bluuebunny/crossref_metadata_2025 huggingface dataset:
A sting in the tail of Hurricane Charley
Authors: Ramsdale David R , Aziz Shahid , Beeching Nick
Published: May 2014

A 76-year-old man with maturity onset diabetes mellitus, hypercholesterolaemia, hypertension and a history of coronary artery bypass surgery was well until his home in Punta Gorda was devastated by Hurricane Charley. He and his wife had remained in their home as it was torn apart by the ferocious wind and rain but amazingly they survived. He received numerous insect bites while searching among the flooded ruins. Within 48 hours, he became unwell, with fatigue, lethargy, myalgia, rigors and anorexia. Despite deteriorating, he did not seek medical attention until returning to the UK 3 weeks later by which time he had lost 2 stones in weight. He had received oral cephalosporin but this was not based on the evidence of infection or the result of any investigation.

On examination, he looked unwell with a sallow complexion. He was initially apyrexial. An abdominal examination revealed fullness but no palpable mass. Investigations showed leucocytosis 19.0 × 109/litre – 95% neutrophils. C-reactive protein (CRP) was 160 mg/litre. Abdominal ultrasound confirmed splenomegaly with a suggestion of an intrasplenic mass. Computed tomography (CT) scanning demonstrated a large multilobulated, low density mass within the spleen extending close to the capsular surface, indicative of an abscess (Figure 2). Five days after cessation of antibiotics, he was pyrexial (37.8°C) and blood cultures yielded Gram-negative bacillus, Escherichia coli. Echocardiography showed no evidence of infective endocarditis.

Percutaneous drainage of the intrasplenic abscess using a pigtail catheter revealed 500 ml of chocolatebrown coloured pus. A Gram stain showed Gram-negative bacilli and culture of the aspirate revealed Escherichia coli sensitive to ceftriaxone. He was treated with a single intravenous dose of gentamicin 360 mg, intravenous ceftriaxone 1 g twice daily for 2 weeks and metronidazole 500 mg three times daily for 2 weeks and the abscess resolved. He improved rapidly and 7 days after draining the abscess, the CRP fell to 13 mg/litre and the leucocyte count to 6.9 × 109/litre. Subsequent CT scanning showed resolution of the splenic abscess. Although genitourinary investigation revealed no abnormality, a barium enema showed a 5 mm polyp and diverticula in the sigmoid colon.
Menière's disease: myths and realities
Authors: Hawthorne Maurice
Published: May 2014

Many of the theories of the aetiology and pathogenesis of Menière's disease are often taught as being fact. This article explores how flimsy the evidence is for these theories along with the evidence of the effectiveness of the many treatments available.
Headache
Authors: Bahra Anish
Published: May 2014

Headache can be divided into primary headache and secondary headache. In primary headache the headache syndrome, i.e. the head pain and any associated features, are the disease process. In secondary headache the headache syndrome is a symptom of an underlying disorder. The secondary headache may have the same clinical features as a primary headache disorder.
Interpretation of elbow and forearm radiographs
Authors: Allen Steve D , Harvey Chris , O'Regan Declan
Published: May 2014

Upper limb trauma is extremely common, with the elbow joint frequently injured. This usually occurs secondary to direct trauma or as a result of a fall onto an outstretched arm. Plain radiographs remain the first-line investigation in these patients, but interpretation can be difficult because of the variety of possible injuries, and their sometimes subtle appearances. Understanding of the anatomy, especially in the developing elbow, is key to avoiding errors in the management of these injuries. This article provides a systematic approach to interpreting elbow and forearm radiographs and describes the common conditions requiring these X-rays along with radiological signs.
Right iliac fossa pain
Authors: Singh I , Collins REC
Published: May 2014

Right iliac fossa (RIF) pain is a common presentation and the underlying cause can be difficult to ascertain. The casualty officer or GP may be puzzled as to which speciality to refer such patients, being torn between the surgeon, the gynaecologist, the urologist or even the medical team on-call.
Caring for people who are dying: implications of the Burke vs GMC case
Authors: Campbell Colin W
Published: May 2014

The General Medical Council (GMC) has successfully appealed against a court ruling which would have had far-reaching effects not only for doctors, but for society at large. In effect, the GMC (2002) is vindicated in its carefully considered guidance on withdrawing and withholding life-prolonging treatments. If the appeal had been unsuccessful, doctors would have been obliged to administer treatments which they considered to be futile.
Endobronchial actinomycosis: is a repeat bronchoscopy after treatment necessary?
Authors: How Soon Hin , Ramachandram K , Aziz Azian Abd
Published: May 2014

A 51-year-old Chinese woman without any significant past medical history was admitted in October 2003 for cough of 18 months' duration. There was minimal clear expectoration and no haemoptysis. She denied any shortness of breath, anorexia and weight loss. There were no symptoms of rhinitis, gastrooesophageal reflux or choking. She was afebrile with good dental hygiene. There were fine crepitations and localized rhonchi over the right lung base. Despite short courses of antibiotics from her general practitioner there was no improvement in her symptoms.

