bluuebunny/crossref_metadata_2025 huggingface dataset:
Teaching tips for busy clinicians
Authors: Whitehouse Andrew , Lloyd Ben
Published: May 2014

Most consultants enjoy teaching but clinical priorities often interfere. Adult education principles and simple models that apply them can help doctors make better use of the available time. This article describes these, and looks at ways to create a more stimulating hospital learning environment.
PRHOs in primary care: what is happening out there?
Authors: Cantillon Peter , Williams Clare , Cochrane Mac
Published: May 2014

Preregistration house officer (PRHO) placements in general practice were introduced throughout Britain in August 1998. This paper describes an evaluation of PRHOs in primary care rotations in South Thames during 1998–99. There are important messages for both educational supervisors and undergraduates considering a PRHO in primary care rotation.
Fungi, mycological disease and pathogenic determinants
Authors: Richardson Malcolm , Ellis Michael
Published: May 2014

The rapid evolution of human fungal infections is providing a strong impetus for understanding pathogenesis and host–fungus interactions and hence new diagnostics.
Receptor pharmacology of neuroleptics
Authors: Pearson Richard M
Published: May 2014

The term ‘neuroleptic’ originated from animal experiments — these drugs caused profound sedation and abnormal posturing as if the animal had been ‘seized’ (Greek ‘lepsis’, meaning seizure). All early neuroleptic drugs had antipsychotic actions and vice versa. Now there are drugs which are potent antipsychotics without the classic neuroleptic actions known as atypical neuroleptics.
Computed tomography colonography
Authors: Mendelson Richard M , Forbes Geoffrey M
Published: May 2014

Computed tomography colonography (virtual colonoscopy) is an exciting technique that continues to evolve but promises to be a valuable tool for diagnosis of and screening for colorectal neoplasia.
Angiotensin II antagonists in systolic blood pressure control
Authors: McInnes Gordon T
Published: May 2014

Control of systolic blood pressure should be the primary goal of treatment as it is increasingly recognized as a major determinant of cardiovascular risk. Better control offers enormous potential benefits. Effective treatment is desirable but difficult to achieve. AII antagonists, particularly eprosartan, are likely to have an increasingly important role in management strategies.
Managing complaints: part of daily clinical practice
Authors: Scott Hilary
Published: May 2014

Almost every clinician will, at some time, be involved in responding to a complaint made about the care provided to a patient. What can doctors do to help make sure complaints are less likely to arise and, when they do, that they are handled well?
How to get your medical book published
Authors: Richardson Peter
Published: May 2014

What do medical publishers want? What types of book sell well? How you should you approach a publisher with an idea for a book? This article provides answers to these and other questions. Doctors with good ideas for books are in demand. But beware, success also carries penalties!
Intermediate care: private—public partnership
Authors: Garner Victoria A
Published: May 2014

The NHS Plan (Department of Health, 2000a), unveiled in July last year, was a watershed for health and social care in the UK. The plan contained, among many other policies and promises, the announcement of a 'concordat' between the Government and the Independent Healthcare Association.
Why doctors should think more carefully before prescribing
Authors: Hawkey Christopher
Published: May 2014

Each year, adverse reactions to medications kill more people than road traffic accidents. In fact, they are one of the biggest killers after cancer and heart disease (Bates et al, 1995). But medical advancement is a wonderful thing, and a massive investment in the development of medical products has given doctors new, improved drugs with greater efficacy and selectivity, the end result of which is fewer adverse reactions and deaths.
The urinary catheter: 'a-voiding catastrophe'
Authors: Patel Hitendra RH , Arya Manit
Published: May 2014

A quarter of all patients admitted to hospital are catheterized. This is associated with significant morbidity and occasional mortality. This article reviews the risks of urinary catheterization and suggests preventative measures.
New national standards for specialist practice in public health
Authors: Golding Anthony
Published: May 2014

If the government is to meet its public health agenda it will need public health specialists from a range of disciplines. At present those without a medical background lack any agreed career structure which would develop their skills. This editorial describes the steps being taken to create a multidisciplinary specialty of public health.
Career success after flexible training in psychiatry: a survey of former flexible trainees in the Thames regions
Authors: Etchegoyen Alicia , Stormont Fiona , Goldberg Ilfra
Published: May 2014

This article outlines the findings of a study which indicate that flexible training in psychiatry was considered adequate to prepare doctors for both full-time and part-time work and that those wishing to work part time had no difficulty in finding jobs after accreditation. However, there was evidence to suggest that part-time consultants experienced more problems and less job satisfaction and that part-time training and working may restrict opportunities for an academic career.
Diagnosis and immediate care of fractured neck of femur
Authors: Parker Martyn
Published: May 2014

The classical presentation of a patient with a hip fracture is an elderly person (female in about 80% of cases) who had tripped while walking and fallen. The symptoms are of pain in the hip and inability to walk. Clinical examination usually reveals a shortened and externally rotated limb for which all attempts at hip movement are painful. The diagnosis is readily confirmed by X-ray. Unfortunately, for about 14% of patients, the diagnosis is delayed (Pathak and Parker, 1996).
Evidence-based lumbar puncture: best practice to prevent headache
Authors: Cooper Nicola
Published: May 2014

