bluuebunny/crossref_metadata_2025 huggingface dataset:
Common rashes in children: 1
Authors: Johnston Graham , Mansouri Yasaman
Published: May 2014

While one of the great attractions of dermatology is the wide variety of clinical cases seen, a relatively small number of conditions make up the majority of dermatological cases seen in paediatric clinics. A simple lack of both education and clinical exposure mean that these cases often cause a disproportionate amount of anxiety for the doctor asked to diagnose and treat a child with a rash. Most present with a clear history and distinctive examination findings and respond well to appropriate treatment. This is the first of two articles which will help the physician approach a child with a rash with greater confidence.
Techniques for effective bedside teaching
Authors: Jenkins Christopher , Page Charlotte , Hewamana Saman , Brigley Stephen
Published: May 2014

Junior doctors need to acquire many skills in their training for the efficient and successful day-to-day clinical management of patients. These include effective communication skills, which are essential for a doctor to be able to ask the relevant questions in a sympathetic manner to the patient to acquire the precise facts. Correct examination techniques are also needed to allow doctors to effectively spot clinical signs and formulate their thinking to provide a differential diagnosis, and good presentation skills are needed to enable the students to deliver their findings in a systematic and logical manner.
Educational resources on the internet for trainee doctors: a practical guide
Authors: Singh Gurmit , Gupta Mradul
Published: May 2014

The quantity of educational resources which are available on the internet is enormous and the quality of these is very variable. This two-article series will provide practical guidance for doctors on assessing quality and making effective use of these resources. The second article will discuss some good quality radiology and medical learning resources available on the internet.
Intravenous inotropic agents in heart failure
Authors: Banner NR , Lyster H , Prabhakar A , Rahman-Haley S
Published: May 2014

Inotropes are some of the most commonly used drugs in intensive care. However, their value in treating patients with heart failure is limited and prolonged use is associated with an increased mortality. Nevertheless inotropic agents increase cardiac contractility and can improve the cardiac output of patients with heart failure.
Cardiac device therapy 1: theory, technology and terminology
Authors: Modi Simon , Rao Archana , Hughes Susan , Ramsdale David
Published: May 2014

With advancing technology and ever-expanding indications for implantable cardiac pacing and defibrillation devices, this article reviews modern day practice in this field. This article focuses on topics pertinent not only to cardiologists but also to general physicians, medical trainees and allied medical specialties.
Chemical sympatholysis: indications, technique and complications
Authors: Durai Rajaraman , Hoque Happy
Published: May 2014

Chemical sympatholysis is commonly performed for palmar or plantar hyperhidrosis, Buerger's disease, critical lower limb ischaemia where there is no revascularization option available and palliation of pain. The outcome varies from symptomatic improvement to failure, which may result in limb loss in the case of ischaemic limbs.
The end of the great war
Authors: Ellis Harold
Published: May 2014

Ninety years ago, on 11 November 1918, at 11 am (‘the eleventh hour of the eleventh day of the eleventh month’), an armistice was declared which marked the end of ‘The Great War’ as it was then called, now downgraded to ‘World War 1’ or even ‘WW1’.
A confusing presentation of giant cell arteritis
Authors: Rogers Matthew , Young Laurel
Published: May 2014

A 56-year-old woman presented with a pale, painful, paraesthetic right arm. Examination revealed a cold right hand, with absent right radial, ulnar and brachial pulses. A provisional diagnosis was made of thrombotic or embolic arterial occlusion; the patient was anticoagulated and referred to the vascular surgical service.

Magnetic resonance angiography showed an occluded right brachial artery (Figure 1). Ultrasonography confirmed this, but also demonstrated widespread narrowing of the vessel, with surrounding hypoechoic tissue and fluid within the connective tissue suggesting an inflammatory process.

On questioning, the patient admitted to occipital headache and scalp tenderness. The erythrocyte sedimentation rate was 63 mm/hr, and the C-reactive protein level 155.1 mg/litre. A temporal artery biopsy showed changes typical of giant cell arteritis.

Prednisolone 60 mg daily was commenced with good effect. However, the patient's symptoms recurred when steroids were tapered below 50 mg daily. Moreover, 2 months later she developed bilateral calf claudication at 100 yards. Magnetic resonance angiography of the legs demonstrated narrow, diseased anterior and posterior tibial arteries bilaterally, but normal peroneal and proximal vessels.

Cyclophosphamide treatment was started, with resolution of the claudication and other symptoms.
Fresh whole blood transfusions for life-threatening haemorrhage
Authors: Blackshaw Rachel
Published: May 2014

For patients with life-threatening haemorrhage, restoration of circulating volume is essential and blood transfusion is inevitable. The ability to separate and store red blood cells, fresh frozen plasma, platelets and cryoprecipitate revolutionized the management of blood loss. Before this, blood donors were relied on to come to hospital for each emergency. This was unpopular, unreliable and impractical. Current military practice permits the use of warm fresh whole blood, donated by on-site military personnel, for casualties with life-threatening injuries when stored products are unavailable or if the response to haemostatic resuscitation with blood products is poor (Spinella, 2008). Indications for fresh whole blood transfusions in civilians include massive haemorrhage, burns, cardiac surgery, neonatal exchange transfusion and traumatic brain injury (Repine et al, 2006). This article looks at the advantages and disadvantages of fresh whole blood transfusions.
Recent advances in the management of rectal cancer
Authors: Maslekar S , Anwar S
Published: May 2014

