bluuebunny/crossref_metadata_2025 huggingface dataset:
Endoscope Decontamination: Concern for Patient Safety
Authors: Puzey Annette
Published: May 2014

An urgent press statement released during the United European Gastroenterology Week stated that there was ‵Wide spread concern for patient safety′ and that over three quarters of delegates were worried about the cleanliness of endoscopy equipment in their hospital. Should we be worried or is it all ‵spin′?
Endoscopy and the JAG visits
Authors: Campbell Diane
Published: May 2014

Those of you working in endoscopy units may be aware of the need to undergo a formal visit in order to gain the Joint Advisory Group (JAG) approval for training of endoscopists, whatever your professional discipline or background. Following two pilot projects in 2004 and 2005 to define an acceptable format, a considerable amount of work was put into refining the visit process during 2006, largely due to a successful visit being a pre-requisite for acceptance as a bowel cancer screening centre.
Approaches to tackling obesity in children
Authors: Green Sue , Wigley Wendy
Published: May 2014

The increasing prevalence of obesity in children is an issue in many countries across the world. While undernutrition (in terms of deficient nutrient intake) continues to be a problem for many children, overnutrition (in terms of energy intake in excess of needs) is an increasing public health concern. Our genetic make−up has evolved to deal with an environment where food is scarce at times and plentiful at other times. In this type of environment the capacity for fat deposition means that we are more likely to survive through periods when food is scarce. Our bodies may also seek to minimise energy expenditure in order not to expend too much of our fat stores. Children today are faced with an environment where food is of a high quality and plentiful, and there are many opportunities to limit physical activity. Play is often focused on sedentary games and entertainment,such as watching television. Many children today are, therefore, dealing with an environment which promotes obesity.
An overview of the diagnosis, prevention and management of hepatitis C
Authors: Poll Ray
Published: May 2014

Hepatitis C is a RNA viral infection and there are six genotypes (strains), with types 1, 2 and 3 most commonly seen in the UK (National Institute for Health and Clinical Excellence (NICE), 2004). Hepatitis C was first described in 1989 by Michael Houghton and colleagues (cited in Bukh, 2000) who cloned and sequenced the genome of hepatitis C, and was subsequently shown to be the major cause of non−A and non−B hepatitis. If left untreated it can result in significant morbidity and mortality. Hepatitis C infection contributes to some of the 5000 deaths each year in the UK from the complications of chronic liver disease, including cirrhosis and primary liver cancer (Department of Health (DH), 2004). About 15% of liver transplants in England are undertaken because of liver damage caused by the virus. This article provides an overview of the diagnosis, prevention, management (including treatment) of HCV infection, and the significant role played by the specialist nurse.
Barrett's Oesophagus Foundation
Authors: Salmon Paul
Published: May 2014

Barrett′s oesophagus (BO) or columnar−lined oesophagus (CLO), as it is more appropriately known, is an important condition since it is a precursor lesion of oesophageal adenocarcinoma. This form of oesophageal cancer has increasedthreefold in the last decade and tenfold in the past 30 years, currently having the most rapidly increasing incidence of any solid tumour in the western world (see Figure 1) (British Society of Gastroenterology (BSG), 2006). The only known precursor of adenocarcinoma of the oesophagus is CLO.
what the journals say
Authors: Williams Julia
Published: May 2014

The incidence of oesophageal carcinoma according to American statistics is on the increase and has steadily risen over the past 30 years. Besides chronic gastroesophageal reflux disease, the aetiology of Barrett′s oesophagus is relatively unknown; however, it is known to be a predisposing factor to oesophageal carcinoma. As a means of understanding the disease process further, the authors undertook a case controlled study investigating the relationship between body mass index (BMI), central adiposity, smoking and the risk of Barrett′s oesophagus.
what the journals say
Authors: Williams Julia
Published: May 2014

As a means of managing faecal incontinence most people will use an absorbent pad; however, very few products are specifically designed to absorb leaked stool. The purpose of this study was to examine the use of a small surgical dressing that can be placed between the buttocks to absorb leaked faeces.
Patient education and endoscopy: a literature review
Authors: Kielty Lucy Ann
Published: May 2014

The purpose of this review is to determine current knowledge in relation to patient information in endoscopy. The terms ′patient education′ and ′patient information′, used synonymously, involve provision of information based on the patient′s needs to improve health status (Falvo, 1994). Adequate information increases patient satisfaction (Sincock et al, 1999), although limited literature exists regarding patient satisfaction with endoscopy services (Calvin, 2000). Advances in technology and the drive to reduce health−related costs have led to increasing numbers of day case endoscopy. Therefore, the need to adequately prepare patients at home and enable them to self−care on discharge is mounting.
what the journals say
Authors: Williams Julia
Published: May 2014

It is well documented that rehabilitation and adaptation to stoma surgery is hindered by stoma complications. This US study sets out to explore if demographic, clinical and quality−of−life (QoL) variables relate to stoma complications, such as skin irritation, leakage and adjustment, in well established ostomists.
Making decisions about nutritional support for adults via a gastrostomy
Authors: Roberts Sally
Published: May 2014

