bluuebunny/crossref_metadata_2025 huggingface dataset:
Thyroid storm treated with intravenous methimazole in patients with gastrointestinal dysfunction
Authors: Thomas DJB , Hardy J , Sarwar R , Banner NR , Mumani S , Lemon K , Hillson RM
Published: May 2014

A 27-year-old man, who had type 1 diabetes, presented with agitation, confusion, vomiting and faecal incontinence. There was an abscess on his right upper arm at an insulin injection site (temperature 38.5°C, pulse 140 per minute, and blood pressure 125/85 mmHg). Investigations included neutrophil count 13.6 ×109/litre, glucose 26 mmol/litre, pH 7.4, free thyroxine (T4)>77 pmol/litre (normal range (NR) 9–22.7), thyroid-stimulating hormone (TSH) <0.01 mu/litre (NR 0.35–5). After sedation with haloperidol 15 mg intramuscularly, he was rehydrated with physiological saline and treated with intravenous (IV) cefotaxime 3 g three times daily, IV dexamethazone 2 mg twice daily, IV methimazole 15 mg two doses 8 hours apart (Favistan injection solution, Temmler Pharma, Marburg, Germany), labetolol 120 mg (infused over 1 hour twice daily), and an insulin infusion using up to 4 u/hour.

After 24 hours there was a marked clinical improvement with resolution of his agitation and confusion and his pulse rate was normal (T4 22 pmol/litre, TSH <0.05 mU/litre after 72 hours). He was discharged on carbimazole 60 mg daily and propranolol 20 mg four times daily, and had radio-iodine treatment (339 MBq) 6 months later. He is well on thyroxine 50 μg daily 2 years later.
The carpal tunnel
Authors: Ellis Harold
Published: May 2014

The carpal bones are deeply convex anteriorly. This bony gutter is converted by the flexor retinaculum into a tube – the carpal tunnel, which conveys the median nerve, together with the long flexor tendons of the fingers and thumb, into the hand. It is of special interest to the surgeon because it is the site of a common nerve entrapment, the carpal tunnel syndrome.
Mild cognitive impairment
Authors: Amar Khaled , Ibrahim Ibrahim Rakha
Published: May 2014

Mild cognitive impairment refers to the transitional period between normal cognition and dementia, but is not an extension of normal ageing. Subjects with mild cognitive impairment have subtle but measurable cognitive impairment that is not severe enough to interfere with independent living or fulfil diagnosis criteria of dementia.
‘Just a sharp scratch’: permanent radial, median and ulnar neuropathy following diagnostic venepuncture
Authors: Dawson Joe , Christie Martin
Published: May 2014

An 82-year-old woman was admitted to hospital with acute left ventricular failure following a recent myocardial infarction for which she had been commenced on clopidogrel. An uneventful venepuncture in her left antecubital fossa yielded a normal full blood count and coagulation profile. Diuretics were commenced to which she responded well.

Five days later she described pain, swelling and bruising of her left forearm with numbness over her thumb, index and middle fingers. Prophylactic low molecular weight heparin was discontinued and the arm elevated. Nine days later she was unable to move her left hand. Bruising extended from the shoulder to the hand with swelling distal to the antecubital fossa (Figures 1 and 2). Woody subcutaneous oedema was present around the antecubital fossa with forearm tenderness. The radial pulse was present with good capillary circulation in all fingers. Neurological examination revealed complete wrist drop, minimal finger flexion and no small muscle function of the hand. The dorsal aspect of the forearm and hand were hypersensitive, with numbness over the volar aspect of the thumb, index and middle fingers.

These findings were consistent with an ischaemic neuropathy of the median, radial and ulnar nerves as a result of compartment syndrome, secondary to a compressive haematoma at the antecubital fossa following venepuncture. Surgery to relieve compartment pressures at this stage was thought to provide little chance of recovery, with the additional risk of supervening infection. Initial treatment was therefore conservative consisting of physiotherapy, vitamin B and gabapentine. An ultrasound scan confirmed the presence of a haematoma occupying the entire flexor compartment of the forearm. Nerve conduction studies revealed completely absent sensory potentials, with motor potentials 1%, 30% and 60% of normal in the radial, median and ulnar nerves respectively. This confirmed a severe subtotal axonotmesis of the radial nerve with partial axonal injury to the median and ulnar nerves. The prognosis was one of permanent major neurological deficit and despite intensive hand physiotherapy there was little functional recovery 1 year later.
Unusually positioned abscesses of the head and neck following suppurative otitis media
Authors: Onyon Clare , Goodyear Helen M
Published: May 2014

A 5-year-old boy presented to the authors' paediatric admissions unit with a sudden onset of swelling of his left temple. He had a 4-day history of fever and otalgia. He had been prescribed cefalexin by his GP the previous day for suspected acute otitis media. His mother described him waking from his afternoon nap when she noticed, for the first time, a swelling over his left temple. He had a history of two previously treated episodes of acute otitis media in the preceding year.