Recently there have been significant advances in the management of patients with rectal cancer, attributed mainly to advances in surgical techniques and pre- and postoperative therapy. This review addresses some of these advances and their impact on the prognosis for rectal cancer patients.
John Snow: early anaesthetist and pioneer of public health
Authors: Ellis Harold
Published: May 2014

This year marks the 150th anniversary of the death of an English physician who achieved lasting fame in two entirely unrelated fields. He was the first professional anaesthetist in England, making important contributions to the newborn specialty, and he was also one of the founding fathers of modern epidemiology and public health.
Bilateral ankle pain and quinolone use: a case of tendon rupture secondary to quinolone use
Authors: Panigrah R , Longcroft-Wheaton G , Laji K
Published: May 2014

An 80-year-old man presented to the acute medical take in September 2007 with a mechanical fall at home. For the preceding 2 weeks he had developed progressive bilateral heel tenderness following a course of afloxacin prescribed by his GP for a chest infection. This spread to his calves, with the ankles giving way on weight-bearing. He had seen his GP after a week of symptoms, who had noted this as a possible rare side effect of the medication but continued the drug. He had started falling as a result of pain in the tendons, and had no history of trauma before developing these symptoms.

On examination both Achilles tendons were tender with associated bruising. The ankles were hot to touch with flexion confined to 20° because of the pain. It was not possible for the patient to weight bear because of the pain. Simmonds test showed that there was no continuity of the Achilles tendon. Blood tests revealed a C-reactive protein level of 269 mg/litre. The impression was that there was bilateral Achilles tendonitis secondary to the quinolone. Simple analgesia was given and the patient was advised to immobilize because of the significant risk of rupture of the tendons.

An orthopaedic opinion and magnetic resonance imaging was sought to confirm the diagnosis. This revealed bilateral rupture of Achilles tendons (Figures 1a and b), and repair was needed. A kersler suture repair and vicryl plication was performed.
Pituitary disorders: an overview for the general physician
Authors: Thorogood Natalia , Baldeweg Stephanie E
Published: May 2014

The pituitary gland is responsible for the production of the trophic hormones that control normal homeostasis. The hyper- or hypofunction of one or more of these may result in a distinct pathological clinical presentation, particularly in the presence of macroadenoma. Most pituitary disorders, however, present with non-specific signs and symptoms. This review gives an overview of pituitary disorders, their causes, clinical presentation, diagnosis and management.
Prevention and medical management of postherpetic neuralgia
Authors: Dainty Philip
Published: May 2014

Postherpetic neuralgia is the commonest complication of shingles, a debilitating disease common in daily clinical practice. Treatment of postherpetic neuralgia is often complicated, with numerous potential options. This review looks at the evidence in support of the more commonly used medical therapies for this challenging condition.
Current issues in the management of female urinary incontinence
Authors: Hoyle Victoria , Al-Machhour Mohamad K , Briggs Karen , Hammadeh Mohamed Y
Published: May 2014

Urinary incontinence can affect the quality of life of many women at all ages. When assessing a woman with urinary incontinence, it is important to establish the type and severity of problem to allow provision of the correct type of treatment. This article highlights current issues in the diagnosis and management of this condition.
Deadly acidosis but home in 24hours
Authors: Cegla Jaimini , Nimalan Nisha , Edwards C Mark B
Published: May 2014

A 51-year-old man drank two bottles of whisky and passed out. He woke with epigastric pain, which worsened during the day, and he vomited six times. Although normally teetotal, he binged sporadically. On presentation, he was tachycardic with a normal blood pressure, and inebriated with a Glasgow Coma Scale of 15. Urinalysis revealed a trace of ketones and pH of 5. Arterial blood gas analysis demonstrated severe metabolic acidosis with pH 6.73 (normal range (NR)=7.35–7.45), pO2 19.1 kPa (NR >10.6 kPa), pCO2 2.54 kPa (NR 4.7–6 kPa), bicarbonate 4 mmol/litre (NR 22–28 mmol/litre) and lactate 22 mmol/litre (NR 0.5–1.6 mmol/litre).

He was diagnosed with severe alcohol-related lactic acidosis. Fluid resuscitation, broad-spectrum antibiotics and a proton pump inhibitor were commenced. He was given 1 litre of 1.26% sodium bicarbonate. The next morning after 7 litres of crystalloid and 75 ml of 8.4% sodium bicarbonate the patient was much improved with only mild epigastric pain. He had a pH of 7.53, bicarbonate of 27 mmol/litre and lactate of 1.7 mmol/litre. He was monitored for 24 hours and discharged.
Bilateral synchronous testicular torsion in a young adult
Authors: Dindyal S , Kumaraswamy P , Khattak A , Sooriakumaran P
Published: May 2014

An 18-year-old man presented to accident and emergency with acute left testicular pain of 2 hours’ duration. He woke up with the pain radiating to his left hemiscrotum, left groin, left iliac fossa and left lumbar flank. Nausea and vomiting accompanied the pain. He had not opened his bowels for 48 hours. He denied any lower urinary tract symptoms or any previous history of genital trauma.