A growing number of people receive nutritional support via percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG) (Noble, 2008). Sally Roberts explains indications, insertion techniques, advantages and complications, as well as the ethical issues involved in deciding whether to provide nutritional support via a gastrostomy. Such decisions need to reflect ethical principles of respect for autonomy, beneficence, non-maleficence and justice. If necessary, a deprivation of liberty safeguard authorization may be obtained; however, a multidisciplinary nutrition support team needs to work with patients, carers and patient advocates to ensure decisions weigh up ′rights′ and ′risks′ and how the quality of a patient′s life will be affected.
what the journals say
Authors: Williams Julia
Published: May 2014

Our social network is an important structure when facing and experiencing lifechanging events. Studies have found that people with cancer value family support, as it provides emotional and practical support and assists in vital decision-making with regard to treatment. As the authors point out, good family communication and high levels of perceived family support are associated with lower psychological distress in people with cancer.
what the journals say
Authors: Williams Julia
Published: May 2014

The Healthcare Commission′s report, ′Caring for Dignity′ (2007) has raised awareness of dignity and privacy ensuring it becomes the underlying principle in care-giving situations. In light of the fact that there is little guidance and no way of measuring how well a service respects people′s privacy and dignity, the authors set out to explore how dignity can be maintained in continence care.
Pre- and postoperative management of patients with oesophageal cancer
Authors: van Baalen Cathy
Published: May 2014

This series is designed for the nursing professional as a review of the key clinical skills necessary for patient care, clearly presenting common clinical procedures and their rationale, together with the essential background theory. In this seventh article in the series, Cathy van Baalen discusses pre- and postoperative management of oesophageal cancer, the potential complications and the importance of understanding the physical, psychological and social adjustments to life after surgery.
A personal approach to quality
Authors: Harrison Penny
Published: May 2014

Penny Harrison, senior lecturer in adult nursing, De Montfort University, Leicester, examines some of the pertinent professional issues in the challenging environment of gastrointestinal nursing.
Encouraging political engagement
Authors: Black Pat
Published: May 2014

For many stoma care and continence nurses, the thought of politics invading their nursing space does not make them shout for joy. However, today more than ever, nurses are faced with the challenges of a modern-day health service that aims to give a seamless journey for patients and improve the quality of their care. If, as nurses, we do not know what is happening at the top, we cannot air our views and make ourselves heard as an advocate for our patient group.
Rising to the challenge
Authors: Porrett Theresa
Published: May 2014

As new years go, 2010 has certainly started off snowy, cold and icy for lots of us. After too much turkey and way too many mince pies, we probably all just want to hibernate until spring. Unfortunately, given the multiple changes and pressures in the NHS at the moment, this is not a realistic strategy for any colorectal, gastroenterology or stoma care nurses who wish to ensure that their patients continue to receive the range and quality of services which they currently do. I don′t mean to sound like a ′party pooper′, but it has to be acknowledged that 2010 will present nurse specialists with many challenges.
Understanding 'silent' coeliac disease: Complications in diagnosis and treatment
Authors: Evans Kate E , Hadjivassilou Marios , Sanders David S
Published: May 2014

Once thought to be a rare disease of childhood, coeliac disease is now recognized as a common but underdiagnosed cause of gastrointestinal symptoms in adults. Recent guidelines aim to improve recognition and assessment of this condition and will impact on the workload of all gastrointestinal specialists. In this article, current understanding of coeliac disease and controversies in diagnosis will be discussed. By considering the varied presentation of coeliac disease as well as high-risk groups and common complications, the implications for the role of the specialist nurse will be examined.
Front Line Care: The impact on GI nurses
Authors: Harrison Penny
Published: May 2014

As the nation awaits the forthcoming general election and the inevitable hard sell of proposed policies by the major political parties, it can be easy to overlook developments that are occurring currently within nursing. Front Line Care, a report by the Prime Minister′s Commission into the Future of Nursing and Midwifery in England (2010) is such an example. Given the importance of this report, scant attention has been given to it by the mass media. This is in stark contrast to the news that pre-registration nursing programmes are converting to an all graduate profession on qualification by 2013. The old chestnut of ′degree nurses are too posh to wash′ debate reared its ugly head in the tabloid press and many of us smiled ironically at the mis-representation of our profession once again.
Step up and be counted with NACC
Authors: Driscoll Richard
Published: May 2014

On 11 March 2010, the National Association for Colitis and Crohn′s Disease (NACC) launched the campaign ′Step Up and Be Counted′ at 11 Downing Street, calling for a national inflammatory bowel disease (IBD) patient register. Hosted by Maggie Darling, wife of the Chancellor of the Exchequer, the Rt Hon Alistair Darling MP, the launch event was supported by celebrities who are all personally affected by ulcerative colitis and Crohn′s disease, including Emmerdale actor Jeff Hordley, singer Rick Parfitt Junior and TV personality Carrie Grant.
what the journals say
Authors: Coutts Alison
Published: May 2014

Electromagnetic sensing devices (ESDs) have been used to facilitate bedside placement of nasogastric and post-pyloric feeding tubes. They reduce the need for X-ray confirmation of correct placement, avoid the risk of pulmonary intubation and are of particular value when placement is difficult due to paralysis or other anatomical abnormalities, thus reducing the number of patients requiring parenteral feeding, with all the associated risks.
Up-to-date management of megarectum: The role of point-of-care ultrasound
Authors: Watson Nicola
Published: May 2014

