bluuebunny/crossref_metadata_2025 huggingface dataset:
Follow-up of patients with ileo-anal pouch following stoma reversal
Authors: Winslow Fiona
Published: May 2014

The treatment of choice for patients with familial adenomatous polyposis or ulcerative colitis is ileo-anal pouch surgery with the formation of a defunctioning ileostomy. A small (n = 27), multicentre, qualitative questionnaire study was undertaken to ascertain patients' perceptions of the follow-up received from the stoma care nurse and the form of that follow-up (if any) following stoma reversal. Results showed that the majority of respondents had acceptable pouch function and received some type of follow-up. Less than 10% received no follow-up but would have liked it. Respondents thought the nurse specialist was the person of choice to provide the follow-up care, in conjunction with the surgeon. Further research to establish guidelines and clarity are needed.
The implications of Ogilvie's syndrome for midwives and gastrointestinal nurses
Authors: Smith Graeme D , Mander Rosemary
Published: May 2014

Ogilvie's syndrome is is an acute intestinal pseudo-obstruction associated with massive dilatation, usually of the colon, but also of the small intestine. Mechanical obstruction is absent, and there is parasympathetic nerve dysfunction. Ogilvie's syndrome affects mainly the caecum and right colon, and can lead to life-threatening spontaneous perforation. The syndrome is attributed to imbalance of the autonomic nervous system, but the pathogenic mechanism remains unknown. This article gives an overview of the normal anatomy and physiology of the large bowel, and examines the aetiology, diagnosis and management of Ogilvie's syndrome. The role of the nurse and midwife in the recognition and management of this potentially life-threatening condition is highlighted.
Campylobacter jejuni: bacterial characteristics, transmission and treatment
Authors: Banning Maggi
Published: May 2014

Campylobacter jejuni is a global and common form of food poisoning. It is thought that C. jejuni colonizes the intestines of animals, in particular cattle and chicken. During food preparation, poor hand and food hygiene and undercooked meat and chicken can harbour and transmit the bacterium. The infective dose is relatively small - up to 500 toxin-producing bacteria can cause infection and food poisoning. The main symptom of food poisoning is watery painful diarrhoea, which in most cases is self-limiting. Severe cases of food poisoning may require antibiotics. Nurses should be aware of the importance of hand and environmental hygiene when nursing patients with C. jejuni as human carriage is known to exist and the bacterium can easily grow in temperatures ranging from 36-37°C and therefore has the potential to cause cross infection.
Specialist roles will generalize
Authors: Fretwell Ian A
Published: May 2014

Gastrointestinal specialist nursing is under threat from workforce reviews and Trust financial deficits. Both the RCN gastrointestinal forum and the Association of Coloproctology (ACPGBI) nurses′ forum have been assessing changes to colorectal and stoma care specialist nursing by asking members to complete and return separate questionnaires. RCN returns (see GIN 2006, 4 (7): 8−9) showed that 38% of the 460 replies felt that they were unable to deliver their service in line with national guidelines. Provisional ACPGBI returns suggest specialist nurses are being asked to work as ward staff nurses and reduce their specialist nurse activity. Others have been downgraded and job descriptions changed from specialist roles to practitioner roles. From the RCN questionnaire 219 (48%) respondents were aware of posts that had been disestablished, downgraded or frozen when vacant. In some areas staff have left and have not been replaced, or have been replaced by a lesser band.
Coeliac UK...Intolerant of gluten
Authors: Mendoza Nicky
Published: May 2014

Coeliac disease is caused by intolerance to gluten which leads to inflammation and damage to the gut. The villi become flattened which greatly decreases the surface area for absorption of nutrients and so can lead to nutritional deficiencies and even malnutrition. Coeliac disease is the most common cause of malnutrition in the UK (Thomas et al, 2003).
Stomal stenosis, a complex stoma complication: case study
Authors: Johnson Antoinette , Porrett Terri
Published: May 2014

There are a variety of complications that can affect people who have a temporary or permanent stoma. This article discusses the complication of stomal stenosis, and the causes and predisposing factors that contribute to this occurrence. The article also explores a case study in which stoma stenosis resulted in peri−stomal fistula formation, and explains the stoma care management used to deal with this complex stoma complication.
A bit of everything...
Authors: Norton Christine
Published: May 2014

As ever, we bring you a range of clinically relevant articles in this month′s GIN. The series of organizational profiles continues. We often think that we are familiar with what the voluntary organizations do, but sometimes we can be surprised at the range of services and information on offer. And maybe we need reminding to make sure that all patients are put in touch with as many different organizations as are relevant to their needs. In an era when information is all too easily available via the internet, it can be very difficult for patients to identify which are the quality sources of information.
Barrett's Oesophagus Foundation
Authors: Simon Paul
Published: May 2014

Barrett′s oesophagus (BO) or columnar−lined oesophagus (CLO) as it is more appropriately known is an important condition since it is a precursor lesion of oesophageal adenocarcinoma. This form of oesophageal cancer has increased threefold in the past decade and tenfold in the past 30 years, currently having the most rapidly increasing incidence of any solid tumour in the western world (British Society of Gastroenterology (BSG), 2006). The only known precursor of adenocarcinoma of the oesophagus is BO.
A framework for practice
Authors: Cox Carol
Published: May 2014