His past medical history revealed that he had suffered from intermittent left testicular pain for 3 years and, 6 months before this admission, had been admitted with a similar episode of left testicular pain, which was treated as epididymitis. There was no family history of testicular torsion.

On examination, he was apyrexial, distressed with pain and retching. His left scrotum was erythematous and mildly oedematous, lying relatively high. It was extremely tender at the upper pole, which made evaluation of its contents difficult, but a ‘knot-like’ structure was palpated. Cremaster reflexes were absent bilaterally. The right testis was also tender, but on palpation it felt normal and was not swollen. The left inguinal canal and left iliac fossa were also painful.

A midstream urine showed no pyuria or haematuria. A kidney-urinary bladder radiograph showed faecal loading of the large bowel. Transverse testicular ultrasound scanning showed a markedly inflamed left epididymis with decreased blood flow. The left distal spermatic cord showed a whorled appearance. The right testis was normal in echotexture, size and blood flow. Bilateral hydroceles were noted.

The patient underwent immediate bilateral scrotal exploration, which revealed the left testis to be cyanosed and the cord to be twisted 540° anticlockwise. The right testis was normal in colour and the cord was twisted 360° clockwise. Bilateral bell-clapper deformity was noted. Detorsion, orchidopexy and drainage of serous-coloured hydrocele was performed bilaterally.

Postoperatively the patient recovered well and was discharged home 2 days later with an outpatient follow-up appointment. Serum sex hormone levels were all within the normal ranges. Semen analysis was of normal consistency and pH. The count was 38 million, but 54% were immotile and 87% displayed abnormal morphology.
Isolated olfactory nerve agenesis
Authors: Carswell Andrew J , Whinney David , Hollings Nick , Flanagan Philip
Published: May 2014

An otherwise fit and well 12-year-old girl presented to the otolaryngology clinic with lifelong anosmia. Although she had suffered a nasal injury when she was 4 years old, she was adamant that the deficit pre-dated her injury. Interestingly, her maternal grandfather also complained of this problem.

Clinical examination was entirely normal, except for her anosmia. There was no intranasal pathology such as obstructive deviations of the nasal septum or polyposis and cranial nerve examination, including trigeminal stimulation, only confirmed the absence of olfaction.

Subsequent imaging with the magnetic resonance scanner revealed a complete absence of the olfactory bulbs and nerves (see Figures 1–3 and compare to the normal image in Figure 4). T2-weighted coronal sections through the anterior cranial fossa were performed. As demonstrated in the normal image (Figure 4), one can expect to see high signal in the olfactory sulcus along the base of the frontal lobe. This was entirely absent in this case, with no other significant pathology apparent. There is a high signal return in the right maxillary sinus of the subject, which is incidental and not related to smell perception. Also, Figure 4 is in a patient with a cyst in the left maxillary sinus. Such incidental, asymptomatic 'sinusitis' on magnetic resonance scans is present in 30–40% of cases (Wani et al, 2001).

Both the patient and her mother were counselled about the risks of environmental hazards. No further investigation was deemed necessary, or indeed desired by the patient.
Endocrinology and the skin
Authors: Al Niaimi Firas , Cox Neil H
Published: May 2014

This article discusses various cutaneous features associated with endocrine disease, which are of general medical relevance. Many of these, such as features associated with hypothyroidism, are common, while others, such as features of adrenal insufficiency, are relatively rare but important.
Hepatitis E: a UK perspective
Authors: Turner J , Green J
Published: May 2014

Hepatitis E is increasingly recognized as a cause of viral hepatitis within the UK and should be considered in any patient presenting with acute hepatitis. Mortality rates of around 4% have been described, but are even higher during pregnancy.
Potential complications of the blind technique of port insertion during laparoscopy
Authors: Shaikh S , MacAuley E , Brittenden J
Published: May 2014

A 32-year-old previously fit and healthy woman underwent laparoscopy, dye test, hysteroscopy and endometrial biopsy as part of the investigation of infertility, under the care of a consultant gynaecologist in a remote district general hospital. A radial umbilical incision was made, and the abdomen was raised by hand. An initial attempt was make to insert a trifin nailed trocar gently with a screwing movement, but the failure of this manoeuvre was attributed to relaxed thick fascia or a blunt trocar. A Veress needle was therefore introduced to its full length and was then withdrawn to half length; pneumoperitoneum was established. A good view of the pelvic organs was obtained and no abnormality was observed. The patient became haemodynamically unstable although no obvious source of bleeding was identified.

A laparotomy was performed through a right subumbilical paramedian incision and a large haematoma was noted anteriorly on the left side overlying the inferior vena cava and aorta, extending up to the left renal pedicle and down to the pelvic brim. The lateral extensions of the haematoma were contained at the peritoneal reflections. It was unclear which vessel was injured and as intensive therapy unit care was not available on site and the haematoma was contained, the incision was closed and the patient was transferred to the authors' tertiary care centre. Blood loss at this point was a 50 ml clot. On arrival the patient was unstable, acidotic and in coagulopathy with a systolic blood pressure of 50 mmHg. A second laparotomy was performed by extending the previous incision proximally into the epigastrium. A 1 cm tear at the origin of the right internal iliac artery was seen and repaired along with a tear of a right lumbar artery, which was ligated.