The initial chest radiograph showed opacity in the right middle lobe with a subtle air-bronchogram. Blood investigations revealed an erythrocyte sedimentation rate of 113 mm/hr, and fasting and random blood glucose levels of 10.4 mmol/litre and 13.4 mmol/litre respectively. The full blood count, renal and liver function tests were within normal limits. Contrast enhanced chest computed tomogram (Figure 1) revealed a right middle lobe consolidation with air-bronchogram. A few pre-tracheal and subcarinal lymph nodes of less than 1 cm in diameter were present. Bronchoscopy showed nodular lesions causing subtotal occlusion of the middle lobe bronchus. Biopsy of these lesions revealed filamentous-like bacterial colonies which were Gram stain positive and modified Ziehl–Neelson stain negative with a background of acute and chronic inflammation consistent with actinomycosis. Bronchoalveolar lavage specimens were culture-negative. She was treated with intravenous benzylpenicillin 5 mega units 6-hourly for 1 month followed by oral penicillin V 1 g 6-hourly for 6 months.

She returned to the clinic with complete resolution of symptoms 7 months after the treatment and a follow-up chest radiograph showed near complete resolution the right middle lobe opacity. Repeat bronchoscopy still showed nodular lesions in the right main bronchus which appeared much smaller now. The bronchoscope could now be passed beyond the lesion and a piece of ‘tissue’ was seen at the bifurcation of the middle bronchus. The ‘tissue’ was grasped with a biopsy forceps. However, it dropped above the vocal cords and most likely was swallowed by the patient. A repeat biopsy of the nodule showed persistence of actinomycosis. In addition, necrotic vegetative matter was present. Oral penicillin at the same dose was continued. Three months later, a third bronchoscopy showed complete resolution.
Benign cystic nephroma
Authors: Makepeace JC , Sellaturay S , Mushtaq I , Sebire NJ
Published: May 2014

A 6-month-old female presented with a palpable mass on the left side of her abdomen. Ultrasound and computed tomography suggested benign cystic nephroma. Nephrectomy was performed, and histology confirmed a diagnosis of benign cystic nephroma (Figure 1).
Etomidate vs thiopentone for rapid sequence induction in critically ill patients
Authors: Moonesinghe SR
Published: May 2014

Etomidate and thiopentone are two of the most commonly used induction agents for rapid sequence induction (RSI) in critically ill patients. The use of etomidate infusions for sedation on intensive care has been abandoned following data showing an alarmingly increased mortality in multiply injured trauma patients compared with those managed otherwise (77% vs 28%, P<0.0005) (Watt and Ledingham, 1984). However, the use of etomidate for induction has persisted, despite more recent evidence demonstrating adrenocortical suppression even after single dose administration. Both thiopentone and etomidate are acknowledged to produce quick onset anaesthesia appropriate for emergency RSI, thus it is suggested that the choice between these two agents should be made on their perceived disadvantages rather than advantages.
A qualitative evaluation of the trainees' experience of assessments in the MMC foundation programme
Authors: Bardhan Suchitra , Morgan Emma , Jones Hywel
Published: May 2014

The foundation programme for training junior doctors officially started in August 2005, with one key component being assessment of competencies. This qualitative study examined the opinions of foundation programme trainees regarding the perceived use of the assessments for training purposes and where the difficulties lay in completing assessments. Early identification of possible pitfalls should help improve the system for future trainees.
Myositis ossificans progressiva
Authors: Waller SL , Porter DE , Huntley JS
Published: May 2014

A 23-year-old man with myositis ossificans progressiva was seen in the orthopaedic clinic with pain on sitting as a result of a bony spur extending caudally from the right ischiopubic eminence. The fragment of bone was mobile and exquisitely tender on palpation. There was a recent history of falling out of bed which was thought to be relevant to its onset. A pelvic radiograph (Figure 1a) showed an ischiopubic spur in conjunction with a substantial ischiofemoral bar that had effectively fused the right hip. He also had ectopic ossification deformities of the spine, left shoulder (Figure 1b) and thoracic cage (Figure 1c).

He initially presented at 6 years of age with a palpable exostosis of the proximal right tibia. Over the next 3 years he developed several haematomas with subsequent calcification often following minor trauma. By the age of 9 years, at which time the diagnosis was made, calcification was present at multiple sites and corresponding joint mobility was reduced. A maternal history of Addison's disease had prompted the exclusion of autoimmune disorders. Repeated coagulation screens were also normal. The diagnosis was eventually made on the basis of short hypoplastic halluxes (Figure 2) which are the classical dysmorphic markers of this condition. This was supported by biopsy, the tissue showing features of fibroblastic proliferation. Unfortunately the biopsy site was further affected by ossification. He was commenced on a course of etidronate and physiotherapy.