Children suffering from chronic constipation may develop megarectum, in which faeces accumulate on reaching the rectum, resulting in an enlarged and dilated rectum.Until recently, there has been no easy way to diagnose or monitor megarectum in children. Nicola Watson explains the work of a team of professionals at Nottingham University Hospital into the use of portable ultrasound to overcome the restrictions of previous techniques; this modality has now been established as an important tool in helping nurse practitioners manage this condition.
Removal of colonic polyps through endoscopic mucosal resection
Authors: Mannath J , Pettman M , Ragunath K
Published: May 2014

Endoscopic mucosal resection (EMR) is a widely-used technique which is a minimally invasive alternative to surgery for treating superficial neoplasms of the colon. It is particularly useful for removing colonic polyps which are difficult to remove by conventional snare polypectomy. These include large, sessile and flat colonic polyps. The removal of large colonic polyps during endoscopy raises a number of concerns, including the risk of the procedure and the possibility of inadequate polypectomy. In order to avoid major complications such as perforation, adequately trained experienced endoscopists should perform this procedure. In this article, an overview of the technique, indications and complications associated with this technique will be provided.
ߢLiberating the NHSߣ: Implications for nurses
Authors: Harrison Penny
Published: May 2014

The debate as to how public finances will be managed in the next 2–5 years continues to rage, and much of the information published in the media since the start of the new coalition government in May has not made comfortable reading. Reports suggest up to 25% of public money may have to be saved in forthcoming years (Butler, 2010). This in turn raises the question of how this will affect the NHS and those of us working in the world of gastrointestinal (GI) nursing. The specific details are not yet known. The government spending review, due on 20 October 2010, will dictate how public money and funding for the NHS is allocated, budgeted and managed over the forthcoming years (HM Treasury, 2010).
Giving patients a choice in treatment
Authors: Davies Mark
Published: May 2014

When Mark Davies was told at the age of 31 years that he required an abdominoperineal excision due to cancer, he sought a second opinion. He shares a lay person's view of the available—and less available—treatment options.
Specialist or advanced roles?
Authors: Coutts Alison
Published: May 2014

Specialist nurses or advanced practitioners have had an increasing role within our health services over recent years, and we claim that they save money by providing a streamlined service while improving patient satisfaction (Royal College of Nursing, 2010). For these reasons these posts are often quite rightly aspired to by nurses wishing to offer their patients the best possible service, and to maximize their own professional achievements. However, as a profession we have still not decided what we mean by these terms, and tend to use them interchangeably. Moreover, we have not implemented any definition of these roles.
An overview of acute liver failure: Managing rapid deterioration
Authors: Sargent Suzanne
Published: May 2014

Acute liver failure is a rare condition in which rapid deterioration of liver function results in altered coagulopathy and hepatic encephalopathy in individuals with no pre-existing liver disease. Aetiology varies geographically, and the prognosis is often dependent on the underlying cause, patient's age and length of disease progression. Many patients develop multisystem failure, which is associated with a high mortality and morbidity, despite advances in intensive care and management. For many patients super-urgent liver transplantation remains the only effective treatment. In this article, Suzanne Sargent provides an overview of the current medical and nursing strategies for managing this complex and often challenging syndrome.
Maximizing effective learning for students
Authors: Harrison Penny
Published: May 2014

Penny Harrison, senior lecturer in adult nursing, De Montfort University, Leicester, considers how gastrointestinal nursing staff can ensure nursing students experience personal and professional development as well as enhancing their practical learning and clinical skills in the work environment.
The physiology of food intake regulation and eating disorders
Authors: Blows William T.
Published: May 2014

Normal food intake is controlled by complex mechanisms, which remain only partially understood. Anorexia nervosa and bulimia nervosa are eating disorders, which are linked to chronic stress and disturbs these mechanisms. If not fatal, the long-term effects of anorexia nervosa can cause permanent brain changes that may perpetuate the problem. Obesity is sometimes the result of genetic mutations affecting the normal leptin regulation of eating. If not corrected early, the physical complications of eating disorders cause severe ill-health and are often fatal. In this article, William Blows discusses the physiology of food intake regualtion and eating disorders.
Nurse specialist involvement in patients who undergo sacral nerve stimulation for faecal incontinence
Authors: Ness Wendy
Published: May 2014

Faecal incontinence (FI) can have an extremely negative effect on quality of life (QoL) in terms of physical, psychological, social and emotional wellbeing. Furthermore, FI is not always curable. For those patients who live with it lifelong, the aim of care is to improve symptoms; at first with conservative treatment but if this is not successful, more invasive options such as sacral nerve stimulation (SNS) are considered. SNS is an acceptable and clinically-efficient therapy that improves QoL with reproducible results. Nurse Specialist involvement is imperative for patients to have confidence in the procedure and achieve the best possible results. In this article, Wendy Ness considers the prevalence, aetiology, assessment and management of FI and explores SNS with nurse specialist involvement as an option when conservative treatment fails.
Nicorandil-induced ulceration complicating a novel treatment of a peristomal tubovillous adenoma
Authors: Raman Sudarsanam , Fadipe Yetunde , Perston Yvette , Karandikar Sharad
Published: May 2014