The patient remained in the intensive therapy unit for 48 hours and received a total of 36 units of packed red cells transfusion plus factor 7, fresh frozen plasma and platelets. Further postoperative recovery was uncomplicated. The patient developed secondary depression after the incident and also experienced intermittent abdominal pain.
Is there a role for thiopentone in modern anaesthetic practice?
Authors: Sultan P , Sultan P
Published: May 2014

Thiopentone is a barbiturate first used in 1934 by Lundy and Waters. The classic rapid sequence induction describes the use of thiopentone, for which it was preferred because of its rapid smooth induction and its reliable end point.
How to prepare for a research viva
Authors: Durai Rajaraman
Published: May 2014

Competition in medical training is on the increase. Many junior doctors undertake an additional research degree ranging from BSc to MD and PhD (Higginson and Corner, 1996; Durai and Venkatraman, 2005). There is no clear concise guide on how to prepare for a research viva, which is also known as defending your thesis. Inadequate preparation may lead to you not passing the viva (Shinton, 1978; Jack, 2002). At times it may be difficult to get advice: supervisors are often too busy and may not have enough time to teach every student about the viva. Passing the research viva may help you progress in your career (Farndon, 1991). This article is based upon the author's own experience in preparing for the research viva.
Consultation with a dizzy patient
Authors: Visvanathan V , Aucott W , O'Keith A
Published: May 2014

The management of a patient presenting with dizziness is a common task otolaryngologists face in clinic. Failure to obtain an adequate history or perform a thorough clinical examination results in sub-optimal evaluation and inadequate treatment of these cases.
The survivors' guide to working in the medical admission unit
Authors: Imran Faraz , Yousuf Mohamed Y , Bhaumick Swapan
Published: May 2014

The medical admission or assessment unit is a relatively new specialty in the NHS which has been developed to cope with the demands of the accident and emergency department. It provides a practical hub for the flow of emergency medical patients into the hospital. The principal aims of the medical admission unit are two fold: first to direct patients who require inpatient care to the most appropriate facility and second to provide high quality care through a multidisciplinary team focused on achieving a clear diagnosis and management plan, which will either enable patients to return home or to access specialist care.
Voluntary work overseas for foundation doctors
Authors: Carbonaro Francis , Hay-Smith Graham
Published: May 2014

There is a stark difference between health care in western countries like the UK and that of poorer, less developed countries. The United Nations Development Programme (2005) has shown that the death rate in children under the age of 5years in sub-Saharan Africa is 179 in 1000, whereas in the UK it is 6 in 1000. Life expectancy for a woman in sub-Saharan Africa is 46years of age, while in the UK it is 78years.
Anticoagulation therapy
Authors: Shakur R , Joshi A , Halifax B , Scott D
Published: May 2014

Every junior doctor will have to prescribe some form of anticoagulation therapy for their patients. Foundation year 1 doctors should be familiar with the use of warfarin and heparin as anticoagulants, and be able to prescribe them appropriately, safely and effectively. The use of these drugs is outlined here.
Examination of the bone marrow
Authors: Jenkins Christopher , Karunanithi Kamaraj , Hewamana Saman
Published: May 2014

An abnormal full blood count is a common finding in many different medical conditions; however, the cause may often not be immediately apparent. The history and examination of the patient, together with other tests such as the blood film, may help towards the diagnosis. Occasionally it is necessary to further investigate the patient with a bone marrow examination to determine the origin of the abnormalities. The indications for this are described in Table 1.
Haemoglobin-based oxygen carriers: is the benefit worth the risk?
Authors: Mackenzie Colin F
Published: May 2014

When blood is indicated but not available, haemoglobin-based oxygen carriers can sustain oxygen carriage in acute anaemia, expand circulating volume and improve rheology to ischaemic tissues. When blood is limited, not available or not an option, the risks associated with these carriers must be weighed against the risk of death.
How can bronchoscopy training for respiratory trainees be improved?
Authors: Goldring JJP
Published: May 2014

All respiratory trainees must become competent at bronchoscopy in order to obtain their Certificate of Completion of Training. This article reports the comments of trainees regarding the quality of bronchoscopy training and whether there may be room for improvement.
Concurrent emphysematous cholecystitis and emphysematous cystitis in a non-diabetic patient
Authors: Ayoub Tariq , Arshad Ilyas , Donnellan Imelda
Published: May 2014

A 84-year-old non-diabetic man presented with central colicky, abdominal pain. The pain was worse on movement and radiated to his back. It began 2 weeks before admission and had progressively become worse. During this time, he had two episodes of vomiting and one episode of diarrhoea. There was no associated jaundice or weight loss. He had long-standing anaemia as a result of angiodysplasia. He did not complain of any urinary symptoms but had a previous history of chronic renal failure, hydronephrosis and transurethral resection of the prostate. On examination he had a temperature of 36.8°C, a regular pulse rate of 85/min and blood pressure of 109/95 mmHg. He had tenderness in the right para-umbilical region and an ejection systolic murmur in the aortic region without any radiation (he had a previous history of aortic valve replacement). Blood tests showed a haemoglobin of 10.7 g/dl, white cell count of 17.5×109/litre, urea of 11.8 mmol/litre and creatinine of 181 μmol/litre. Blood glucose on admission was 4.6 mmol/litre. Urine dipstick showed ++ leucocytes but was negative for nitrites. Urine microscopy showed the presence of >105/cm3 of Escherichia coli and numerous white cells but no red cells. Blood culture was negative. Computed tomography of the abdomen showed an enlarged gall bladder with intraluminal air within the gall bladder wall and an air fluid level within the gall bladder itself (Figure 1). No calculi were seen within the gall bladder. Coincidentally the scan also showed air pockets within the bladder wall (Figures 2a and b).

