bluuebunny/crossref_metadata_2025 huggingface dataset:
Boerhaave's syndrome complicating status epilepticus
Authors: Bailey Cheron , Burke Siun
Published: May 2014

A 40-year-old woman with a history of absence seizures presented to the accident and emergency department in status epilepticus following generalized tonic clonic seizures. The patient was drowsy (Glasgow Coma Scale 10/15) and had vomited several times during the preceding 24 hours. The seizures were controlled with lorazepam and phenytoin. She was sedated and intubated uneventfully and transferred to the radiology department for a computed tomography brain scan. The computed tomography scan of the brain was normal; she had no further seizures and was extubated, with a Glasgow Coma Scale of 12/15 post extubation. She had two further episodes of vomiting following extubation.

Two hours later she developed respiratory distress associated with a high-pitched voice, stridor, and massive facial and upper body swelling. She was intubated once again, this time there was a limited view of the airway secondary to soft tissue swelling. Chest X-ray and computed tomography of the thorax revealed massive subcutaneous emphysema and bilateral pneumothoraces (Figures 1 and 2), which were decompressed. The computed tomography scan also revealed a focus of air within the mid-third of the oesophagus representing an oesophageal perforation (Figure 2). The patient was managed conservatively with intravenous antibiotics and nasojejunal feeding. Ten days later she was weaned from mechanical ventilation and transferred to the ward. She was discharged home 1 month after admission.
The clinical examination of the thyroid gland
Authors: Ellis Harold
Published: May 2014

Accurate examination of a thyroid swelling requires a good knowledge of its anatomy, and appreciation of its congenital anomalies is aided by an understanding of its embryological development.
Extensive pneumocephalus after nose blowing: an unusual cause of severe headache
Authors: Rial Carlos Lojo , Oldfield Matthew
Published: May 2014

A 54-year-old Afro-Caribbean woman presented to the emergency department with a 1-day history of severe headache and general malaise. The pain started suddenly after blowing her nose, was frontal in location and became rapidly severe and throbbing in nature. There were no symptoms that would suggest orthostatic headache, no dizziness or vertigo, no visual or auditory disturbance and no neurological weakness. The pain was worse on movement, coughing and bending and was associated with photophobia, nausea and the development of a clear nasal discharge. Previous medical history was unremarkable; there was no history of sinus or nasal problems, no recent headaches or migraines, no visual abnormalities and no life history of head injury or nasal trauma. Examination was largely unremarkable; on arrival her Glasgow Coma Scale was 15 and she was apyrexial with no meningism or photophobia. No evidence of intracranial hypertension was found. There was slight skull tenderness on palpation over the frontal sinus, but the remainder of her neurological (including cranial nerve) examination and general examination was unremarkable. Biochemical (electrolytes, liver function, glucose, calcium) and haematological tests revealed a mild neutrophilia (12.5×109cells/litre) but were otherwise normal.

Over the course of the admission, she became increasingly unwell with increasing nausea, further vomiting and fluctuant levels of consciousness. A computed tomography scan of the head showed an extensive pneumocephalus extending to the foramen magnum with marked sulcal and basal cistern effacement (Figure 1 and 2). Bone windows revealed a hole in the roof of the right sphenoid sinus. The clear discharge was found to be CSF and sent for microbiology analysis.

Prophylactic cefotaxime and metronidazole antibiotics were commenced and she underwent endoscopic endonasal exploration. The bony defect in the roof of the right sphenoid and the CSF leak were identified. The dural defect was closed with a fascia lata graft and fat harvested from the thigh.

Four days after the operation, she became increasingly confused and a repeat computed tomography scan showed new hydrocephalus. A lumbar puncture was performed and showed an opening pressure of 43 cm (5–20 cm). Two days later she underwent ventricular-peritoneal shunting. She eventually made a full recovery. It is still uncertain whether the hydrocephalus was secondary to a disruption of the sinus by the air pressure in the skull or whether there was hydrocephalus before the events leaking through the ethmoidal bone, suggesting the possibility of spontaneous CSF leak syndrome complicated with pneumocephalus (Schievink, 2000).
Sydney Ringer: physician, physiologist and pharmacologist
Authors: Ellis Harold
Published: May 2014

This year marks the centenary of the death of Sydney Ringer, whose name crops up daily in clinical hospital practice. I have often asked my new entries of anatomy demonstrators at Guy's: ‘have you seen Ringer's solution used?’, to which most of them reply in the affirmative. I follow this up by asking if any of them know its composition and I am usually met with a profound silence. In fact, using modern units, it contains Na 148, K 4, Ca 2 and Cl 156 mmol/litre. Today, Ringer's lactate is often used, which is made up of Na 130, K 4, Ca 2, Cl 109 and lactate 28 mmol/litre. This is very similar in composition to the more commonly used Hartmann's solution. Finally, I ask if anyone can tell me who Ringer is or was, and this, to date, I have invariably found to be a strictly no-go area.
Integrating feedback into medical education
Authors: Burr Steven , Brodier Elizabeth
Published: May 2014

Maximizing the potential of feedback requires being receptive to suggestions for change, adapting feedback according to different learning styles, and making the most of new developments. This article provides a foundation in the theory of modern medical education for those receiving or giving feedback at any level.
Lethal obstructive jaundice: a diagnosis not to be missed
Authors: Durai Rajaraman , Smedley Frank
Published: May 2014