Nicorandil, a potassium-channel activator that is used in the treatment of ischaemic heart disease, has been known to cause debilitating peristomal ulceration (Skellett et al, 2009). In this paper, Sudarsanam Raman, Yetunde Fadipe, Yvette Perston and Sharad Karandikar describe an unusual case in which a peristomal tubovillous adenoma was complicated by nicorandil-induced ulceration. Ileostomy neoplasms are rare; if they do occur, they usually occur more than 15 years after the surgical treatment of colitis or polyposis ( Attanoos et al. 1995 ; Quah et al. 2005 ).
Familial adenomatous polyposis: natural history and care of the patient
Authors: Samarasinghe Muditha , Hawkins Jacqueline
Published: May 2014

Familial adenomatous polyposis (FAP) is a rare, autosomal dominantly inherited condition. It is characterised by the development of hundreds to thousands of colorectal adenomas, which usually develop during adolescence (Bussey, 1975). The diagnosis of FAP is based clinically upon the identification of the colorectal adenomas, and may be confirmed by genetic testing. In many cases, a family history will reveal an autosomal dominant inheritance pattern. This article will review the natural history of FAP and discuss the care of this patient group. It will include the recommended screening and surgical options for the lower gastrointestinal tract and discuss suggestions for screening the upper gastrointestinal tract. The associated extra-colonic manifestations of FAP will be explained and the importance of a multidisciplinary approach for the care of these patients will be highlighted.
The experienced GI nurse: current developments
Authors: Harrison Penny
Published: May 2014

Penny Harrison, Senior Lecturer in Adult Nursing at De Montfort University, Leicester, reviews the developments for specialist nurses
Encouraging independence, nurturing friendships
Authors: Bastin Julie
Published: May 2014

Julie Bastin, Founder and Trustee of The Breakaway Foundation and mother of a child with bowel and bladder dysfunction, tells us about this unique Foundation
Intestinal failure and parenteral nutrition
Authors: Nunwa Annmarie
Published: May 2014

Parenteral nutrition is a life-saving therapy for patients with an inaccessible or non-functioning intestine. Nurses play an important role in contributing to the management and care of patients with intestinal failure. To ensure that the delivery of services are both evidence-based and patient-centred, nurses need to have a complete understanding of the causes and consequences of intestinal failure, as well as the options and management for nutritional therapy. This article provides an overview of published definitions and classifications of intestinal failure. In addition, it reviews the factors to be considered in determining the route of delivery, and explores the associated complications linked with the therapy and catheter placement.
Overview of Peutz-Jegher's and juvenile polyposis syndromes
Authors: Neale Kay , Hawkins Jacqueline
Published: May 2014

Peutz Jegher's syndrome (PJS) and juvenile polyposis syndrome (JPS) are rare, autosomal dominantly inherited conditions. They are both characterised by the development of polyps in the gastrointestinal tract, but the exact distribution of the polyps is different in each syndrome and the polyps themselves differ histologically. The diagnosis of both syndromes is based on the identification of the polyps and the histological type, and in most cases, can be confirmed by genetic testing. This article will review the natural history of PJS and JPS and will include the recommended screening and management of patients with these two conditions.
Intravascular ultrasound: defining plaque regression
Authors: Houslay Emma S , Uren Dr Neal G
Published: May 2014

Intravascular ultrasound allows accurate assessment of the arterial vessel, including vessel luminal diameter and assessment of vessel disease in terms of plaque morphology, plaque volume and extent of calcification. Recently published trials highlight the role of intravascular ultrasound in monitoring disease progression in a clinical setting.
Professionalizing postgraduate medical education: schools and academies
Authors: Moore Julia , Heard Shelley
Published: May 2014

In the UK, the Modernising Medical Careers (MMC) initiative has promised a new approach to postgraduate medical education, through programmes of curriculum-driven, competence-based, in-service learning designed to ensure that doctors are safe to deliver patient care in teams and in an NHS which has patients at its centre. Implementation of the proposed changes will be substantially supported and driven by the new Competent Authority for postgraduate medical education, the Postgraduate Medical Education and Training Board.
IT innovation in histopathology recruitment, training and research
Authors: Naik Paras , Rashbass Jem , Bennett Mark , Cossins Sue , Griffin Nick R
Published: May 2014

The introduction of national recruitment and cohort training in histopathology in England has produced significant challenges and highlighted opportunities for development. Innovative information technology solutions have been deployed to facilitate recruitment and enhance education provision and research.
How to organize a ‘taster’ week for foundation year 2 doctors
Authors: Young Jane , Ross Elleni
Published: May 2014

This article describes the aim of short, focussed placements (‘taster’ experiences), and outlines some of the practicalities of organizing them.
Should 22G spinal needles for accessing the subarachnoid space be banned?
Authors: Barker Horace , Curran Natasha
Published: May 2014

The 22 gauge (22G) spinal needle has been used extensively for both diagnostic lumbar puncture and administration of spinal anaesthesia. A significant complication of these procedures is a postdural puncture headache (PDPH). Other factors influencing the choice of needle size are ease of operator use, failure rate and CSF flow rates.
The expert witness and the lawyers
Authors: Badenoch James
Published: May 2014