Lumbar puncture is routinely used to access cerebrospinal fluid. Headache is the most common complication, and can be debilitating. The risk of headache is related to age, sex, needle size and shape, and lumbar puncture procedure. Doctors continue to use 20 G bevelled needles followed by bed rest, although overwhelming evidence supports use of 22 G atraumatic needles with no bed rest.
The pathogenesis of atopic eczema
Authors: Friedmann Peter S
Published: May 2014

Atopic eczema is associated with a genetic predisposition to dysregulation of the immune system. T lymphocytes differentiate towards the Th2 type with promotion of immunoglobulin E antibodies. Allergic responses to environmental allergens develop and microbes, including staphylococci and pityrosporum yeasts, may contribute to the inflammatory process.
Development of a database of clinical guidelines
Authors: Pearson Michael , Ingham Jane , Bunn Anna-Maria
Published: May 2014

The quality agenda has become even more important to the NHS in the last 5 years. Guidelines to set standards and audits to measure whether standards are being met are essential to good quality control. This philosophy led to the formation of the National Institute for Clinical Excellence (NICE) to commission guidelines and the Commission for Health Improvement to assess the quality of clinical care in 1999. With the introduction of clinical governance and revalidation, guidelines are now relevant for every clinician.
Penile cancer: an overview
Authors: Hamid R , Shergill I , Arya M , Patel HRH
Published: May 2014

Carcinoma of the penis affects 1 in 100 000 men per year in most developed countries. It accounts for less than 1% of adult malignancies in Europe and the USA. Survival is excellent if diagnosed early, but most men present up to 1 year after the initial lesion is noted. Unfortunately the treatment of metastatic disease is still disappointing.
Formal, structured teaching in postgraduate training: a learner-centred educational programme
Authors: Khan Khalid S , Pakkal Mini V
Published: May 2014

Medical education focuses on a learner-centred approach, but postgraduate training programmes have struggled to embrace this practice. In the West Midlands Deanery, a 2-year rolling postgraduate educational programme in obstetrics and gynaecology has been developed to equip trainees with the knowledge, skills and attitudes necessary to promote self-directed learning, via independent learning, interactive large-group presentations and small-group, peer-led activities.
Alcoholic hepatitis with ascites may mimic advanced ovarian malignancy
Authors: Prince Martin I , Gunn Melanie C , Hudson Mark
Published: May 2014

Cancer antigen-125 (CA125) is a glycoprotein tumour marker that may be helpful in screening, diagnosis and monitoring of ovarian carcinoma (Kehoe and Selman, 2001). However, elevated CA125 levels are not specific for this condition. In the case described here elevated CA125 levels lead to a missed diagnosis of alcoholic liver disease complicated by ascites.
Acute leukaemia masquerading as acute abdomen
Authors: Wahid Fadilah binti S Abdul , Keng Cheong Soon , Ali Raymond bin Azman
Published: May 2014

This article reports three patients with acute leukaemia who presented with acute abdomen as the first manifestation of the disease. Leukaemic infiltrates of the bowel and appendix may have caused the abdominal symptoms in these patients. Acute leukaemia should be included in the differential diagnosis of severe abdominal pain associated with an abnormal blood count. This report highlights the importance of early diagnosis of acute leukaemia as initiation of cytotoxic chemotherapy results in prompt resolution of the abdominal catastrophe and obviates the need for surgery.
Arterial injury
Authors: South LM
Published: May 2014

Urban violence, collision of high-speed vehicles, acts of terrorism and military conflict continue to present difficult arterial injuries. The immediate threat of exsanguination, combined often with multiple trauma, and the challenge of limb salvage makes speedy effective management essential to improve the outcome for victims, who are frequently young adults.
The new generation of antidepressants
Authors: Diab Tarig , Singh Ashok N
Published: May 2014

A major goal of antidepressant development is to improve on preceding drug classes with agents with better efficacy, tolerability and with more rapid onset of action. This article describes the new generation of antidepressants which have been recently introduced and also briefly describes possible future antidepressants which are currently being researched.
Percutaneous and surgical tracheostomy
Authors: Lams E , Ravalia A
Published: May 2014

Percutaneous techniques for elective tracheostomy have provided a quick and relatively simple method that can be performed in the intensive care unit. Evidence-based studies comparing surgical and percutaneous tracheostomies suggest similar complication rates in trained operators of both techniques.
Two cases of primary thyroid disease and hip fracture
Authors: Ohmori M , Harada K , Sugimoto K , Kobayashi E , Ohkami H , Fujimura A
Published: May 2014

Although the exact mechanism is not fully understood, some skeletal abnormalities are reported in patients with primary thyroid disease (McLean and Podell, 1995; Rosen, 1997). Prompt and adequate medication may improve the prognosis. This article describes the clinical course of two patients with primary thyroid disease and reviews thyroid hormone-related skeletal problems.
Huntington's disease of early onset or juvenile Huntington's disease
Authors: Gordon Neil
Published: May 2014

The presentation of juvenile Huntington's disease can cause diagnostic difficulties. The genetics and pathogenesis of the condition are discussed. The diagnosis will depend on the symptoms raising suspicions and the exclusion of other disorders, especially by genetic studies.
NICE appraisals and cardiology: glycoprotein IIb/IIIa inhibitors and acute coronary syndromes
Authors: Hyde Tom , Knight Charles
Published: May 2014