An ultrasound scan of a 60-year-old man with obstructive jaundice demonstrated sludge in the gall bladder and a dilated biliary tree. He underwent an endoscopic retrograde cholangiopancreatography and biliary stenting. He experienced poorly localized abdominal pain and a magnetic resonance cholangiopancreatography demonstrated normal biliary and pancreatic ducts.
Autism spectrum disorders
Authors: Rao S , Salmon G
Published: May 2014

The term autism spectrum disorder refers to a constellation of symptoms involving impairments in social interaction and communication, and restricted, repetitive behaviours and interests. This article highlights the disorder among professionals who may come into contact with people with autism spectrum disorder.
Mentoring
Authors: Viney Rebecca , McKimm Judy
Published: May 2014

Many clinical teachers and supervisors may be required to act as a mentor for a colleague, either informally or as part of a formal scheme. The skills required of an effective mentor are similar to those of a coach, involving career advice, goal setting and support, and can be learned and applied in a range of work-based situations.
Medical mystery: an unusual cause of anaemia
Authors: Pasha Yasmin , Banks Matthew
Published: May 2014

An 82-year-old Indian man presented with a month's history of increasing lethargy, shortness of breath and 2 kg weight loss. No significant past illness was elicited, specifically no history of change in bowel habit, malaena, haematemesis, fever, abdominal or chest pain. At admission, he was on oral iron therapy only and was a non-smoker who rarely drank alcohol. On examination he was pale, haemodynamically stable, with normal cardiorespiratory, abdominal and digital rectal examinations.
Tackling the organ donor shortage effectively: optimism or realism?
Authors: Sheridan Kelda , Farid Shahid , Ahmad Niaz
Published: May 2014

There continues to be a growing disparity between the demand for and supply of organs for transplantation. This article reviews the status of current strategies in the UK to tackle the organ donor shortage.
A rare cause of acute abdominal distension presenting as a surgical emergency
Authors: Alkhalil Mohammad , Brough William A , Hadjiloucas Ioannis
Published: May 2014

A 16-year-old man, who was previously fit and well, presented as an emergency with a 2-day history of abdominal distension. Clinical examination showed a diffusely distended non-tender abdomen dull to percussion.

Plain abdominal X-ray (Figure 1) showed no gas shadows on the right side of the abdomen, suggesting displacement of the intestine to the left side. Abdominal computed tomography scan (Figure 2) showed an enormous, multilocular fluid-filled mass lesion occupying most of the peritoneal cavity and measuring about 152 × 259 × 384 mm with no evidence of a solid component. The intestine was shifted to the left of the abdomen. There was evidence of compression of the retroperitoneal structures, in particular the renal vessels.

Laparotomy and resection of this lesion was undertaken following mobilization of the lesion and division of the feeding vessels. Following excision of the lesion, a large defect in the mesentery of the ascending colon was found on the right side of the superior mesenteric vessels. The lesion contained haemoserous fluid (Figures 3 and 4).

Histological examination of the lesion showed that the multicystic mass was partly lined by a single layer of flattened attenuated cells, fibrous tissue and histiocytes with foreign body-type giant cell reaction associated with cholesterol-like clefts. The fluid in the cyst lumen contained inflammatory cells, red blood cells, proteinaceous fluid and fibrin. The overall histological appearance, supported by immunohistochemistry, favoured the diagnosis of multilocular cystic lymphangioma.

The patient made a good postoperative recovery and was discharged. He underwent surveillance computed tomography scan 6 months following surgery and a surveillance ultrasound scan 12 months following surgery and no evidence of recurrence was found. Further surveillance was planned with clinical review and abdominal ultrasound scans every 6 months for the next 2 years and annually thereafter.
Quality of life issues in aesthetic breast surgery
Authors: Srinivasaiah Narasimhaiah , Drew Philip J , Platt Alastair
Published: May 2014

Health is multi-dimensional. Mortality, morbidity and cost are traditional health indicators, whereas outcomes research relates to quality of life and health-related quality of life. This article reviews the literature on quality of life issues in aesthetic breast surgery, highlighting the concepts of health and health outcome measures.
As rare as false teeth? An unusual cause of dysphagia
Authors: Warriner David , Lee Simon
Published: May 2014

A n 86-year-old man was admitted with acute dysphagia. There was no past medical or drug history of note and examination proved unremarkable. The patient did complain, however, of having lost his false teeth. A chest and lateral neck X-ray revealed the diagnosis: he had swallowed them (Figure 1). The teeth were subsequently removed by nasoendoscopy, repositioned (Figure 2) and his swallow returned to normal. The authors would like to alert readers to this dual pathology of acute dysphagia and missing false teeth.
Current issues in the management of adult faecal incontinence
Authors: Findlay John M , Maxwell-Armstrong Charles
Published: May 2014

Faecal incontinence is a common yet under-reported cause of reduced quality of life. Adequate assessment is crucial in establishing the underlying aetiology and appropriate treatment. This article explores such an assessment, its challenges and the management options for faecal incontinence.
Aspirin sensitivity and the nose
Authors: Douglas GC , Karkos PD , Swift AC
Published: May 2014