He was treated with intravenous cefuroxime and metronidazole for 5 days as well as being fluid resuscitated. Once his temperature subsided he was discharged on a 5-day course of amoxicillin as advised by the microbiologists. A follow-up computed tomography scan showed complete resolution of the emphysematous cholecystitis and emphysematous cystitis.
Regional anaesthesia for caesarean section: a choice of three techniques
Authors: Campbell J , Sultan P
Published: May 2014

Over the last 20 years, there has been a large increase in the proportion of caesarean sections (Brown and Russell, 1995) which are performed under regional rather than general anaesthesia. A bilateral sensory block from the T4 dermatome (nipple level) to the sacral nerve roots (perineum) is necessary.
What is sport and exercise medicine?
Authors: Speed Cathy
Published: May 2014

Sport and exercise medicine involves the provision of preventative and reactive care for all aspects of health in relation to sport and the use of exercise prescription in the management of health and disease. This article gives an overview of the specialty as it develops in the UK.
The role of the sports physician
Authors: Bundy Mike
Published: May 2014

Sports medicine is an emerging specialty. With the London Olympics on the horizon and the government encouraging people to be more active, more people are likely to participate in sport. But what role will sports physicians play in this new, more active society, and how can they complement physicians and surgeons in the provision of health care?
Perioperative use of dual antiplatelet therapy for patients with coronary artery stents
Authors: Jones Chris , Liban Bernard
Published: May 2014

Percutaneous coronary intervention is an accepted part of management of coronary artery disease. An estimated 2 million patients will undergo percutaneous coronary intervention per year worldwide, and of those up to 90% will have a coronary artery stent inserted (Steinhul et al, 2002). Of these roughly 5% will then present for non-cardiac surgery within the first 12 months after percutaneous coronary intervention (Vicenzi et al, 2006).
The autism spectrum: definitions, assessment and diagnoses
Authors: Lord Catherine , Bishop Somer L
Published: May 2014

This article summarizes current research related to autism spectrum disorders. Current epidemiological trends, theories about aetiology, and relevant issues in assessment and diagnosis of autism spectrum disorders are discussed.
An unusual cause of progressive weight loss and dysphagia in a 10-year-old
Authors: Chew Ne Siang , Pasha Yasmin
Published: May 2014

A previously well 10-year-old presented to his GP with worsening epigastric pain and dysphagia, associated with bouts of nausea. These symptoms and signs, originally ascribed to indigestion, were progressively getting worse. His mother noted that her child, who was normally of thin habitus, was gradually losing weight.
Arthroplasty in the young patient
Authors: Keller Julie M , Vadasdi Katie B , Bigliani Louis U
Published: May 2014

Shoulder pain and loss of function caused by degenerative joint disease is extremely disabling to young people who have an active lifestyle. If non-operative and minimally invasive treatment fails, shoulder arthroplasty is a reasonable option. This article reviews the options and indications for their use in shoulder disability in the young patient.
An unusual case of acute onset lower lip numbness
Authors: Hegarty Anne , Hodgson Tim
Published: May 2014

An 84-year-old Caucasian woman was referred by her primary care dentist to the authors' department with progressive lower lip numbness of 2 months' duration initially noticed by the patient during toothbrushing. The paraesthesia was initially intermittent but became permanent within 1 month. The patient had not sustained any injury to the jaws and no dental treatment had been provided before symptoms started. A course of empirical antibiotics had no impact.

She was previously diagnosed with hypertension, ischaemic heart disease and atrial fibrillation for which she was prescribed lisinopril, valsartan, atorvastatin, digoxin and warfarin. She had no known allergies. She was a non-smoker and drank alcohol occasionally. She was the main carer for her husband who suffers from multiple sclerosis.

Clinical examination revealed reduced sensation to light touch and pinprick in the distribution of the left mental nerve. No other cranial nerve abnormalities were noted. Apart from mild tenderness in the left buccal sulcus opposite the lower left first premolar and a polyp-like lesion on the lower left lip, no other intraoral abnormalities were found.

Initial blood tests including full blood count, haematinics, liver and renal function, glucose, erythrocyte sedimentation rate and bone profile were performed to rule out possible systemic causes of mental paraesthesia and were unremarkable. A panoramic radiograph (Figure 1) showed generalized osteoporosis with a loss of the lower border cortex and inferior dental canal outlines bilaterally. Subsequent magnetic resonance imaging (Figure 2) revealed extensive T1 areas of low marrow signal throughout the skull vault, skull base, cervical vertebrae and the clavicles with the entire left side of mandible showing reduced T1 signal in keeping with mandibular marrow replacement. The appearances were consistent with extensive bone metastatic disease with marrow infiltration of the left side of the mandible involving the mental nerve. Further blood tests revealed normal immunoglobulins and absence of paraprotein.