It was decided to proceed with limited surgery to excise the ischial spur. The patient accepted the possibility of recurrence or exacerbation following the procedure, the rationale being that any subsequent ossification was unlikely to form such a sharp spur (Figure 1a). Following surgery discomfort has been dramatically reduced and he is able to sit without pain.
Should non-steroidal anti-inflammatory drugs be given to neurosurgical patients?
Authors: Sebastian Joseph , Hunt Katharine
Published: May 2014

Non-steroidal anti-inflammatory drugs (NSAIDs) feature prominently in the armoury for treating postoperative pain. Importantly, they help to reduce the necessity for, and hence the side effects of, opioid analgesics.
Targeting smokers in the hospital setting
Authors: Stansby Gerard , McCaslin James
Published: May 2014

Smoking cessation is a government priority to reduce the future burden of smoking-related disease. Targeting smokers in the secondary care setting is often overlooked, and should be part of a hospital doctor's role in treating these patients.
Cutaneous manifestations of lung disease
Authors: Chew Ali-Lean , Creamer Daniel
Published: May 2014

Skin disease may be associated with pulmonary disease in a variety of ways. This article describes cutaneous manifestations of selected pulmonary conditions and other associations between the skin and lung.
Cutaneous T-cell lymphoma
Authors: Perez Alfonso , Whittaker Sean
Published: May 2014

Primary cutaneous T-cell lymphomas include a wide variety of lymphoproliferative disorders with disease confinedto the skin at the time of presentation. This article reviews this heterogeneous condition focusing mainly on mycosis fungoides, Sezary syndrome and primary cutaneous CD30-positive lymphoproliferative disorders.
Chronic pelvic pain: the enigma of gynaecological practice
Authors: Sundarapandian Vani , Shankar Meena , Konje Justin C
Published: May 2014

Chronic pelvic pain is a debilitating condition with a complex and poorly understood aetiology. It is an important cause of chronic ill health and a major reason for time off work. This review focuses on how a systematic approach to its management significantly reduces morbidity and the consequences thereof.
Unilateral ocular myasthenia gravis in an acute medical take: is a Tensilon test useful?
Authors: McCarthy D , Patel C , Ahlquist JAO , Stephens JW
Published: May 2014

A 42-year-old woman presented to an eye clinic with a 2-week history of diplopia. Examination revealed signs of a right sixth nerve palsy. A computed tomography (CT) brain scan was normal. Six weeks later she presented during the acute medical take with increasing diplopia, a drooping right eyelid and unsteadiness. Direct questioning revealed that the drooping became progressively worse throughout the day. She had no relevant past medical history or any regular medication. Examination revealed a partial right ptosis and signs of right third, fourth and sixth nerve palsy. Diplopia on binocular vision resolved on patch testing; neurological examination was otherwise unremarkable, with no evidence of limb weakness.

A magnetic resonance imaging scan of the brain and CSF examination were unremarkable. Ocular myasthenia was suspected, anti-acetylcholine receptor antibody test was requested, and a Tensilon test was performed with full resuscitation equipment available. Following the administration of the test dose (2 mg) of intravenous edrophonium (Tensilon) a visible improvement in the right ptosis was observed. Subsequent administration of a further 8 mg edrophonium yielded more marked improvement, with complete correction of the right ptosis (Figure 1) and a subjective decrease in diplopia on right gaze. A diagnosis of unilateral ocular myasthenia gravis was made on the basis of the clinical picture and the positive Tensilon test.

A neurological opinion was sought and the patient commenced on pyridostigmine 60 mg four times a day. Further investigations included a CT scan of the thorax which revealed a 2 cm retrosternal mass, compatible with thymic hyperplasia. Five weeks after the positive Tensilon test, a report of strongly positive anti-acetylcholine receptor antibodies (anti-acetylcholine receptor antibodies >8 nmol/litre, normal range 0–0.5 nmol/litre) was received. The diplopia continues to improve and the patient has regular follow up.
Acute hot joint
Authors: Mathews Catherine J , Coakley Gerald
Published: May 2014

The acute hot joint has a broad differential diagnosis. It presents to a wide spectrum of practitioners in primary and secondary care, many of whom may be unfamiliar with the management of musculoskeletal disease. This review discusses the most serious cause of the hot joint, sepsis, and discusses the other less worrying, but more frequent, diagnoses.
Should trainees conduct research to assess the effects of drugs on patients?
Authors: Goebel Andreas
Published: May 2014

The world of drug trials has changed dramatically in recent times. In the past, it sufficed to pose a clinical question (for example: ‘Does morphine cause less postoperative nausea and vomiting than fentanyl?’), then formulate a proposal for prospective evaluation. Subsequent submission of this proposal to ethics and then research and development committees was usually relatively straightforward, such that it was often possible to start a project within 3 months of formulating the original idea.
Perils of pericardiocentesis
Authors: SH Ng Calvin , Wan Song , Yim Anthony PC , Arifi Ahmed A
Published: May 2014

A 51-year-old woman underwent elective cardiac surgery for the closure of an atrial septal defect. The surgery was uneventful and the patient was making good progress. On postoperative day 6, she developed shortness of breath, tachycardia and raised jugular venous pressure. Transthoracic echocardiography noted a high pulmonary artery pressure of 65 mmHg (preoperative 78 mmHg), and a 3 cm pericardial effusion with tamponade effect on the right atrium.

