authors: Hafizi Sepehr , Favaron Elisa
Published: May 2014

Interferon-alpha therapy in cancer or hepatitis C infection is significantly associated with depression. Interferonalpha can enhance tryptophan metabolism leading to reductions in serotonin and accumulation of toxic kynurenine metabolites. Antidepressants may be effective as prophylaxis in patients with risk factors.
Recent advances in inflammatory bowel disease
Authors: Hunter John
Published: May 2014

Recent developments in our knowledge of inflammatory bowel disease (IBD) have been dramatically exciting, but the speed and diversity of progress may seem bewildering. A forthcoming conference on IBD, in association with the British Journal of Hospital Medicine (see p. 351 or www.mahealthcareevents.co.uk/ for full details), provides an opportunity to reflect on the significance of new findings in the pathophysiology of these disorders and ways of improving disease management.
Prostate cancer presenting as neuropathic urinary retention
Authors: Amonkar Sunil J , Zachariah Kuruvilla , Feggetter Jeremy
Published: May 2014

Early in doctors’ careers all are taught the importance of recognizing symptoms suggestive of cauda equina compression (saddle anaesthesia, disturbance of bowel and/ or bladder function, lower limb weakness) associated with back pain and its urgent management. These symptoms should be regarded as just as serious even in the absence of back pain to help prevent irreversible damage. This article presents such a case, which led to a diagnosis of metastatic prostate cancer.
Tuberculosis of the peripancreatic lymph nodes in an immunocompetent patient
Authors: Liu YM , Satyadas T , Cheong E , Smith S , Sinclair MT , Rae DM
Published: May 2014

A 34-year-old man of Indian origin presented with a week’s history of epigastric and upper abdominal pain associated with malaise and jaundice, but no fever, 2 months after returning from India. He also noticed pale stools and dark urine. He denied any weight loss, nausea and vomiting. He had no previous history of liver disease or jaundice and had had childhood bacillus Calmette–Guérin (BCG) vaccination. He was otherwise fit and well, and not on any regular medication. There was no history of recreational drug use and no family history of liver disease.

Blood tests at initial presentation showed a raised alkaline phosphatase of 1012 u/litre (range 80– 260 u/litre), alanine aminotransferase 463 u/litre (range 0–37 u/litre) and bilirubin 120 μmol/litre (range 0–20 μmol/litre). Abdominal and respiratory examinations were unremarkable with no gross lymphadenopathy. At this stage, a biliary cause was suspected and an ultrasound scan was organized which showed a slightly dilated common bile duct. Magnetic resonance cholangiopancreatography showed a constant filling defect in the distal common bile duct but no obvious visible mass (Figure 1). Computed tomography scanning revealed no biliary dilatation but an irregular mass measuring 4x3 cm, inseparable from the upper aspect of the pancreatic head and the portal vein. There was also a 1.3 cm rounded density anterior to the pancreas close to the mesenteric vessels, showing low central attenuation (Figure 2). This mass was thought to be separate from the pancreas itself, even though the point of origin could not be accurately determined from the images, and enlarged lymph nodes were present. Exploratory laparotomy revealed enlarged rubbery lymph nodes in the lower omentum and around the portal triad. Pus was aspirated from these lymph nodes and sent to the laboratory, and neighbouring tissue biopsies were taken. The liver, spleen and peritoneum were normal, as was the pancreas on frozen section of trucut biopsy. Frozen section of the lymph nodes showed features consistent with tuberculosis. Mycobacterium tuberculosis was subsequently grown from the aspirated pus and tissue histology revealed evidence of granulomas. The patient was started on anti-tuberculosis therapy (isoniazid, rifampicin, pyrazinamide and pyridoxine) and referred to the respiratory physicians. The respiratory physicians continued the anti-tuberculosis medications, and added ethambutol, with a view to continuing this combination for a total of 2 months. After this period, the patient continued to take pyridoxine and rifampicin for 6 months. To date, the patient continues to be fit and well.
Aftermath of intensive care: the scale of the problem
Authors: Jones Christina
Published: May 2014

There can be physical, psychological and cognitive sequelae of critical illness, which have a significant impact on the patient's quality of life. This article discusses some of the recent work looking at the scale of the problem.
Dawkins tackles unreason
Authors: Goodman Neville
Published: May 2014