Oncological referral and further investigation including chest X-ray, whole body computed tomography scan and bone marrow aspiration and trephine confirmed a diagnosis of follicular lymphoma.
Amylase
Authors: Reynolds Tim M
Published: May 2014

The amylases are a group of enzymes responsible for the breakdown of starches into sugars. The important amylase in animals is α-amylase (EC3.2.1.1 – alternate names 1,4-α-D-glucan glucanohydrolase, or glycogenase) which is a calcium metalloenzyme that acts at random locations along a starch molecule hydrolyzing α-1,4 links to ultimately yield mono-, diand trisaccharides. Its primary function is as a digestive enzyme and its optimum operating pH is 6.7–7.0.
Understanding the metabolic response to trauma
Authors: Sritharan Kaji , Thompson Hilary
Published: May 2014

The management of the polytrauma patient is still a great challenge and trauma remains the leading cause of death in people under 40 years of age in the developed world (Keel and Trentz, 2005). The pattern of death following injury is classically described as having a trimodal distribution:
The safe referral and transfer of patients to major trauma centres
Authors: Rogers BA , Pearce R , Jones C
Published: May 2014

Polytrauma patients sustain multiple injuries that frequently require staged management in more than one hospital, depending on the clinical scenario and available resources.
So you want to be … a sport and exercise medicine physician
Authors: Tillett Eleanor , Haddad Fares
Published: May 2014

Have you ever dreamed of working at an Olympic games? Perhaps your passion is health promotion? Not activities you might expect to find in the same working week, but that's what you could be doing if you choose a career in sport and exercise medicine.
Transabdominal ultrasound in the initial assessment of adult bowel diseases
Authors: Kuzmich Siarhei , Harvey Chris J , Speirs Archie J
Published: May 2014

Transabdominal ultrasound is increasingly chosen as the initial imaging technique in the radiological work-up of bowel abnormalities in adults because ultrasound can provide substantial information about gastrointestinal disorders. In the presence of pathological changes in the intestine, sonographic findings, such as thickening of the bowel wall, changes in the perienteric fat and vascularity, have recognizable and reproducible appearances (Kuzmich et al, 2009). Although the diagnostic quality of ultrasound can be compromised by bowel gas and obesity, ultrasound has a number of strengths, including its ability to allow real-time correlation between the sonographic findings and the area of maximum tenderness combined with excellent spatial resolution, wide availability, lack of radiation and its non-invasive nature.
Clinical audit 1: a guide for the foundation year doctor
Authors: Trivedi Deepali , Weerakoon Wijitha , Hooke Rachel
Published: May 2014

Clinical audit is the component of clinical governance used to assess the quality of care within the NHS. All NHS organizations are required to have a comprehensive programme of quality improvement activity. Clinical audit is defined as ‘the systematic and critical analysis of the quality of clinical care, including the procedures for the diagnosis, treatment and care, the associated use of resources and the resulting outcome and quality of life for the patient’ (National Institute for Clinical Excellence (NICE), 2002).
Supervision: what the foundation year doctor needs to know
Authors: George Sanju , Abdel-Maksoud Mohamed B , Merali Shahid
Published: May 2014

The foundation programme, introduced in the UK in August 2005, is a 2-year training programme that equips the medical graduate with all necessary clinical and professional skills required of a doctor in the NHS. Thus, on completion of foundation year training, a doctor will be ready to enter a speciality training programme. Self-directed learning is a key feature of the programme, but this process is facilitated and the foundation doctor is closely supported by the educational and clinical supervisors (Figure 1) through regular supervision.
Liver function tests
Authors: Smellie WSA
Published: May 2014

The term ‘liver function tests’, used typically to describe the liver profile on a laboratory request form, is in fact a misnomer as several of the tests involved are not tests of liver function, but of hepatic enzyme release either as a result of induction or damage. This article will refer to liver profile tests except when specifically referring to liver function. As the body's hepatic reserve is considerable, liver function generally only begins to decline in the face of advanced or severe acute disease, and the liver profile is used to detect abnormalities that may indicate disease. They rarely diagnose the cause of the liver disease in question but can throw light on the category of disease, i.e. obstructive or hepatic.
Clinical audit 2: a guide for the foundation year doctor
Authors: Trivedi Deepali , Singh Anil , Hooke Rachel
Published: May 2014

Part 1 of these articles introduced audit methods and the initial stages of clinical audit (Trivedi et al, 2009). This part looks at the further stages of the audit process and features of successful audits. Barriers to successful audits are also considered.
Writing for publication
Authors: Broad Jonathan , Hayden Sophie , Stephenson Paul , Brigden David
Published: May 2014

As the number of medical students increases, the competition for foundation and specialist training posts becomes more intense. One way to strengthen your application is to show the selection committee that you have written articles that have been peer reviewed and published in respected journals. This article is intended to guide you through the process of writing for publication.
Cardiac markers
Authors: O Collinson Paul
Published: May 2014