The English legal system permits an expert qualified by learning and experience to give opinion evidence in court. This is an exception to the sensible general rule that a witness may only give evidence of fact (what he did, said, saw or heard) and may not express his opinion on the facts, however sincerely held. The rationale for this unique exception to the normal rule is not that the expert opinion is intended to be definitive of guilt or innocence, or in a civil case determinative of the outcome of the dispute. It is rather that where the allegations or issues to be tried involve complex matters of which the judge and/or jury are ignorant, they shall receive proper assistance from those who are skilled in them, and who are by specialist knowledge equipped and able to interpret and explain them, and to promote a proper understanding in the minds of those who must do the deciding.
Managing metastatic prostate cancer
Authors: Ngan S , Mazhar D , Waxman J
Published: May 2014

Prostate cancer is one of the most commonly diagnosed malignancies in the west. Most patients with metastatic or recurrent prostate cancer initially respond to androgen deprivation therapy, but almost all eventually progress. This review will focus on current treatment options for metastatic prostate cancer, with a focus on hormonal therapies, chemotherapy and treatment of bony disease, along with biological and targeted therapy.
Emery–Dreifuss muscular dystrophy with cardiac manifestations
Authors: Cullington D , Pyatt JR
Published: May 2014

An asymptomatic 40-year-old man attended clinic for cardiology assessment before cataract surgery. He had been diagnosed 9 years earlier with a ‘non specified limb-girdle muscular dystrophy’ following investigation for lower limb muscle weakness. Earlier electrocardiograms (ECGs) showed a bradycardic, junctional escape rhythm of 30–40 beats per minute (BPM). He had previously refused pacemaker insertion.

He denied any syncope, shortness of breath or palpitations. He had muscle wasting to his upper arms and calves plus mild elbow contractures. He was normotensive, resting regular heart rate = 42 BPM and cardiorespiratory examination was unremarkable. His ECG showed atrial fibrillation, with a slow junctional escape rhythm of approximately 40 BPM and normal QRS width (Figure 1). Blood tests showed no haematological, electrolyte or thyroid dysfunction and no impaired glucose tolerance.

Echocardiography showed good left ventricular function and 24-hour ECG Holter monitoring showed 8 pauses (longest 2.13s), with a heart rate varying between 29 and 79 BPM. He was commenced on clopidogrel to prevent thromboembolic complications and then he agreed for a VVIR system to be implanted to avoid bradyarrhythmic death. No complications ensued and he remains well at present.

The patient also had two brothers, one died suddenly and the cause of death was not clearly determined. His elder brother was 52 years old and was diagnosed with a non-specific muscular dystrophy also associated with a junctional rhythm. He had a VVIR permanent pacemaker inserted in April 2003 following recurrent episodes of dizziness.

An hereditary skeletal myopathy in association with pathognomic cardiac abnormalities suggested a diagnosis of Emery–Dreifuss muscular dystrophy (EDMD). Prognostically and therapeutically a definitive genetic diagnosis was required. Genetic testing confirmed that both siblings had inherited the X-linked form of EDMD involving a single base change of the emerin gene.
Craniectomy for middle cerebral artery infarction
Authors: Tarnaris A , Kitchen ND
Published: May 2014

Malignant middle cerebral artery (MCA) infarction is defined as rapid clinical deterioration and poor outcome as a result of increased intracranial pressure and transtentorial herniation, occuring in 10–15% of supratentorial infarctions and with a mortality rate of up to 80%. The case report by St George et al (p. 702) published in this issue of the British Journal of Hospital Medicine aims to increase the awareness of this clinical condition among physicians managing patients with ischaemic stroke and discusses the implications of an early vs late referral to the local neurosurgical unit.
Visual impairment in the elderly
Authors: Taylor Simon , Lightman Sue
Published: May 2014

Visual impairment and blindness are common in older people in Britain and it is becoming increasingly important to develop research and health service priorities accordingly. The population of the UK is ageing rapidly: by 2041, the number of people aged 75 years and above is projected to increase by over 100% and the number of people aged 90 years and above by over 260% (Government Actuary's Department, 2004). It is clear that age-related diseases such as cataract and age-related macular degeneration (ARMD) will assume increasing importance in the public health of the nation, and the symposium in this issue seeks to examine the common causes of visual loss in the elderly in greater detail.
The glaucomas
Authors: Clarke Jonathan , Clare Gerry , Khaw Peng Tee
Published: May 2014

Glaucoma is the second commonest cause of blindness worldwide, after cataract. Recent developments include new topical antihypertensive drugs and anti-scarring drugs in glaucoma surgery. Improved techniques for imaging the optic nerve are enabling early diagnosis and identifying progression of disease.
Bivalirudin: role in current percutaneous coronary intervention practice
Authors: West Nick
Published: May 2014

Bivalirudin is the only thrombin-specific anticoagulant currently licensed in the UK for use as an anticoagulant during percutaneous coronary intervention. This review examines the rationale for, and data supporting, its use in contemporary percutaneous coronary intervention practice.
Panda eyes and heart failure
Authors: Dubrey Simon W , Recica Hilmi , Grocott-Mason Richard , Hawkins Philip
Published: May 2014