Over the years, different professional and government organisations in the UK have developed and promoted frameworks for practice. One of the most well known is Essence of Care (Department of Health (DH), 2001), a toolkit for benchmarking the fundamentals of care. Since its publication, this document has been the foundation for clinical audit within the nursing clinical governance structure. The intention of developing the toolkit was for health and social care personnel to use it to address issues of concern within their areas of work, to improve services already provided and to monitor existing practices.What is of primary concern is that all health care practitioners engaged in benchmarking, including patients and carers, where involved, should agree the indicators that demonstrate best practice within their area of care. The importance of getting these fundamental aspects of care right is essential for patient, client and carer care to improve. This was also reinforced in the NHS Plan (DH, 2000). Since the introduction of these documents, many health care organisations have begun special programmes designed to ensure clinicians possess the necessary skills and knowledge to guarantee high standards of care.
what the journals say
Authors: Williams Julia
Published: May 2014

The literature to date explores the development of biological agents that could improve outcomes for metastatic disease, while minimizing toxicity to the patient with colorectal cancer. Here, the authors review the use of bevacizumab in patients with metastatic colorectal cancer and discuss aspects related to how it acts upon the tumour, therapy dosage, administration and management of potential side−effects.
Raising the profile of the National Colorectal Cancer Nurses Network: an email survey
Authors: Taylor Claire , Whayman Kathy
Published: May 2014

This article seeks to raise the profile of the National Colorectal Cancer Nurses Network, which was formed for colorectal cancer clinical nursing specialists (CNSs) in the UK. It describes the aims and format of this network and defines its membership. A recent email survey of its members is then presented to highlight the current complexities and priorities of the colorectal cancer CNS role. The survey ascertained these CNSs′ current interest and involvement with one particular component of the specialist role-research. The responses indicate the time spent on this role component and identifies their research priorities. The findings of this study highlight the different demands that exist between colorectal cancer nursing services and the perceived difficulties in meeting all role components adequately. The respondents were clearly dedicated to ensuring all patients received the highest quality of clinical care possible. Their ability to do so was often constrained by the number of patients referred to their services. Clinical demand also meant that their engagement with nursing research within colorectal cancer care was limited. This has implications for the future theoretical development of this nursing speciality.
A NICE approach to coeliac disease: Implications for gastroenterology
Authors: James Shirley
Published: May 2014

Coeliac disease has long been under-diagnosed and commonly misdiagnosed as irritable bowel syndrome. In this recommendations and financial and patient implications are discussed. Finally, the effect of the guidance on secondary care gastroenterology services is considered, as well as how the gastrointestinal nurse specialist can play a proactive role in defining the way coeliac disease is managed for the future.
Survivorship at the ACPGBI
Authors: Wordley Anna
Published: May 2014

Collaborative working between nurses and doctors in the field of coloproctology continues to evolve,and is supported by the framework of the Association of Coloproctology of Great Britain and Ireland (ACPGBI).
Ongoing misdiagnosis of coeliac disease
Authors: Peterson Amy
Published: May 2014

Coeliac disease is a lifelong autoimmune condition caused by intolerance to gluten, the protein found in wheat, barley and rye. Some people with coeliac disease may also be sensitive to oats. Coeliac disease affects 1 in 100 people in the UK (West et al, 2003). Only 10–15% of those with the condition are clinically diagnosed (National Institute for Health and Clinical Excellence (NICE), 2009).
What the journals say
Authors: Coutts Alison
Published: May 2014

Alison Coutts, senior lecturer in applied biological sciences, City University, London, provides a brief overview of recently published nursing and health articles. A reference is provided for further information.
Preventing and managing peristomal skin infections and sore skin
Authors: Burch Jennie
Published: May 2014

People with a stoma need to wear an appliance to contain the stomal output of faeces or urine and to protect the peristomal skin in order to improve adhesion of the appliance and prevent troublesome leaks. However, even if an appliance is worn, peristomal skin infections and sore skin can and do occur. These can be bacterial infections such as folliculitis or contact irritant dermatitis. Jennie Burch explains that thorough assessment and often simplistic changes are necessary to maintain the integrity of peristomal skin.
Never events in gastrointestinal nursing
Authors: Cox Carol
Published: May 2014

Gastrointestinal diseases and disorders frequently require interventions that can lead to serious consequences for patients when an organization has not put in place the correct systems and processes to prevent incidents from happening, procedures have not been followed (generally due to poor observation), or when an individual disregards protocol (generally due to lack of judgment). It has been identified that over 400 000 patients suffer potentially preventable harmful events each year ( Emslie, 2002 ). In this article, Carol Cox describes the types of risks that can lead to never events and factors that increase the potential for error.
Choosing the correct accessory for each stoma type
Authors: Burch Jennie
Published: May 2014