On examination he was febrile with a temperature of 37.9°C. A tender, firm, non-erythematous swelling was present over his left temple and several left cervical lymph nodes were palpable. Otoscopy revealed bilaterally scarred tympanic membranes. Initial investigations revealed a white cell count of 31.2 × 109/litre with a neutrophilia of 27.5 × 109/litre and a C-reactive protein of 261 mg/litre. Intravenous cefuroxime was started to cover a suspected soft tissue infection. Skull radiographs showed no areas of osteolysis. Ultrasonography of the lump was reported as showing a small fluid collection beneath a soft tissue swelling overlying the left temple, separate to the skull vault.

Inflammatory markers returned to normal levels after a few days of antibiotic treatment. However, the temporal swelling was slow to resolve and he developed difficulty in opening his jaw fully. The original diagnosis was reconsidered and the opinion of a paediatric otolaryngologist was sought. A diagnosis of an abscess deep to the temporalis muscle (Luc's abscess) secondary to chronic suppurative otitis media was made and intravenous metronidazole was commenced in addition to cefuroxime. Computed tomography scanning, performed under sedation, revealed an ipsilateral mastoiditis ith opacification of the mastoid air cells (Figure 1) and confirmed soft tissue thickening and a fluid collection overlying the left squamous temporal bone (Figure 2). Mastoid exploration and drainage were considered. However, as the swelling resolved completely and his clinical condition quickly improved, he was managed conservatively with a total of 2 weeks intravenous antibiotics.
Life-threatening fungal meningitis-ventriculitis secondary to vaginal candidiasis
Authors: Choudhari Yashashri K , Choudhari Kishor A
Published: May 2014

A 39-year-old woman presented with headache and drowsiness. Computed tomography scan confirmed aneurysmal subarachnoid haemorrhage with acute hydrocephalus, necessitating insertion of an external ventricular drain. This improved her consciousness level but she remained restless and confused. Cerebral angiography revealed an aneurysm arising at the origin of the posterior communicating artery. On the third day following haemorrhage the aneurysm was successfully treated by endovascular coiling. During this time she was often noticed to be scratching her vulval area as well as the scalp at the site of insertion of the drain. On vaginal speculum examination copious curdy white discharge was seen. A vaginal swab confirmed this to be caused by Candida albicans.

On the eighth day, her condition deteriorated again. She became drowsy with high grade fever, pyrexia, neck stiffness, vomiting and left hemiparesis. On the tenth day she became very ill and toxic with fulminant signs of meningitis-ventriculitis requiring a transfer to the intensive care unit. The CSF showed a high white cell count of 9500/mm3 with 90% neutrophils. No bacterial organisms were detected on direct microscopy but the culture grew Candida albicans. With aggressive antimicrobial therapy using vaginal clotrimazole pessaries, intravenous fluconazole and intraventricular vancomycin, her neurological condition gradually improved over the next 4 weeks. Clinical improvement also correlated with normalization of CSF picture and eradication of Candida on subsequent cultures. Vaginal discharge also gradually diminished and vulval redness subsided. Six weeks later, she was discharged with mild residual left hemiparesis. She did not have any itching or vaginal discharge.
Inhaled heroin causing a life-threatening asthma exacerbation and marked peripheral eosinophilia
Authors: Whale Christopher I , Molyneux Andrew W , Ward Michael J
Published: May 2014

Miss H was born in 1982 and diagnosed with asthma at the age of 7 years. In 2004 she presented with cough and wheeze, a peak flow of 55% predicted, an eosinophil count of 3.75 × 109/litre (normal range 0−0.4 × 109/litre) and a normal chest radiograph. In the preceding year, she attended the accident and emergency department twice and required six courses of prednisolone, despite taking low-dose inhaled steroids on a regular basis. A smoker, she lived in a rented room and was not registered with a doctor. Following standard treatment, she was prescribed an inhaled corticosteroid and long-acting β2-agonist. She took discharge against medical advice and failed to attend follow-up clinic.

Two months later she was admitted with increasing wheeze and breathlessness, but refused investigations. During this admission, but only after direct questioning, she admitted to smoking heroin. She was discharged with community drug liaison service follow-up and abstained from heroin until she attended clinic 6 weeks later. At this point she had no symptoms and a supranormal peak flow.

In February 2005, she become wheezy after inhaling heroin and was admitted overnight. She took her own discharge before seeing the hospital drug liaison team and again refused investigation. Admissions followed in June, July and August 2005, with life-threatening features on the last occasion, when she narrowly avoided ventilation. During this admission she recognized that exacerbations always followed heroin inhalation and she was referred to a direct access clinic to commence oral buprenorphine (Subutex, Schering-Plough, NJ, USA), a partial opioid antagonist.
Haematuria 1: risk factors, clinical evaluation and laboratory investigations
Authors: Keeler Barrie , Ghani Khurshid R , Nargund Vinod
Published: May 2014

Haematuria is a common complaint presenting to doctors in both community and acute centres. It can be a sign of underlying urinary tract malignancy. Appropriate investigation and management should follow evidence-based practice and recognized guidelines, and subsequently lead to a rapid diagnosis.
Methaemoglobinaemia: a case of mistaken identity
Authors: Washington Stephen J , P Meadows Diana , McCluskey Anthony
Published: May 2014

A 69-year-old man was admitted under the care of the orthopaedic surgeons after fracturing his femur. He had been diagnosed with polyarteritis nodosa 10 years previously and was asthmatic. A recent echocardiogram had revealed moderate aortic stenosis. His medications were dapsone 250 mg daily, prednisolone 5 mg daily, salbutamol and beclomethasone inhalers. The planned orthopaedic management was open reduction and internal fixation.