There is a well-recognized association of aspirin sensitivity, aspirin-induced asthma, nasal polyposis or sinusitis, known as Samter's triad. This article outlines the pathogenesis and clinical features of this condition and reviews current management options.
Radiology of acute elbow injuries
Authors: Jacob ADC , Khan SHM
Published: May 2014

Elbow injuries are common and usually result from a fall onto an outstretched hand. Plain radiograph is the main modality used in the initial evaluation of these injuries. Clinical assessment can often be limited, especially in children who may be unable to communicate specific complaints and are sometimes difficult to examine reliably. Equally, interpretation of these radiographs is a daunting task as there are multiple ossification centres and normal variations. Therefore a good understanding of normal anatomy and common injury patterns is essential in evaluating elbow radiographs in the acute setting. This article reviews basic developmental anatomy, classical radiological signs and common elbow injuries.
Radiology of acute foot injuries
Authors: Gummow AD , Khan SHM
Published: May 2014

Many traumatic foot injuries can be adequately managed clinically without the use of imaging, even in the presence of metatarsal or phalangeal fractures. However, plain radiographs remain the first-line investigation for traumatic injury to the foot.
Maintaining medical professionalism at the heart of radiology
Authors: Thomas Robert , Biglatid Charlotte , Burke Christopher , Howlett David
Published: May 2014

Professionalism is a complex blend of values, behaviours, ideals and obligations that are hard to define but recognizable when observed. This article reflects on medical professionalism as an entity, reviews the challenges it faces, and considers proactive ways of nurturing the concept of professionalism in radiology.
Venous complications of thoracic outlet syndrome
Authors: Ward Anthony S , Chand Manish
Published: May 2014

Venous complications of thoracic outlet syndrome may be related to the position of the arm, underlying venous stenosis or repeated microtrauma of the vein. Correct management involves imaging, anticoagulation and a combination of interventional radiology techniques with or without surgery.
Anaemia in hospital practice
Authors: Richards Toby
Published: May 2014

This article describes the current problem of anaemia in hospital patients, functional iron deficiency and reviews the current roles of intravenous iron therapy. Attention to and correction of anaemia in the hospital patient may reduce the reliance for blood transfusion, with improvement in the patient's quality of life and outcomes.
The role of thoracic imaging in the intensive care unit
Authors: Soo Eleanor , Edey Anthony J
Published: May 2014

Radiology is critical in managing patients on intensive care units. The portable chest X-ray is widely used, but ultrasound and computed tomography are of diagnostic value in selected cases. This article discusses the role of thoracic imaging in the intensive care unit.
Supportive and palliative care for people with end-stage renal disease
Authors: Hussain Jamilla A , Russon Lynne
Published: May 2014

Advanced renal failure has a mortality rate worse than for most cancers with significant symptom burden. Despite this palliative care for this group has been poor. This article summarizes the role that palliative and nephrology teams can play in optimizing end-of-life care.
Identifying patients at risk of severe Clostridium difficile–associated disease
Authors: Potter Valerie A , Aravinthan Aloysious
Published: May 2014

Clostridium difficile infection is responsible for a wide spectrum of clinical presentations, ranging from mild diarrhoea to fatal toxic colitis. This article reviews factors which may identify individuals who are at high risk of severe C. difficile-associated disease, and aims to help clinicians predict patients at risk of severe disease.
Kangaroo mother care
Authors: Bailey Sarah
Published: May 2014

Kangaroo mother care is a safe, simple method to care for low birth weight infants. This article looks at its origins, what is involved in kangaroo mother care and reviews the evidence for improved outcomes resulting from its implementation.
Medical revalidation: a route to excellence?
Authors: Starke Ian D
Published: May 2014

All doctors who hold a licence to practise will need to revalidate every 5 years. The process includes the consideration of defined items of supporting information at five annual appraisals. These essentials must support professional development and the achievement of excellence in patient care.
Posterior tibial tendon dysfunction: a silent but disabling condition
Authors: Singh Rahul , King Amanda , Perera Anthony
Published: May 2014

Posterior tibial tendon dysfunction is common and a major cause of flat foot (pes planus) and functional impairment in adults. It is frequently undiagnosed and therefore inappropriately managed. This review raises awareness of posterior tibial tendon dysfunction with the intention of improving patient management.
Ventricular arrhythmias complicating hypertrophic cardiomyopathy
Authors: Hutchings David C , Sankaranarayanan Rajiv , Venetucci Luigi
Published: May 2014

Hypertrophic cardiomyopathy is the most common genetic cardiovascular disorder and the leading cause of sudden cardiac death in the young. This article reviews the ventricular arrhythmias associated with hypertrophic cardiomyopathy, the difficulties in risk stratification, and current and future therapeutic strategies.
Computed tomography urography 1: techniques and technology
Authors: Reddy Kiran , Mohammed Aza , Reeve Robert , England Roland
Published: May 2014

Contrast-enhanced computed tomography urography has become possible because of the development of multidetector technology, which has evolved to try and increase its diagnostic efficacy and reduce the radiation exposure. This review highlights important aspects of computed tomography urography as an imaging technique.
Classical Hodgkin's lymphoma: past, present and future perspectives
Authors: Eyre Toby A , King Andrew J , Collins Graham P
Published: May 2014