It was no surprise that I was completely on Richard Dawkins' side as he went after water dowsers, astrologers, and a variety of other psychic peddlers in Channel 4's The enemies of reason (13 August). But I do agree with the various television critics the following day, whose turn of phrase underlined what was wrong with the programme. Fish and barrels (in two newspaper), sledgehammers and nuts, lambs and slaughter, the obvious observation that the people he was confronting were ‘bonkers’: to quote the Times' Andrew Billen, ‘If Oxford University's Professor for the Public Understanding of Science could not humiliate this lot, there would be something wrong. There wasn't and he did.’ Billen's excellent suggestion was that Dawkins should be making a 13-part series on natural selection rather than gunning for intellectual inferiors caught in a media spotlight. I mean, is it worth anybody's time at all to discuss the spiritual ‘rockness’ of a rock?
Legal aspects of death and the coronial system: responsibilities of the foundation year doctor
Authors: Seymour Carol
Published: May 2014

It is timely for the foundation year doctor to be aware of the law and procedure relating to coroners and inquests, which is changing fast. Following the Shipman inquiry, and the Bristol and Alder Hay cases, the system for death certification, the coronial procedure and disposal and handling of the human body and body parts have come under close public scrutiny. This has resulted in proposed reform of the coronial system, tightening up of death certification and the cremation process, and regulation of what happens to body parts under the Human Tissue Act 2004. These are very sensitive matters for both the bereaved and for the foundation year doctor.
Prescribing analgesia for the surgical patient
Authors: Nagaratnam Maya , Sutton Hannah , Stephens Robert
Published: May 2014

One of the responsibilities of a surgical house officer is to manage patients' pain during the perioperative period. This is important for humanitarian reasons and because good pain relief has significant physiological benefits (Table 1).
Part 2: how to critique a manuscript
Authors: Leon Rebecca , Bayat Ardeshir
Published: May 2014

Critical appraisal is a structured, focused approach for analysing research articles. It is a process of reviewing a paper to select the most valuable information and also involves asking a series of questions as a means of interrogation (Davies, 2000). These questions provide a framework and consistent method when reviewing medical literature.
Teaching styles: a guide for the foundation year doctor
Authors: Trivedi Deepali , Hooke Rachel
Published: May 2014

In the authors' view, teaching is the best way of learning. One has to understand any subject thoroughly before one is able to make others understand it. All medical professionals will be involved in teaching, either formally or informally, at some point during their careers so why not begin as a foundation doctor. Teaching medical students, nursing staff, paramedical staff, junior doctors and various other team members, or even participating in regional teaching sessions, may later become a part of one's routine.
Management of pyrexia of unknown origin
Authors: Srikugan L , Loganayagam A
Published: May 2014

Pyrexia of unknown origin is the term used to describe persisting fever without an obvious focus. A definition derived by Petersdorf and Beeson (1961) from analysis of 100 cases is as follows:
Survival kit for a foundation doctor
Authors: Hijazi Bader
Published: May 2014

During this transitional period in which senior house officer posts are being abolished and new specialist and GP training programmes are being introduced, it is becoming increasingly difficult to secure a training job in your chosen specialty after your foundation year 2 (FY2) post. This article is a general guide to help jump the FY2 hurdle and secure your next job.
Assertiveness: a guide for the foundation year doctor
Authors: Trivedi Deepali , Hooke Rachel
Published: May 2014

Assertiveness (Lindsay, 2002) is an important tool if used appropriately at the right time and in the right manner. It is an aspect of communication that reflects confidence, faith and leadership attitude. Being assertive is a skill attained with time, experience and technique. Quite often, what you may think of as being assertive could be misinterpreted by others as being aggressive – there is a very thin demarcation between the two. Frequently, people expect foundation doctors beginning their careers to be passive and submissive, lacking experience and confidence.
Surgical instruments, sutures and suturing techniques
Authors: Bush Jim , Bayat Ardeshir
Published: May 2014

Anthropological studies suggest that prehistoric man used various techniques to close skin wounds (Ellis, 2001). The jaws of termites or beetles were used to bite across wounds and hold skin edges together in India and South America, and in East Africa acacia thorns were stuck along the two wound edges and then plaited together (Ellis, 2001). Suture materials used included horsehair, fibres from tree bark, cotton and, in ancient Rome, human hair and catgut (made from sheep's intestine) (Burnand and Young, 1998), which was used until recently in the UK. The sutures used in modern surgical practice are almost exclusively synthetic materials.
Acute heart failure and cardiogenic shock
Authors: Moore PR , Kharbanda R , Banner NR
Published: May 2014