He had no complaints apart from the pain associated with his injury. He did not complain of breathlessness or chest pain. He was alert and orientated; heart rate 80/minute and regular; arterial pressure 132/74 mmHg; respiratory rate 16/minute; his chest was clinically clear. However, his lips were blue and pulse oximetry was 79% with a good waveform. A differential diagnosis of pulmonary or fat embolism was made and high flow oxygen was given. Further investigations were ordered and a medical opinion sought from a chest physician.

Laboratory haemoglobin was 105 g/litre; a chest X-ray showed chronic pleural thickening but no acute lung changes; an electrocardiogram confirmed normal sinus rhythm. Arterial blood analysis (breathing oxygen 15 litres/min from a face mask with attached reservoir bag) showed PaO2 23 kPa, PaCO2 4.5 kPa, pH 7.42, bicarbonate 24 mmol/litre, base excess zero. The chest physician agreed with the diagnosis of acute thrombotic pulmonary embolism and the patient was heparinised pending further investigation by computed tomography pulmonary angiography. This showed minor atelectasis, bronchiectasis and chronic pleural thickening consistent with previous asbestos exposure but no evidence of pulmonary embolism or parenchymal lung disease.

The patient was referred for an anaesthetic opinion before the proposed surgery, and the raised PaO2 was noted. As the patient was clinically well and all investigations were negative, he was deemed fit for urgent surgery under general anaesthesia.

In the anaesthetic room routine monitoring was attached. Again, a low peripheral oxygen saturation (approximately 86%) was observed on pulse oximetry breathing air. After routine induction of general anaesthesia, the low saturation persisted despite ventilation of the patient's lungs with 100% oxygen. At this point, a diagnosis of acquired methaemoglobinaemia – secondary to dapsone therapy – was considered. Methylene blue 20 mg was injected intravenously slowly and the pulse oximetry reading increased from 86 to 96% within a few minutes. The rest of the anaesthetic was uneventful.

Postoperatively he was transferred to the high dependency unit for observation and started on ascorbic acid. He had a methaemoglobin concentration of 4.8% (normal range 0–2%) even after the methylene blue and return to normal peripheral oxygen saturation. His dapsone was not restarted. Further investigation confirmed normal red cell methaemoglobin reductase concentration and a diagnosis of acquired methaemoglobinaemia secondary to dapsone therapy.
Management of foreign bodies in the ears and upper aerodigestive tract
Authors: Osman EZ , Swift A
Published: May 2014

A foreign body in the ear, nose or throat is common, especially in children. This article presents an overview of the management of foreign bodies.
Explosive proctitis: potential treatments and pitfalls in the treatment of chronic radiation proctitis
Authors: Farmer AD , Zanetto U , Lewis MJV
Published: May 2014

A 73-year-old man presented to the authors' clinic with profuse rectal bleeding, defaecatory urgency and symptomatic anaemia. He had been treated for prostatic adenocarcinoma 12 months previously, with neoadjuvant hormones and radiotherapy (total dose of 60 Gy). Chronic radiation proctitis was confirmed endoscopically and histologically in the absence of any other left-sided colonic pathology.

His initial medical management with sucralfate enemas and oral metronidazole failed. However, he withheld consent for further topical or endoscopic treatment despite continued symptomatic deterioration and transfusion dependency, presenting a therapeutic impasse.

Oral thalidomide (75 mg/day) was started and he made an excellent symptomatic response and became transfusion independent. However, 23 days after starting thalidomide peripheral neuropathy ensued, a well documented side effect (Mileshkin and Prince, 2006), which resolved rapidly following its discontinuation.

His symptoms and anaemia rapidly re-emerged and at this point he consented to endoscopic therapy with argon plasma coagulation. An unprepared flexible sigmoidoscopy, to the rectosigmoid junction, demonstrated features of chronic radiation proctitis and argon plasma coagulation was applied exclusively to the rectum. However, the patient developed sudden onset abdominal pain necessitating abandonment of the procedure. A chest radiograph showed free air under the right hemidiaphragm. An emergency laparotomy revealed multiple perforations and lacerations in the proximal descending colon without abdominal contamination. A Hartmann's procedure was performed. A direct perforation as a sequelae of the procedure is unlikely as multiple perforations and lacerations were evident proximal to the upper limit of the examination. Furthermore, no perforation was observed in the rectum or sigmoid where the argon plasma coagulation was applied. As bowel preparation was not administered before the flexible sigmoidoscopy and given the aforementioned findings at laparotomy, the likely cause of the perforation was an intracolonic gas explosion, a rare iatrogenic complication of using thermocoagulative endoscopic techniques within the colon.

