bluuebunny/crossref_metadata_2025 huggingface dataset:
Papulonecrotic tuberculide: a forgotten cutaneous manifestation of tuberculosis
Authors: Tay E , Chinegwundoh J , Sahota A , Cerio R
Published: May 2014

A 30-year-old Chinese man presented with a 2-month history of enlarging neck masses and a widespread rash. He had first noticed the swellings 10 years ago when a diagnosis of tuberculosis was made. The lymphadenopathy improved after anti-tuberculous therapy but never completely regressed. Seven years later, a skin eruption developed over his limbs and trunk. He described recurring crops of asymptomatic reddish papules which discharged a yellowish fluid and subsequently healed with scarring and hyperpigmentation. There was no pruritus or tenderness and no pulmonary symptoms.

Clinical examination revealed a non-tender, 10 cm, firm and ovoid mass with overlying erythema in the right anterior triangle of his neck (Figure 1) with several smaller lumps on the other side. There was a widespread eruption on his trunk and limbs, sparing the face, palms, sole and scalp (Figure 2). Recent lesions consisted of 1cm erythematous papules with a scaly collarette (Figure 3). Older lesions had left atrophic scarring and hyperpigmentation. A clinical diagnosis of papulonecrotic tuberculide was made.

An X-ray of the chest was normal. Serum immunoglobulins (IgG, A and M) were moderately elevated. Erythrocyte sedimentation rate and C-reactive protein level were normal. Syphilis serology was negative. A Heaf test was strongly positive (Figure 4).

Fine needle aspirations of the neck mass were negative for microscopic identification of acid-fast bacilli and for malignancy. On the other hand, a lymph node biopsy on the left side revealed fragments of connective tissue showing granulomatous inflammation and non-caseating necrosis. Occasional acid-fast bacilli were seen with a Ziehl-Neelsen stain. Skin biopsies were taken of recent, established and old lesions. The histological features of the established lesion were diagnostic, showing a florid, acute on chronic, perivascular and periappendiceal inflammmatory infiltrate involving both the superficial and deep dermis. There was also evidence of lobular panniculitis with fibrinoid necrosis of medium-sized arterial vessels, venulitis and extensive endothelial cell swelling. Histological features of the other two skin specimens were non-specific. No organisms were identified with special stains.

Anti-tuberculous therapy with rifampicin, isoniazid and pyrazinamide was started and 2 weeks after treatment, the patient reported a complete cessation in the development of new skin lesions. His skin remains in remission after 6 weeks of treatment.
MRS of the brain in patients with anorexia or bulimia nervosa
Authors: Rost Barbara , Roser Werner , Bubl Reinhard , Radue Ernst W , Buergin Dieter
Published: May 2014

Twenty patients with anorexia or bulimia nervosa were prospectively investigated by magnetic resonance spectroscopy (MRS) of the brain. Compared to healthy controls, MRS of those with eating disorders revealed metabolic changes, which seem to be a consequence of their nutritional deficiency.
Tribes or teams? The challenge of multiprofessional education
Authors: Herzberg Joe
Published: May 2014

Evolving service development initiatives and clinical governance systems will require greater use of multiprofessional teamwork, underpinned by multiprofessional education delivered in clinical teams. Current professionally based education and training systems do not help to deliver this agenda.
Effects of anaesthesia on the human immune system
Authors: Hunter John D
Published: May 2014

The ability of certain anaesthetic agents to influence the immune response has been recognized for almost 30 years. The purpose of this review is to briefly describe the different components of the immune system and examine the way in which surgery and anaesthesia influence these.
Atypical neuroleptics
Authors: Pandarakalam James Paul
Published: May 2014

The discovery that clozapine alleviates both positive and negative symptoms of schizophrenia has resulted in the emergence of newer atypical neuroleptics. Even though they are more expensive than traditional antipsychotics they have distinct and important advantages, which may influence the extent of the patient's rehabilitation and compliance.
Revised guidelines for the control of MRSA in hospitals
Authors: Wiggins RJ
Published: May 2014

The first report of a combined working party of the Hospital Infection Society and the British Society for Antimicrobial Chemotherapy on methicillin-resistant Staphylococcus aureus (MRSA) (Report of a combined working party of the Hospital Infection Society and the British Society for Antimicrobial Chemotherapy, 1986) was revised in 1990 (Report of a combined working party of the Hospital Infection Society and the British Society for Antimicrobial Chemotherapy, 1990) and commended to the NHS in 1994.
Spiral computed tomography for pulmonary embolism
Authors: Howling Sarah J , Hansell David M
Published: May 2014

Spiral computed tomography pulmonary angiography is increasingly used in the non-invasive investigation of patients with suspected pulmonary embolism. This review will focus on current techniques and indications with an explanation of the computed tomography signs of pulmonary embolism, possible pitfalls in interpretation and limitations of the technique.
Controversies within colorectal surgery
Authors: Monson John RT
Published: May 2014

This issue gives a useful introduction to some of the controversies and current debates within colorectal surgery. By their very nature, as the articles do not represent a comprehensive review of the subject matter the authors can only hope to stimulate the reader to explore the issues at greater depth.
Investigation of colonic disease
Authors: Wan Andrew , Darzi Ara
Published: May 2014