Cardiac markers or, more correctly, cardiac biomarkers are now integral to diagnostic and management strategies in cardiovascular disease. Scarcely a week passes without another publication claiming a new and allegedly useful cardiac biomarker. The actuality is that only two cardiac biomarkers are currently in routine clinical use; the measurement of the cardiac troponins for the differential diagnosis of suspected acute coronary syndromes and measurement of B type natriuretic peptide (BNP) for the differential diagnosis of suspected cardiac failure.
General management of acute kidney injury
Authors: Hussein HK , Lewington AJP , Kanagasundaram NS
Published: May 2014

Acute renal failure, or acute kidney injury, is a relatively common problem that occurs in patients under the care of all medical specialties. Around 7% of hospital admissions (Kaufman et al, 1991; Nash et al, 2002) and up to 20% of critically ill patients experience acute kidney injury during the course of their illness. The severity of acute kidney injury directly contributes to mortality, and even relatively small changes in serum creatinine levels can confer a worse outcome (Lassnigg et al, 2008).
Haemostasis screening
Authors: Moore Gary W , Rangarajan Savita
Published: May 2014

Haemostasis comprises the balanced orchestration of vascular integrity, circulating procoagulant and anticoagulant proteins, and cellular blood components (Moore and Rangarajan, 2009). Disturbances of one or more of these integrated compartments can lead to abnormal bleeding. The main reasons for requiring haemostasis screening tests are preoperative checks, investigation of bleeding or monitoring of anticoagulant therapy.
Advanced life support resuscitation protocols
Authors: Prout R , Nolan J
Published: May 2014

The use of standardized protocols during resuscitation attempts should enable resuscitation team members to work effectively together. The current Resuscitation Council (UK) guidelines (Handley, 2006) are based on the recommendations that came from an international consensus on resuscitation science conference held in 2005. These guidelines are revised and updated regularly to take account of improvements in knowledge and treatments.
So you want to be… a public health physician
Authors: Aitsi-Selmi Amina , Gibbons Daniel C
Published: May 2014

Public health has been defined as ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals.’ (Wanless, 2003).
Under-representation of the elderly in cancer clinical trials
Authors: Lang Kathryn J , Lidder Surjit
Published: May 2014

Cancer predominantly affects the elderly, but those over 65 years of age are significantly and consistently under-represented in clinical trials of potential new treatments. How important is this to cancer care in the elderly, are there identifiable reasons for the disparity and can anything be done to redress the imbalance?
Managing patients without their consent: a guide to recent legislation
Authors: Musters Charles
Published: May 2014

Patients who do not consent to treatment are frequently encountered in the general hospital setting. Issues of personal autonomy, best interests, mental health and capacity need to be carefully considered in these cases. This article summarizes recent changes in the law governing the management of patients who do not, or cannot, consent.
Traumatic brain injury in children
Authors: Jamjoom AAB , Gupta RK , Devkota UP
Published: May 2014

This article provides a clinical overview of traumatic brain injury in children. It concentrates on the current management guidelines from initial assessment in the accident and emergency department through to specialist critical care.
Agomelatine in the treatment of mood and anxiety disorders
Authors: Baldwin David S , Lopes Antonio T
Published: May 2014

The antidepressant agomelatine combines a novel mechanism of action with certain advantages over currently available antidepressants, in terms of restoration of sleep, absence of treatment-emergent sexual dysfunction, and fewer discontinuation symptoms. What is its potential role in clinical practice?
Ambroise Paré: pioneer of trauma surgery
Authors: Ellis Harold
Published: May 2014

This year marks the 500th anniversary of the birth of Ambroise Paré, who made important contributions to trauma and military surgery. A man of humble background, he based his work on personal observations and did not fear to go against established teaching. I have to confess that he is one of my surgical heroes!
How well are graduates prepared for practice when measured against the latest GMC recommendations?
Authors: Brown JM , Watmough S , Cherry MG , Fewtrell R , Graham DR , O'sullivan H , Shaw NJ
Published: May 2014

This article investigates the perspectives of University of Liverpool graduate foundation doctors and their consultants on their preparedness for professional practice.
Dysphagia in a 30-year-old woman: too old for a congenital abnormality?
Authors: Longcroft-Wheaton G , Ellis R , Somers S
Published: May 2014

A 30-year-old woman presented to the acute medical take with nausea and vomiting of 48 hours' duration. Clinical examination showed no evidence of bowel obstruction. X-rays showed no abnormalities and blood tests were unremarkable. A gastroenterology opinion was sought. A closer probing of the history revealed that the vomiting consisted of regurgitation of completely undigested food contents shortly after eating. As an infant she had been diagnosed with a ‘narrow’ oesophagus, but had been told by paediatricians that she would ‘grow out of it’. She was of short stature, and on closer questioning revealed that she had always found eating difficult and had a poor appetite. The possibility of partial oesophageal atresia was raised.