The National Institute for Clinical Excellence (NICE) was set up in 1999, with the aim of creating an independent body to evaluate and recommend therapies for NHS patients. NICE examines research evidence, assesses effectiveness (likely effects on patients in the community) and takes into account efficiency (cost effectiveness) before making recommendations.
Who should stage upper gastrointestinal tract malignancy?
Authors: Mathew John , Jenkinson Lloyd R
Published: May 2014

District general hospitals with trained upper gastrointestinal surgeons should undertake staging of patients with upper gastrointestinal cancers within their catchment areas. This could considerable reduce the workload at regional cancer centres.
Should activated protein C be given to a patient who has an epidural?
Authors: Wyncoll Duncan , Mythen Monty
Published: May 2014

Significant progress has been made recently in the treatment of patients with severe sepsis. A number of evidencebased therapies improve outcome in these patients. The largest study is the PROWESS study, a randomized placebo controlled trial of activated protein C (APC) vs placebo (Bernard et al, 2001). This reduced mortality by 19% in a highly selected group of patients with severe sepsis. APC has been licensed for use in patients with multiple organ failure secondary to severe sepsis in the UK since October 2002. Practical dilemmas have arisen surrounding its use in certain situations.
A pain in the neck: dissection of the vertebral artery
Authors: Scott Glyn , Jack Catherine
Published: May 2014

A49-year-old male model developed an acute severe occipital headache and neck stiffness following a day spent striking dynamic poses for a modelling assignment, during which he had been required to hold his head in several awkward positions for protracted periods of time. In the subsequent 24 hours he developed slurred speech, poor balance and a persistent pain in the neck. On presentation to hospital he was dysarthric and ataxic of gait, and had upper limb weakness, finger nose ataxia, an upper motor neurone facial nerve palsy and an extensor plantar response.

Magnetic resonance imaging of the brain showed a 2 cm × 1 cm infarction in the left pons extending to the midbrain (Figure 1).

The patient was commenced on aspirin and by 8 weeks his neurological symptoms had completely resolved.
Osteoporosis and fractures: the size of the problem
Authors: Daphne J Theodorou , Theodorou Stavroula J , Sartoris David J
Published: May 2014

The public health impact of osteoporosis-related fractures is enormous, with important economic implications. Government agencies and health-care providers must recognize the importance of early diagnosis of osteoporosis, implement policies for the prevention of disease, and develop effective payment policies for densitometry examinations.
The extended role of the midwife
Authors: Lavender Tina , Baker Lisa
Published: May 2014

Midwifery is one of the oldest professions in history. Midwives were first mentioned in the Bible and even Socrates wrote of his respect for his mother's profession of midwifery. The word ‘midwife’ meaning ‘with woman’ continues to be the fundamental principle from which midwives work. Midwives play a pivotal role in the provision of maternity care in the antenatal, intrapartum and postnatal period. However, a number of contributing factors has led to some midwives diversifying and obtaining skills to enable them to develop their role. These factors include a reduction in junior doctors' hours, a reduction in GP involvement in maternity care, the desire to provide continuity of carer for women and the need to provide a clinical career framework.
Should antifibrinolytics be used in orthopaedic surgery?
Authors: Meeran Hanif
Published: May 2014

Greater appreciation of the risks of blood transfusion, coupled with concerns about the future availability and cost of donor blood, have led to increased interest in techniques to reduce transfusion requirements. Aprotinin and tranexamic acid are antifibrinolytic agents which are used to reduce blood loss. In cardiac surgery aprotinin has been shown to reduce blood transfusion requirements and mortality without any increase in thrombotic complications. Although less evidence exists to support the safety and efficacy of tranexamic acid, its use results in a similar reduction in transfusion during cardiac surgery (Hardy, 2001).
Difficulties in the diagnosis of acute aortic dissection
Authors: Anand R , Cumberbatch G , Swallow R , Loehry J
Published: May 2014

A69-year-old woman with known hypertension presented to hospital with sudden onset severe central chest pain radiating between her shoulder blades and into her abdomen. This was associated with loss of power and sensation in her left leg lasting for 30 minutes. She complained of residual discomfort between her scapulae. Examination revealed a well-looking woman with unequal blood pressures in both arms: right 140/70 mmHg, left 100/80 mmHg, a pulse rate of 84/min and no audible murmurs. There was no vascular or neurological deficit in either leg. 12-lead electrocardiogram showed left ventricular hypertrophy by voltage criteria and chest radiograph was normal. Urgent spiral computed tomography of the chest and abdomen showed an extensive type A dissection of her aorta from her aortic valve to the abdominal aortic bifurcation (Figure 1). Despite attempts at haemodynamic resuscitation, she died in the ambulance en route to the regional cardiothoracic centre. Post mortem revealed a tense haemopericardium.
Pseudoangiomatous hyperplasia of mammary stroma: an unusual entity
Authors: Lawrentschuk Nathan , Scott Alan R , Archer Richard , Clark Don
Published: May 2014

A74-year-old woman was noted to have a lesion in her right breast. It was painless and had been present for an unknown period. There were no other associated symptoms. A clinically large, firm, non-tender mass (3×4 cm) was felt in the upper outer quadrant of the right breast. There was minimal adherence to overlying tissue. On further examination, no evidence of metastatic disease was found. There was no past history of breast disease.