Pericardiocentesis under echocardiography guidance was performed without difficulty. The drainage from the pericardial catheter was good, and the patient noted immediate improvement in her dyspnoea. However, shortly following the procedure, she complained of increasing breathlessness, dizziness and became visibly pale. The oxygen saturation dropped rapidly from 96% to 53% and then became unrecordable. Systolic blood pressure fell to 52 mmHg and she became severely drowsy (Figure 1). The differential diagnosis included iatrogenic pneumothorax (tension) and myocardial injury. The bedside pericardiocentesis collection bag was then noted to be full to the bursting point of 2 litres with heavily blood-stained fluid. The draining tube was clamped, the bed was put to head down position, resuscitation with oxygen via rebreathable mask, and 1 mg intravenous adrenaline was administered. Intravenous colloid totaling 1.5 litres was actively squeezed into the patient through large intravenous catheters. At that point, the thought of elevating and inverting the pericardiocentesis collection bag to allow return transfusion of its contents did briefly cross the authors' minds. Fortunately, the patient swiftly regained consciousness, but her haemoglobin had fallen from 9.8 to 4.7 g/dl. She was rushed to the operating theatre for emergency surgery, which revealed the pericardiocentesis catheter had punctured and was lying within the right ventricle (Figure 2). The right ventricle was repaired with 3/0 prolene pleget and the pericardial blood clots were removed. The patient recovered well and was discharged 4 days later.
Renal vein thrombosis in a renal allograft
Authors: Summers SA , Partridge W , Laing C , Cook PR
Published: May 2014

A 61-year-old woman with end-stage renal disease secondary to post-streptococcal glomerulonephritis received a live related transplant from her brother in 1980. For 23 years she had no medical or nephrological problems and had excellent transplant function with creatinine ranging from 60–80 μmol/litre. In 2004 a cystic lesion was noted on her right breast, biopsy of which revealed a high grade B cell non-Hodgkin's lymphoma.

Ten days before admission she noticed pain over her transplant kidney and over the ensuing days she reported passing progressively less urine. Initial blood tests were suggestive of pyelonephritis with a neutrophil leucocytosis (white cell count 19.1×109 cells/litre) and acute phase response (C-reactive protein 58 mg/litre). Her creatinine was 368 μmol/litre. An ultrasound scan of the transplant kidney demonstrated globally poor perfusion and the renal vein could not be demonstrated (Figure 2). This was in stark contrast to a scan performed 1 year earlier (Figure 1). A transplant nephrectomy was performed uneventfully that night and confirmed the diagnosis of renal vein thrombosis.
The superficial veins of the leg
Authors: Ellis Harold
Published: May 2014

The superficial veins of the leg – the great (long) and small (short) saphenous veins and their tributaries – are of great clinical importance. They are used as vascular conduits and patches (in both instances the great saphenous is more commonly used), and, of course, they are both subject to the development of varicosities (varicose veins). They come to our attention in the diagnosis and management of this all too common condition.
Radial arterial lines
Authors: Hignett Rachel , Stephens Robert
Published: May 2014

Intra-arterial cannulae in the radial artery are used for invasive arterial blood pressure (IABP) measurement and for collection of blood for analysis. The radial artery is the preferred site for insertion because of low complication rates. Arterial lines are the gold standard for accurate blood pressure (BP) measurement. They may be used in intensive care units (ICU) and high dependency units and in anaesthetized patients undergoing surgical procedures. An understanding of basic principles enables arterial lines to be used safely in these settings.
Fractures around the knee
Authors: Young Claire F , Haddad Fares
Published: May 2014

The proximal tibia forms the distal surface of the knee joint. The medial plateau is larger and concave anteroposteriorly and mediolaterally. The lateral plateau is smaller, higher and convex in both anteroposterior and mediolateral directions. The central non-articular area comprises the tibial spines with the anterior cruciate ligament taking origin from the anterior spine.
Management of epistaxis
Authors: Tassone Peter , Syed Irfan
Published: May 2014

With changes in working hours it is becoming more common for the on-call ear, nose and throat (ENT) doctor to be non-resident. There is also a trend for junior doctors to provide cover for a number of specialities on-call. It is therefore important for foundation doctors to understand the basics in management of the major ENT emergencies.
Preregistration house officer skill and competency assessment through questionnaires
Authors: Watmough Simon , Ryland Ida , Taylor Reverend David CM , Garden Anne
Published: May 2014

In 1996 the University of Liverpool reformed its medical course from a very traditional lecture-based curriculum to an integrated problem-based learning curriculum. This article summarizes the results of questionnaires sent to both traditional and reformed curricula Liverpool graduates asking them to assess their competencies.
Placental haematomas in early pregnancy
Authors: Johns Jemma , Jauniaux Eric
Published: May 2014

A common ultrasound finding in women with threatened miscarriage is a subchorionic bleed or intrauterine haematoma. This review examines the available data on the incidence and clinical significance of these haematomas.
Antibiotics on the intensive care unit: continuous infusion or intermittent bolus?
Authors: Szawarski Piotr
Published: May 2014

Sepsis is common among patients admitted to hospital and especially to the intensive care unit (ICU). Early antibiotic administration forms the mainstay of treatment. Correct antibiotic dosing, optimal duration of treatment, monitoring of levels when appropriate and avoidance of drug interactions are vital in achieving appropriate tissue levels of antibiotics. Secondary objectives include avoiding toxicity and prevention of emergence of antibiotic resistance (Kollef, 2001). Given altered pharmacokinetics and a high prevalence of resistant pathogens among the severely sick ICU patients, should infusions of antibiotics be used or should tried and tested intermittent bolus regimens be adhered to? Can that impact on clinical outcome?
Management of recurrent colorectal cancer with positron emission tomography
Authors: Haji Amyn
Published: May 2014