Many ostomates require nothing more than an appliance to care for their stoma. However, if problems occur, stoma accessories can be invaluable. It is essential that a problem is assessed before commencing the use of the stoma accessory and the effectiveness of the subsequent accessory is monitored. In this article, Jennie Burch focuses on the indications for choosing and using some of the available stoma accessories. The types of appliances required to care for colostomies, ileostomies and urostomies are explained. Several ostomy accessories including accessories that address skin protection, such as barrier wipes or protective powder, are explored.
Using acceptance and commitment therapy in irritable bowel syndrome
Authors: Bravo Ferreira Nuno , Eugenicos Maria , Graham Morris Paul , Gillanders David
Published: May 2014

Biopsychosocial conceptualizations of irritable bowel syndrome (IBS) see the physical and psychological experiences (e.g. bowel discomfort, pain, stress, IBS-related anxiety) of this condition as the key influence in the poorer outcomes of this population. Most of the current therapeutic targets proposed by practitioners and patients are somehow limited to control, change or elimination of these experiences. In this article, Nuno Bravo Ferreira, Maria Eugenicos, Paul Graham Morris and David Gillanders argue for a new functional conceptualization of the suffering in IBS as a result of psychological inflexibility. Acceptance and commitment therapy (ACT) as a new form of approach, not based on elimination strategies, will be proposed for the improvement of IBS outcomes. Finally, the possible applications and implications that ACT could have for gastrointestinal nursing will be considered.
Factors impairing quality of life for people with an ostomy
Authors: Davis Janet Stoia , Svavarsdóttir Margrét Hrönn , Pudło Małgorzata , Arena Raimondo , Lee Yunjin , Jensen Mette Kaad
Published: May 2014

The DialogueStudy documented real-life experiences of the use of a double-layer adhesive ostomy appliance, SenSura (Coloplast A/S) with a focus on quality of life (QoL) and peristomal skin conditions. The overall mean QoL measured using the Stoma-QoL questionnaire improved from 58.1 ±10.2 at visit 1 to 59.9 ±9.9 at visit 2, 6–8 weeks later (P<0.0001). Factors correlating with QoL at visit 1 included leakage from the ostomy appliance, peristomal skin condition, age, gender and time since surgery. Three factors correlated with the improvement in QoL from visit 1 to visit 2: male gender, baseline leakage level and baseline Stoma-QoL value. As frequency of leakage influenced both the baseline QoL and the change in QoL, minimizing leakage is an important goal for stoma care nurses to improve the QoL for people with an ostomy.
Introduction to the DialogueStudy: methods and baseline demographic findings
Authors: Andersen Birgitte Dissing , Keizerswaard Paula van , Castro Maria Manuel , English Elizabeth , Carter Daniel
Published: May 2014

The DialogueStudy, an open-label, non-comparative, multinational post-marketing study, was set up to document real-life experiences of users of a new ostomy appliance, SenSura, manufactured by Coloplast A/S, with a focus on quality of life (QoL) and peristomal skin conditions. The largest study of its kind, the DialogueStudy involved more than 500 stoma care nurses (SCNs) from 379 sites in 18 countries and a total of 3017 participants with a colostomy, ileostomy or urostomy. During the study, participants completed two visits with an SCN and were given advice on maintaining healthy peristomal skin and provided with an appropriate ostomy appliance, SenSura. The primary endpoint was the difference in QoL between the first and second visit. Secondary endpoints included self-awareness of skin disorders, leakage and peristomal skin condition at the study start and then at the study end (6–8 weeks later). The mean QoL score increased significantly during the study (P<0.0001).
Developing the role of the clinical nurse specialist in inflammatory bowel disease
Authors: Whayman Kathy , Stansfield Cath , Duncan Julie , O’Connor Marian
Published: May 2014

Almost two decades have passed since the role of clinical nurse specialist (CNS) in inflammatory bowel disease (IBD) was first recognised and developed to improve the quality of care, education and support to patients with IBD ( Phillips, 1995 ). The role of IBD CNS is now pivotal within the multidisciplinary IBD team. UK national IBD standards ( IBD Standards Group, 2009 ) and the RCN role descriptives document ( RCN, 2007 ) have resulted in greater clarity of the IBD CNS’s roles and responsibilities. In this article, Kathy Whayman, Cath Stansfield, Julie Duncan and Marian O’Connor explore the role in relation to wider definitions of advanced nursing practice, looking at preparation for practice and characteristics of the CNS role. In addition to role clarity, education, support from colleagues, networking and research evidence are all vital for nurses to establish and deliver effective specialist services for people with IBD.
Understanding smoking and nicotine effects on the gastrointestinal tract
Authors: Graham Cope Dr
Published: May 2014

Dr Graham Cope discusses cigarette smoking and its profound effects on the gastrointestinal system. Smoking cigarettes reduces the gastric mucosal barrier, increasing the risk of gastric ulceration and cancer, probably by reducing prostaglandin synthesis, which controls mucus and bicarbonate production. Smoking increases the risk of Crohn’s disease in the small intestine and is detrimental to surgical and non-surgical treatment, possibly increasing mucosal permeability and reducing wound healing. In the colon, smoking is protective against ulcerative colitis, as nicotine suppresses the associated enhanced immune response. However, smoking is positively related to colon cancer and collagenous colitis, by the inhibition of other types of immune cells and the increase of free radical-mediated mutations and carcinogenic changes. Recent evidence shows that nicotine is a direct stimulus to the production of cancer cells, which may cast doubt on the use of nicotine-replacement therapy (NRT) as a long-term aid to smoking cessation.
Managing overgranulation tissue around gastrostomy sites
Authors: Warriner Linda , Spruce Pam
Published: May 2014