Acute heart failure and cardiogenic shock are medical emergencies requiring urgent medical intervention. This article defines each syndrome and reviews the latest evidence regarding their clinical presentation, management and prognosis.
The management of haemorrhoids
Authors: Chand Manish , F Nash Guy , Dabbas Natalie
Published: May 2014

Haemorrhoidal disease is common, but there is still no consensus on optimal treatment. The most appropriate treatment is tailored to the individual patient. This article defines and classifies haemorrhoids, reviewing the efficacy of current treatments including the latest techniques.
Myeloma in a very young woman presenting with bone pain
Authors: W Dubrey Simon , Patel Ketan
Published: May 2014

Figure 1 shows the chest X-ray of a 29-year-old Ethiopian woman who presented to the accident and emergency department with a 9-day history of vomiting and a 3-month history of chest and back pain. She had been previously fit and healthy and had no past history of any illnesses. On examination she appeared dehydrated and had lower abdominal tenderness with no palpable organomegaly. Palpation of the ribs themselves was particularly uncomfortable for the patient.

The chest X-ray (Figure 1) shows fractures with callus formation in the posterior left 6th rib, the left 10th and the right 7th rib posterolaterally. In addition there is abnormal bone texture in virtually all the thoracic bones, particularly the clavicles and the ribs. There are multiple lucent areas within the marrow, causing endosteal scalloping of the cortex. There are similar lucencies in the scapulae. There is also a band of atelectasis in the left lung base.

Blood tests revealed a haemoglobin of 91 g/litre (the mean cell volume was normal at 87 fL), erythrocyte sedimentation rate 57 mm/h, potassium 3.1 mmol/litre, creatinine 233 umol/litre, albumin 23 g/litre and a corrected calcium 3.29 mmol/litre. Subsequent investigations showed a paraprotein band consisting of immunoglobulin G kappa at 62 g/litre. A bone marrow aspiration and trephine confirmed the diagnosis of multiple myeloma with approximately 50% of the cells thought to be plasma cells on the aspirate. Immunophenotyping of the bone marrow showed CD138 expression of 24% and kappa chain restriction.

Treatment was started with a regimen of cyclophosphamide, thalidomide and dexamethasone, with a view to subsequent autologous bone marrow transplantation.
Peripheral arterial disease in patients with diabetes mellitus
Authors: Hamish M , Gohel MS , Davies AH
Published: May 2014

Peripheral vascular disease is commonly seen in diabetic patients and the disease progression is often more aggressive in this patient group. This article discusses the clinical assessment, and looks at medical and surgical treatment options.
An unusual presentation of giant cell arteritis
Authors: Currie Samantha , Linnane Seamus J
Published: May 2014

A 72-year-old woman presented with a 6-month history of dry, persistent cough after visiting a deer park. Initially a transient rash developed on the ankles and spread proximally. This was associated with malaise, weight loss and arthralgia which all quickly resolved. Examination revealed a right carotid bruit, impalpable left brachial artery and reduced left radial and dorsalis pedis pulses. The blood pressure was 120/80 mmHg in the right arm but unrecordable in the left. Respiratory examination was unremarkable. Temporal arteries were impalpable and non-tender; fundoscopy was normal.

Borellia burgdorferi serology was negative. The haemoglobin was 10.2 g/litre (normal range 12.0–15.1 g/litre), mean corpuscular volume was 79.8 fl (normal range 80.0–99.0 fl) and platelets were 634×109/litre (normal range 130–475×109/litre); white cell count was minimally elevated at 11.3×109/litre (normal range 4.0–11.0×109/litre). Erythrocyte sedimentation rate was 100 mm/hr (normal range 0–35 mm/hr) and C-reactive protein 140 mg/litre (normal range <6 mg/litre). Lung function tests and chest radiography were normal.

Computed tomography pulmonary angiography detected a descending aortitis (Figure 1).

The Venereal Disease Research Laboratory (VDRL) enzyme-linked immunosorbent assay (ELISA) for IgG for Treponema pallidum was negative and a white cell scan identified normal uptake within the aorta, excluding syphilis. Bronchoscopy was grossly normal. Bronchoalveolar lavage showed a differential cell count of 75% macrophages, 24.9% lymphocytes and less than 1% of both neutrophils and eosinophils, indicative of a lymphocytic alveolitis. A transbronchial biopsy identified non-specific chronic inflammatory changes; granuloma and changes of vasculitis were absent. Stains for fungi, pneumocystis, legionella and acid-fast bacilli were negative. Temporal artery biopsy identified chronic inflammation with occasional giant cells. Giant cell arteritis with descending thoracic aortitis and lymphocytic alveolitis was diagnosed. A complete resolution of the cough occurred within a week of starting high-dose steroids.
Maternal safety: what is the cost?
Authors: Farquharson Roy G
Published: May 2014