A 91-year-old man developed peri-orbital echymoses (panda eyes) spontaneously after drying his face gently with a towel (Figure 1). He gave a 6-month history of increasing susceptibility to bruising and to shortness of breath. He was cachectic and had numerous petechiae over his torso and upper limbs. Clotting studies and haematology were normal. He was hypotensive and had signs of biventricular heart failure. Despite his slim body habitus, an electrocardiogram showed low limb voltages (Figure 2). In addition, an echocardiogram confirmed very poor systolic function and thick walled ventricles.
Correspondence
Authors: Lee Harry A
Published: May 2014

The editorial by Deahl (vol 66(11), 2005, p. 608) is a reasonably fair and balanced opinion. It puts the concept of ‘Gulf War illness’ and/or ‘Gulf War syndrome’ in perspective. The independent and highly authoritative Medical Research Council review of 2003 found no evidence to support a single Gulf War syndrome.
Sacred cows: milking the controversies in resuscitation
Authors: Mackenzie Colin F
Published: May 2014

The eleven articles about resuscitation in this issue of Hospital Medicine are the products of a session of the joint Royal Society of Medicine, Association of Academic Health Centers and University of Maryland meeting on 20–22 September 2004 titled Terrorism and Trauma: a transatlantic perspective, held at the University of Maryland School of Medicine, Baltimore, USA. The remarkable thing about these papers is that they challenge some of the most basic tenents of common practice for trauma patient management.
Assessment for improvement: Healthcare Commission consults on new approach
Authors: Singh Iqbal
Published: May 2014

The Healthcare Commission has announced its proposed new approach to assessing the performance of health-care organizations in England and that 2005 will be the last year of Star Ratings. The Healthcare Commission (Commission for Healthcare Audit and Inspection, or CHAI) was established under the Health and Social Care (Community Health and Standards) Act 2003 and came into existence in April 2004. It is a new body and took over the functions of Commission for Health Improvement (CHI), the Mental Health Act Commission and some value-for-money studies of the Audit Office.
Thinking about the SHO curriculum
Authors: Brigley Stephen , Golby Michael
Published: May 2014

This discussion of the reform of senior house officer (SHO) training draws on important evidence from the evaluation of a pilot curriculum for basic surgical education. Variations and anomalies in SHO teaching and learning were detected, many related to the service context. They highlight the need for explicit curriculum frameworks that build on, and are consonant with, current best practice in SHO education.
Modernising Medical Careers or ‘Modernising Clinical Careers’?
Authors: Heard Shelley
Published: May 2014

Modernising Medical Careers (MMC) (Department of Health, 2003) was 2years old in February 2005. Its marks a new era in UK medicine and sets the context for a programme of change that will have a far-reaching impact on the delivery of safe patient care, and on the nature of the British medical workforce. An early foundation programme emphasizes the acquisition of clinical and professional skills followed by specialist training that is focused on the needs of the NHS for accredited doctors. Both are designed to create a modern workforce that works effectively with other health professionals for patients.
Parenteral nutrition: multidisciplinary management
Authors: Nightingale Jeremy MD
Published: May 2014

Parenteral nutrition may be needed to give nutritional support to patients with severe acute (temporary or reversible) or chronic intestinal failure. Parenteral nutrition needs to be given only by health workers trained in its use otherwise life-threatening complications (especially sepsis) may occur.
Importance of haemodynamic monitoring in cardiac tamponade
Authors: Mahajan Nitin , Thekkoott Deepak , Kabalkin Chaim , Hollander Gerald , Vaynblat Mikhail , Rankin Lydia
Published: May 2014

A55-year-old man presented to the emergency room (ER) with complaints of anorexia, feelings of being unwell and anuria from the previous day. He denied any chest pain, palpitations, dyspnoea on exertion or fever. He was recovering from a recent throat infection and had a past medical history of diabetes mellitus, hypertension and hypercholesterolaemia.

He was pale-looking and his physical examination revealed hypotension (90/60 mmHg) and tachycardia. He appeared in mild respiratory distress. Examination of neck veins showed raised jugular venous pressure of 6 cm above the sternal angle. His chest was clear on auscultation and the intensity of heart sounds were diminished with no added sounds. He had a measured pulsus-paradoxus of 20 mmHg.

His electrocardiogram showed diffuse low-voltage complexes with no evidence of electrical alternans. There were ST segment elevations in lateral leads with tall T-waves in anterior precordial leads suggestive of posterolateral myocardial infarction (Figure 1). Posterior changes were confirmed on a posterior electrocardiogram (Figure 2). Right-sided electrocardiogram failed to reveal any ST-T abnormalities suggestive of right ventricular infarction. The initial set of laboratory tests done in ER revealed high blood urea nitrogen (9.64 mmol/litre) and serum creatinine (150.28 μmol/litre). The first set of cardiac enzymes revealed high troponin I (23.05 μg/litre) with normal myoglobin and creatine kinase. An arterial line was placed that revealed pulsus-paradoxus of 20 mmHg. A Swan–Ganz catheter was placed and showed: right ventricle of 53/33 mmHg; right atrium of 28 mmHg; pulmonary artery of 50/32 mmHg; pulmonary capillary wedge pressure of 30 mmHg.