Hodgkin's lymphoma treatment is a modern medical success story. Historically, staging involved invasive laparotomies, chemotherapy was highly emetogenic, and radiotherapy extensive. Cure was possible, but morbidity high. Now trials aim to maximize cure, minimize toxicity and introduce exciting targeted therapies.
Computed tomography urography 2: clinical applications
Authors: Reddy Kiran , Mohammed Aza , Reeve Robert , England Roland
Published: May 2014

Contrast-enhanced computed tomography urography has become possible because of the development of multidetector technology, which has evolved to try and increase its diagnostic efficacy and reduce the radiation exposure. This review outlines the applications of computed tomography urography in day-to-day urology practice.
The future of ambulatory emergency medical care
Authors: Rose Sarah , Oliver Rowan , Bonnici Karl , Bonny Stephen
Published: May 2014

Ambulatory emergency care offers an attractive method of caring for patients who would traditionally require hospital admission. As well as a superior patient experience, ambulatory care also offers significant cost benefits. In future, implementation of purpose-built units with dedicated teams will alter the delivery of acute health care.
Anaemia in congestive heart failure
Authors: Eyre T , Littlewood TJ
Published: May 2014

Anaemia is common in patients with congestive heart failure, and has an adverse effect on prognosis. This article discusses the advances in understanding of the pathophysiology of the anaemia, the treatment options including transfusion, and highlights areas in need of further development.
Oxygen therapy in patients with chest pain of acute onset: single centre audit experience
Authors: Lagan Jakub , Garg Pankaj , Tang Joseph MF , Burgess Malcolm
Published: May 2014

Introduction:

Although oxygen therapy has been commonly used in the treatment of acute coronary syndromes, evidence shows that oxygen administration is not always beneficial to patients with acute chest pain and in certain circumstances may, in fact, be harmful. Hence, several national and international organizations have issued guidelines restricting its use to hypoxic patients only.

Aim:

To audit and change the inappropriate practice of administering oxygen therapy indiscriminately to patients with acute chest pain.

Setting:

Emergency department, coronary care unit and heart assessment centre in a large teaching hospital.

Methods:

The authors identified 100 patients who presented with acute chest pain and collected data on oxygen prescription, administration and documentation from clinical notes and observation charts.

Results:

Only 71% of patients in a hospital setting were correctly assessed for requiring oxygen therapy. After introducing local guidelines and a series of lectures, this rose to 94%. A third audit showed sustained change, with 96% of patients being appropriately assessed for needing oxygen therapy.

Discussion:

The introduction of local guidelines and a series of lectures improved handling of oxygen in patients presenting with acute chest pain.
Demystifying encephalitis: guidelines for an emergency not to miss
Authors: Gibani Malick MM , Brown Rachel L , Davies Nicholas WS
Published: May 2014

The clinical presentation of encephalitis is often non-specific, complicating the immediate diagnosis and management. This article highlights key messages from recently published guidelines, identifies common pitfalls and discusses how these lessons can be applied to routine clinical practice.
Non-motor symptoms: the core of multi-morbid Parkinson's disease
Authors: Sauerbier Anna , Chaudhuri K Ray
Published: May 2014

Non-motor symptoms of Parkinson's disease are the leading cause of poor quality of life both for people with Parkinson's disease and their caregivers. Non-motor symptoms are almost universal in Parkinson's disease yet are under-recognized and under-treated. This article considers the causes and aspects of treatment.
Tying the knot: helping patients who want to get married in hospital
Authors: Seaman Siwan , Pengelly Michele , Noble Simon
Published: May 2014

When faced with a serious or terminal illness people may want, for practical or emotional reasons, to get married to their partner. This article gives guidance to health-care professionals about their role in helping to organize weddings and civil partnerships for patients who are terminally ill and too unwell to leave hospital.
Pairing trainee managers and doctors: an initiative to facilitate joint working for better patient care
Authors: Hadley Lindsay , Marshall Patrick , Black David
Published: May 2014

Clinical leadership is part of the curriculum for all doctors in training. This article describes one deanery's approach to developing leadership skills while improving collaborative working.
Characterizing malignant liver lesions with contrast-enhanced ultrasound
Authors: Wills Mark , Harvey Chris J , Kuzmich Siarhei , Afaq Asim , Lim Adrian , Cosgrove David
Published: May 2014

Microbubbles as an ultrasound contrast agent allow characterization of focal liver lesions. This article summarizes the ultrasound appearances and enhancement characteristics of malignant liver lesions, and also discusses its potential use for ultrasound-guided intervention and ablation of liver lesions.
Myositis and malignancy: is there a true association?
Authors: Brown Helen , Steven Malcolm
Published: May 2014

There may be an association between polymyositis/dermatomyositis and malignant disease. Cancer occurs in patients with polymyositis/dermatomyositis with a frequency estimated between 2.5% and 29% (relative risk 1.0 to 6.5). We present two such cases, associated with colorectal carcinoma and non-Hodgkin's lymphoma respectively, together with an overview of existing controlled studies in the area.
Management of carcinoma of the prostate
Authors: Kirby RS
Published: May 2014