The patient died 16 days postoperatively of multiorgan failure.
General surgical manifestations of Marfan's syndrome
Authors: Thomas GP , Purkayastha S , Athanasiou T , Darzi A
Published: May 2014

Marfan's syndrome can manifest as various general surgical pathologies (herniae, diverticulosis, bowel obstruction and abdominal vasculature aneurysms). These pathologies often have abnormal presentations, and in some cases can be life-threatening.
Are supraglottic airways a safe alternative to tracheal intubation for laparoscopic surgery?
Authors: Thompson Julian , O'Neill Sarah
Published: May 2014

Laparoscopic surgery is widely used for a range of elective and emergency procedures but presents significant challenges to the anaesthetist managing the airway. Compared to laparotomy, laparoscopic surgery reduces wound size, postoperative pain and ileus while improving postoperative respiratory function, allowing earlier mobilization and shorter hospital stays. However, the creation of a pneumoperitoneum has a number of disadvantageous effects on ventilation. Peritoneal insufflation increases airway pressures and ventilation/perfusion mismatch while reducing functional residual capacity and pulmonary compliance. The risk of regurgitation and gastric aspiration is also increased. These effects can be compounded by head-down patient positioning for lower abdominal procedures.
Franz Torek (1861–1938): first successful resection of an oesophageal tumour
Authors: Ellis Harold
Published: May 2014

This year marks the 70th anniversary of the death of Franz Torek, a surgeon of remarkable skill and dedication, who performed the first successful resection of a cancer of the oesophagus.
Peritonitis
Authors: Spalding DRC , Williamson RCN
Published: May 2014

Peritonitis simply means inflammation of the peritoneum. Most surgical cases of peritonitis arise secondary to bacterial contamination of the peritoneal cavity by organisms derived from the gastrointestinal tract. This common form of acute peritonitis is described in detail in this article, while other less common forms are discussed briefly.
Ultrasound of the thyroid
Authors: Hart Jonathan L , Lloyd Claire , Harvey Chris J
Published: May 2014

Ultrasound has become the investigation of choice for patients with palpable thyroid gland abnormalities because of its high anatomical resolution, wide availability, low cost and lack of radiation exposure. This article reviews the indications for thyroid ultrasound, examination techniques and the sonographic features of both benign and malignant thyroid pathology. Particular emphasis is placed on the role of ultrasound, in combination with fine needle aspiration cytology (FNAC), in evaluating thyroid nodules for malignancy.
Leadership skills: a guide for the foundation year doctor
Authors: Trivedi Deepali , Trivedi Kinjal , Hooke Rachel
Published: May 2014

It is often said that: ‘One is a born leader and leaders cannot be made’, but to what extent is this statement true? What did Mahatma Gandhi and Adolf Hitler have in common that made them effective leaders, despite being very different individuals?
Augusta Klumpke: pioneering female neurologist
Authors: Ellis Harold
Published: May 2014

The latter part of the 19th century was an exciting period when women at last were succeeding in their battle to obtain their medical training and qualifications to practice in the UK, continental Europe and in the USA. Moreover, and perhaps not surprisingly, many of these determined and doughty pioneers showed themselves to be exceptionally able in their chosen specialities. Perhaps the best example of this was Augusta Klumpke (Figure 1), who became an outstanding neurologist in Paris. This year marks the 150th anniversary of her birth.
Specialty and curriculum development
Authors: Batt Mark E , Cullen Michael
Published: May 2014

In February 2005 the government announced that sport and exercise medicine would be developed as a new speciality of medicine. This article provides an understanding of the process involved in the development of the new speciality of sport and exercise medicine, its scope and curriculum.
Introduction to teaching for junior doctors 1: opportunities, challenges and good practice
Authors: Cook Vivien , Sharma Anita , Alstead Elspeth
Published: May 2014

Doctors are expected to contribute to teaching activities and those who do should develop requisite skills. This two-part article highlights approaches to teaching for doctors in training based on sound educational principles. The first part focuses on identifying teaching opportunities, meeting logistical challenges and implementing good practice.
Small group teaching
Authors: McKimm Judy , Morris Clare
Published: May 2014

Small group teaching is effective in encouraging student engagement and discussion. Clinical teachers can use small group teaching techniques to facilitate learning in a range of settings.
Pulmonary complications in liver disease
Authors: Sen Sambit , Alexander Graeme JM
Published: May 2014

Pulmonary complications of liver disease are poorly understood and often identified late. Abnormalities of the pulmonary vasculature lead to two distinct complications, hepatopulmonary syndrome and portopulmonary hypertension, which differ in their clinical features and management. This article focuses on these two entities.
Effects of artificial colloids on haemostasis
Authors: Jin Shan-liang , Yu Bu-wei
Published: May 2014

Artificial colloids are used in situations with a high risk of bleeding such as trauma or during surgery. Although more efficacious than crystalloids, colloids can be associated with derangements of the haemostatic system and may also interfere with normal haemostasis via a number of different mechanisms.
Lambert–Eaton myasthenic syndrome
Authors: Chiang Yi Zhen , Tan Kian Tjon , Hart Ian K
Published: May 2014

A 64-year-old man presented with proximal lower limb muscle weakness that had ascended over 3 months to involve the upper limb, bulbar and periocular muscles. In addition, he had muscle aches, dry eyes and mouth, with 10 kg of weight loss. He was an ex-smoker of 50 pack-years.