Bowel cancer awareness among the general public has heightened in recent years. The promotion of prompt referral and the pressure on early diagnosis will alter our previous strategies on colonic evaluation. This article gives an overview of the colonic investigations currently available.
Ulcerative colitis
Authors: Miller Matthew , Windsor Alastair
Published: May 2014

Ulcerative colitis is a relatively common cause of altered bowel habit and rectal bleeding. Coordinated management of the investigation and care of patients with this condition is vital to optimize treatment. This article reviews current management options.
Postnatal care: no time for complacency
Authors: Reid Margaret , MacArthur Christine
Published: May 2014

Only a decade ago, postnatal maternity care was little mentioned in policy documents and the research literature devoted to postpartum issues, whether pertaining to the organization of maternity care, or to women's mental or physical health, was minimal. Studies reporting women's views of their experiences after childbirth had highlighted a number of difficulties associated with the delivery of care women faced, including lack of continuity of carer and confusing and conflicting information (Reid and Garcia, 1989). The service implications of these findings were not picked up. There was little research of the range of physical or mental problems that women might anticipate postnatally.
Can we finally get it right with cancer pain control?
Authors: Ahmedzai Sam H
Published: May 2014

The control of pain in cancer patients has been an international priority for nearly two decades, since the first publication and updating of the World Health Organization (WHO) cancer pain control programme (WHO, 1990). The modern hospice movement, which has its origins in the religious foundations at the turn of the 20th century but which really became a force in the 1970s, also made cancer pain its leading target.
Extrapancreatic tumour hypoglycaemia
Authors: Ratoff JC , Gossage AAR
Published: May 2014

A64-year-old woman presented with drowsiness and a history of worsening abdominal pain associated with abdominal bloating. Before admission her GP had arranged an ultrasound scan to investigate the abdominal symptoms and the finding of hepatomegaly. However, the development of drowsiness with slurred speech and dizziness prompted her admission. There was no other history of ill health. She was a non-smoker and took alcohol only occasionally.

On examination she was drowsy, restless and had recently vomited. Her Glasgow coma score was 9/15 and her speech was slurred. She was moving all four limbs, plantar reflexes were flexor, pupils equally reactive and fundi appeared normal. She was afebrile, her pulse was 80 beats/minute and regular. Her blood pressure was 170/100 mmHg, and auscultation of heart and lungs was normal. Abdominal examination revealed a football-sized irregular mass in the right upper quadrant.
Wisdom tooth extraction under general anaesthesia
Authors: Down Jim , Mitchell V
Published: May 2014

The challenge of airway management for wisdom teeth extraction is to protect the lower airway from upper airway surgical debris without compromising surgical access. This has been traditionally achieved using nasotracheal intubation with a throat pack but this carries well documented comorbidities of nasal trauma and tracheal intubation.
Perceptions of flexible training in medicine
Authors: Peters Eleanor , Flett Andy , Challis Maggie , Jones Jo
Published: May 2014

Most flexible trainees believe that their full-time colleagues perceive flexible training as flawed in some way. However, most consultants and full-time trainees actually view flexible trainees and their posts in a positive light.
Photodynamic therapy
Authors: Rhodes Lesley E
Published: May 2014

Photodynamic therapy (PDT) is a selective therapeutic approach involving uptake of a sensitizer by the target cells followed by their destruction on lightinduced activation of the chemical. Although the technique was discovered at the turn of the 20th century, its widespread use has awaited the development of suitable drugs and light sources (Brown, 1999). It is now being applied to a range of malignant and non-malignant disorders, with a continual expansion in its licensed indications.
Challenging the stigma of Alzheimer's disease
Authors: Benbow Susan M , Reynolds Darren
Published: May 2014

Changing Minds — Every Family in the Land is a national campaign launched by the Royal College of Psychiatrists which aims to reduce discrimination against people who suffer from mental disorders. One of its target areas is dementia. What is the stigma associated with Alzheimer's disease and how can hospital doctors challenge it in everyday practice?
The demon drink
Authors: Henry Colm , Irving John B
Published: May 2014

A 42-year-old woman was brought in by ambulance to our accident and emergency department with a short history of blackouts. Her neighbours had alerted the emergency services after they heard her screaming late at night. On the way to hospital she appeared to faint for short spells broken by screaming on recovery. Initially, it was felt that she may have been fitting or even psychiatrically disturbed. One of the staff remarked that she looked as if she was 'possessed by demons'.
Understanding the GMC
Authors: Brearley Stephen
Published: May 2014

The General Council of Medical Education and Registration, now the General Medical Council (GMC), was established in 1858 to maintain a register of qualified medical practitioners so that the public could distinguish qualified doctors from the unqualified.
Can doctors self-manage stress?
Authors: Herzberg Joe
Published: May 2014

The NHS has expressed concern about stress in its workforce and is taking steps to reduce it. This paper reviews the factors associated with stress and burnout throughout a medical career. Clear messages emerge for all doctors and their employers.
Unusual cases of endocarditis
Authors: Wilson APR
Published: May 2014