The use of positron emission tomography, on its own and in combination with computed tomography, has been integrated into the management algorithm of patients with suspected recurrence of colorectal cancer. This article looks at the biological basis of positron emission tomography, its clinical advantages and disadvantages.
Clinical evaluation of vaccines for pandemic influenza H5N1
Authors: Pareek Dr Manish , Stephenson Dr Iain
Published: May 2014

Avian influenza (H5N1) was first associated with human respiratory disease in Hong Kong in 1997. In 2004 the virus re-emerged among poultry and migratory birds in Asia and has spread into Europe and Africa, raising concerns that an H5 pandemic is imminent.
Practical management of common atrial arrhythmias 1: cardioversion
Authors: Fitzpatrick Adam P , Earley Mark , Petkar Sanjiv , Diab Ihab , Fox David , Williams Paul
Published: May 2014

This is the first in a series of four practical articles highlighting the important management steps for non-cardiologists and non-cardiac electrophysiologists dealing with patients with atrial fibrillation and common atrial flutter. This article will deal with care pathways and management principles for cardioversion of atrial arrhythmias.
Interferon-alpha in the management of patients with Behçet's disease
Authors: Yang David SF , Taylor Simon RJ , Lightman Sue L
Published: May 2014

Behçet's disease is a multisystem vasculitis which often leads to serious complications. Current treatment is largely based on non-specific immunosuppression, but interferon-alpha may be able to induce disease remission. This article reviews what is known about interferon-alpha and its potential as a treatment for Behçet's disease.
Lessons learnt from the reorganization of maternity services
Authors: Arulkumaran S , Wells M , Boddington R
Published: May 2014

Recent experiences of working with maternity services in difficulty have highlighted the need for regular surveillance of clinical governance parameters, using a performance chart or ‘dashboard’ to monitor and assure quality and safety.
HIV and the kidney
Authors: Post Frank A , Hendry Bruce M
Published: May 2014

Kidney disease is an important complication of HIV infection. Antiretroviral therapy has dramatically improved the life expectancy of HIV-infected patients with end-stage renal disease. Renal replacement therapy, including kidney transplantation, should be offered to HIV-positive patients.
Vertigo: clinical assessment and diagnosis
Authors: Macleod David , McAuley Duncan
Published: May 2014

Dizziness is a common presenting complaint to emergency departments and medical admission units; the key is to differentiate between central and peripheral causes of vertigo. This review focuses on bedside assessment of vertigo and, by looking at patterns of symptoms and signs, provides guidance as to when to suspect a central cause.
The changing face of medical negligence law: from Bolam to Bolitho
Authors: Sooriakumaran Prasanna
Published: May 2014

The Bolam test was the standard by which medical negligence cases were judged. However, recently, the Bolitho case has resulted in a shift away from Bolam, with significant effects for all future negligence suits. Doctors need to have a thorough understanding of these issues in order to practice successfully in the current litiginous climate.
Catastrophic antiphospholipid (Asherson's) syndrome
Authors: Cervera Ricard , Asherson Ronald A
Published: May 2014

Catastrophic antiphospholipid syndrome is characterized by multiple organ involvement developing over a very short period of time, histopathological evidence of multiple small vessel occlusions, and laboratory confirmation of the presence of antiphospholipid antibodies. Knowledge of its treatment is vital as the outcome can be lethal.
Making the most of the doctors' mess: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

The doctors' mess has always been an integral part of medical culture. It stems back to the days when doctors were on duty for long hours, but not necessarily actually working. Therefore, they had to have somewhere where they could retreat while waiting to be called. It was always a haven of relative tranquillity where you could take your break away from the wards. The New Deal (NHS Management Executive, 1991) says that there is supposed to be a doctors' mess away from clinical areas, separate from any dining room. In this day and age of shifts, some would argue that the mess is an anachronism. However, there is still a place for it.
How to make the most of your imaging department
Authors: Sbano Hela , Harvey Chris
Published: May 2014

Radiology is a rapidly changing and expanding speciality with little formal training in its different modalities during medical school. Very few patients will be seen in a hospital without requiring some form of imaging. Indeed a significant proportion of the foundation doctor's workload involves organizing and interpreting diagnostic tests carried out within the imaging department.
Ultrasound in the acute abdomen
Authors: Harvey Chris J , Hart Jonathan L , Lloyd Claire R
Published: May 2014

Ultrasound is widely used as the first-line imaging modality in the assessment of the acute abdomen and in trauma (Marincek, 2002). Ultrasound has the advantages of low cost, real-time bedside imaging, accessibility, portability, lack of ionizing radiation, noninvasiveness, and multiplanar imaging. Ultrasound is also uniquely interactive and by asking the question ‘Where does it hurt?’ frequently directs the operator to the pathology. Doppler allows the detection of alteration in vascularity which may be a feature of inflammation, trauma and neoplasia.
Arthroscopic treatment of femoroacetabular impingement
Authors: Tzaveas Alexandros , Villar Richard
Published: May 2014

Femoroacetabular impingement is a recently recognized pathological entity. Arthroscopic treatment, as a modern and minimally invasive technique, has become an attractive and promising treatment.
Early social communication interventions for autism
Authors: Aldred Catherine R , Green Jonathan
Published: May 2014

Given the impact of autism as a disorder there has been surprisingly little rigorous research into its treatment. Positive findings from pilot trials of parentchild interventions have led to funding of the Pre-school Autism Communication Trial, which will be an important step in developing an evidence base for early intervention.
Subcutaneous endometrial deposit: an unusual cause of right iliac fossa pain
Authors: A Hodnett Philip , McSweeney Sean E , Bogue Conor , Kelly Denis , Redmond H Paul , Maher Michael M
Published: May 2014

A 35-year-old woman presented to hospital with a 7-day history of worsening right iliac fossa pain. The patient reported a 7-month history of intermittent right iliac fossa pain, associated with a palpable nodule in the right iliac fossa. This nodule showed apparent increase in size and tenderness, on palpation, during her menses. Twelve months previously, the patient had undergone a caesarean section.