On examination, he had mild dysarthria, bilateral ptosis and proximal muscle weakness (MRC power 4/5) in all limbs that improved transiently after muscle use. All limb tendon reflexes were absent at rest but returned after sustained muscle contraction for 10 seconds.

The serum voltage-gated calcium-channel antibody titre was 237 pmol/litre (normal <45 pmol/litre). High frequency repetitive nerve stimulation (Figure 1) produced a successive increase in compound muscle action potential amplitude, confirming the diagnosis of Lambert–Eaton myasthenic syndrome. On spiral computed tomography there was a pretracheal mass extending into the right paratracheal region (Figure 2). Tissue biopsy confirmed small cell lung carcinoma.
Traumatic anterior shoulder instability: current concepts in management
Authors: Dobson M , Cobiella C , Lee M
Published: May 2014

This review will give an overview of the current management practice and ethos of recurrent anterior shoulder instability, a condition which continues to puzzle and intrigue the shoulder surgeon.
Two contrasting presentations of Peutz-Jeghers syndrome
Authors: Cathcart Paul , Aziz Omer , Desai Anil , Ziprin Paul
Published: May 2014

A 17-year-old girl of Chinese origin was referred as a case of suspected acute appendicitis with a 3-day history of a colicky abdominal pain which had started off in her peri-umbilical region. She had presented to another hospital 2 days before, but was discharged home after an overnight stay because her symptoms had improved. The pain had now become more severe and was associated with bilious vomiting, absolute constipation for 3 days, and increasing abdominal distension. On further questioning she had experienced a self-resolving peri-umbilical pain intermittently over the past 3 years, but had never had this investigated. Her last period was 3 months ago, and she was being investigated for irregular menstruation in China. There was no family history of any gastrointestinal problems.

On examination, she was markedly dehydrated and noted to have ‘freckle-like’ lesions around her mouth and on her lips (Figure 1). She had a pyrexia of 38.1 °C, a tachycardia of 130 beats per minute, and was normotensive. The abdomen was visibly distended, tender (mostly in her epigastrium and left upper quadrant) and absent of bowel sounds. There was no evidence of previous surgery and scars, and digital rectal examination was unremarkable with an empty rectum. Blood tests showed marginally raised white cell count (13.8×109/litre) and C-reactive protein (51 mg/litre), and urine tests were unremarkable with a negative β-human chorionic gonadotrophin level. A plain abdominal radiograph showed an isolated loop of small bowel in the left upper quadrant (Figure 2), and a computed tomography scan of her abdomen was performed showing a long intussusception of the proximal jejunum with free pelvic fluid (Figure 3). This segment of bowel was grossly dilated and a diagnosis of small bowel obstruction secondary to intussusception was made.

Exploratory laparotomy was performed and revealed a 45 cm-long segment of intussuscepted jejunum which was ischaemic and non-viable, thereby requiring small bowel resection and primary anastomosis. On opening of the resected specimen a small polyp was identified at the lead point of the intussusceptions (Figure 4). The remainder of the small bowel did not contain any palpable or visible polyps, but a Meckel's diverticulum was found and resected. Histology of the intussuscepted small bowel segment revealed three pedunculated polyps (the largest 45×25×25 cm) with branching muscle pattern and relatively bland nuclei, consistent with a diagnosis of Peutz–Jeghers syndrome. The patient made a complete uncomplicated recovery and was discharged at postoperative day five.
An e-mail GP advisory service: a more efficient way of dealing with clinical enquiries
Authors: Walker JN , Rourke D , Allen K , Karavitaki N , Levy J , Wass JAH
Published: May 2014

Good communication between primary and secondary care is vital for patient management. This article describes how an e-mail enquiry service for endocrinology and diabetes was established within one hospital and the potential benefits that it offers.
Identification badges: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

In the interests of security, there is a requirement for suitable identification (ID) of people in a hospital. Anyone on site is assumed, perhaps misguidedly, to be a genuine worker (including contractors), patient or visitor. Obviously, visitors and outpatients will not have ID, but other people should. Inpatients are issued with wrist-bands and staff with badges.
Working hours in surgery: the junior's perspective
Authors: Patel Shelain , Hossain Fahad S , Colaco Henry
Published: May 2014

The advent of the European Working Time Directive (EWTD) has had a massive impact upon medical training in the UK. It became law in 1998, but junior doctors were excluded until 2004. Since then, there has been a gradual reduction in the number of hours that juniors are allowed to work and this will culminate in the 52-hour week in August 2009. Whether all specialities see it as a detriment, however, is open for debate and a brief look through the literature would suggest that it is the surgical specialities who seem to discuss this the most. This article will examine the impact of the reduction in hours upon junior surgical trainees, other factors that have influenced surgical training and what can be done to maximize one's time and efforts.
Paediatric palliative care: not so different from adult palliative care?
Authors: Mellor Charlotte , Hain Richard
Published: May 2014