The development of overgranulation tissue around gastrostomy devices is a common problem. While there is little evidence to suggest that one treatment is more effective than another, a review of current practice suggests that there is an opportunity to improve clinical practice and patient outcomes in this area of care. A simple practice-based audit was undertaken to identify the extent of the problem within one geographical location. A care pathway approach was introduced, which reinforced the basic principles of care and introduced the use of a ‘double foam’ dressing on overgranulation tissue. A foam dressing impregnated with polyhexamethylene biguanide was used at the wound interface, providing a safe and effective alternative to managing overgranulation. Findings from the audit show that a strategic approach to managing overgranulation around gastrostomy devices can improve patient outcomes and improve clinical practice.
Dietary advice for patients with a stoma
Authors: Cronin Elaine
Published: May 2014

In the enormity of stomal surgery, dietary advice for patients is key to rehabilitation. Yet it is too often overlooked (Porrett and Joels, 1996) and patients are given conflicting advice. These patients desperately want to do what is right. They want to recover, get well and go home. They are therefore happy to follow instructions, but need to understand the rationale for them. The author believes that dietary advice is invaluable and should be offered to all new stoma patients. She also believes that, if dietary advice is presented before and after surgery, in a clear and concise manner, it will equip patients for life with their stoma. Having knowledge brings power and patients are empowered with a good knowledge base. The formation of a stoma disrupts the normal functioning of the gastrointestinal tract and alters its reabsorptive process, not to mention its flow. Initially, having a stoma is daunting and, for the vast majority of patients, terrifying. Patients need advice from ward or stoma nurses that will give them the confidence to make independent food choices. This, however, takes time, patience and lots of reiteration. Both verbal and written information are helpful. This article sets out to provide an understanding of ostomists' dietary needs to allow healthcare professionals to provide information with confidence, as and when required.
How complex is coeliac disease?
Authors: Welyczko Nikki
Published: May 2014

Nikki Welyczko, Senior Lecturer and Academic Lead for Adult Nursing at the Faculty of Health and Life Sciences, De Montfort University, provides a brief overview of recently published nursing and health articles
Molecular virology in chronic hepatitis B: genotypes
Authors: Lai-Hung Wong Grace , Lik-Yuen Chan Henry
Published: May 2014

Different hepatitis B virus genotypes have different geographical distributions, natural disease progression, risk of hepatocellular carcinoma and treatment responses. This article summarizes the recent literature in this area.
Making do not attempt resuscitation decisions: do doctors follow the guidelines?
Authors: Harris DG , Linnane SJ
Published: May 2014

When do not attempt resuscitation orders are contemplated, guidelines exist to outline standards for planning patient care and decision making. These guidelines may not always be fully followed as ethical issues arise which may prevent doctors from doing so.
Tackling ageism and promoting equality in health care
Authors: Singh Iqbal , Ayyar Anita , Bhat Sarita
Published: May 2014

With an ageing UK population people are living longer and enjoying longer periods of retirement. It is projected that the number of people over the age of 65 years in the society will rise from the present 16% to 20% by 2051 (Office of National Statistics, 2004). These demographic trends have consequences across all areas of public policy and add to challenges in health and delivery of health care. Society’s expectations of old age mean that people are not only living longer but are expecting to have improved quality of lives through minimizing disease and other risks, thus contributing to successful ageing.
Suicide prevention and audit
Authors: Saunders Kate , Hawton Keith
Published: May 2014

Suicide is a devastating event and a major public health issue. On average one person dies every 2 hours in England as a result of suicide. It is the commonest cause of death in men under the age of 35 years. This article reviews the epidemiology, causal factors and prevention of suicide, and also briefly discusses the role of audit in this area.
Isotretinoin-related optic disc swelling
Authors: Wenham CJ , Clarke I , Shun Shin GA
Published: May 2014

A 19-year-old Asian woman presented to eye casualty via her optician. She complained of a 3-week history of an intermittent ‘misty’ patch in her left vision. This lasted less than 5 seconds at a time and occurred more frequently in the mornings. There were no other symptoms and she was systemically well.

The patient was currently in the 11th week of a 16-week course of oral isotretinoin for recalcitrant acne, but was on no other medication. She had been using oral tetracycline until 1 year previously.

Examination revealed visual acuities of right 6/6, left 6/9 with pharmacologically dilated pupils. Clinical examination was unremarkable (including normal ocular movements, visual fields to confrontation, colour vision and cranial nerves) with the exception of grossly swollen optic discs, left greater than right (Figure 1).

The isotretinoin therapy was stopped and blood tests, Goldman visual fields (Figure 2), Heidelberg retinal tomography (Figure 3), computed tomography (CT) scan of the head and electro-diagnostic tests (EDTs) were arranged.

Fields showed an enlarged left blind spot but no other abnormality. Blood tests showed elevated cholesterol, alkaline phosphatase and alanine aminotransferase levels. CT head scan revealed no intracranial abnormality and EDTs were normal. Neurology review corroborated a diagnosis of druginduced raised intracranial pressure and lumbar puncture was felt to be unnecessary.