The hallmark of a modern, wealthy and caring society is how well it provides pregnancy and newborn care. It is a measure of how much that society treasures the very seed corn of the next economic generation. With economic buoyancy and increased investment in the NHS, there should be clear benchmarks to measure improvements against expenditure.
Antidepressants: will new mechanisms of action improve poor outcomes?
Authors: Palaniyappan Lena , McAllister-Williams R Hamish
Published: May 2014

Depression is one of the most common mental illnesses and has a high impact on individuals and society. Despite the numerous treatment approaches, poor response combined with the burden of residual symptoms negatively affects the overall outcome. Novel pharmacological approaches could help to address this issue.
Spontaneous splenic rupture in the postpartum period
Authors: Paravastu Sharath CV , Burdge Anthony , da Silva Antonio
Published: May 2014

A 24-year-old woman, who was 8 weeks postpartum, presented to the surgical emergency unit with sudden onset of severe generalized abdominal pain. Apart from a previous ovarian cyst, there were no other significant past medical problems. She denied any recent abdominal trauma or strain.

On examination, the patient had a very tender upper abdomen. Ultrasound scan demonstrated free fluid in both the abdomen and the pelvis. It also showed a large complex focal lesion in the spleen, close to the hilum, measuring 80×76 mm (Figure 1). Conservative management was planned initially, but surgery was performed as the patient developed signs of generalized peritonitis along with severe pain in both shoulders. A diagnostic laparoscopy revealed massive haemoperitoneum and bleeding from the upper pole of the spleen (grade II splenic rupture). Haemostasis could not be achieved, and hence a splenectomy was performed via an upper midline laparotomy. The patient made an uneventful recovery. Appropriate vaccinations were given post splenectomy (Haemophilus influenzae, Neisseria meningitides and pneumococcus).

On macroscopic examination, the spleen measured 160×120×75 mm and weighed 342 g (Figure 2). Transverse section revealed a unilocular cyst of 85–90 mm in diameter containing haemorrhagic material. Histological examination revealed that the cyst was an epidermoid cyst and showed the presence of both old and new clots. Further additional history from the patient after splenectomy disclosed an admission to the medical ward 4 weeks after her delivery with left shoulder pain, left-sided chest pain and left-sided neck pain that was worse on movement and with cough. There was no history of trauma or fall. She was stable haemodynamically and all her haematological investigations were normal. She was treated as having musculoskeletal pain, given analgesics and was discharged home on the day of presentation. She had two further episodes of left shoulder pain that were treated similarly at a different hospital.
Restless legs syndrome: symptoms, management and new developments
Authors: Hyman Nigel
Published: May 2014

Restless legs syndrome is a common but misdiagnosed disorder. Symptoms include an intense desire to move the legs when a patient is sitting or lying which is relieved by leg movement or walking. The condition is associated with abnormalities of the dopaminergic system. Drug treatment can be effective but should be confined to more severe cases.
A simple case of heart failure?
Authors: Lee Lydia , Donaldson Anna , Lok She
Published: May 2014

A 68-year-old woman presented with a 6-week history of progressive lethargy and weight loss. Over the previous 2 weeks she had also complained of increased ankle swelling, orthopnoea, a sensation of chest tightness, dyspnoea and dry cough. Her only past medical history was hypothyroidism, for which she was on adequate replacement therapy and hypertension. She had no other cardiovascular risk factors, had given up smoking at 32 years of age and was a retired health-care worker with no known exposure to asbestos.

Clinical examination revealed signs of heart failure and a left-sided pleural effusion. Her blood pressure was 125/55 mmHg, pulse rate 90 beats per minute and oxygen saturation of 94% on air. Basic blood tests, including cardiac enzymes, came back within normal parameters except for white cell count of 15.0×103/mm3 and a C-reactive protein of 114 mg/litre. An electrocardiogram showed inverted T waves across the chest leads. A chest radiograph demonstrated a left-sided pleural effusion, with no apparent cardiomegaly or lung lesion.