This article compares and contrasts paediatric and adult palliative care, two specialties which are commonly rooted in the need to provide high-quality holistic care for life-limited patients. It explores how professionals can work together to meet the needs of young people transitioning from paediatric to adult health-care systems.
Florence Nightingale: nurse and public health pioneer
Authors: Ellis Harold
Published: May 2014

August 2010 marks the centenary of the death of Florence Nightingale, who must be, without doubt, the most famous name in nursing. Most people, even those in the health professions, think of her as ‘The Lady with the Lamp’; the heroine of the Crimean War, who tended the sick and wounded soldiers at Scutari. Important though this was, her main contribution, which continued long after Crimea, was in the organization of nursing training, in hospital planning, public and military health, and in effective collection of medical statistics.
Surveillance for colorectal cancer in patients with inflammatory bowel disease
Authors: Hurley Joanna J , Turner Jeff , Berrill James , Swift Gillian , Dolwani Sunil , Green John
Published: May 2014

Surveillance for colorectal cancer is necessary in patients with inflammatory bowel disease. This article summarizes the rationale for surveillance in this patient group and gives an overview of updated national guidelines.
The role of plain films in imaging major trauma
Authors: Burke Christopher J , Thomas Robert H , Owens Emma , Howlett David
Published: May 2014

This article reviews the role of imaging in the management of trauma patients. First the trauma series is reviewed, principally the chest, pelvis and cervical spine radiographs along with an approach to their interpretation. The role of computed tomography in trauma imaging is then discussed.
Using bevacizumab to treat metastatic cancer: UK consensus guidelines
Authors: Miles D , Bridgewater J , Ellis P , Harrison M , Nathan P , Nicolson M , Raouf S , Wheatley D , Plummer C
Published: May 2014

Concise guidance is lacking for the use of bevacizumab by practicing oncologists. Eight oncologists with experience of bevacizumab were joined by a cardiologist interested in treating hypertension to develop practical guidelines for managing patients receiving bevacizumab, using available clinical data.
Mandatory reporting of non-accidental injury in children
Authors: Sanders Tom , Cobley Cathy
Published: May 2014

Policies aimed at improving detection and referrals of suspected child abuse have not been effective overall. Unless mandatory reporting by clinicians is legally enforced, existing organizational and professional barriers may hinder the ability of agencies to safeguard children from harm.
Transition to adult services for children with renal failure: age or ability to cope?
Authors: Lewis Malcolm A , Smith Trish
Published: May 2014

Established renal failure is a manageable but incurable problem. Safely transitioning young people from paediatric to adult services remains a major challenge.
Radiology of acute wrist injuries
Authors: Basu S , Khan SHM
Published: May 2014

One of the most frequent skeletal injuries to the body is a fracture of the distal forearm or wrist. These injuries commonly arise from a fall onto an outstretched hand. Plain radiographs are the mainstay in the initial evaluation of these injuries. Factors affecting injuries to the forearm and wrist depend on the age of the patient, severity of injury, exact mechanism and direction of force to the injury. However, wrist injuries in particular can be subtle on plain radiographs and therefore difficult to identify. It is essential to identify injuries early so that appropriate management is implemented and early recovery of normal function is seen. This article reviews basic anatomy, classical radiological signs and common distal forearm and wrist injuries.
Radiology of acute shoulder injuries
Authors: Basu S , Khan SHM
Published: May 2014

Shoulder injuries are common, particularly following trauma. It may be helpful to group injuries into certain age categories. For example, fractures to the clavicle are commonly witnessed in childhood or early adulthood. Shoulder dislocations are commonly seen from teenage years up to the 4th decade of life. Finally, fractures of the humeral head are seen more frequently in elderly patients. Plain radiographs are the mainstay in the initial evaluation of these injuries, but other modalities like ultrasound and magnetic resonance imaging can aid diagnosis and management of more chronic symptoms and soft tissue injuries. It is essential to identify injuries early so that appropriate management is implemented and early recovery of normal function is seen. This article reviews basic anatomy, classical radiological signs and common shoulder injuries.
Endoscopic ultrasound in the assessment of solid and cystic pancreatic lesions
Authors: Mason Karen , Higgs Simon M , Norton Ms Sally A
Published: May 2014

Pancreatic masses can be solid or cystic, benign or malignant. Rapid and accurate diagnosis is essential for optimal management. Clinical presentation and radiological appearance are often inadequate for a definitive diagnosis. Endoscopic ultrasound allows more detailed assessment of the pancreas than traditional imaging techniques.
Exercise and cancer survivorship
Authors: Grimmett Chloe
Published: May 2014