Eleven weeks later the patient was asymptomatic with a clear reduction in the swelling of both discs. Liver function tests and Goldman visual fields were returning to normal. The patient remains asymptomatic and under regular review.
Superior mesenteric artery syndrome in a young girl following spinal surgery for scoliosis
Authors: Amarawickrama H , Harikrishnan A , Krijgsman B
Published: May 2014

A 15-year-old girl was admitted with nausea, severe bilious vomiting, loss of appetite and loss of weight of 2 weeks' duration. She underwent spinal surgery for thoracic scoliosis with multiple congenital abnormalities of the spine 3 weeks before admission. Examination revealed a thin, dehydrated patient with distended upper abdomen, positive succussion splash and normal bowel sounds. Blood investigations including urea and electrolytes were normal except for mild leucocytosis. Abdominal X-ray was unremarkable. A nasogastric tube was inserted which drained 2–3 litres of bilious fluid each day. She was treated conservatively with intravenous fluids and anti-emetics.

The history of spinal surgery and copious amount of bilious nasogastric aspirate suggested upper gastrointestinal obstruction for which a barium meal with follow through was done on day 3 (Figures 1 and 2). It revealed a distended stomach and dilatation of the first and second parts of the duodenum with an abrupt linear cut-off at the third part, suggesting extrinsic compression. On the basis of her history and radiological findings, the diagnosis of superior mesenteric artery syndrome was made. Conservative treatment was continued with total parenteral nutrition for about 3 weeks, by which time the nasogastric output gradually reduced to less than 100 ml and the patient was tolerating oral fluids

The patient was discharged after 4 weeks on soft diet. She was reviewed in clinic after a month and was found to be completely asymptomatic and comfortable.
Emergency anaesthetic strategies for the bleeding upper airway
Authors: Kamming Damon , Patel Anil
Published: May 2014

The shocked patient with life-threatening haemorrhage from the upper airway is a major anaesthetic and surgical challenge. Causes of bleeding, may include infective, trauma, tumour or postoperative sequelae. Sources of bleeding, include epistaxis, tonsillar bed, tongue and oro- or nasopharynx. Despite full resuscitative measures, bleeding may persist and the airway can become increasingly compromised. Surgical intervention is required sooner rather than later. A strategic anaesthetic approach to this emergency is essential before surgery. The risks and benefits of several alternative strategies are considered (Table 1).
Plantar fasciitis: a review
Authors: Cullen NP , Singh D
Published: May 2014

Plantar fasciitis is a common cause of heel pain. The aetiology is not fully understood leading to confusion in terminology. Plantar fasciitis may affect patients of any age, being most common in middle-aged women and younger, predominantly male, runners. If treatment is initiated soon after the onset of symptoms, most patients can be cured within 6 weeks, but usually symptoms have been present for months.
Supplements and injections for joint disease
Authors: Derrett-Smith E , Beynon HLC
Published: May 2014

Dietary supplements and single joint treatments are gaining increasing popularity, with evidence of efficacy in randomized controlled trials compared with placebo, and minimal side-effects compared with some more traditional therapies. This article clarifies some of the newer approaches and the science behind them.
What makes a good doctor in the 21st century? A qualitative study
Authors: Abu-Hilal Moh'd , C Morgan Emma , Lewis Gemma , MC Phail Mark , Malik Hassan Z , Hocken David
Published: May 2014

Society wants and expects good doctors. The definition of a good doctor is difficult to characterize. This study aims to identify those features considered by patients and health-care professionals to be important in making a good doctor.
Post-poliomyelitis syndrome: clinical features and management
Authors: Ramaraj Radhakrishnan
Published: May 2014

Post-poliomyelitis syndrome affects mostly women who have had paralytic polio. Most patients do very well when they are given non-fatiguing exercises in a warm environment. Patients must be correctly diagnosed with this syndrome and offered appropriate management and rehabilitation.
Obesity: surgical management
Authors: Baxter John N
Published: May 2014

Obesity surgery is the most cost-effective form of treatment for morbid obesity. Unfortunately the NHS has failed to provide widespread comprehensive assessment and obesity surgical services. As a result we are lagging behind many developed countries to the detriment of our patients.
How much do new junior doctors in emergency medicine understand about oxygen therapy?
Authors: Mbamalu David , Banerjee Ashis , Hinchley Geoff , Idowu Akin
Published: May 2014

Oxygen is routinely prescribed in hospital practice. It should be prescribed like any other drug, specifying delivery device, flow rate and desired inspired concentration. There appears to be continued deficiency in the provision of guidance for, and understanding of, the principles of oxygen therapy.
Doctors and demons
Authors: Syed Hafiz , Liakis Iannis , Gompertz Patrick
Published: May 2014

Mrs MB is a 68-year-old woman of Bangladeshi origin who presented to the acute stroke unit with dense right-sided hemiplegia. Computed tomography scanning confirmed that she had had an acute infarction of the left middle cerebral artery territory. Her past medical history included type 2 diabetes mellitus of 14 years' duration. Apart from serum cholesterol of 6.5 mmol/litre there were no other risk factors for cerebral infarction identified. On admission she was not taking an antiplatelet agent or statin.