A gastroscopy was performed which revealed almost complete obstruction of the oesophagus at 35 cm. On barium swallow a thin string-like 4 cm passage into the stomach was evident, enough to allow the passage of fluids (Figures 1–3). A computed tomography scan was performed to further delineate the anatomy and to exclude a mass lesion associated with the stricture. Owing to the severity of the stenosis, it was felt that dilatation would only provide temporary relief and could be potentially dangerous, with a high risk of perforation. A surgical review was requested and it was decided that a Merendino jejunal transposition may be required to allow effective swallowing. The patient was consented for this elective procedure, and she was fed on a liquid diet of build-up products for 3 weeks. Surgery went ahead as planned. However, during the operation it was decided that the changes were not as severe as previously felt and that a simple myotomy would provide adequate relief, with the option to proceed to more aggressive surgery at a later date if needed. It was probable that a degree of the narrowing seen on imaging was caused by inflammation from eating solid foods, and that this had improved on the liquid diet. The postoperative period was complicated by an anastomotic leak. However, the patient recovered quickly from this and was discharged home shortly afterwards. In the 3 months post surgery she continued to improve, and she is now able to eat a normal diet without difficulty.
High grade lymphoma: acute presentation and management
Authors: Herbertson RA , Webb A
Published: May 2014

Patients with high grade non-Hodgkin lymphoma can present acutely with a wide variety of signs and symptoms. Accurate staging and prompt treatment is essential if patient outcome is to be optimized.
Intermittent positive pressure ventilation: endotracheal tube vs laryngeal mask airway?
Authors: Jigajinni Suyogi , Sultan Pervez
Published: May 2014

Intermittent positive pressure ventilation was traditionally provided through an endotracheal tube, but indications for endotracheal tube placement are quite separate from the indications for intermittent positive pressure ventilation. The laryngeal mask airway is widely used for intermittent positive pressure ventilation, spontaneous breathing techniques and management of the difficult airway. This article compares the provision of intermittent positive pressure ventilation through an endotracheal tube vs a laryngeal mask airway.
Evaluating trainee doctors' educational use of a personal digital assistant: a pilot study
Authors: Morgan Matt , Pugsley Lesley , Bullock Alison , Phillips Suzanne , Stacey Mark
Published: May 2014

In recent times, health-care providers in the western world have embraced modern technology to advance patient care. Ease and speed of access to modern technologies has enhanced the quality of medical education and provided a valuable new adjunct to workplace-based learning.
The intensive care unit handover: the most stressful part of the shift
Authors: Jigajinni Suyogi , Sultan Pervez
Published: May 2014

Training in clinical handover skills is not widely given either to undergraduates or postgraduates in the UK. Since qualification in 2003 the first author has never had any formal training in clinical handover despite it being of great importance to safe practice and something performed daily at work.
Knowing the risk? NCEPOD 2011: a wake-up call for perioperative practice
Authors: Cain David , Ackland Gareth
Published: May 2014

The high-risk surgical population comprises a minority of cases but accounts for the majority of postoperative complications and deaths. The most recent National Confidential Enquiry into Patient Outcome and Death review of these patients found highly variable standards of care and made several recommendations for change.
Current management of Barrett's oesophagus
Authors: Williamson JML , Almond LM , Shepherd NA , Barr H
Published: May 2014

Barrett's oesophagus is one of the most common pre-malignant conditions in the world and its incidence is increasing. The management of this disease is currently the subject of research and debate, with medical, endoscopic and operative intervention all having a therapeutic role.
Leading change in health-care quality with the Institute for Healthcare Improvement Open School
Authors: Patel Eva , Nutt Sarah L , Qureshi Imran , Lister Sue , Panesar Sukhmeet S , Carson-Stevens Andrew
Published: May 2014

The Institute for Healthcare Improvement Open School for Health Professions is an international organization that provides the next generation of health-care leaders with the skills to lead improvement in health care. This article discusses how doctors can get involved and implement change at their hospital.
Medical students' views and understanding of a career in academic medicine
Authors: Mulla Suleman , Watmough Simon , Waddelove Christine
Published: May 2014

Academic medicine is crucial to the advancement of health care with responsibilities in research, teaching and clinical practice. There have been problems recently recruiting for academic posts. This article illustrates medical students' views and understanding of a career in academic medicine.
A multidisciplinary team approach to weaning from prolonged mechanical ventilation
Authors: Black Claire J , Kuper Martin , Bellingan Geoff J , Batson Steve , Matejowsky Claire , Howell David CJ
Published: May 2014

Objective:

To establish whether multidisciplinary team-led strategies to maintain continuity across the weaning process result in an increase in the proportion of patients surviving prolonged mechanical ventilation and reduce the length of time patients are ventilated.

Design:

A quality improvement programme was conceived and implemented for patients receiving mechanical ventilation for ≥21 days.

Setting:

University teaching hospital general intensive care unit.

Interventions:

The introduction of long-term weaning plans.

Measurements and main results:

intensive care unit survival odds ratio and 95% confidence interval 0.181 (0.06–0.49) P<0.01 and hospital survival odds ratio and 95% confidence interval 0.2 (0.08–0.61) P<0.01. Duration of mechanical ventilation (median and 95% confidence interval) 53 days (32–74) vs 42 days (39–44) P=0.03.

Conclusions:

Long-term weaning plans led by a multidisciplinary team were associated with a reduction in intensive care unit and hospital mortality, and duration of mechanical ventilation in patients ventilated for ≥21 days. Strategies to maintain continuity in this complex patient group are likely to be fundamental to improving outcome.