Plain film of the abdomen was unremarkable. Ultrasound examination using a high frequency probe (7.5 MHz) showed a 2 cm nodule in the subcutaneous fat of the anterior abdominal wall superficial to the right rectus abdominus musculature which was hypoechoic relative to adjacent subcutaneous fat and of inhomogenous echotexture with low level internal hyperechoic echoes. Doppler interrogation showed a single vascular pedicle entering the mass at the periphery (Figure 1a). The margins were slightly irregular. There were no ultrasound features of incisional hernia. Computed tomography with intravenous and oral contrast revealed a 2 cm solid, slightly spiculated nodule, located in the subcutaneous fat without involvement of the anterior abdominal wall musculature and parallel to the Pfannensteil incision (Figure 1b). The nodule was hyperdense compared to rectus abdominus musculature following intravenous contrast enhancement, measuring approximately 80 Hounsfield units. There was minimal stranding of the surrounding subcutaneous fat. Differential diagnosis included haematoma, abscess, sebaceous cyst, enlarged lymph node, desmoid tumour, and malignant tumours such as malignant melanoma, or metastatic breast or renal cell carcinoma. Percutaneous biopsy using a 17 gauge coaxial needle system was performed under ultrasound guidance (Figure 2a). Histopathological examination confirmed endometrioma (Figure 2b).
Rotator cuff tears in athletes
Authors: Auplish Sunil , Funk Lennard
Published: May 2014

A rotator cuff tear in the athlete is different to the classic, more common cuff tear in the elderly. It is either a traumatic or an overhead, overuse injury in high functional demand patients, so it requires more active and earlier intervention, suspicion of injury, and specific assessment and treatment to enable return to the pre-injury level of sport.
Assessing learning needs
Authors: McKimm Judy , Swanwick Tim
Published: May 2014

Clinical teachers and educational supervisors work with a range of students and trainees on different programmes. Learners from diverse backgrounds have different learning needs which can be difficult to assess. Teachers who pay attention to individual learners' needs will help learners get the most from their training. This can be enhanced through the use of tools such as professional development plans and formal assessments.
Setting learning objectives
Authors: McKimm Judy , Swanwick Tim
Published: May 2014

Clinical teachers may be involved with students and trainees on a variety of different programmes who are required to achieve a diverse range of learning outcomes or objectives. Teachers who better understand the relationship between learning outcomes and the planning and delivery of educational activities can help learners receive more from their education and training.
Understanding the metabolic response to sepsis
Authors: Sritharan Kaji , Abu-Habsa Mamoun
Published: May 2014

Systemic inflammatory response syndrome (SIRS) is the response of the body to an infection or injury (e.g. pancreatitis, burns, multiple trauma or haemorrhagic shock) (Table 1). When SIRS occurs in the presence of a presumed or confirmed focus of infection, the term sepsis is used to describe the syndrome (Levy et al, 2003). Other terms such as severe sepsis and septic shock represent further categorization based on haemodynamic and biochemical parameters noted on presentation. These have important prognostic implications with worse respective outcomes (Brealey and Singer, 2000; Levy et al, 2003).
Pleural mesothelioma presenting as recurrent pneumothoraces
Authors: Bright-Thomas Rowland J , Ahmed Rizwan Y , Pearson Stanley B , Muers Martin F , Luksza Andrew R , Turkington Peter M
Published: May 2014

A 79-year-old man presented with a 2-week history of increasing dyspnoea and reduced exercise tolerance. He was previously fit and well with no medical history of note. He was an ex-smoker of 25 pack years. Examination findings were of a right pneumothorax which was confirmed by chest X-ray. A chest drain was inserted and the lung expanded fully. He was discharged after 2 days but was readmitted 6 weeks later complaining of recurrent breathlessness over a 24-hour period and chest X-ray again revealed a large right pneumothorax. Once again a chest drain was inserted with good result.

Four weeks later the problem recurred. An occupational history revealed that he had worked for 40 years as a shipwright in a shipyard with regular asbestos exposure. A right thoracotomy and pleurectomy was performed – the pleura appeared normal macroscopically but histology demonstrated pleural infiltration by an epithelial-type malignant mesothelioma. He died 4 months after pleurectomy in an advanced cachectic state. Post-mortem confirmed a malignant mesothelioma.
Has Lemierre's syndrome become a bacteriological diagnosis?
Authors: Hill Uta G , Vallis Martin P , Cotter Tim , Hegarty Michael A
Published: May 2014

A 35-year old woman presented to her GP with a 2-day history of sore throat, myalgia and fever. A provisional diagnosis of acute viral pharyngitis was made and conservative treatment with analgesia recommended. However, her symptoms increased in severity with the addition of severe pain in the left thigh and hip necessitating hospital admission 5 days later.