Endocarditis is an uncommon disease, with approximately one episode per 1000 admissions. However, patients frequently have a prolonged hospital stay and may need cardiac surgery, sometimes with a diff icult postoperative course requiring intensive care. Endocarditis can mimic many other illnesses and sometimes other illnesses can present like endocarditis. onsequently, delayed diagnosis is a major factor in patients who fail treatment. Management of this disease is only likely to be successful if there is close cooperation between physician, surgeon and microbiologist.
Preventing perinatal transmission of HIV-1 infection
Authors: Fiore Simona , Newell Marie-Louise
Published: May 2014

It is now known that with the use of antiretroviral prophylaxis with zidovudine, elective caesarean section delivery and refraining from breastfeeding the rate of mother–child transmission of HIV infection can be reduced to less than 2%.
An unusual case of enterococcal tricuspid valve endocarditis
Authors: Kelly J , Prasan A , Costello J
Published: May 2014

A 52-year-old male smoker presented with a 10-week history of weight loss and malaise, together with a 1-week history of left-sided pleuritic chest pain, haemoptysis and mild dyspnoea. He had used intravenous drugs for a short time 30 years previously although he denied any intravenous drug use since. There was no other past medical history of note.

On examination, he was thin and appeared chronically unwell. He was apyrexial. There was a left pleural rub. There were no murmurs or stigmata of endocarditis. There were no other findings of note.

Full blood screen was normal apart from a white cell count of 11.2x109/litre (normal range 4.0–11.0x109/litre). Erythrocyte sedimentation rate was 52 mm/hr and C-reactive protein was 16 mg/litre (normal range <7.0 mg/litre). Urinalysis and urine culture were normal. The chest X-ray showed a circumscribed left lower zone lesion (Figure 1). Figure 2 shows the computed tomography appearance of the lesion.

At this stage, pulmonary malignancy was suspected (either a primary or secondary). The following day, two sets of blood cultures were taken in view of a low grade pyrexia. Enterococcus faecalis grew from all four bottles and the patient was started on intravenous amoxycillin.

Five days after admission a new soft pansystolic murmur at the left sternal edge was noted. Intravenous gentamicin was added. Transthoracic echocardiogram was normal but was repeated after an interval of 10 days in view of continuing low grade pyrexia and at this stage showed a vegetation adherent to the tricuspid valve (Figure 3).

The patient was treated with intravenous amoxycillin and gentamicin for a total of 6 weeks. He did not develop any further complications and has remained well at follow up.
Investigation of pancreatic disease
Authors: Hart RS , Williamson RCN
Published: May 2014

The diagnosis of pancreatic disease is often difficult because of its retroperitoneal location and the non-specific nature of abdominal pain. There is no one test which provides all the information needed, and a series of complementary tests are generally required. This article discusses the different modalities available for investigating the patient with pancreatic disease.
Introducing critical appraisal
Authors: Davies Huw TO
Published: May 2014

All health-care professionals are being encouraged to use research evidence more in developing their clinical practice. To do this they need to inculcate the skills of ‘critical appraisal’. Such skills involve assessing the appropriateness of research designs for answering clinical questions, critiquing the quality of the data gathering in individual studies, and assessing the implications of research findings.
A simple sore throat?
Authors: Maher Bridget , Pirmohamed Munir , Carey Peter
Published: May 2014

Apreviously healthy 26-year-old man presented with a 3-day history of sore throat, fever, rigors, loin pain and vomiting. He was pyrexial (40°C) and tachycardic (104 beats/minute), but had a normal blood pressure. Clinical examination revealed erythematous fauces without any exudates, and bilateral submandibular Iymph node enlargement. There was no meningism or para-spinal tenderness. The platelet count was decreased (108 × 109/litre, normal range (NR) 150–400x109/litre) and white cell count was elevated (16.1×109/litre, NR 4–11x109/litre) with a neutrophilia. Markers of inflammation (erythrocyte sedimentation rate 61mm/h and C-reactive protein 226mg/litre) and urea (11.1 mmol/litre, NR 3–7 mmol/litre) were also elevated.

Chest X-ray and glandular fever slide test were both normal. The patient was started on intravenous ceftriaxone after blood, urine and throat swabs were sent off for culture.

The patient's temperature settled over the next 4 days, and he was converted to oral antibiotics. Gram-negative anaerobes were cultured from the blood; these were identified as Fusobacterium nucleatum, suggesting that the patient had necrobacillosis. Throat swabs failed to grow the organism. In order to exclude an abdominal source for the organism, the patient also had an abdominal ultrasound and a radiolabelled white cell scan, both of which were normal. The patient's inflammatory markers and renal function returned to normal with antibiotic treatment, and he remains well 1 year after his illness.
Making job-sharing a success
Authors: Pardoe HD , Shaper K
Published: May 2014