The association between exercise and cancer incidence has long been established. Increasingly research is considering the role of exercise in the oncology setting. This article summarizes the current evidence for exercise promotion in cancer survivors and guidelines for exercise participation in this population.
Medical leadership: from policy to practice
Authors: McKimm Judy , O'Sullivan Helen
Published: May 2014

Medical leadership is now becoming embedded at all stages of medical education and training. This article summarizes key policy and practice drivers, highlights some of the debates around what constitutes medical leadership and provides examples of leadership development initiatives.
Recognizing dying in terminal illness
Authors: Taylor Paul M , Johnson Miriam
Published: May 2014

Recognizing dying in terminally ill patients is a complex clinical skill. This article outlines the approach to the decision, common difficulties encountered in patients with both malignant and non-malignant disease, and a simple approach to considering the question ‘Is this patient dying?’
The total artificial heart in a cardiac replacement therapy programme
Authors: Barnard James , Tsui Steven SL
Published: May 2014

The increasing prevalence of heart failure coupled with the shortage of donor hearts has lead to an ever-growing demand for mechanical devices that can augment or replace the failing human heart. This article describes the modalities used to treat end-stage heart failure and how these fit into a cardiac replacement therapy programme.
Pharmacokinetic interactions between antiretroviral drugs and herbal medicines
Authors: Lamorde Mohammed , Byakika-Kibwika Pauline , Merry Concepta
Published: May 2014

Pharmacokinetic interactions between herbal medicines and antiretroviral drugs may increase the risk of toxicity or antiretroviral treatment failure. This review highlights known and potential interactions between antiretroviral drugs and commonly used herbal medicines.
Diagnosis and treatment of hereditary angio-oedema attacks
Authors: Longhurst Hilary J , Nzeako Ugo C
Published: May 2014

Patients with hereditary angio-oedema will often present to the emergency department or hospital with cutaneous swelling, abdominal pain or laryngeal oedema. This article reviews the diagnosis and acute management of patients with hereditary angio-oedema.
The role of neurosciences intensive care in neurological conditions
Authors: Sadek Ahmed-Ramadan , Damian Maxwell , Eynon C Andy
Published: May 2014

The neurosciences intensive care unit provides specialized medical and nursing care to both the neurosurgical and neurological patient. This second of two articles describes the role it plays in the management of patients with neurological conditions.
A cry for help: time to re-think the patient call bell in an ageing population
Authors: Chadwick Andrew , Hearn Andrew
Published: May 2014

Historically, the patient call bell has been the mechanism by which patients can alert a health-care worker to provide help. The authors were concerned that, in an increasingly comorbid population, this method of raising help was not fit for purpose. They therefore reviewed every level 3 bed space (n = 283) in a district general hospital over a 2-week period and assessed the usability of the call bell at each occupied bed. The call bells were on average 82 cm away from the bed. More worryingly, over one third (38.1%) of all inpatients were unable to understand independently the role of the call bell and how to use it. The authors conclude that, in times of immense inpatient bed pressures, it is critical that there are robust strategies to highlight the significant number of patients who cannot use the call bell and ensure they are given an appropriate ward location.
Allergy: a risk factor for cardiovascular diseases?
Authors: Xu Zhanwen , Li Yaqin , Zhao Xingzhou , Liu Zhi-Qiang
Published: May 2014

Allergic diseases and cardiovascular diseases are increasing in prevalence. There is an association between allergic diseases and cardiovascular diseases, as they share similar inflammatory processes. This article focuses on current understanding of the detrimental influences of allergic diseases on cardiovascular diseases.
The artificial heart: current concepts
Authors: Westaby Stephen
Published: May 2014

Heart failure is a global problem which predominates in those countries where aggressive medical treatment improves survival after myocardial infarction. In Europe the incidence of heart failure in the over-65s exceeds 100 patients per thousand population, with hospitalization rates of 18 000 per million per year.
Clinical governance in primary care
Authors: Drage Stewart
Published: May 2014

The government's stated top priority for the NHS is the quality of care of patients and there now exists a new duty of quality on all those providing care, accompanied by a drive for greater accountability to the public of clinical decision making. The process which governs these initiatives is termed clinical governance.
Staff grade doctors and the consultant ladder: falling off or stepping off?
Authors: Baker Maureen , Williams Jacky , Petchey Roland , Flett Andy
Published: May 2014

The majority of the doctors in staff grade posts surveyed had qualified overseas and a substantial proportion were dissatisfied with their posts. Very few doctors had received adequate careers counselling before starting their post and many were concerned at the lack of opportunities for career development.
Management of severe upper airway trauma
Authors: Tomlinson Simon , Earlam Chris
Published: May 2014

A 32-year-old man presented to casualty at night following an accident at work with a large industrial circular saw. His overalls were caught by the blade and he was pulled into the machine. The blade had struck him on the left side of his face and neck but nowhere else. He had been conscious throughout even though he had bled profusely from his wounds. On arrival he was pale, tachycardic (pulse 130 beats/minute) and hypotensive (blood pressure 90/40 mmHg). He had been given 2 litres of colloid by the paramedics. He was sitting upright and his Glasgow Coma Score was 15.
Palivizumab: an overview
Authors: Russell Alison Bedford
Published: May 2014