A diagnostic pleural aspirate was performed, fluid was blood stained. It was a borderline transudate according to Lights criteria (pleural:serum ratio of total protein and lactate dehydrogenase being 0.48 and 0.47 respectively). Two separate aspirates were negative for malignant cells on cytological analysis. A computed tomography scan to investigate the effusion further revealed irregular pericardial thickening, a large left pleural effusion and some consolidation in the posterior aspect of the left lung base (Figures 1 and 2). Echocardiography demonstrated a pericardial effusion but without evidence of tamponade.

For definitive diagnosis of the suspicious pericardial thickening a decision was made to undertake a radiologically-guided biopsy. This was performed at a local tertiary referral centre. The histology obtained on balance suggested that this was pericardial mesothelioma.
The role of heart rate reduction in angina management and beyond
Authors: Izzat Lena Marie
Published: May 2014

This article highlights the significance of heart rate as an independent risk factor and prognostic marker for cardiovascular disease and examines the pharmacological measures available that lead to effective heart rate reduction.
Adult-onset diabetes insipidus caused by congenital midline brain abnormalities
Authors: Zachariah Sunil , Byrne Paul , Hyer Stephen
Published: May 2014

A 30-year-old man presented with a 4-month history of polyuria and polydypsia. There was no significant past medical history and no significant family history as he was adopted

Clinical examination revealed an obese gentleman with a body mass index of 45 kg/m2. His blood pressure was 130/80 mmHg and fundus examination was normal. Examination of his external genitalia revealed a small penis and testicular volume of 10 ml each. His full blood count, glucose, electrolytes, liver and bone profile were normal. Serum prolactin=463 mU/litre, insulin-like growth factor=15.7 nmol/litre (normal range (NR) =13–45 nmol/litre), free thyroid hormone level=9.8 pmol/ litre (NR=10–23 pmol/litre), testosterone=1.7 nmol/litre (NR=10–40 nmol/litre), cortisol=484 nmol/litre rising to 880 nmol/litre after Synacthen. Luteinizing hormone level was 0.1 u/litre rising to 1.7 after luteinizing hormone-releasing hormone, thyroid-stimulating hormone=0.98 mU/litre rising to 8.9 mU/litre after thyrotropin-releasing hormone stimulation. These results suggested partial anterior pituitary deficiency affecting the gonadal and thyroid axis.

Urine failed to concentrate more than 100 mmol/litre during an 8-hour water deprivation test. After desmopressin, urine osmolality rose to 535 mmol/litre. Plasma arginine vasopressin levels were undetectable throughout the test indicating cranial diabetes insipidus. A magnetic resonance imaging scan of the brain (Figure 1) showed absence of the posterior portion of the corpus callosum. A transsphenoidal encephalocele was demonstrated with stretching of the hypothalamus, optic chiasm and pituitary gland through the defect.
A history of carpal tunnel syndrome
Authors: Wardle NS , Pourgiezis N , Ashwood N , Bain GI
Published: May 2014

Carpal tunnel syndrome is the commonest entrapment neuropathy seen in clinical practice. The history of its aetiology and diagnosis gives an interesting insight into how the condition has evolved to also become the best understood neuropathy.
Traumatic brain injury: from impact to rehabilitation
Authors: Halliday J , Absalom AR
Published: May 2014

Traumatic brain injury is a significant cause of mortality and morbidity in our society, particularly among the young. This review discusses the pathophysiology of traumatic brain injury, and current management from the acute phase through to rehabilitation of the traumatic brain injury patient.
Careers fairs for medical students and junior doctors
Authors: Goodyear Helen M , Gadsby Michele , Wall David
Published: May 2014

Careers fairs are an integral part of careers management. This article looks at how to plan and run a careers fair and what attendees valued about a careers fair held in the West Midlands.
The reflective elective: using the elective to develop medical students' skills in career planning
Authors: Elton Caroline , Newport Melanie
Published: May 2014

The Tooke inquiry into Modernising Medical Careers highlighted the need for medical schools to become more actively involved in preparing their students for the critical career decisions that they will make during the foundation programme. Incorporating a reflective careers assignment into the elective module may be a useful way of encouraging students to become more highly skilled in self-assessment and career exploration.
Managing acute on chronic respiratory failure: a guide to non-invasive ventilation
Authors: Goldring JJP , Wedzicha JA
Published: May 2014

Acute-on-chronic respiratory failure is becoming an increasingly common medical emergency, mostly as a result of exacerbations of chronic obstructive pulmonary disease. It is associated with high mortality rates and so practising the best evidence-based management is vital.
Children refusing general anaesthesia: to postpone or proceed?
Authors: Prabhu Aparna , Lockie Jane
Published: May 2014