Mammography demonstrated a well-circumscribed soft tissue mass (40 mm) without associated microcalcification or conspicuous regions of fat density (Figure 1).

Ultrasound demonstrated an ellipsoid, lobular, solid mass of variable parenchymal reflectivity (Figure 1). No cystic component was identified. The mass was predominantly hyperreflective compared with adjacent parenchyma, with a few regions casting acoustic shadowing. Colour Doppler energy imaging demonstrated prominent abnormal vessels within the mass.

Based on the clinical findings a provisional diagnosis of a carcinoma was made. In view of the hyperreflectivity, vascularity, and relatively small amount of acoustic shadowing, a differential diagnosis of hamartoma, phylloides tumour or sarcoma was offered.

Under ultrasound guidance, core biopsy was undertaken. A diagnosis of pseudoangiomatous hyperplasia of mammary stroma (PASH) was made, although angiocarcinoma could not be excluded.

The mass was then surgically excised. The tumour was of a rubbery texture and was shelled out from the surrounding stroma with ease. It had a capsule and was solid throughout (Figure 2). Further histology confirmed the core biopsy diagnosis of PASH (Figure 3). This was supported by immunohistochemistry. The patient recovered without incident.
Helicobacter pylori: a microbiologist's view
Authors: Williams Craig
Published: May 2014

Helicobacter pylori infection is known to cause a number of gastrointestinal diseases. From the standpoint of a microbiologist there are several important facets to this organism, which include the nature of the organism, it's diagnosis and the effectiveness of eradication therapy.
The eye in gastrointestinal disease
Authors: Khan Aldrin , Lightman Susan
Published: May 2014

This article reviews disorders in which both gastrointestinal and ocular disease can occur. Gastrointestinal disease can affect the eye as part of the disease spectrum, and in other instances both the gastrointestinal system and the eye may be involved as part of a systemic disease process. The gastrointestinal system may be adversely affected by the treatment of an unrelated eye disease. Also, certain infections of the gastrointestinal system can have an adverse effect on the eye.
Euglycaemic diabetic ketoacidosis
Authors: Davies RG , De P , Child DF , Gemmell L , Rincon C
Published: May 2014

A74-year-old woman with insulin-dependent diabetes was admitted to the medical high dependency unit with a 2-day history of increasing nausea and confusion. On examination she was afebrile, dehydrated and confused. Systemic examination was unremarkable. Capillary blood glucose by self-monitoring strip was 10.6 mmol/litre and urinalysis demonstrated 3+ ketones and 3+ glucose. Biochemical examination revealed plasma glucose 11.9 mmol/litre, sodium 127 mmol/litre, potassium 5.1 mmol/litre, urea 13.9 mmol/litre and creatinine 87 mmol/litre. Arterial blood gas analysis showed pH 7.30, partial pressure of carbon dioxide = 4.4 kPa, partial pressure of oxygen = 9.0 kPa, bicarbonate = 15.3 mmol/litre, base excess -9.2 mmol/litre and oxygen saturation 97%. She was treated with intravenous dextrose-saline and low dose insulin infusion. She made a good recovery and was well within 48 hours of presentation.
Management of oral and maxillofacial infection
Authors: Witherow H , Swinson BD , Amin M , Kalavrezos N , Newman L
Published: May 2014

Maxillofacial infections are common but can potentially be life threatening. Accurate diagnosis is essential to prevent mismanagement with potential severe consequences. This article discusses the aetiology, differential diagnosis, host response, spread of infection and treatment.
Performance review procedures for the preregistration year: a map through the minefield
Authors: Keeling Carole , Bailey Stewart , Agius Steven
Published: May 2014

When a case of underperformance occurs, it can be a stressful event for both the educational supervisor and the trainee. This article explains the procedures for managing underperformance of preregistration house officers, developed by the North Western Deanery.
Combating mortality from severe sepsis
Authors: Ridley Saxon
Published: May 2014

Thousands of patients suffering from severe sepsis are set to benefit from the publication of the National Institute for Clinical Excellence (NICE) guidelines recommending the use of Xigris (drotrecogin alfa (activated), Eli Lilly & Company Ltd, Basingstoke). Drotrecogin alfa (activated) is the only drug specifically designed to treat severe sepsis and has been recommended for use in adult patients who have severe sepsis that has resulted in multiple organ failure and who are being provided with optimum intensive care support (NICE, 2004).
Acute management of paediatric respiratory failure
Authors: Inwald David
Published: May 2014

Respiratory failure may be defined as failure of the lungs to maintain adequate gas exchange. It may occur as a result of alveolar hypoventilation, diffusion impairment, intrapulmonary shunting or ventilation–perfusion mismatch. Respiratory failure may be associated with hypoxaemia, hypercarbia or both. Hypoxaemia can cause tissue hypoxia and progressive hypercarbia can cause carbon dioxide narcosis. Both of these complications are potentially life threatening. Thus treatment of respiratory failure must aim both to maintain gas exchange and to treat the underlying cause.
Squamous cell carcinoma of the nasal vestibule presenting as chronic vestibulitis
Authors: Badran Khaled , Rapado Fernando , Simo Ricard , Carpentier John de
Published: May 2014

A 62-year-old male smoker was referred to the department of otorhinolaryngology in January 1998. He described a 6-year history of intermittent soreness and scabbing of the right nostril, which was treated with topical antibiotics on three occasions in the same department. Previous medical history included several dermatology visits in 1994, during which the diagnosis of psoriasis and recurrent nasal furunculosis had been made. No history of irradiation to the face was present.