As we move into the 21st century more doctors are looking at different schemes of working to achieve a balance between their professional and personal lives. Flexibility in working practice in the workplace is becoming more common because of the diversity of modern lifestyles and the desire to resolve conflict between work and external interests. A number of doctors are finding ways to work fewer hours while maintaining their commitment to training and patient care. The commonest reason for wanting flexible working hours is family commitments, although there are other reasons such as political or sporting commitments.
Referral guidelines for colorectal cancer: a threat or a challenge?
Authors: Baig MK , Marks CG
Published: May 2014

Colorectal cancer is a major cause of death in England and Wales where there are 30 000 new cases per annum with approximately 40% of patients surviving 5 years. Survival from bowel cancer in the UK is worse than the United States and Europe, perhaps because approximately one quarter of UK patients are diagnosed with incurable disease (Sharp, 1999). Large bowel cancer accounts for more hospital expenditure than any other cancer site and for between 10 and 20% of all palliative care provision (East Riding Cancer Services Alliance, 1998).
Management of unstable angina
Authors: Grubb Neil R , Fox Keith AA
Published: May 2014

Unstable angina is a common condition that presents a challenge to physicians because of its complex pathophysiology, and because of the high incidence of associated death and myocardial infarction. This article summarizes key strategies that can be employed in managing unstable angina and describes their interaction with the mechanisms that underpin the condition.
How to supervise a thesis: best practice
Authors: Isenberg DA , Salmon M
Published: May 2014

Adequate supervision of a research thesis is no simple matter. In this article, the requirements of both the supervisor and the student are considered, and essential recommendations are outlined.
Familial ovarian malignancy
Authors: Crawford Robin , Everest Sarah , Mackay James
Published: May 2014

Familial ovarian cancer is a subset of ovarian cancer where there appears to be a definable genetic link in families. It accounts for less than 5% of cases of ovarian cancer seen at present. The main genes responsible, BRCA1 and BRCA2, are discussed. Screening and the prophylactic measures for women identified having a genetic trait are discussed.
A surgeon in New York: a view of the American internship
Authors: Schachter Lee R
Published: May 2014

A young surgeon describes life as an intern in New York. Well-supervised hands-on operative experience and an assured place on a training programme for most residents compensate for low pay and gruelling hours of work.
False diagnosis of a catecholamine-secreting paraganglioma in a patient with hypertension and depression
Authors: Thomas Glyn , Winocour Peter
Published: May 2014

A48-year-old man was referred to the accident and emergency department. He had been suffering from intermittent episodes of headaches, palpitations and sweating with ‘flushing’ for the past 2 years. On the day of presentation he had suffered a typical ‘attack’ while at work, and was found to be hypertensive (blood pressure 160/120 mmHg). He denied any intense anxiety associated with these symptoms, but had been receiving treatment with imipramine (150–225 mg daily) for depression over the past 12 months. There was no significant past medical history.

On examination he was slightly obese and mildly tachycardic (rate 100 beats per minute) with normal heart sounds. Radial pulses were present and equal, with no radiofemoral delay. Fundoscopy revealed healthy discs and normal retinal vasculature. The remainder of the examination was unremarkable. Baseline renal function was normal with a serum creatinine of 96 μmol/litre, and urinary albumin:creatinine ratio of 0.5. Measurement of urinary catecholamine excretion revealed persistent elevation of noradrenaline on three subsequent samples, at 749, 764, and 1008 nmol/24 hours (reference range <590 nmol/24 hours). Values for adrenaline and dopamine, however, were well within normal limits at 48, 49, 88 nmol/24 hours (reference range <190 nmol/24 hours) and 2301, 2432, 2619 nmol/24 hours (reference range <3279 nmol/24 hours), respectively.

On the basis of this clinical picture, a presumptive diagnosis of hypertension caused by a catecholamine-secreting tumour was made. Imipramine was stopped, and antihypertensive medication commenced. An attempt to locate the neuroendocrine tumour using both computed tomography and magnetic resonance imaging failed to locate any mass lesion in either the adrenal glands, retroperitoneum, mediastinum, abdomen or bladder.

An 123I-MIBG scan was then performed (potassium perchlorate 400 mg once daily for 3 days beforehand, then 398 MBq of 123I-MIBG and 79 MBq of 99Tcm mercaptoacetyltriglycine (MAG3)), which revealed an isolated focal high uptake in the region of the lower pole of the left thyroid lobe (Figure 1). The presence of a 1.2 × 1.5 cm lesion at this site was confirmed on magnetic resonance imaging (Figure 2) and ultrasonography. An ultrasound-guided fine needle aspiration was performed on the lesion, before anticipated surgical intervention. This revealed simple cystic changes in a degenerative thyroid nodule, with no evidence to suggest the presence of a neuroendocrine tumour. Repeat measurement of both blood pressure and catecholamine excretion had returned to within the normal range.
Delayed diagnosis of HIV in patients with reactive lymphadenopathy
Authors: Sam WIC , Nye FJ , Beeching NJ , Taylor W
Published: May 2014