The competency of a child to give or withhold consent for surgery is a frequent problem encountered in anaesthetic practice. Children of all ages should be involved in the decision-making process regarding their care (General Medical Council, 2007).
Caval interruption: methods and indications
Authors: Sadat Umar , Ward Caleb , Gillard Jonathan H , Gaunt Michael
Published: May 2014

Venous thromboembolism is a significant cause of morbidity and mortality worldwide. Anticoagulation is the preferred treatment, but is not feasible in some patients. Caval interruption is the treatment of choice for prevention of recurrent pulmonary embolism. This article looks at the development of caval interruption.
Anxiety and stress management: a guide for the foundation year doctor
Authors: Trivedi Deepali , Hooke Rachel
Published: May 2014

Medicine is known to be an anxiety-provoking occupation. It is not unusual for doctors to go to bed fretting about patients. Anxiety is absolutely expected when you enter a new life as a foundation doctor – and not just anxiety about clinical judgment and decision-making. There are other pressures such as dealing with patients, meeting new colleagues, making up your portfolio, preparing for postgraduate examinations, attending interviews and so on. To cope with all this at the same time can be stressful. However, it is all part of life. You will have to face it, learn how to deal with it, and eventually get over it.
Prescribing for depression
Authors: Brown Rachel
Published: May 2014

Depression is one of the most common psychiatric illnesses, with a point prevalence of approximately 5% (Kumar and Clarke, 2002). Depression is associated with significant morbidity and mortality, primarily from suicide (Hatloy, 2008).
Writing a book review: frequently asked questions answered
Authors: George Sanju , Dharmadhikari Anupam
Published: May 2014

This article provides some guidance on how to write a book review. Before reading this article note the following caveats. First, it needs to be emphasized that there is no right or wrong way to write a book review, nor are there any ‘absolute’ rules. Hence what is offered here is mere guidance and not a rigid, step-wise guide. Second, although mostly the same principles apply to academic and literary book reviews, this article focuses on writing academic reviews.
Gynaecological ultrasound
Authors: Lloyd Claire R , Patel Nayna , Hart Jonathan L , Niewiarowski Sylwia , Harvey Chris J
Published: May 2014

Ultrasound is the first-line imaging investigation in gynaecological disorders. It has the advantages of being readily available and inexpensive as well as avoiding the use of ionizing radiation. Common indications for performing pelvic ultrasound include menstrual disorders, pelvic pain, symptoms suggestive of a pelvic mass and postmenopausal bleeding. This article summarizes the technical aspects and anatomy relevant to gynaecological ultrasound before describing the conditions commonly encountered during sonographic assessment of the female pelvis.
Laboratory medicine: a guide for foundation doctors
Authors: Smellie W Stuart A
Published: May 2014

As increasing pressure is placed on the medical school curriculum, many foundation doctors will begin their first jobs with little or no formal training in the disciplines making up pathology. However, a large part of the work done by foundation doctors involves organizing and interpreting diagnostic tests and using their results in the clinical context to trigger further investigations or treatment.
The art of prescribing
Authors: Shakur Rameen , Scott David
Published: May 2014

Most junior doctors are unaware of the sizeable contribution that prescribing aberrations make to hospital adverse events and medicolegal activities. The incidence of drug-related adverse events in patients in hospital varies widely. It is estimated that about 7% of hospital admissions are related to medication problems, although this may rise to 30% in the elderly, and these account for 4–7000 deaths per year in the UK (Karch and Lasagna, 1975; Brennan et al, 1991; Dean et al, 2002).
Risk management and incident reporting: a guide for the foundation year doctor
Authors: Hooke Rachel , Trivedi Deepali
Published: May 2014

Risk management is the process of identifying, assessing, analysing and managing all potential risks. Risk can be clinical or non-clinical. It is impossible to eliminate risk altogether, as any aspect of patient care is inherently risky. The aim is to minimize this without actually withdrawing services.
Paediatric abdominal ultrasound
Authors: Lloyd Claire R , Hart Jonathan L , Harvey Chris J
Published: May 2014

Ultrasound is widely used in the imaging of many paediatric conditions. Children are excellent candidates for ultrasound examination as they are generally smaller than adults with less body fat allowing excellent quality images to be obtained. In addition, ultrasound has several advantages over other cross-sectional imaging modalities used in paediatrics, including the lack of exposure to ionizing radiation, the avoidance of intravenous and oral contrast agents and the relative ease with which examinations can be performed without the need for sedation (De Bruyn, 2005). This article will focus on some aspects of paediatric abdominal ultrasound, namely renal tract abnormalities, common paediatric abdominal tumours and some common conditions presenting as acute abdominal emergencies.
Communication skills: a guide for the foundation year doctor
Authors: Trivedi Deepali , Singh Savita , Hooke Rachel
Published: May 2014