She denied having previously suffered a stroke. She was widowed and had been independent with all aspects of daily living.

On further discussions with her daughter it came to light that Mrs MB had experienced mild weakness and ‘lack of feeling’ in her right arm and leg approximately 4 years ago. This was thought to be caused by what is literally translated from Bangla as ‘evil or demonic wind’. At the time she urgently consulted the help of a local spiritual healer in East London as recommended by neighbours and family. The diagnosis of a ‘demonic processes’ was confirmed by the healer who massaged the affected limbs with ‘holy’ water. The patient's symptoms resolved completely within hours so a consultation with her GP was not sought.
Optimizing decisions about treatment in locally advanced prostate cancer
Authors: Payne Heather , Lim Faye
Published: May 2014

The decision-making process for the management of locally advanced prostate cancer is very complex for both patients and health-care professionals. The Vitality Index can be used to help tailor therapy approaches to match the individual lifestyle needs of patients.
Spinal cord tumour presenting as neck pain
Authors: Freitas Ryan P De , Choudhari Kishor A
Published: May 2014

In April 2003, a 48-year-old GP was admitted to the authors' hospital with severe neck pain. He had a 2-week history of progressively worsening neck pain without antecedent trauma or strain. Pain was initially relieved by paracetamol, but progressed to waking him from sleep and became continuous during the day. Physiotherapy and opiates did not alleviate symptoms. Power, sensation and sphincter functions were unaffected. After a further week of unremitting pain, neurosurgical referral was made.

A magnetic resonance imaging scan showed an intrinsic spinal cord tumour extending from C3 to C6 level (Figure 1). Urgent laminectomy and resection of tumour was performed. Complete excision was possible as the tumour had not infiltrated into surrounding normal cord. Pathology confirmed intramedullary ependymoma. After a short period in a spinal rehabilitation unit followed by regular outpatient physiotherapy the patient regained full function, resuming work, and was even able to participate in a local relay marathon 2 years later.
Attention-deficit/hyperactivity disorder or hyperactivity in preschool children
Authors: Thompson Margaret
Published: May 2014

This article describes the evidence for the presentation of attention-deficit/hyperactivity disorder in young children and discusses the literature describing the manifestations of the condition, and assessment and treatment techniques.
Management of attention-deficit/ hyperactivity disorder
Authors: Jamdar Saroj , Thara Sathyamoorthy Brahan
Published: May 2014

Management of attention-deficit/hyperactivity disorder is both a challenging and a rewarding experience. Diagnosis is difficult because of the complexities of presentation and lack of biological markers. However, personalized management improves the individual’s quality of life and also benefits the family and society as a whole.
Physiology of sport
Authors: Maughan Ron
Published: May 2014

The elite athlete represents the extreme of the human gene pool, where genetic endowment is developed by an intensive training programme. Sport encompasses many different activities, calling for different physical and mental attributes. Understanding the physiology of exercise provides insights into normal physiological function.
How to improve the selection process of surgical trainees
Authors: Fassiadis Nicholas , McIrvine Andrew
Published: May 2014

The assessment of potential surgical trainees should involve assessment of decision making, based on knowledge and experience, with an evaluation of communication skills. Until now knowledge and decision making have been evaluated during basic surgical training (ST1 and ST2 in the future) and in the MRCS examination.
Hypoalbuminaemia and colonic polyps: a case of protein-losing enteropathy with cap polyposis?
Authors: Longcroft-Wheaton G , O’Brien J , Woolfe K
Published: May 2014

A 69-year-old woman was admitted in September 2005 dehydrated and unwell. She had a 6-month history of constipation, poor appetite and weight loss, and was hypoalbuminaemic (21 g/litre). She had initially been referred for colonoscopy in March to exclude colonic malignancy. Multiple pedunculated polyps up to the splenic flexure were seen, with histology felt to be consistent with hyperplastic polyps and mild inflammation. Her symptoms persisted, and by August she had lost 3 stone in weight. She started to experience loose stools, and repeat colonoscopy was planned. However, the bowel preparation made her feel unwell. She couldn't walk, and so presented to the acute medical take.

The patient looked pale and dehydrated. Her chest was clear, with a diffusely tender abdomen. Bowel sounds were present, and there were no palpable masses. Bloods showed a corrected calcium of 1.58 mmol/litre. Fluid resuscitation and calcium replacement was started. A malignant process was queried. Liver function tests showed a low albumin of 21 g/litre but were otherwise unremarkable. A computed tomography scan of the abdomen and chest were normal. A gastroscopy showed mild oesophagitis with Candida in the mid and lower oesophagus, gastritis in the antrum of the stomach with heavy Helicobacter pylori growth, and a normal duodenum. Biopsies showed no evidence of coeliac disease or giardia.

The patient's albumin fell to 8 g/litre. A 24-hour urine protein collection was 0.46 g, excluding nephrotic syndrome. Nasogastric feeding was commenced.