On examination, she was tachycardic, tachypnoeic and hypotensive with basal crepitations in the right lung and reduced mobility of the left hip. She had a neutrophil leucocytosis (33×103/litre) and a high C-reactive protein level of 230 g/litre. The chest X-ray showed consolidation of the right middle lobe with multiple nodular infiltrates throughout both lung fields. Aspiration of the hip joint showed numerous white cells but the culture was sterile. Severe community-acquired pneumonia and infective arthritis of the hip were suspected and she was treated with benzylpenicillin, clarithromycin and flucloxacillin, but 36 hours following admission, her condition deteriorated because of the sepsis and she was transferred to the intensive care unit for ventilatory and inotropic support.

Culture of the blood taken on admission yielded an anaerobic gram-negative rod which was subsequently identified as Fusobacterium necrophorum by the reference laboratory. As it was sensitive to penicillin, metronidazole and clindamycin, the antibiotic treatment was changed to high doses of all three. The pneumonia resolved, inflammatory markers returned to normal and the mobility of her left hip improved; 14 days after admission, she was well enough to be discharged home with oral amoxicillin and metronidazole for a further 4 weeks and appropriate outpatient follow-up.
Assessment and treatment of trigeminal neuralgia
Authors: Zakrzewska Joanna M
Published: May 2014

Patients with trigeminal neuralgia, a rare facial neuropathic pain, present to both medical and dental specialists. International guidelines on diagnosis and management of trigeminal neuralgia provide a useful framework for this article.
Interviews: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Interviews are a frequent experience for doctors in training who have no choice but to keep changing jobs. Some people sail through them undaunted, whereas others find them intimidating and never get used to them.
Maximizing your career potential
Authors: Goodyear Helen M , Jones Melanie
Published: May 2014

In the last few years, the NHS has undergone a frantic pace of change and reform. These include the Modernising Medical Careers (MMC) reorganization of medical training (Department of Health, 2004), introduction of the European Working Time Directive, Darzi centres and a community focus to health-care provision (Department of Health, 2009). These affect all career pathways although the exact impact of moving care into the community upon careers is yet to be seen. In addition, there is now much more overlap between traditional ‘medical’ and ‘surgical’ specialties, e.g. cardiology and radiology are becoming increasingly interventional. There is also increased regulation of doctors throughout their careers with revalidation and Postgraduate Medical Education and Training Board requirements which must be satisfied to gain entry to the specialist register, a prerequisite to being a consultant or GP.
Dealing with switchboard: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Switchboard operators are hard-working and busy, with much responsibility, but they are relatively low-paid. It is important to bear with them and be polite to them. They can be very helpful to you when necessary.
Ophthalmic manifestations of giant cell arteritis
Authors: Waqar Salman , Salman Rabia , Sleep Tamsin
Published: May 2014

This article reviews the ophthalmic manifestations of giant cell arteritis. An overview of giant cell arteritis as a disease spectrum is presented with special emphasis on the ophthalmic involvement.
Dyslexia
Authors: Smythe Ian
Published: May 2014

Despite over 100 years of research, dyslexia continues to be controversial because of the failure to agree on a definition and underlying causes, as well as the funding implications. This article identifies evidence-based factors that influence the development of reading and may cause difficulties, and the areas of continuing controversy.
Medical futility: a commonly used and potentially abused idea in medical ethics
Authors: Thompson Richard J
Published: May 2014

Hospital doctors frequently invoke the idea of medical futility in making decisions regarding end-of-life care. This concept of futility will be reviewed and the differing definitions and how it relates to other important principles in biomedical ethics discussed.
Do not attempt resuscitation orders, ethics and the Mental Capacity Act
Authors: Thomas Ruth H , Schuster-Bruce Martin
Published: May 2014

‘Do not attempt resuscitation’ orders are common in hospital medicine practice. With reference to the guidance issued by the General Medical Council, this article offers a framework that will be useful when making these sometimes difficult decisions.
The cost of postgraduate training
Authors: Pawa Nikhil , Vanezis Andrew , Maula Asiya
Published: May 2014

The Modernising Medical Careers and European Working Time Directive have led to significant changes in the working patterns and training of junior doctors. This article seeks to explore the hidden costs incurred by trainees of various specialties and grades for postgraduate training.
The role of lumbar disc replacement in the surgical management of low back pain
Authors: Freeman Brian JC
Published: May 2014

Spinal fusion has long been the standard surgical treatment for degenerative disorders of the spine, but clinical outcomes are often unpredictable. Lumbar disc replacement allows removal of the pain source while preserving motion. This article explores the role of lumbar disc replacement in the surgical management of low back pain.
Imaging incidental pulmonary nodules
Authors: Pollentine Adrian , Edey Anthony J
Published: May 2014

The incidental nodule is an increasingly common clinical conundrum. This article outlines the characteristics that allow differentiation of benign and malignant pathologies and discusses strategies for their follow up and management.
Fractional flow reserve in the assessment of coronary artery lesions
Authors: Cockburn James , Blows Lucy , Williams Mark , Munir Shahzad , de Belder Adam , Hildick-Smith David , Holmberg Stephen
Published: May 2014