Lymphadenopathy is common in human immunodeficiency virus (HIV) infection, and may be the presenting feature. This article describes f ive patients who underwent biopsy for unexplained lymphadenopathy. Their biopsies showed reactive hyperplasia and four of the patients were discharged without a firm diagnosis; within 5 years, all were subsequently diagnosed HIV positive. In contrast, lymphadenopathy in the fifth case prompted a rapid diagnosis of HIV infection.
Medical students going on elective: who has duty of care?
Authors: Zuckerman Jane N
Published: May 2014

Medical training is unique in more ways than many people consider, and one particular aspect is the elective period. Students of other disciplines undertake placements abroad in which they are exposed to a variety of travel-related hazards. However, medical students on their elective studies abroad are exposed to an additional risk — occupational exposure to blood-borne viruses. It is this aspect of the elective period which has received much attention in recent years, as reviewed by Wilkinson and Symons (1999). Much has been debated concerning the possibility of restricting clinical activities and destinations as well as the provision of human immunodeficiency virus (HIV) postexposure prophylaxis.
Acute myocardial infarction: patent or die?
Authors: Coutts James , Redwood Simon R , Marber Michael S
Published: May 2014

The treatment of acute myocardial infarction (AMI) has changed dramatically over the past 15 years. In this issue (p. 617), Dr Gershlick presents an excellent review of strategies available to promote coronary artery patency in AMI, highlighting the limitations of thrombolytic therapy. In particular, he criticizes the preoccupation with door to needle or pain to needle time. Is there really more to optimizing myocardial salvage than timely thrombolysis?
Pathophysiology of venous thromboembolism
Authors: Hampton KK
Published: May 2014

Venous thromboembolism remains an important cause of morbidity and mortality for surgical and non-surgical patients, and its pathophysiology in acutely ill, non-surgical patients is not well understood. The clinically silent nature of thromboembolism makes it a significant threat to hospital patients.
Women in hospital medicine: career choices and opportunities
Authors: Fitzgerald Rebecca C , Black Carol
Published: May 2014

A significant number of women now enter hospital medicine. However, many do not make the expected progression within the medical specialties. The Royal College of Physicians set up a working party to examine and collect evidence on the career choices and progression of women in the hospital medical specialties under its remit and published a report of this evidence. This article outlines the findings of the report and the implications for hospital medicine.
Arterial strokes associated with factor V Leiden mutation
Authors: Munshi Sunil K , Hall David , Evans Rachel , Robinson Thompson
Published: May 2014

A 41-year-old Caucasian woman was admitted with right hemiparesis and blurred vision. There was no history of hypertension, diabetes, ischaemic heart disease, previous stroke, oral contraceptive use or miscarriages nor any family history of stroke. She was a non-smoker. Clinical examination confirmed the presence of right-sided weakness. There were no carotid bruits and her fundi were normal. Computed tomography scan of the brain confirmed the presence of a large infarct in the right middle cerebral artery territory (Figure 1). Full blood count, urea, creatinine, glucose and cholesterol levels were normal. Autoimmune profile, including antinuclear antibody, antineutrophil cytoplasmic antibody and anticardiolipin antibody, were negative. Other thrombophilia tests, including lupus anticoagulant, antithrombin III, plasminogen and protein S levels, were normal. Her electrocardiogram, chest X-ray, echocardiogram and a carotid Doppler study were unremarkable. A thrombophilia screen revealed markedly decreased activated protein C activity at 1.32 (normal ratio 2.25—2.63) when tested with factor V deficient plasma suggestive of factor V Leiden mutation.
How to write a review article
Authors: Williamson Robin CN
Published: May 2014

Writing a good review article is a real challenge. It requires not just a detailed literature search but a thorough 'digest' of the material obtained. Readers seek an up-to-date guide through a morass of data that has been sifted by the author and then integrated into a coherent and authoritative account.
Intrauterine growth restriction: diagnosis and management
Authors: Waugh Jason , Kilby Mark
Published: May 2014

The diagnosis of intrauterine growth restruction often results in preterm delivery with its associated morbidity and mortality. This review aims to outline the main diagnostic and management tools available to obstetricians for the management of such pregnancies as well as the aetiological factors that might be associated with this condition.
The use of botulinum toxin in otorhinolaryngology
Authors: Walshe Peter , O'Hare Dara , McShane Donald , Timon Conrad
Published: May 2014

In recent years, the use of botulinum toxin has become more popular for the treatment of a wide variety of diseases in the head and neck. It offers the possibility of non-invasive treatment of conditions whose aetiology lies in neuromuscular dyskinesis.
From protocol to pantogen and pantino: customizable surgical scripts with all the expert information
Authors: Edwards Michael H
Published: May 2014

Operative surgical training is handicapped by the lack of space and time of traditional training methods. This article reveals the extent and dangers of such constraints, and the benefits of surgical scripts with unlimited information, stored on a computer.
The use of vena caval filters
Authors: Mills TD , Chan O , Matson M
Published: May 2014

Deep vein thrombosis with pulmonary embolus is a frequent event, which is usually treated by anticoagulant drug therapy alone. Caval filters tend to be used infrequently in most centres in the UK. This article intends to help hospital doctors make use of these devices appropriately.
Treatment of acute porphyria
Authors: Elder George H , Hift Richard J
Published: May 2014