Gut hormones showed a modestly elevated chromogranin A (164 pmol/litre) and gastrin (307 pmol/ litre) but were not diagnostic of a neuroendocrine tumour. Amyloid was queried and the original colonic biopsies re-examined. This was not found, but cap polyposis was suggested.

The patient failed to improve and died 15 days after admission. Post mortem found the distal large bowel to contain multiple dark sessile polyps, looking like slugs, on exaggerated mucosal folds (Figure 1). The histological findings comprised elongated, tortorous and distended crypts, with evidence of inflammation and a 'cap' of granulation tissue, confirming cap polyposis. In addition the patient had a right haemothorax. This was caused by a dissection in the pulmonary artery, with evidence of atheroma identified. The right ventricle was hypertrophic, with the lungs showing multiple haemorrhagic infarcts. These changes suggested pulmonary hypertension. Whether this was related to the cap polyposis was unclear. A reasonable explanation is that the patient had showered off pulmonary emboli from a deep vein thrombosis (DVT) for some time, secondary to immobility associated with her poor state of health. This was supported by a right calf DVT identified at post mortem. The dissection of the pulmonary artery was probably secondary to the low protein state and pulmonary artery hypertension.
Psychological consequences of critical illness: aftercare or an afterthought?
Authors: M Hull Alastair , Cuthbertson Brian H
Published: May 2014

As the physical care of individuals with critical illness has improved greater numbers have survived. However, until recently the psychological response to such critical illness has received comparatively little attention.
Physical consequences of critical illness
Authors: Thirugnanam Subarna , Herridg Margaret S
Published: May 2014

Patients who survive critical illness are at risk of permanent physical and functional deficits which decrease the health-related quality of life. The reasons for physical morbidity include the nature of and treatment for the inciting critical illness, new decrements in organ function and worsening of pre-existing organ dysfunction, and prolonged physical immobility and long intensive care unit stay.
Should codeine still be used for post-craniotomy analgesia?
Authors: Sharma Vikas , Sebastian Joe
Published: May 2014

The traditionally held belief that craniotomies are not as painful as other surgical procedures is increasingly being questioned. Pain following this type of surgery is now considered to be a greater problem than previously thought. De Benedittis et al (1996) showed that 60% of post-craniotomy patients suffered pain and in two thirds of these, pain intensity was moderate to severe especially in the first 48 hours after surgery.
Part 3: medical literature and impact factors
Authors: Leon Rebecca , Bayat Ardeshir
Published: May 2014

The impact factor, provided by the Institute for Scientific Information (ISI), Philadelphia, has become the most vital evaluation tool for scientific research and academic work (Hoeffel and Fornes, 1999). It has now replaced subjective criteria used in the past to define journal quality and prestige. Impact factors have a vast, yet controversial influence on the way published scientific research is perceived and evaluated.
Digital nerve blocks
Authors: Kang Sertaz-Niel
Published: May 2014

The ability to obtain digital nerve blockade is a valuable tool in the armamentarium of the emergency practitioner. As well as providing reliable, effective analgesia it is simple to perform and therefore is commonly implemented for a variety of surgical problems involving the digits.
The unwell patient on peritoneal dialysis: what you need to know on an acute medical take
Authors: Campbell Gary , Woodrow Graham
Published: May 2014

Chronic kidney disease is common and its prevalence is increasing. Acceptance of patients onto renal replacement therapies is also increasing and currently it is estimated that around 640 people per million are on some form of renal replacement therapies (Renal Association, 2005), of whom 25% are over the age of 75 years. Annually, the acceptance rate for renal replacement therapy in adults is just over 100 people per million. Chronic kidney disease is associated with a heavy burden of co-morbidities, especially cardiovascular, where there is around a 10–20-fold increased incidence than in the general population (Foley et al, 1998).
Acute breathlessness
Authors: M Maher Toby , Wells Athol U
Published: May 2014

Acute breathlessness is terrifying for the patient and is a symptom often greatly feared by junior medical staff. The sudden development of dyspnoea heralds, in most cases, a significant cardiopulmonary insult. Left untreated, most causes of acute breathlessness can prove rapidly fatal. Thus, physicians presented with an acutely dyspnoeic patient must provide prompt supportive care, an accurate diagnosis and appropriate management of the underlying disease process.
The Mental Capacity Act
Authors: Davies Marika
Published: May 2014

Decisions made by doctors on behalf of patients who lack capacity are currently made according to accepted best practice and common law principles. The Mental Capacity Act 2005 (the Act) sets this approach in statute law, providing protection for incompetent patients and clear legal requirements for those caring for them.
Medical causes of abdominal pain
Authors: Reid Richard , Hutchins Robert
Published: May 2014

The majority of patients presenting with abdominal pain will have an intra-abdominal cause and, particularly in the emergency setting, surgery is usually required.
Advice for foundation doctors on dealing with elderly patients
Authors: McGonagle Lorcan , Morgan Samer
Published: May 2014

With the continuing growth of the elderly population and the increasing life expectancy, almost all clinicians (with the exception of paediatricians and obstetricians) deal with elderly patients on a daily basis. The elderly population uses a disproportionate amount of most health services, reflecting the increased prevalence of most diseases and physical disabilities in this age group (Cassel et al, 1996).
Technique of knee joint aspiration
Authors: Patel RV , Haddad FS
Published: May 2014