Examination revealed a 1 × 1 cm area of ulceration on the lateral aspect of the right nasal vestibule (Figure 1) in a superimposed picture of chronic rhinitis. Examination of the throat, ear, larynx and neck revealed no other abnormality. Haematological, biochemical and chest radiology assessments were all normal. Microbiology studies of the area did not grow any organisms.

Biopsy and frozen section analysis revealed a superficially invasive squamous cell carcinoma arising in an area of carcinoma in situ. Subsequent excision biopsy of the affected area with wide margins (Figure 2) revealed no evidence of residual carcinoma. The patient remains well and disease free 5 years later.
Leiomyoma of the nasal cavity: case report and literature review
Authors: Kumar S , Taylor W , Swift AC
Published: May 2014

A 73-year-old man presented with a history of left nasal obstruction and mucosal discharge from the nose for several years. Nasal endoscopy showed a smooth red polyp in the left nasal cavity (Figure 1). A computed tomography scan showed the lesion was present in the left nasal cavity and the paranasal sinuses were clear (Figure 2). The polyp arose from the left sphenoethmoidal recess and was removed endoscopically. The patient has been followed up for 6 months with no evidence of recurrence.

Macroscopically the tumour consisted of a polypoid mucosal-covered mass measuring 4 × 2.5 × 1.5 cm. The consistency was firm and the cut surface was homogeneous grey-white. Microscopically the lesion comprised interweaving bundles of spindle-shaped cells with ovoid nuclei, mild nuclear pleomorphism and eosinophilic cytoplasm (Figures 3 and 4). There was a variable amount of oedematous and fibrous stroma. There was no mitosis or necrosis. Immunocytochemical labelling showed patchy smooth muscle actin, mainly towards the periphery of the tumour and patchy central labelling for S-100 protein, but was negative for caldesmin, CD34, desmin, epithelioid membrane antigen and cytokeratin. The differential diagnosis included benign leiomyoma, benign nerve sheath tumour, solitary fibrous tumour and haemangiopericytoma. The lesion was considered to be a leiomyoma.
Ocular symptoms and signs as presenting features of endocarditis caused by Streptococcus bovis II
Authors: Menezo Victor , Lightman Susan , Yeo Tun Kuan , Liyanage Sidath , Lynn William A
Published: May 2014

A previously healthy 76-year-old man was referred to the uveitis clinic at Moorfields Eye Hospital with a 2-month history of bilateral painless blurred vision and floaters. He had undergone intraocular surgery on his left eye a long time ago after trauma to remove a cataract. He also complained of generalized arthralgia, night sweats and headache.

On examination, both eyes had a visual acuity of 6/6 and normal pupillary reactions. Slitlamp biomicroscopy showed no evidence of anterior uveitis. Funduscopy revealed few inflammatory cells in the vitreous and multifocal yellow subretinal lesions in both eyes, with a retinal haemorrhage in the right eye but no cotton wool spots or exudates and normal retinal vasculature (Figure 1).

Uveitis masquerade syndrome was considered and investigations to detect lymphoma were initiated. Full blood cell count revealed normocytic anaemia with mild neutrophilia and an erythrocyte sedimentation rate of 105 mm/h. The blood film showed mild toxic granulation in some neutrophils. Renal and liver function and chest X-ray (CXR) were normal. Computed tomography (CT) scan of the brain and orbits showed no abnormality.

Shortly after, his vision decreased to 1/60 in the left eye with associated increased vitritis, retinal exudates and peripheral retinal haemorrhages. The patient was systemically well, admitting no further constitutional symptoms. On examination no lymphadenopathy or abdominal masses were detected. CXR and further blood investigations including immunoglobulin screen and tumour markers were normal. A left vitreous biopsy showed predominantly chronic inflammation with a lymphohistiocytic infiltrate but no specific features of intraocular lymphoma. Since it was not possible to completely exclude lymphoma, further systemic work up was suggested.