Every year in the UK nearly 10 000 men die from advanced prostate cancer. On average these individuals lose 9 years of their anticipated lifespan. The cumulative loss of expected life years therefore amounts to around 90 000 per annum, and many hundreds of thousands more retirement years are blighted or lost worldwide as a consequence of this very prevalent neoplasm.
Introducing clinical governance in an acute trust
Authors: Haslock Ian
Published: May 2014

The introduction of clinical governance is a major imperative for the NHS. This paper describes the initial actions taken in a large acute trust to prepare for the clinical governance process. While this description is particular to one trust, it is hoped that it offers some generalizable lessons.
Pregnancy and the heart
Authors: Williams David
Published: May 2014

Pregnancy places a huge demand on the heart. Such a burden cannot always be met by women with pre-existing heart disease. This article covers the important physiological changes of healthy pregnancy, and discusses how to assess and manage heart disease during pregnancy.
Autoimmune rheumatic diseases and the heart
Authors: Hussain Shabina , Isenberg David A
Published: May 2014

Involvement of the heart is a common finding in autoimmune rheumatic diseases. Although clinically silent changes are common, potentially life-threatening manifestations are well known but early recognition is important if appropriate therapy is to be instituted.
Maternal mortality: lessons from the confidential enquiry
Authors: Drife James
Published: May 2014

The Confidential Enquiry into Maternal Deaths is the world's longest running self-audit of professional practice. The most recent report (Department of Health, 1998), while taking care to preserve continuity, has revamped its presentation and broadened its scope. Some of its findings should shake our complacency.
Alternative ways of using and abusing drugs and complicity of doctors
Authors: Winstock Adam , Strang John
Published: May 2014

Many drugs that have been prescribed by doctors are not taken as directed. Altered dose, frequency and route of administration may lead to misuse of drugs that have been prescribed in good faith. Awareness of the abuse potential of prescribed and over-the-counter drugs is the first point of intervention, followed by monitoring of each doctor's practice.
Tracheostomy management in ordinary wards
Authors: Heafield Siobhan , Karnik Amod , Rogers Maria
Published: May 2014

Tracheostomy is more commonplace, particularly since the introduction of percutaneous techniques performed at the patient's bedside in the intensive care unit. Subsequent care and management within ordinary wards causes anxiety among staff. This review identifies some of the problems encountered and discusses their potential management.
Current issues in mammographic breast cancer screening
Authors: Rickard Mary T
Published: May 2014

Mammographic screening for the early detection of breast cancer is widely accepted as the most effective means currently available to reduce breast cancer deaths. However, evidence shows that to maximize benefits and minimize harm, mammographic screening must be of high quality.
Intern discussion group: a supportive educational experience for junior doctors
Authors: Davis Mark
Published: May 2014

The intern year is often a very demanding and stressful experience. To support the interns in a New Zealand hospital, a facilitated weekly discussion group was set up. The group's main goals were to provide training in the management of personal and professional stress while encouraging frank and open discussion. It proved to be a supportive and valuable learning experience for the interns. A similar format could be beneficial for senior hospital doctors.
Traumatic subarachnoid haemorrhage
Authors: Patel HC , Hutchinson PJA , Pickard JD
Published: May 2014

The presence of subarachnoid blood following head injury is a significant risk factor for poor outcome. Treatment aims to prevent and treat secondary hypoxia, hypotension, intracranial haematoma, epilepsy and infection. There is good evidence for the benefit of nimodipine in aneurysmal subarachnoid haemorrhage. Its role in preventing cerebral ischaemia following trauma is currently under investigation.
Clinical governance: setting the scene
Authors: Ayres Phil
Published: May 2014

The concept of clinical governance was first introduced to the NHS in late 1997. Since then, it has become a commonly used term, but there is still a great deal of uncertainty about what it means and how it should be implemented. This paper places clinical governance in the context of previous quality initiatives, and considers the roles of both managers and clinicians.
Erectile dysfunction in patients with diabetes
Authors: Cummings MH , Alexander WD
Published: May 2014

Erectile dysfunction, which is common among men with diabetes, leads to significant reduction in quality of life, and as with other complications of diabetes deserves to be treated on the NHS. This article explores the problem of erectile dysfunction and diabetes and the role of sildenafil, which is likely to be the first choice treatment of patients presenting with erectile dysfunction.
Who should do thyroid surgery?
Authors: Watkin David
Published: May 2014

Who should do thyroid surgery? The brief and simple answer is ‘anyone who has been trained to do it’. In reality the issue is more complicated — too many surgeons might be trained, so that they each have an insufficient number of cases to maintain their skills. At the other extreme, a few experts might achieve a large practice in regional centres, but at the cost of poor access for many of the population.
Ciprofloxacin-induced oral facial dyskinesia in a patient with normal liver and renal function
Authors: Lee Chi-hang , Cheung Raymond Tak-fai , Chan Tak-mao
Published: May 2014

A 49-year-old Chinese woman with good past health presented to a general practitioner with fever, chills, dysuria, and loin pain. Urinary tract infection was diagnosed and she was treated with oral ciprofloxacin. She was hospitalized because of persistent chills and fever. Physical examination showed hyperpyrexia of 38.6°C, together with suprapubic and bilateral loin tenderness. White cell count was 11.2×109/litre. Ultrasonogram of kidneys showed no structural abnormality. She was treated as having acute pyelonephritis with ciprofloxacin 200 mg intravenously twice daily. Her symptoms improved. Urine and blood culture yielded negative results.