Communication is a process of conveying your thoughts and views across to others clearly and effectively. Communication is a two-way process, wherein an effective communicator tries to get the point across without creating any confusion or misunderstanding at the receiver's end (Bull, 1983).
A guide to the acute medical unit
Authors: Bell Derek , Skene Hannah , Jones Mike , Vaughan Louella
Published: May 2014

Acute medicine is the fastest growing medical speciality in the UK and acute medical units, which provide the best possible care for acutely unwell medical patients, are increasingly common.
Recruitment lessons to be learnt from obstetricians
Authors: Wedisinghe Lilantha
Published: May 2014

The first and main Modernising Medical Careers (MMC) recruitment process for most specialties and GP training in England in 2008 opened on 5 January and ran to 16 May 2008 (Modernising Medical Careers, 2008). Recruitment for obstetrics and gynaecology, general practice and paediatrics was run nationally where there are welltested, successful national processes of enlistment (Department of Health, 2007; Modernising Medical Careers, 2007). Specialty training recruitment for all other specialties is deanery based, although six subspecialties were coordinated centrally.
Providing effective pain management
Authors: Knaggs Roger D , Scott David , Shakur Rameen
Published: May 2014

Pain is a common presenting symptom, both in primary and secondary care. For over 30 years, studies of adult patients have consistently demonstrated inadequacies in the treatment of acute pain in the postoperative period. However, acute pain is not confined to surgical wards. Many patients on medical wards also experience moderate or severe pain on movement or at rest, commonly of musculoskeletal or visceral origin (Johnson et al, 2003).
Tight glycaemic control and cardiovascular disease in type 2 diabetes
Authors: Demssie Yared N , Soran Handrean , Younis Naveed
Published: May 2014

The role of tight glycaemic control in reducing cardiovascular events and mortality in type 2 diabetes has not yet been firmly established. Recent clinical trials have yielded unexpected outcomes. This review summarizes the background and outcome of these trials and the implications for management of glycaemia in type 2 diabetes.
Surgical site infection: are we using the right skin preparation?
Authors: Elliott TSJ , Lambert PA
Published: May 2014

The NHS has prioritized the prevention of health-care-associated infections and these strategies are meeting with success. In 2008 meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections had fallen by 57% compared to the baseline from 2003–4 when targets were set (UK Government, 2008; Health Protection Agency, 2009). This has been achieved through a range of initiatives from a greater focus on hand hygiene to implementation of the Saving Lives highimpact interventions. While this multifaceted approach is resulting in decreased numbers of infections, are there any further initiatives we should consider?
Screening for eye disease in the elderly: is it worth it?
Authors: Gibson Jonathan
Published: May 2014

Should we be screening for eye disorders in the elderly population? Visual impairment in the elderly can be associated with reduced functional status and quality of life, low social contact, depression, and falls and hip fractures (Dargent-Molina et al, 1996). It therefore would seem sensible to identify those elderly patients who have or are at risk of developing sight-threatening eye disorders, and offer them treatment. However, screening for disease of any kind raises a number of issues.
Management of acute ischaemic stroke
Authors: Al Mahdy Husayn
Published: May 2014

Ischaemic strokes comprise the majority of strokes in clinical medicine. With the widespread use of thrombolytic therapy within 3 hours of presentation the long-term disability as a result of ischaemic stroke has improved markedly. This article summarizes the clinical management of ischaemic strokes including recent advances.
An evaluation of the sources and availability of careers advice in UK medical schools
Authors: Tapper-Jones Lorna , Prout Hayley , Grant Andrew , Houston Helen , Sweetland Helen , Jones Melanie
Published: May 2014

This article reports a study evaluating the sources and availability of career advice available to students in UK medical schools in order to ascertain the need for an enhanced role for careers information in undergraduate curricula.
The perils of femoral vein catheterization
Authors: Kaur Navkiran , Walker David A
Published: May 2014