Fractional flow reserve is a vital tool for assessing the functional significance of a coronary stenosis, with higher sensitivity and specificity relative to non-invasive techniques. This article reviews the basic principles and applications of fractional flow reserve measurement, potential pitfalls and areas of controversy.
Electrophysiology and ablation of arrhythmias
Authors: Lim P Boon , Robb Daniel , Lambiase Pier D
Published: May 2014

Major advances in diagnosis and treatment of arrhythmias have created the subspeciality of cardiac electrophysiology. This article reviews supraventricular and ventricular arrhythmias and outlines the indications and process of electrophysiological testing, arrhythmia mechanisms and their treatment by catheter ablation.
Communication in early pregnancy ultrasound: avoiding misunderstandings
Authors: Magowan Brian A , Madhra Mayank
Published: May 2014

Pregnant women in the UK are usually offered at least two ultrasound scans during their pregnancy. While these almost certainly cause no physical harm to the baby, communicating the findings to the parents, whether there is a problem or not, carries real potential for confusion, worry and perhaps unnecessary intervention.
Biologic therapies in dermatology
Authors: Chularojanamontri Leena , Griffiths Christopher EM
Published: May 2014

Biologic therapies, the anti-cytokines in particular, have proved to be a significant addition to the dermatologist’s armamentarium for the management of severe skin disease. This article summarizes the mechanism of action, dosage, approved indications, off-label uses and the future of biologic therapies in dermatology.
Where next for the Cancer Drugs Fund?
Authors: Joffe Johnathan
Published: May 2014

The Cancer Drugs Fund is a unique national fund that supports new therapies for malignant disease that would normally be unavailable through usual funding mechanisms. This article looks at the origins, the effectiveness and the future of the fund.
Quality improvement in low resource settings: an Ethiopian experience
Authors: Bashford Tom
Published: May 2014

Improving surgical and anaesthetic mortality in the developing world is a global health priority. Quality improvement processes have a role to play in addressing this need and are applicable to low-resource settings despite difficulties in their implementation. International initiatives to reduce perioperative mortality can be focussed to support interventions at the level of individual departments, but this requires integration with existing local systems and an understanding of the specific needs of the institutions concerned. There is a small but growing evidence base for quality improvement in low resource settings, but this needs to be locally accessible to allow self-sustaining evidence-based quality improvement.
LOREC: the English Low Rectal Cancer National Development Programme
Authors: Dayal Sanjeev , Moran Brendan
Published: May 2014

Low rectal cancer is a challenging disease. Recent evidence has shown that the treatment of low rectal cancer can be optimized. The purpose of the English Low Rectal Cancer National Development Programme is to enhance multidisciplinary colorectal cancer team knowledge and skill to improve outcomes of this complex condition.
Hypomagnesaemia: clinical relevance and management
Authors: Demssie Yared N , Patel Leena , Kumar Mohit , Syed Akheel A
Published: May 2014

Hypomagnesaemia is a relatively common yet frequently under-diagnosed and poorly managed electrolyte disorder. Untreated hypomagnesaemia could result in severe life-threatening neurological and cardiac complications. This review discusses the clinical relevance, commonly encountered causes and management of hypomagnesaemia.
Improving patient handover between teams using a business improvement model: PDSA cycle
Authors: Luther Vishal , Hammersley Daniel , Chekairi Ahmed
Published: May 2014

Background

Medical admission units are continuously under pressure to move patients off the unit to outlying medical wards and allow for new admissions. In a typical district general hospital, doctors working in these medical wards reported that, on average, three patients each week arrived from the medical admission unit before any handover was received, and a further two patients arrived without any handover at all. A quality improvement project was therefore conducted using a ‘Plan, Do, Study, Act’ cycle model for improvement to address this issue.

Method

P – Plan: as there was no framework to support doctors with handover, a series of standard handover procedures were designed. D – Do: the procedures were disseminated to all staff, and championed by key stakeholders, including the clinical director and matron of the medical admission unit.

Results

S – Study: Measurements were repeated 3 months later and showed no change in the primary end points. A – Act: The post take ward round sheet was redesigned, creating a checkbox for a medical admission unit doctor to document that handover had occurred. Nursing staff were prohibited from moving the patient off the ward until this had been completed. This later evolved into a separate handover sheet. Six months later, a repeat study revealed that only one patient each week was arriving before or without a verbal handover. Conclusions: Using a ‘Plan, Do, Study, Act’ business improvement tool helped to improve patient care.
The educational value of ward rounds in conveying knowledge and developing trainees' clinical skills
Authors: Laskaratos Faidon-Marios , Gkotsi Despoina , Panteliou Eleftheria , Epstein Owen
Published: May 2014

The ward round is a complex task, which has been described as ‘walking a tightrope’. This article reviews the available literature on the educational value of ward rounds in conveying medical knowledge and developing trainees' history taking and clinical examination skills.
Image-guided neurosurgery
Authors: Wadley John , Kitchen Neil , Thomas David
Published: May 2014

Accurate localization of lesions and minimization of trauma to the surrounding brain are of paramount importance in intracranial surgery. Stereotactic frame systems provide highly accurate methods of localization, which has been further enhanced by the introduction of sophisticated imaging modalities, and recently by the development of interactive image-guided neurosurgical technology.