She developed involuntary facial grimacing 2 days after starting ciprofloxacin treatment. Neurological examination did not reveal other abnormal findings. Her only other medication was paracetamol 500 mg orally four times a day. She had no prior history of similar involuntary movements. The oral facial dyskinesia occurred intermittently every 4–6 hours, with each attack lasting about an hour. She maintained a clear sensorium during the involuntary movements. Computed tomography and magnetic resonance imaging of the brain, as well as lumbar puncture, yielded normal results. Electroencephalogram showed normal wave form. The levels of liver transaminases were raised transiently after starting ciprofloxacin treatment, with aspartate aminotransferase 82 U/litre (normal 12–28 U/litre) and alanine aminotransferase 176 U/litre (normal 5–31 U/litre). Serum albumin, bilirubin, prothrombin time and creatinine levels were normal. The involuntary movements improved slightly with clonazepam therapy, but did not subside completely. In view of the possibility of ciprofloxacin-induced neurotoxicity, ciprofloxacin was stopped and substituted with netromycin. Her oral facial dyskinesia stopped and did not recur. The patient had an uneventful recovery.
Recovery from surgery: grappling with an elusive concept
Authors: Lee John , Stephens Robert
Published: May 2014

When we ask our patients 'How are you?', can we quantify the answer? There is no ideal measure for every circumstance. This article will discuss the issues in measuring postsurgical recovery, describe different approaches, and consider future research.
Re-emergence of syphilis
Authors: Waugh Michael A
Published: May 2014

Recent reported outbreaks of early syphilis in Bristol, Manchester (Communicable Disease Report, 2000a) and Brighton (Communicable Disease Report, 2000b), and further afield the epidemic in Russia (Borisenko et al, 1999) and in some groups in the USA (Drusin, 1996), remind us that this classical venereal disease, often overlooked when making a diagnosis, should not be forgotten. After a peak incidence at the end of the Second World War, the disease became uncommon in Western Europe, except in discrete groups such as homosexual men, prostitutes or intravenous drug users. By 1995 an incidence of around 1 per 100 000 was the typical figure for Western Europe.
Amniotic fluid embolism: the UK register
Authors: Tuffnell DJ , Johnson H
Published: May 2014

Amniotic fluid embolism is rare but is a significant cause of maternal death. No clear risk factors seem to be identifiable from previous cases. A register has been established in the UK to look at possible therapies.
Giant urethral calculi
Authors: Shanmugam TV , Dhanapal V , Rajaraman T , Chandrasekar CPM , Balashanmugam K Pitchai
Published: May 2014

A60-year-old man presented with a complaint of a hard mass in the subnavicular fossa for the past 10 years. He had had minimal discomfort in micturition for the past 2 years but was able to manage with it. He had a history of passing a calculus of 1 cm diameter 15 years ago.

On examination, a hard mass of 7×5×4 cm was palpable in the subnavicular fossa (Figure 1). Rectal examination was normal.

Urine culture and sensitivity showed no growth, the renal parameters, metabolic work-up, plain X-ray and ultrasound scans of the kidney, ureter and bladder area were all normal. X-ray of the penis showed a large calculus in the subnavicular fossa

Meatotomy was done and a calculus of 6×4×3.5 cm was extracted (Figure 2), which weighed 40 g. The meatus was reconstructed with Blandy's flap. The postoperative period was uneventful.
A Winter's Tale: the barber and the quack
Authors: Bennett John , Hobbs Kenneth , Williamson Robin
Published: May 2014

Shakespeare and Medicine: Twins and Siblings was the theme of a conference held at the Royal Society of Medicine on Saturday 1 September 2001. An afternoon of light-hearted science at the Royal Society of Medicine was followed by an evening performance of King Lear at the Globe Theatre, Southwark. The scientific programme culminated in an example of sibling rivalry, in which representatives of the Royal Colleges of Surgeons and Physicians argued over the management of a 16th century patient. The case report and the learned opinions are reproduced by kind permission of Dr Jack Tinker, Dean of the Royal Society of Medicine, and the three participants. No prizes are available for recognition of the patient.
Management of malignant salivary gland tumours
Authors: Vaughan ED
Published: May 2014

Malignant tumours of both major and minor salivary glands are extremely rare: the parotid gland is most frequently affected by malignant change, followed by the submandibular gland. Malignant tumours of minor salivary glands may occur anywhere in the upper aerodigestive tract, but more common sites are the upper lip, junction of hard and soft palate and paranasal sinuses.
How to write a critical letter and respond to one
Authors: Goodman Neville W
Published: May 2014

Critical letters are important. They correct the published record. To write a critical letter requires tact; to respond to one requires tact — and the humility that comes with the realisation that belief in an observation or an idea does not make it true.
Non-surgical management of faecal incontinence
Authors: Cheetham Mark J , Kenefick Nicholas J , Kamm Michael A
Published: May 2014

Faecal incontinence is a common symptom causing reduction in quality of life and social isolation. Conservative treatments should be used as first and second lines of therapy and can also be of use as adjuncts to surgical treatment. This article reviews the current status of these modalities of treatment.
Managing postoperative pain
Authors: Stuart Taylor Malvena
Published: May 2014