A 69-year-old patient was admitted to the intensive care unit for haemofiltration following an overdose of lithium carbonate. A venous haemofiltration catheter was passed 4 cm below the inguinal ligament, 1 cm medial to the femoral artery pulsation, into the femoral vein. Non-pulsatile blood was aspirated easily from the catheter and the patient commenced filtration. Three hours later, clinical examination revealed a cold pulseless leg. Pressure transduction of the femoral catheter showed venous waveform and a central venous pressure of 18 mmHg. Digital subtraction angiography of the femoral vessels revealed complete occlusion of the superficial femoral artery. The patient underwent surgical exploration, where the catheter was found to have transected the artery and occluded its lumen, before entering the femoral vein which lay directly beneath. Surgical repair was carried and the patient made an uneventful recovery.
Perforated colonic diverticulum in old age: surgical or medical management?
Authors: Whiteoak Simon , Khan Omar , Allen Stephen C
Published: May 2014

Perforation of a colonic diverticulum is a common surgical emergency particularly in older people. Surgical treatments result in the best outcomes for patients with good functional and physiological status, but for frailer patients there are minimally invasive and medical alternatives. This article considers the evidence for the different options.
Which vasopressor for caesarean section?
Authors: Bannard-Smith J , Yuill G , Washington SJ
Published: May 2014

One of the longest running debates in obstetric anaesthesia surrounds the prevention and treatment of maternal hypotension during caesarean section. Anaesthetic techniques have evolved and maternal mortality and morbidity is markedly reduced, but hypotension remains a problem, particularly following neuraxial blockade. Despite over 30 years of research no definitive consensus has been reached on the best treatment strategy and particular controversy surrounds the use of vasopressive agents. This article explores the evidence relating to the three most commonly used agents in the UK: ephedrine, phenylepherine and metaraminol.
Management of mood disorders in patients with advanced illnesses
Authors: Ward Jason , Smith Jenny
Published: May 2014

Hospital doctors often assume that patients with advanced life-limiting illnesses will be depressed and that as depression is understandable treatment is not indicated. However, differentiating natural sadness from major depression has important therapeutic implications.
Should having an elective laparotomy mean having an epidural for postoperative pain relief?
Authors: Jones Chris , Thompson Owain
Published: May 2014

Outside of obstetric anaesthesia, epidurals are usually used to provide continuous, postoperative pain relief for patients undergoing major abdominal or gynaecological surgery. Some consider them essential especially when using enhanced recovery protocols for laparoscopic surgical techniques.
Indications for tonsillectomy: the evidence base and current UK practice
Authors: Munir Nazia , Clarke Raymond
Published: May 2014

Tonsillectomy is one of the most common surgical procedures, and nearly two thirds of those performed annually in England and Wales are paediatric cases. Over the years the associated complications have not changed and the indications continue to be controversial. This article looks at the evidence base for current UK practice.
Venous thromboembolism: not as easy as it looks
Authors: Johnson Miriam J
Published: May 2014

Venous thromboembolism persists as a significant cause of death, much of which could be prevented. The symposium in this month's journal includes an overview of the UK perspective by Professor Kakkar, welcoming recent Department of Health policy developments which attempt to reduce hospital venous thromboembolism-related mortality. He highlights the considerable evidence base regarding risk factors, thrombophylaxis efficacy and outlines new advances in anticoagulation.
Recent initiatives to reduce the spread of meticillin-resistant Staphylococcus aureus
Authors: Wilcox Mark H
Published: May 2014

Recent initiatives have achieved marked reductions in meticillin-resistant Staphylococcus aureus bacteraemias. However, the relative effectiveness of prevention interventions is unclear. Initiatives to control meticillin-resistant Staphylococcus aureus have tended to ignore the benefits of altering antimicrobial prescribing.
Transient osteoporosis of the foot
Authors: Shariff Sajid S , Baghla Davinder PS , Clark Callum , Dega Raman K
Published: May 2014

Transient osteoporosis is a rare cause of pain in the foot. There is a broad differential diagnosis. A multidisciplinary assessment by both an orthopaedic surgeon and rheumatologist with review of the imaging by a radiologist is useful, as this condition is a diagnosis of exclusion.
Chronic heart failure and hypertension: risks, diagnosis and management
Authors: Warriner David
Published: May 2014

Chronic heart failure and hypertension are major clinical problems. This article gives an overview of some of the talks from a recent BJHM conference supported by Takeda which brought together leading experts in the field to discuss current issues, latest developments and practical management of chronic heart failure and hypertension.
Early vs late tracheostomy in critical care
Authors: Down Jim , Williamson Wilby
Published: May 2014

This article reviews the current literature and practice of tracheostomy with consideration of timing and the benefits of early tracheostomy, taking account of the results from the recent TracMan study.