The central venous pressure tracing showed complete obliteration of ‘y’ descent. Dopplerechocardiography was done. It showed mild-to-moderate pericardial effusion with possible thrombus overlying the right ventricular wall. Posterior and lateral walls were found to be hypokinetic. The patient underwent coronary angiography before emergency pericardiocentesis. Angiography revealed complete occlusion of the first obtuse marginal. Aortic-pulse tracing is shown in Figure 3. These pressure tracings were consistent with cardiac tamponade with a demonstrable pulsus-paradoxus of about 20 mmHg. Ventriculography was not performed because of a suspected subacute rupture of the myocardial wall.

A cautious pericardiocentesis was performed. Examination of the pericardial cavity revealed 300 cm3 of blood clots. In the absence of an ongoing leak, a pericardial window was created and a drain was left in situ. The patient was dialysed once after the procedure. His haemodynamics improved significantly after surgery. He remained stable through the course of his stay in the hospital and was discharged 3 days after pericardiocentesis.
Secondary syphilis: a multisystem disease not to be forgotten
Authors: Thein Michael , Acland Katharine , Lightman Susan , Lynn William
Published: May 2014

A42-year-old homosexual man presented with a 3-month history of painful mouth ulcers and a hyperkeratotic, erythematous scaly rash affecting his palms and soles (Figure 1). He also had a 2-month history of bilateral anterior tibial pain, balanitis and a panuveitis. There was a recent history of a non-specific urethritis and a past history of shingles. In addition to the rash affecting his palms and soles, he had facial seborrhoeic dermatitis, mucosal ulceration with leukoplakia, and a balanitis with phimosis. A tender firm lump was noted over his left anterior shin. He was apyrexial and there was no lymphadenopathy or hepatosplenomegaly.

Routine investigations revealed a raised erythrocyte sedimentation rate of 42 mm/h, associated with a polyclonal rise of immunoglobulins with a normal full blood count and C-reactive protein. A plantar skin biopsy showed numerous plasma cells in addition to lymphocytes within the papillary dermis (Figure 2). A Warthin–Starry stain for bacteria was negative. At the same time as the skin biopsy his vision worsened with bilateral mid-peripheral retinitis in addition to panuveitis. The skin biopsy showing numerous plasma cells and the mid-peripheral distribution of the retinitis were highly suggestive of secondary syphilis.

The diagnosis of secondary syphilis was confirmed by a positive venereal disease research laboratory (VDRL) titre of 1:256, in association with a positive fluorescent treponemal antibody (FTA) test and treponema pallidum haemagglutination assay. He was also found to be positive for human immunodeficiency virus with a CD4 (t-helper cell) count of 145 × 106/litre (10.5%), and a viral load of 115 305 copies/ml. X-rays of his tibial bones revealed bilateral lytic cortical lesions, in keeping with a syphilitic osteitis. The firm tender lump over his left shin corresponded to a cortical lesion with a marked periosteal reaction (Figure 3).

He was given a 10-day course of high-dose intravenous benzylpenicillin, after which his skin and mucosal lesions had almost resolved. The initial ocular inflammatory reaction settled quickly but visual acuity deteriorated 2 days after the commencement of penicillin, thought to result from an intraocular Jarisch–Herxheimer reaction. This complication was treated with a tapering dose of oral prednisolone, starting at a dose of 60 mg/day. His visual acuity subsequently returned to normal leaving a residual typical ‘salt and pepper’ scarring in the fundus (Figure 4).
The death of Nelson at Trafalgar
Authors: Ellis Harold
Published: May 2014

This year marks the 200th anniversary of the most famous naval battle in British history — the Battle of Trafalgar on October 21 1805 — and with it the poignant fatal wounding of Horatio Nelson.
Intermittent gastric volvulus secondary to gall bladder adhesions: a rare cause of gastric outlet obstruction
Authors: Sultan J , Vassallo P , Davis P , Viswanath YKS
Published: May 2014

A51-year-old man presented with a history of intermittent epigastric pain over a course of 18 months, associated with feeling bloated, and episodic nausea and non-bilious vomiting, which relieved the pain. During recent months vomiting had been replaced by severe retching. Ultrasound scan of the gall bladder revealed gallstones. Clinical examination was unremarkable. Routine haematological and biochemical investigations were also normal.

Two gastroscopies were incomplete, since on both occasions the endoscope could not be negotiated beyond the antrum and the pylorus could not be visualized. A water-soluble contrast swallow revealed a ‘cup and fill’ configuration (Figure 1), suggesting mesenteroaxial gastric volvulus. A repeat ultrasound scan revealed a thick-walled gall bladder with several calculi.