Three months after the initial presentation the patient developed lassitude, anorexia, breathlessness on exertion and progressive peripheral oedema. A repeat CXR and abdominal ultrasound showed bilateral pleural effusions and splenomegaly respectively. A new diastolic murmur was detected and infective endocarditis was considered. Echocardiography showed severe aortic regurgitation resulting from a large vegetation with depressed left ventricular function (Figure 2). Blood cultures isolated Streptococcus bovis type II sensitive to penicillin and glycopeptides. He became haemodynamically unstable despite intravenous antibiotic therapy and an urgent aortic valve replacement was undertaken. Following a 1-month course of antibiotic therapy his constitutional symptoms resolved, blood tests returned to normal and his vision improved to 6/6. Fundoscopy revealed few left vitreous debris but no signs of active inflammation or subretinal lesions. A colonoscopy to rule out associated gastrointestinal malignancy was performed and showed no abnormality.
Who Operates When? II: the National Confidential Enquiry into Perioperative Deaths 2003
Authors: Martin Ian C
Published: May 2014

The National Confidential Enquiry into Perioperative Deaths (NCEPOD) recently published its report entitled Who Operates When? II (WOW II) (NCEPOD, 2003). This report examined changes in surgical and anaesthetic practice since the publication of Who Operates When? (WOW I) in 1997 (NCEPOD, 1997). Increased consultant involvement and a reduction in junior trainees performing procedures at night have been identified. However, the report makes recommendations based upon the study findings which, if implemented, would improve the quality of care available, particularly for emergency patients.
Venous thromboembolism registry: a route to improved patient outcomes
Authors: O’Shaughnessy Denise , Rose Peter , Scriven Nick , Cummins Daniel , Amlot Nick
Published: May 2014

Over the last 3 decades, the practice of medicine in the field of venous thromboembolism (VTE) has evolved enormously. An understanding of the pathophysiology of thrombosis and findings from clinical trials indicating the need for thromboprophylaxis (Geerts et al, 2001) have been key developments. However, it is the movement of VTE treatment to the outpatient setting that has most radically altered clinical practice.
Intra-abdominal adhesions: an underestimated problem
Authors: Hershman MJ
Published: May 2014

Intra-abdominal adhesions are an invariable consequence of abdominal surgery. Most adhesions are asymptomatic, but a significant proportion of patients develop complications including small bowel obstruction, visceral damage, pain and infertility. The symposium in this issue of Hospital Medicine describes the extent of the problem, its aetiology, management and consequences. Professor Harold Ellis, an internationally recognized authority on adhesions, describes the early history. He describes the first recognition of postoperative adhesions in 1883.
Consultant contract: the view of the British Medical Association
Authors: Fielden Jonathan
Published: May 2014

The new consultant contract marks a major opportunity for all consultants. For the first time it allows them to truly identify their workload and the resources needed through proper job planning, and allows them to clearly indicate to trusts, strategic health authorities and primary care trusts what they are paying for, or what they need to pay for.
Unusual presentations of tuberculosis: let the clinician beware
Authors: Davies Peter
Published: May 2014

The cases of extrapulmonary tuberculosis published in this issue of Hospital Medicine show what a difficult problem tuberculosis can be for both patient and doctor. Tuberculosis can occur in virtually any organ in the body and is protean in its manifestations.
Antenatal diagnosis of fetal heart disease
Authors: Roberts Devender , Kitchiner Denise
Published: May 2014

Antenatal diagnosis of congenital heart disease is most commonly made at the routine 20-week anomaly scan. Not all abnormalities can be detected by prenatal ultrasound but detection can be improved by obtaining outlet views and by the use of colour Doppler. This article provides an overview of the uses and limitations of fetal echocardiography.
Chest wall tuberculosis involving the second rib in a young Ethiopian woman
Authors: Ansari Aneel , Smith Michael A
Published: May 2014

A 20-year-old Ethiopian woman presented to the orthopaedic clinic with a 6-week history of a painful mass on the anterior aspect of her chest wall above the left breast. It appeared suddenly and increased in size. There was a history of anorexia and weight loss but no cough, haemoptysis, night sweats nor fever. There was no past medical history or family history. She had been resident in the UK for 2 years.

On examination the patient appeared well. She was apyrexial with a normal pulse rate and blood pressure. There was a 6 cm × 4 cm swelling on the anterior chest wall at the level of the first and second ribs. It was firm, warm and tender. It was fixed deeply; the overlying skin was normal although it was hot. There was no associated lymphadenopathy. She had a mild hypochromic microcytic anaemia, normal white cell count and differential but the erythrocyte sedimentation rate was elevated to 54 mm/hr and C-reactive protein was 27 mg/litre. Her chest X-ray was reported as normal. Ultrasound showed an echo-poor septated area within which there were echogenic areas. In addition, there was destruction of the anterior quarter of the first rib with erosion of the superior border of the second rib. A computed tomography scan revealed a soft tissue mass with associated rib involvement (Figure 1). In addition, there was a subcarinal calcified lymph node but there was no parenchymal pathology.

In view of the rapid progression, she was admitted for urgent biopsy. Following incisional biopsy, tissue was taken for histopathology and microbiology. Histology confirmed the diagnosis of tuberculosis. Culture grew a light growth of Mycobacterium tuberculosis that was sensitive. She was commenced on quadruple therapy.