Haem preparations are now available for the specific treatment of attacks of acute porphyria. This review focuses on their use in this uncommon but life-threatening medical emergency.
Update on leprosy
Authors: Marlowe SNS , Lockwood DNJ
Published: May 2014

Leprosy, a result of infection by Mycobacterium leprae, is a leading cause of peripheral neuropathy. The World Health Organization aimed to eliminate leprosy as a public health problem by 2000, but this has not been attained. Patients with leprosy continue to present in the UK. The diagnosis of leprosy is frequently not considered, with resultant pathological and psychological problems for patients.
Managing schizophrenia: an update
Authors: Fear Chris
Published: May 2014

Atypical antipsychotic drugs offer hope to schizophrenics and their families. Controversy continues over their cost-effectiveness but patient surveys suggest increased compliance and thus improved mental health. This article reviews schizophrenia management, exploring the consequences of failing to adopt modern therapies in hampering compliance and stigmatizing the mentally ill.
Frontal osteomyelitis: a serious complication of sinusitis
Authors: Walshe Peter , Walsh Rory McConn , Walsh Michael
Published: May 2014

A12-year-old girl presented with a 6-day history of swelling of the forehead (Figure 1). She had complained of frontal headaches for the previous 2 weeks, but was otherwise well. She denied any history of trauma. The headaches were of a dull boring nature, and the pain extended to the mid-facial region. She complained of a loss of smell and nasal congestion. Neurological examination was normal, as was a subsequent skull X-ray. Computed tomography (CT) of the skull was performed, and indicated osteomyelitis of the frontal bone (Figure 2). There was also evidence of pus in the paranasal sinuses.
Effect of nurse colposcopists on a hospital-based service
Authors: Todd Richard W , Wilson Sue , Etherington Ian , Luesley David
Published: May 2014

The number of colposcopies performed annually in the UK is increasing. Nurse colposcopists have been introduced by many units to cope with this workload. The small amount of evidence to support the introduction of nurse colposcopists suggests that nurses are viable alternative providers of colposcopy. This study compares the performance of nurse colposcopists with that of doctors.
Necrotizing cutaneous mucormycosis
Authors: Akritidis Nikolaos , Papaioannides Demetrios , Korantzopoulos Panagiotis , Kitsiou Evangelia
Published: May 2014

Mucormycosis is generally an acute and rapidly developing fungal infection caused by fungi of the Zygomycetes class. In healthy hosts, these organisms seldom cause infections, but in debilitated or immunocompromised hosts, they produce a fulminant opportunistic infection, resulting in marked tissue destruction (Chun and Stevens, 2000).
Neuroimaging in schizophrenia: from theory to practice
Authors: Sheringham Jessica , Kumari Veena , Sumich Alexander , Sharma Tonmoy
Published: May 2014

Schizophrenia is a serious mental illness that affects 1% of the population. It is beset with problems of diagnosis and difficulties in assessing treatment. Neuroimaging has long contributed to our understanding of schizophrenia but recent developments suggest it may ultimately play a practical role in its early detection and management.
Deep vein thrombosis and air travel
Authors: Scurr John H
Published: May 2014

The death of a 28-year-old woman in October 2000 following a long-haul flight has led to sustained media interest in travel-related thromboembolic disease. In November 2000, the House of Lords Scientific and Technical Committee considered issues relating to the airline cabin environment. The evidence presented to this Committee consisted of many anecdotal case reports, a number of retrospective reviews of patients presenting with thromboembolic disease and oral evidence from many groups claiming an interest in flight-related medical problems. The Committee made a number of specific recommendations which can be summarized as the need for further research and passenger information.
Getting ahead of the curve: a new strategy for infectious diseases
Authors: Oppenheim Beryl A
Published: May 2014

Although infectious diseases have been one of the major problems affecting mankind throughout history, during the latter part of the 20th century an air of complacency seemed to emerge. It was felt that the combination of improved sanitation, availability of vaccines, and the development of powerful broad spectrum antimicrobials would allow us to permanently conquer the threats posed by serious life-threatening infections. Recent events have shown that these optimistic predictions are unlikely to be achievable, and in recent years major infectious disease scares both nationally and internationally have repeatedly hit the headlines.
Education in stroke: strategies to improve stroke patient care
Authors: Gompertz Patrick , Slack Andrew , Vogel Mira , Burrows Sharon , Clark Philippa
Published: May 2014

‘Stroke units save lives’, but organized care requires expert staff and regular training to be effective. However, the quality of inpatient care for stroke remains poor, and stroke education is often fragmented between the health-care professions. This review describes some national and local strategies aimed at ensuring that all patients are cared for by expert staff.
Venlafaxine: a new class of antidepressant
Authors: Hardy Julia , Argyropoulos Spilios , Nutt David J
Published: May 2014

Venlafaxine represents a new class of antidepressant, the serotonin and noradrenaline re-uptake inhibitor (or SNRI). This article discusses its evolution, pharmacological properties and role in the treatment of depression and related disorders, beginning with an outline of the biology of depression.
Does trauma trigger multiple sclerosis? 1: A controversy
Authors: Weatherby SJM , Hawkins CP
Published: May 2014