The postoperative course of a patient can be complicated by events such as pain, nausea and vomiting. These in themselves can have a significant impact upon morbidity and even survival. This article outlines key points to minimize such adverse outcomes.
Pelvic fractures
Authors: Youngman James R , Day Adrian C
Published: May 2014

Pelvic fractures account for 1—3% of all fractures, and around 60% of them occur in men. High energy fractures of the pelvic ring often result from motor vehicle collisions, crush injuries or falls from a height. Pelvic ring fractures may be associated with severe or life-threatening soft tissue injuries. Mortality may be as high as 10—20%, and open pelvic fractures have a mortality of up to 50%.
Somatuline Autogel: an extended release lanreotide formulation
Authors: Lightman Stafford
Published: May 2014

Somatuline Autogel provides effective control of growth hormone levels and is at least as effective as intramuscular Somatuline LA. Somatuline Autogel has a first order kinetic profile providing at least 28 days' efficacy with reduced burst release and a more consistent drug release over the dose period. The product is presented in a pre-filled syringe and is given deep subcutaneously.
Diagnosis and immediate care of open fractures
Authors: Forward Daren , Christopher G Moran
Published: May 2014

Any fracture in which the fracture haematoma communicates with the outside world is an ‘open fracture’. All open fractures must be treated as a surgical emergency with a clear treatment protocol using a team approach. The accident and emergency (A&E) department forms the initial part of that team. The guiding principles for the team are to prevent infection, unite the fracture and restore function - it is in the first of these that A&E plays an important role. The A&E team will also need an understanding of subsequent management to ensure good initial treatment and communication with the orthopaedic surgeons, patient and relatives.
Agalsidase alfa: specific treatment for Fabry disease
Authors: Mehta Atul
Published: May 2014

Fabry disease is a rare genetic lysosomal storage disorder characterized by a deficiency of the enzyme a-galactosidase A. The recent availability of enzyme-replacement therapy with agalsidase alfa offers specific treatment for this serious, progressive condition.
Osteoporosis: prevention and diagnostic work-up
Authors: Theodorou Daphne J , Theodorou Stavroula J , Sartoris David J
Published: May 2014

Prevention of osteoporosis has assumed a paramount role in the decrease of osteoporotic fractures and the associated medical costs. A thorough diagnostic work-up of the patient with osteoporosis helps the physician exclude secondary causes of bone loss and acquire useful data for staging the disease, and contributes to planning the correct therapeutic management.
Acute pancreatitis
Authors: Murphy JO , Mehigan BJ , Keane FBV
Published: May 2014

Acute pancreatitis is an important and extremely common cause of acute hospital admission which may be associated with major morbidity and mortality. Modern treatment is largely supportive with a limited role for surgery.
Containing and combatting bioterrorism
Authors: Spencer Robert C , Lightfoot Nigel F
Published: May 2014

At 09.28 Eastern Standard Time on September 11 2001, President George W Bush stated that the US had succumbed to a serious asymmetric threat and vowed to hunt down the perpetrators. American Airlines flight 11 hit the north tower of New York's World Trade Center at 08.48 Eastern Standard Time, followed by United flight 175 at 09.18 hitting the south tower. The south tower collapsed, followed by the north tower at 10.28. In 100minutes the world had changed forever.
Managing physical illness in people with severe mental illness
Authors: Mirza Ilyas , Phelan Michael
Published: May 2014

People with severe mental illness have poor physical health, and increased morbidity and mortality compared to the general population. Community-based mental health care has led to hospital doctors being more involved in the physical care of psychiatric patients. This paper focuses on key issues in the medical management of psychiatric patients in a general hospital setting.
Prioritizing treatment in cases of concurrent abdominal aortic aneurysm
Authors: Somasekar K , Morris-Stiff G , Foster ME , Lewis MH
Published: May 2014

Patients with concomitant abdominal aortic aneurysm (AAA) and intra-abdominal malignancy present a clinical dilemma because of the difficulty in deciding which pathology to address first. As this scenario is not commonly encountered, clear guidelines are not available to help in the decision-making process. Surgery for malignancy has been said to increase the risk of postoperative aneurysm rupture, but simultaneous cancer surgery and primary repair of the aneurysm may carry the risk of prosthetic graft infection. This paper describes a further complication that may arise in the setting of concomitant intra-abdominal malignancy carcinoma and AAA, namely peripheral embolism.
Dopamine agonist monotherapy in early Parkinson's disease
Authors: Clarke CE
Published: May 2014

While levodopa therapy for Parkinson's disease is still considered the gold standard, motor complications are significant disadvantages of treatment. Monotherapy with dopamine agonists may present an alternative approach with a reduced likelihood of developing dyskinesias. Further studies are required before a definitive judgment can be made.
Safe removal of long-term cuffed Hickman-type catheters
Authors: Galloway S , Bodenham A
Published: May 2014