At 6-month follow up, symptoms had settled, the swelling had subsided and her inflammatory markers were all normal.
Should ketamine be used as a regular analgesic for patients with chronic pain?
Authors: Blackburn JP
Published: May 2014

The N-methyl-D-aspartate (NMDA) receptor antagonist ketamine is a powerful analgesic that has been used in the treatment of acute and chronic pain. Its use may be limited by its side- effect profile. This article will explore the possible use of ketamine as a regular prescription on an outpatient basis for patients suffering with chronic pain.
Drugs and the liver
Authors: Rashid Mohammed , Goldin Robert , Wright Mark
Published: May 2014

This article discusses the classification, epidemiology, mechanisms and pathology of drug-induced liver disease. A number of specific examples involving commonly used drugs are discussed.
Good at medicine, pity about the rest
Authors: Cohen Debbie , Kinneresley Paul , Rollnick Stephen , Edwards Karen
Published: May 2014

What happens when doctors struggle with their communication skills? How can we pick up problems earlier, what help is available? In Cardiff an innovative approach provides support to doctors identified as underperforming. This article describes how the programme fits with other work in this field.
Reading the signals
Authors: Miskin Ruth
Published: May 2014

The government recently unveiled proposals for a ‘reading MOT’. Former headteacher Ruth Miskin discusses techniques for improving literacy rates and examines how to prevent children slipping through the reading net
Perimetry and imaging in glaucoma diagnosis: a pilot study
Authors: Landstedt Gunilla
Published: May 2014

Aim: To compare the findings from Humphrey Matrix and Rarebit (RB) perimetry in relation to the results from Heidelberg confocal laser scanning retina tomography (HRT II).

Material: Data from 22 eyes (12 subjects, age 51–75 years) with known or suspected glaucoma were analyzed.

Methods: The central 30° visual field was examined with two perimetric techniques; Humphrey Matrix, using frequency doubling technology, and the RB test, relying on the detection of very small bright dots on a dark background. In addition, all subjects underwent laser scanning tomography of the optic nerve head.

Results: There was no significant difference regarding the number of normal/abnormal findings between Humphrey Matrix and RB perimetry (9/22 and 8/22, respectively). Abnormal glaucoma index from the HRT II was observed in 5/22 eyes. In four of these, both Humphrey Matrix and RB perimetry were abnormal. In one eye both with abnormal HRTII, both perimetric tests were normal.

Conclusion: This pilot study indicates that the studied perimetric methods appear to give equivalent results in glaucoma, despite the considerable difference in test principles.
Driving and vision
Authors: Marsden Janet , Craig Stephen
Published: May 2014

Driving is an important mode of travel in most of the world and, because it facilitates many activities of daily life, it is seen as fundamental to concepts of quality of life. Up to 3.5 million people in the UK alone could be driving with eyesight below the legal minimum and this has huge implications for them and for all other road users.

Ophthalmic clinicians, by the nature of their speciality, care for and work with people with varying degrees of visual capability. This article discusses the standards of vision for driving and evidence around vision and driving standards, particularly in relation to some of the issues that ophthalmic professionals may need to discuss with their older patients and clients in the practice setting.
Taking conjunctival or corneal swabs
Authors: Marsden Janet
Published: May 2014

There are several indications for taking swabs for the identification of organisms, including situations where Neisseria gonorrhoea infection or chlamydia is suspected, for the identification of herpes virus infections of cornea or conjunctiva and where fungal infections are suspected. Surveillance during outbreaks of particularly virulent types of adenovirus, many of which are nosocomial, may require swabs to be taken.
Bursting the bubblewrap: evolution and monitoring of nurse-performed Nd:YAG laser capsulotomy service
Authors: Forbes Marina
Published: May 2014

Aim To assess a new nurse-led capsulotomy service

Method Evaluation and audit of the first 500 patients treated

Results More patients received individualised care in a calmer environment

Conclusion Advancing nurse practice to increase service capacity benefits staff, patients and the health economy, but other areas lose nursing expertise as a result
The psychosocial needs of patients undergoing ocular-odonto-kerato-prosthesis (OOKP) surgery: a nurse perspective
Authors: Wilson-Miller Rebecca , Stanley Helen
Published: May 2014

This article explains osteo-odonto-kerato-prosthesis (OOKP) surgery from a nursing perspective, offering a detailed view of the surgical process to aid understanding of these complex patients’ needs, enabling nurses to meet the RCN Ophthalmic Competencies (2005), where nurses are expected to anticipate the effects of clinical diagnosis on the individuals and family/supporters and adjust care to enhance wellbeing.

Ocular surface disease and absolute tear deficiency can lead to corneal blindness and severe discomfort ( Geerling et al, 2002 ). It is suggested that OOKP surgery is the keratoprosthesis (artificial cornea) of choice for end-stage corneal blindness ( Liu et al, 2005 ), involving the use of a patient's own tooth root to support an optical cylinder ( Fukuda et al, 2008 ), which is then implanted onto the patient's eye.