Laparoscopy confirmed the presence of the gastric volvulus, with the stomach adherent to the body of a chronically-inflamed gall bladder. At initial intraoperative gastroscopy the endoscope failed to pass beyond the antrum. Following adhesiolysis, cholecystectomy and anterior suture gastropexy, a gastroscope could easily be passed into the pylorus and duodenum. He made an uneventful recovery and remains asymptomatic 1.5 years after the operation.
Otitis media in children
Authors: Clarke RW , De S
Published: May 2014

Otitis media is the term used for a group of conditions characterized by inflammation of the middle-ear cleft. These conditions are particularly common in children where they present important diagnostic and therapeutic dilemmas.
Structured clinical attachments for international medical graduates
Authors: Ong Yong-lock , Idowu Abeke
Published: May 2014

Clinical attachments are an opportunity for international medical graduates to gain some first-hand experience of the UK medical system and thereby improve their chances of finding employment. Unfortunately, these attachments may be hard to find and are of variable quality. This article details one deanery's approach to developing structured clinical attachments.
Nicotine replacement therapy and ischaemic stroke
Authors: Ang Richard , Wroe Stephen , Manji Hadi , Sharma Pankaj
Published: May 2014

A52-year-old right-handed businessman developed sudden onset of non-fluent dysphasia, weakness and sensory disturbance on the right side of his body 3 weeks after starting Nicorette patches (21 mg). He continued to smoke 3–5 cigars a day while on these patches. The patient had a history of depression and excessive alcohol intake.

Examination confirmed an expressive dysphasia with verbal fluency limited to five words beginning with ‘C’ or ‘S’ but with no problems in comprehension, naming or praxis. Rapid alternating movements were impaired on the right and reflexes were brisker on the right side, although both planters were flexor. Cardiovascular and general examination was unremarkable.

Magnetic resonance imaging (MRI) brain scan confirmed a left anterior cerebral artery territory infarct. The following blood tests were normal or unhelpful: erythrocyte sedimentation rate (ESR), C-reactive protein, protein culture and sensitivity, antithrombin, antiphospholipid coagulant, treponemal serology, thyroid screen and autoantibody screen. The patient was found to have mildly raised triglyceride (2.42 mmol/l) and low density lipoprotein (LDL) cholesterol (4.61 mmo/l). Electrocardiogram (ECG), echocardiography and carotid Dopplers were all normal.

Two previous cases of stroke following nicotine patches have been reported by Jackson (1993) and Pierce (1994). In addition, the Medicines and Healthcare products Regulatory Agency (MHRA) have received 12 further cases of cerebrovascular disorders following nicotine replacement (Table 1).
A case of neonatal testicular torsion
Authors: Wong Chee-Yeng , Yong Sin-Chuen , Boo Nem-Yun , Phang Koon-Seng
Published: May 2014

A Malay male infant of 3000 g was delivered via spontaneous vaginal delivery to a primigravida mother. His Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. His mother had an uneventful antenatal and intrapartum period.

Physical examination performed at 1 hour of life detected an enlarged, hard and tender right testis with discolouration of his right scrotal skin. There was a left cystic hydrocoele and the left testis was of normal consistency and size. A clinical diagnosis of torsion of the right testis was made. Ultrasonography of the testes showed absence of Doppler signal within the right testis, which measured 1.46 × 0.91 cm with the presence of an ill-defined hypoechoic area in its superior pole, suggesting an area of infarction. The left testis was of normal size and Doppler signal.

Intraoperatively, the right testis was found to be gangrenous with torsion of the right testicular artery. The left testis was normal. Right orchidectomy and a left orchidopexy were performed. Postoperatively the infant recovered uneventfully and was discharged home on the fourth day of life. On follow-up, the left testis was growing well. Histopathological examination (Figures 1 and 2) of the right testis confirmed the presence of testicular torsion with infarction.
International medical graduates: a tale of two scandals?
Authors: Trewby Peter
Published: May 2014

Many feel uneasy that the UK's expanding health economy is so dependant on doctors trained overseas. This applies particularly to doctors trained in countries in Asia, Africa and Eastern Europe whose health needs are so much greater than ours. The chairman of the British Medical Association (BMA) has been quoted as describing the NHS's record on recruiting staff from overseas as ‘shameful’ and ‘a scandal’ (Dunne, 2004). Putting aside the ethical issue of country of origin, the UK has a duty at least to ensure that those international medical graduates (IMGs) currently in the UK are gainfully employed. But here we fail again, this second scandal compounding the first.
The management and treatment of cervical spine injuries
Authors: Al-Khateeb Hesham , Oussedik Sam
Published: May 2014

The cervical spine is a relatively fragile structure traversed by the spinal cord. Injuries to the cervical spine (c-spine) are therefore associated with potentially catastrophic neurological complications. This article illustrates the importance of routine c-spine immobilization in all trauma patients and highlights how early diagnosis of injuries can optimize outcome.
Pelvic fractures and high energy traumas
Authors: Wardle NS , Haddad FS
Published: May 2014

Pelvic fractures are associated with a high mortality and morbidity and their presence should be considered in all high energy traumas. Early management is directed towards basic advanced trauma life support (ATLS) principles but it is essential to be aware of the diagnosis and management of these complex injuries.
What do specialist registrars know about clinical governance?
Authors: Beavan JR , S Briggs , Corrado OJ , Turnbull CJ
Published: May 2014

Clinical governance is an essential part of quality assurance for everyday clinical practice. It is part of the generic curriculum for all specialist registrars (SpRs) training in medical specialities. The authors of this update undertook a survey of SpRs training in geriatric medicine to determine their perceived knowledge of clinical governance and whether they had received training in this area.