The use of long-term venous access devices is increasing. Most devices are anchored by a cuff, usually made of Dacron. The disadvantage of such cuffs is that a cut-down procedure is required for their removal. This article presents a simple technique for removal of Hickman-type catheters, emphasizing avoidance of complications.
A therapeutic dilemma: atrial fibrillation, transient ischaemic attacks and an unruptured intracranial aneurysm
Authors: Larner AJ , Humphrey PRD , Rose EL
Published: May 2014

Within 1 month, a 69-year-old right-handed man had three episodes of weakness of sudden onset affecting the left arm and face, followed by complete recovery within 10 minutes to 2 hours. He was a non-smoker, but had been diagnosed with hypertension 4 months earlier, treated with bendrofluazide. The neurological examination was normal, but he was in atrial fibrillation (ventricular rate >100/min) with a blood pressure of 160/70 mmHg. There were no carotid bruits. Transthoracic echocardiogram, carotid doppler ultrasonography and computed tomography (CT) of the brain were all normal. A diagnosis of transient ischaemic attacks (TIAs) was made, probably caused by emboli of cardiac origin. He was commenced on sotalol (40 mg twice daily) to attempt to prevent further attacks of atrial fibrillation. The use of anticoagulation was also considered.

In the past medical history, an episode of right-sided weakness of sudden onset, lasting 5 hours with complete recovery, had occurred 8 years earlier. CT brain scan at that time showed a high density lesion in the left internal capsule; it was not possible to decide whether this was haemorrhage into an infarct or a primary intracerebral haemorrhage from a left middle cerebral artery aneurysm. Cerebral angiography showed a small saccular aneurysm close to the trifurcation of the right (sic) middle cerebral artery. This lesion was thought incidental to the clinical history and, because of its size, surgery was not advised. Interval magnetic resonance angiography 3 and 6 years later showed no change in aneurysm size (<2 mm) and management remained conservative.

Despite the evidence supporting anticoagulation to prevent stroke in patients with atrial fibrillation, it was initially thought that this treatment would be contraindicated by the presence of an unruptured intracranial aneurysm. However, in the absence of evidence specific to this clinical situation (see discussion), the available data suggested that benefits of anticoagulation (stroke prevention) outweighed (haemorrhagic) risk in this patient. These issues were discussed with the patient who decided to opt for anticoagulation. Close monitoring to maintain an international normalized ratio between 2.0 and 2.5 was the aim. After 12 months of follow up the patient remained well with no further TIAs and no complications.
The evidence base on the orthopaedic NICE report
Authors: Toms AD , Isbister ES
Published: May 2014

Since the publication of its first guidelines the National Institute for Clinical Excellence (NICE) has come under a lot of criticism, particularly with respect to its recommendations in medicine (Bratby, 2001). The first appraisal in the field of surgery was on total hip replacement (THR) and was issued in April 2000 (NICE, 2000).
Atypical and conventional depot medications
Authors: Pandarakalam James Paul
Published: May 2014

The introduction of atypical antipsychotics created a therapeutic dilemma between choosing the oral novel antipsychotic or the conventional depot form. Clinicians want the advantages of both, resulting in higher levels of polypharmacy. Modern psychiatry is probably in a transitional stage from the depot culture to safer oral medications or even to a safer depot culture.
Mistaken identity: calcific tendinitis in the finger
Authors: Huntley JS , Mr TW
Published: May 2014

A42-year-old woman presented to the emergency department with pain and restricted movement in her right (dominant) index finger. The symptoms had been present for 10 weeks but were increasing in severity. There had been no antecedent trauma or repetitive use. She had a past history of low back pain and stiffness which had been investigated by the rheumatology department. Her white cell count, plasma viscosity, Creactive protein level and lumbar spine radiographs were all normal. She was not HLAB27 positive.

On examination she was apyrexial with no lymphadenopathy. There was minor swelling and focal tenderness on the volar side of the proximal interphalangeal joint of the right index finger, but the finger had a complete range of movement.

A radiograph (Figure 1a) showed two small areas of sclerosis volar to the proximal interphalangeal joint, coincident with the site of tenderness. The diagnosis of a fracture through a sesamoid bone was postulated. Laboratory investigations, including serum urate, were unrevealing.

The patient was referred to the fracture clinic where this diagnosis was initially accepted, but no specific treatment instigated. She was followed up 3 months later, by which time her symptoms had completely resolved. A repeat radiograph (Figure 1b) showed that the calcification had disappeared, allowing the retrospective diagnosis of calcific tendinitis
Non-steroidal anti-inflammatory drugs and the asthmatic child
Authors: Wah Man Alice Fung
Published: May 2014

The administration of non-steroidal anti-inflammatory drugs (NSAIDs) to asthmatic children is a longstanding dilemma. Aspirin- and other NSAIDinduced asthma is a well-recognized phenomenon, but the benefits of NSAIDs are also well known. Some factors that can influence the decision to give NSAIDs include: a history of previous use, severity of asthma, other atopic features (e.g. eczema, hay fever or nasal polyps) and the anticipated degree of postoperative pain. In addition, the level of paediatric experience may also contribute.
Diagnosis and early management of acute pancreatitis
Authors: Powell James J , Parks Rowan W
Published: May 2014

Acute pancreatitis is a common emergency with the potential for significant complications. Despite advances in the understanding of the pathogenetic mechanisms of acute pancreatitis and the completion of a number of randomized trials studying specific therapies, the early management of patients remains supportive.