An in-depth critical review of the literature was performed to offer the reader an explanation of the history of OOKP surgery, and to explore the needs of OOKP patients from a nursing perspective. This literature review indicated that patients undergoing OOKP surgery would benefit from increased psychosocial support from ophthalmic nurses, which can be provided by increasing own knowledge and understanding of the issues relating to this procedure and utilising resources, such as the Changing Faces charity, to facilitate better rehabilitation.
The cultural context of dying from cancer
Authors: Boyle Deborah McCaffrey
Published: May 2014

Dying from cancer is often a process characterized by significant patient and family emotional anguish. While physiological symptom distress during terminal cancer care is mastered with increasing proficiency, psychosocial inter1ventions to enhance adaptation during the dying trajectory warrant continuing investigation. As a component of the psychosocial paradigm, the cultural context of dying requires particular emphasis. This article complements existing nurse knowledge about the role of culture during terminal cancer care, by describing normative culturally-constructed coping behaviors. In addition, ethnically-sensitive interventions with patients and families are specified in an effort to offer practical suggestions for nurses caring for dying cancer patients. A holistic orientation to care which integrates cultural sensitivity about patient and family needs will increase the effectiveness of end-of-life nursing interventions, optimize the dying experience for both the patient and family, and ideally, facilitate bereavement and the resolution of grief.
Teleconferencing support: women with secondary breast cancer
Authors: George Dorothy S
Published: May 2014

The aim of this article is to introduce teleconferencing as a new, innovative and cost-effective approach to providing psychosocial support for women with secondary breast cancer. As medical treatments extend the life-expectancy of women with breast cancer the issue of appropriate professionally-led psychosocial intervention becomes more urgent. A limited review of the literature supporting these psychosocial needs is presented. The participants’ evaluation of a teleconferencing support group is also discussed. This article examines some of the problems associated with the availability of psychosocial support for women with secondary breast cancer. It highlights the value of a cooperative liaison between these women, health professionals and interested others in the decision-making process of any project set up to offer psychosocial support.
Health Promotion: focus on care of the dying
Authors: Russell Phil , Sander Ruth
Published: May 2014

Despite the fact that health is considered to be for all people the literature on health promotion rarely considers the needs of the dying person and his/her family. However, each one of us must face the process of dying at some stage in our lives. The goal of palliative care is to achieve the best quality of life for patients and their families. If health is regarded as enabling a person to maximize his or her potential then palliative care can reasonably be regarded as a health promotion activity. This article explores a positive health promotion approach for palliative care and suggests a health promotion framework for use in care of the dying. This is based on the three fundamental prerequisites for health, i.e. enabling, advocacy and mediacy, as identified by the Ottawa Charter (World Health Organization, 1986). It is argued that the role of the nurse is fundamental in implementing these prerequisites to health in the care of the dying.
An overview of constipation: causes and treatment
Authors: Maestri-Banks Anita
Published: May 2014

Constipation is a common symptom in patients with cancer and advanced illness. It may cause major distress including pain and discomfort for many patients and therefore interventions to prevent and alleviate this problem are of great importance. Where possible care should focus on preventive measures and a detailed patient assessment is essential to inform care for this group of patients. It is also important to establish whether or not the patient is constipated before initiating patient care and treatment. Patient assessment can be achieved by monitoring the frequency, consistency and size of the stool. Predisposing factors such as type of illness and the treatment the patient is receiving will offer health professionals some insight into the causes of constipation. Finally, the treatment and management of the patient should be planned based on patient history, clinical assessment and an evaluation of the type and severity of constipation the patient is experiencing.
District nurses’ perceptions of palliative care services: part 1
Authors: Mcilfatrick Sonja , Curran CI
Published: May 2014

The Campbell report, Cancer Services: Investing for the Future (Department of Health and Social Services, 1996) suggests that the current provision for palliative care in Northern Ireland is ‘patchy’ and has developed in an ‘uncoordinated manner’. Taking this into consideration, a study was undertaken to investigate and evaluate district nurses’ perceptions of palliative care services within a small community trust in Northern Ireland. The objectives of the study were to assess district nurses’ understanding of the term ‘palliative care’, their perception of both their role and the role of other community professionals in palliative care, and to help identify current patterns and gaps in service provision. The study adopted a two-staged approach to the research. This article focuses on the data obtained from the first stage of the study which was designed to obtain information and identify key themes to assist in the development of a questionnaire for the second stage of the study. It involved conducting a number of focus groups with district nursing sisters in the community. The nurses who participated in the focus groups acknowledged the important role they play in coordinating patient care, providing support and developing interpersonal relationships with patients and carers.
The views of terminally ill people and lay carers on primary care services
Authors: Beaver Kinta , Luker Karen , Woods Simon
Published: May 2014

Although there has been a proliferation of specialist services to manage specific diseases and conditions, the majority of people with a terminal illness are cared for in their own homes by generalist practitioners. This study, based on interviews with people with a terminal illness (n=15), lay carers (n=10) and bereaved carers (n=19), aimed to establish the abilities of patients, within an activities of daily living framework, and to ascertain views on key health professionals. Results suggested that lay carers played an important role in meeting the needs of patients and had a number of insightful and useful comments to make on service provision, in particular with regard to specialist nursing services. If lay carers are to be engaged as partners in the caring process then more effective communication patterns between generalists, specialists and service users need to be established.
Spiritual recognition within palliative care
Authors: Wilkinson Susie
Published: May 2014

The modern palliative care movement has developed primarily for patients with cancer. Recent statistics from the Cancer Research Campaign (2000) reveal that a record four out of ten people will develop cancer during their lifetime. The rise in the number of people developing cancer is largely because more people are living to an older age when cancer is more common. As people continue to live longer during the 21 st century palliative nursing care will face new and different challenges. For example, providing care for increasing numbers of people with chronic illnesses, which may result in increased disability and loss of independence.