The potential role of trauma in the development of multiple sclerosis is important but controversial. Patients commonly ask about this and it has important medicolegal ramifications. In addressing such issues this article will consider both physical and psychological trauma, examine pathogenic mechanisms, and discuss the evidence for and against a relationship.
Venous stasis syndrome: the long-term burden of deep vein thrombosis
Authors: Heit John A
Published: May 2014

Currently there is no cure for venous stasis syndrome, a common complication of deep vein thrombosis. Prophylaxis with anticoagulant agents, including new drugs presently under investigation, may decrease the incidence and costs associated with this condition.
Radiofrequency ablation of unresectable liver tumours
Authors: Rai Rakesh , Manas Derek
Published: May 2014

Unresectable liver tumours have a dismal prognosis. Treatment with systemic or regional chemotherapy rarely results in a durable complete response. Radiofrequency ablation is a novel technique to achieve local destruction, which can be repeated and has been shown to be safe and effective.
Broadening medical horizons
Authors: Harper C Mark
Published: May 2014

In the rush to acquire ever more and detailed knowledge, the medical profession appears to have forgotten that there are other academic disciplines, the study of which would benefit both doctors and patients.
Liver transplantation
Authors: Nash Kathryn L , Gimson Alexander ES
Published: May 2014

Liver transplantation has evolved from an experimental procedure to an acceptable therapy for end-stage liver disease. The major challenges now faced are donor organ shortage, long-term complications related to immunosuppressive therapy, and the prevention and treatment of disease recurrence.
Fluid and electrolyte balance: how do junior doctors measure up?
Authors: Somasekar K , Somasekar A , Hayat G , Haray PN
Published: May 2014

Fluid and electrolyte disorders are common in hospital patients and can cause serious complications, especially in the elderly. The task of fluid management is often left to the most junior members of the team, the senior house officer and the preregistration house officer. However, the level of teaching and support available to them in this regard appears to be unsatisfactory.
Epidemiology of diabetic retinopathy
Authors: Chew Emily Y
Published: May 2014

Diabetic retinopathy is associated with a number of systemic risk factors, namely hyperglycaemia, elevated blood pressure and dyslipidaemia. Patients with diabetes should be vigorously treated for these modifiable risk factors to prevent the development and progression of diabetic retinopathy.
The place of ezetimibe in clinical practice
Authors: Weston Clive
Published: May 2014

Ezetimibe is the first selective cholesterol absorption inhibitor to be licenced in the UK. It interferes both with dietary cholesterol absorption and the enterohepatic circulation of cholesterol synthesized by the liver. As monotherapy it leads to modest reductions in plasma low-density lipoprotein cholesterol levels, but has synergistic effects when used with statins.
Atrial myxoma: a cardiocutaneous syndrome
Authors: Conroy Simon , Wassif Wassif S , Cooper John , Jenkins David , Stratakis Constantine
Published: May 2014

A52-year-old man presented with recurrent transient ischaemic attacks (TIA), predominantly causing visual disturbance. In the past he had suffered from migraine and had a horseshoe kidney on the right. Additionally, he had previously undergone surgery for several skin lesions (Figures 1a and b) that were myxoid or called 'neurofibromas', although he did not have any cafe-au-lait patches or axillary freckling and no clear family history to suggest neurofibromatosis.

He underwent echocardiography to investigate the cause of his TlAs, which revealed a 3 cm mass attached to the junction of the inter-atrial septum and the annulus of the anterior leaflet of the mitral valve (Figure 2). The echocardiogram was otherwise normal, as was subsequent coronary angiography. Surgery revealed three masses: the first as documented by echocardiography, the second similar mass was located at the entrance of the right pulmonary veins and the third, smaller mass was also close to the mitral valve (Figure 3). All were completely excised and the atrial wall repaired. The recovery was uncomplicated. Histology confirmed that all three masses were completely excised atrial myxomas.
Perioperative and postoperative nutrition
Authors: Lidder Paul G , Lewis Stephen
Published: May 2014

Nutritional deficiency among hospitalized patients is common, and is often unrecognized and untreated. Perioperative starvation is detrimental to recovery. Nutritional support can reduce morbidity, mortality and length of hospital stay. This article reviews the evidence for parenteral, enteral and oral nutritional support in the perioperative and postoperative period.
The current state of pain management
Authors: Collett Beverly J
Published: May 2014

Pain is a universal human experience. It is a necessary sensation for survival. Acute pain acts as a warning sign. It tells us to rest and protect the affected part of our body and sometimes to seek medical intervention. Acute pain usually resolves and is soon forgotten. However, nearly two thirds (61%) of patients taking part in a survey of hospital patients said that they were in pain all or most of the time (Bruster et al, 1994). The study – which included 5150 randomly selected NHS patients discharged from acute hospitals in England – showed that pain management was one of the main problems reported by patients. Similar concern in the USA has led to the measurement of pain being considered ‘the fifth vital sign’ and a call for pain assessment to be performed whenever routine observations are made.
Oral manifestations of systemic diseases
Authors: Swinson Brian , Witherow Helen , Norris Paul , Lloyd Tim
Published: May 2014