Knee joint aspiration and injection are performed to establish a diagnosis, relieve discomfort, drain off infected fluid, or instill medication.
New Ways of Working: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

‘New Ways of Working’ is a term that has been bandied about for years. In the public and private sectors, organizations are always considering how to work more efficiently. The NHS is very much dictated to by government directives and European legislation.
Learning portfolio: how to get it right
Authors: Hijazi Bader
Published: May 2014

Nowadays, there are new and different selection criteria for a Specialist Training post. Deaneries are increasingly asking for the learning portfolio as part of the evaluation process in the final selection process and the learning portfolio accounts for up to one third of your final score in some deaneries. So, having an excellent portfolio can mean a lot to the progression of your career. This article gives an easy guide to help you get your portfolio right.
Comprehensive geriatric assessment
Authors: Dainty Philip
Published: May 2014

Society is undergoing massive demographic change, the most striking feature of which is the large increase in the proportion of elderly, frail patients. These patients have similar expectations to their younger counterparts, and rationalization of treatment on the basis of age has been consigned to the past. Future health service provision and medical training will need to reflect this, and consequently junior doctors (almost irrespective of chosen speciality) will require in-depth understanding of how to evaluate and manage these complex patients.
Paracentesis in the management of ascites
Authors: Mittal Rahul , Dangoor Adam
Published: May 2014

Ascites is the abnormal accumulation of fluid in the peritoneal cavity. Men have little or no peritoneal fluid, but women may have up to 20 ml depending on the phase of the menstrual cycle. Ascites is a relatively common clinical finding with a range of malignant and non-malignant causes (Table 1). About 85% of ascites is caused by liver disease (Runyon, 2004), and cancer accounts for about 10% of cases (Smith and Jayson, 2003; Becker et al, 2006).
Common rashes in children: 2
Authors: Mansouri Dr Yasaman , Johnston Dr Graham
Published: May 2014

This second article covering rashes commonly seen in children looks at three further conditions with very distinctive clinical presentations that are none the less commonly misdiagnosed.
Time for guidelines in diagnostic imaging?
Authors: Yesuratnam A , Mendelson RM , Bairstow PJ
Published: May 2014

The increasing costs of health care in a modern developed country consume a high percentage of its economy's resources. In 2006, total spending for this sector in the UK represented 9.4% of the gross domestic product. This was substantially greater than 2001, when 7.1% of the gross domestic product was devoted to health (Griffin, 2007). The growth in expenditure is in part a result of the health requirements of an ageing population with inherent chronic medical conditions. Coupled with this, however, is the everemerging new and costly medical technologies that are available to diagnose and treat disease and the public expectation that health authorities will fund the provision of these services.
Surgery for acute heart failure syndromes
Authors: Large Stephen
Published: May 2014

This article describes the role of surgery in the management of acute presentations of heart failure. Intervention is set in the context of medical management. If the cause of the failure is not apparent this help is limited to mechanical support as intra-aortic balloon pumping, heart assistance or replacement. The most dependable management for refractory, severe heart failure remains heart transplantation but is dependent upon donor organ availability.
Too old to exercise? Unusual muscular uptake on 99mTc methylene diphosphonate bone scintigraphy
Authors: Griffiths Grant , Rees John
Published: May 2014

An 81-year-old man was referred for bone scintigraphy. He had recently been diagnosed with prostatic carcinoma. Images obtained 3 hours after injection of technetium-99m methylene diphosphonate showed no evidence of metastatic bone disease, but symmetrical increased soft tissue uptake was seen extending from the inferior margin of the scapula to the neck of the humerus (Figure 1). This was confirmed on single photon emission computed tomography/computed tomography to lie within the teres major muscles. There was also focal radiotracer uptake within the lower cervical and first thoracic vertebral end plate, secondary to osteoarthritis (as confirmed by single photon emission computed tomography/computed tomography).
Antibiotic use and women in preterm labour
Authors: Peebles Donald
Published: May 2014

Preterm birth before 32 weeks' gestation is the leading cause of perinatal morbidity and mortality; the incidence appears to be rising and interventions to reduce the trend are urgently needed (Anonymous, 2006). Inflammation appears to be the final common pathway to preterm birth, causing uterine contractions, cervical ripening and rupture of the membranes; increased levels of pro-inflammatory cytokines are found in the myometrium, membranes and amniotic fluid of women in preterm labour and there is an associated influx of inflammatory cells into the uterus (Lindström and Bennett, 2005).
Acute mesenteric ischaemia: facts and perspectives
Authors: Assar Ahmed N , Zarins Christopher K
Published: May 2014

Acute mesenteric ischaemia is a catastrophic abdominal emergency with an extremely high mortality rate. This article discusses the aetiology, diagnosis and treatment of acute mesenteric ischaemia with emphasis on avoidance of common errors that contribute to the poor outcome inherent to this condition.
Management of tuberculosis
Authors: Bothamley Graham
Published: May 2014

The management of tuberculosis is about responding to patient needs, making an accurate diagnosis, successfully treating a chronic disease and working in a team. It provides a model of how a quality health service should operate.