Respiratory syncytial virus (RSV) affects almost all children in their first 2 years of life and can cause severe or even life-threatening disease in some at-risk infants. Treatment is limited and there is currently no safe or effective vaccine. However, a new monoclonal antibody, palivizumab, reduces RSV hospitalization by 55% in at-risk groups if given prophylactically throughout the RSV season.
Managing trainee doctors in difficulty
Authors: Paice Elisabeth , Orton Victor , Appleyard Jane
Published: May 2014

When the conduct, performance or health of a doctor in training is called into question, there is often confusion about the roles and responsibilities of the parties involved. Where does training stop and employment begin? When should poor performance trigger intensified training, and when should it lead to dismissal? How much information should be transferred from employer to employer as a trainee moves around a training programme? This article describes one Deanery's approach.
Osteoporotic fracture complicating Guillain-Barré syndrome
Authors: Hatfield Alison , Collin Christine
Published: May 2014

Guillain–Barré syndrome is an acute inflammatory demyelinating polyradiculoneuropathy often associated with a prolonged period of immobilization. Between 71 and 80% of patients make a full or near full recovery, but there is a 5–11% mortality and the remainder have an incomplete recovery (Rees, 1995; The Italian Guillain–Barré Study Group, 1996). The paralysed patient with Guillain–Barré is susceptible to the complications of immobility: venous thromboembolism, hypostatic pneumonia and contractures. Osteoporosis is a silent, poorly recognized risk and contributes to significant morbidity and increased hospital stay.
Techniques in conduit harvesting
Authors: Levine AJ , Graham TR
Published: May 2014

Coronary artery bypass grafting is a commonly performed operation for the treatment of ischaemic heart disease. The success of it is largely dependent upon the quality and type of graft used. This article describes the application of and rationale behind techniques commonly used in conduit harvesting.
HELLP syndrome: mechanisms and management
Authors: Ellison Joanne , Greer Ian A , Sattar Naveed
Published: May 2014

Effective management of HELLP syndrome depends on swift recognition of a condition which often masquerades as other pathology. This article reviews clinical aspects of HELLP syndrome and outlines recent advances in our comprehension of what may be the underlying pathophysiology.
Recurrent cervical smear abnormalities following treatment
Authors: Hammond Robert
Published: May 2014

The cervical screening programme has had a dramatic impact on the incidence of invasive cervical cancer and preinvasive disease can be effectively treated in the majority of cases. However, recurrent abnormalities after treatment pose management dilemmas which are considered in this overview of the topic.
Coexisting allergies to latex and to muscle relaxants in a primigravida
Authors: Ayeko MO , Smith NJ
Published: May 2014

A 23-year-old primigravida weighing 67 kg required urgent caesarean section for fetal distress. She had been admitted a week earlier at 34 weeks' gestation for bed rest and observation because of worsening pre-eclampsia.
Hospital radiology: today and tomorrow
Authors: Hare William SC
Published: May 2014

Of all the medical specialties, radiology has developed most rapidly throughout this century to a point where it is central to the management of the majority of hospital patients. The papers in this issue's symposium illustrate the role of radiology in four diverse fields, but are just a sample which could be expanded right across the spectrum of medical practice.
The role of radiofrequency ablation in the treatment of cardiac arrhythmias
Authors: Marshall Howard J
Published: May 2014

In the early 1980s, catheter ablation heralded a new era in the treatment of cardiac tachyarrhythmias. With the development of radiofrequency energy, the procedure has become widely used and has been shown to be safe and effective. This editorial outlines the nature of the procedure and its role in the management of cardiac arrhythmias.
Anticoagulation in atrial fibrillation in older people
Authors: Gupta I , Bennett G , Gompertz P
Published: May 2014

There is controversy and apprehension regarding the routine use of oral anticoagulants in atrial fibrillation, especially in elderly people. Based on current evidence, however, patients with non-rheumatic atrial fibrillation who have no obvious contraindications to warfarin should receive prophylactic anticoagulant therapy for prevention of embolic stroke. Patients unable to tolerate warfarin would benefit from aspirin. It is poor clinical practice to await transient ischaemic attacks or a stroke before considering anticoagulation, and it should be remembered that cost–benefit values need to include the cost of rehabilitation and long-term care.
A psychiatric trainee's guide to the criminal courts
Authors: Lock Martin , Griffiths David
Published: May 2014

This article provides a guide on the criminal justice system in England and Wales to assist psychiatrists who are asked to prepare reports on people subject to criminal proceedings. It describes which sections of the Mental Health Act 1983 are relevant at different stages of the criminal justice process.
Mental health of elderly Asians in the UK
Authors: Ananthanarayanan TS , Cochrane R
Published: May 2014

Elderly Asians constitute a small proportion of the population compared to elderly Caucasians, but this is growing rapidly. They share many of the disadvantages of the white elderly, as well as being non-white and alien. Many elderly Asians have now accepted that they will stay in the UK for good, which may contribute to increased stability in their mental health.