In the clinical examination for systemic diseases, inspection of the oral cavity is often overlooked. This area provides a wide array of clinical signs that may help the clinician establish a diagnosis. This article provides a summary of the more common oral manifestations of systemic disease.
Transfer of information from medical schools
Authors: Frankel Andrew , English Susan
Published: May 2014

Identifying and highlighting 'at-risk' preregistration house officers (PRHOs) has the potential of focussing support and training in a manner that improves the likelihood of successful completion of the PRHO year. The Faculty of Medicine at Imperial College Medical School has piloted and implemented a simple form which has been used to identify at-risk PRHOs. The authors' experience indicates that this mechanism has the potential to provide a robust means of communication between medical schools and trusts employing PRHOs and thereby allow intervention at an earlier stage, in order to improve the performance of an at-risk PRHO.
New aspects of pathogenesis of juvenile angiofibroma
Authors: Schick Bernhard , Urbschat Steffi
Published: May 2014

For over 150 years the aetiology of juvenile angiofibroma has been addressed in numerous theories, but actual details remained unknown. Interesting new findings, reviewed here, are beginning to elucidate the aetiology of this fascinating tumour.
Cost and economics of adhesions
Authors: Wilson Malcolm
Published: May 2014

The burden and cost of adhesions is considerable. Products are available which might reduce these problems. The costing of these products will have a significant effect on their usage. A low-cost product with a 25% efficacy could potentially generate a cost saving of £55 million over a 10-year period in the UK.
Introducing a nurse-led FFA: trials, tribulations and evaluation
Authors: Ring Lynn
Published: May 2014

Introduction: This paper describes the implementation and evaluation of a nurse-led fundus fluorescein angiography (FFA) service following the development of an evidence-based protocol. A national survey was carried out resulting in evidence-based guidance to support implementation.

Literature review: Research-based evidence is scarce however nurse-led FFA has been shown to be safe, improve efficiency, decrease clinic over booking and improve patient satisfaction. However, a clearly defined protocol remained elusive.

Method: A national survey was carried out and 87 completed questionnaires were analyzed.

Data analysis: 61 units ran a nurse-led FFA service. The majority had implemented their services using in-house training including intravenous (IV) cannulation, IV administration, intermediate life support and consent training.

Discussion: Nurses with recognized ophthalmic training and experience were undertaking nurse-led FFA. The issue of informed consent, consistency of information given by nurses and doctors and using patient group direction to administer IV fluorescein raised interesting contradictions when compared with national guidance. This was addressed during implementation of the nurse-led FFA service within the author's unit.

Implementation: A training workbook was formulated including nurse-led informed consent.

Evaluation: The nursing service has been in place for 5 years and has undertaken investigations on 1313 patients. A prospective audit of adverse events has taken place since inception with only 99 patients, approximately 7.5%, being identified as having incomplete FFA performed because of adverse events. Only two patients showed signs consistent with cardiac and respiratory problems.

Conclusion: The lack of robust national guidance limited the ability of the organization to develop practice efficiently, but the survey showed that nurses safely enhance their practice to run FFA clinics and adverse events remain consistently low over 5 years.
Patient experience of intravitreal injections in AMD
Authors: Henriksen Kristina , Adhami Setareh
Published: May 2014

Background:

Age-related macular degeneration (AMD) is a common sight-threatening disease in subjects above 50 years of age and new treatments include intravitreal injection of anti-angiogenic substances. The aim of this study was to evaluate patients’ experiences of such treatment.

Subjects:

Ten subjects, aged 66-95 (8 females and 2 males) participated. Nine of these had recently received their first injection and one the second injection.

Methods:

Interviews were performed in the patient's home and contained only one, open question: Can you tell us how you experienced the injection in your eye? The participants were allowed to speak freely, but follow-up questions were asked by the interviewers. Verbatim records were generated by tape recordings.

Results:

Four main topics were identified in the responses. 1. Information; the subjects experienced deficient information before treatment. 2. Fear and discomfort, related to treatment procedure or to visual loss. 3. Confidence in the care; a few subjects reported a few negative experiences, but no major complaints regarding the current procedure. 4. Subjective expectations on the effect on vision were that further visual impairment would be avoided, but there were also some reports of expected visual improvement, relevant for daily life activities.

Conclusion:

The dominating theme in the responses was fear of further visual loss, indicating a need for individually adapted/targeted information in order to provide the patients with a realistic view of the disease and the expected effects of current treatments.
Allergic ocular disease: from itchy eyes to visual loss
Authors: Johnson Paul
Published: May 2014

It is estimated that allergic conjunctivitis is responsible for 4–5 cases per 1000 attendances in primary care in the UK.

Seasonal allergic conjunctivitis is the most common presentation representing approximately 50% of all allergic conjunctivitis cases. Vernal keratoconjunctivitis and atopic keratoconjunctivitis are less common, but potentially more serious presentations that require management in specialist eye units.

This article will provide an overview of the more common presenting forms of allergic ocular disease, their clinical features and suggested general measures and clinical management plans.