bluuebunny/crossref_metadata_2025 huggingface dataset:
An unusual presentation of globus
Authors: Natt Ravinder S , Karkanevatos Apostolos
Published: May 2014

A previously fit 49-year-old school teacher presented to the ear, nose and throat department with a 6-week history of globus pharyngeus symptoms ' a clicking sensation in her throat associated with some odynophagia and dysphonia. There was no absolute dysphagia but she described a feeling of a lump of phlegm stuck in her throat which was she was unable to clear and which kept her awake at night. She had recently started taking proton pump inhibitors to treat possible reflux oesophagitis and was a lifetime non-smoker.

Fibreoptic laryngoscopy revealed a single large smooth-surfaced polypoidal swelling lateral to the left arytenoid and occluding the ipsilateral piriform fossa, but not obstructing the laryngeal inlet. There was no restriction in movement of her vocal cords. Her ear, nose and throat examination was otherwise unremarkable. Owing to her profound claustrophobia and phobia of intravenous injections, she refused a computed tomography scan and magnetic resonance imaging scan with sedation but consented to a microlaryngoscopy with a view to excising the whole lesion for histological analysis.

Subsequently, microlaryngoscopy revealed a large yellow lesion covered by normal mucosa lateral to the left aryepiglottic fold which was occupying but not extending beyond the left piriform fossa (Figure 1). The lesion was fully excised (Figure 2) and sent for histology, which confirmed the diagnosis of lipoma. She made an uneventful recovery with no signs of recurrence after 12 months during surveillance in the outpatient clinic with full restoration of the quality of her voice and swallowing.
Painless jaundice as a result of metastatic disease?
Authors: Chew Ne Siang , Pasha Yasmin , Khan Nasir
Published: May 2014

A 67-year-old man presented for an abdominal computed tomogram (CT) following development of rapid onset jaundice (bilirubin 74 umol/litre, alanine aminotransferase 62 U/litre, alkaline phosphatase 451 U/litre, C-reactive protein 123 mg/litre, white cell count 8.4×109/litre), right upper quadrant pain and anorexia. There was no history of foreign travel. He had been given antibiotics for a cough and coryzal symptoms 1 week previously. Multiple low-attenuation liver lesions with irregular borders consistent with widespread hepatic metastases were seen on CT (Figure 1), and biopsied under ultrasound. Aspirates sent for histology were culture-negative at 4 days and were positive for the presence of white cells only. He was investigated for a colonic primary; colonoscopy showed diverticular disease only. He developed low-grade pyrexia so oral ciprofloxacin and clindamycin were commenced to cover biliary sepsis.
Marie Carmichael Stopes: pioneer of birth control for women
Authors: Ellis Harold
Published: May 2014

This year marks the 50th anniversary of the death of Marie Stopes, who, in the face of great difficulties and opposition, pioneered the dissemination of information about family planning for women. In addition, 2008 is also the 90th anniversary of the publication of what was probably the most influential popular book on this subject.
Obstetrics: what we need in the future
Authors: Clement-Jones Mark , Scholefield Helen
Published: May 2014

Health-care professionals who work in obstetrics have seen many changes over the last decades, with both good and bad results. But what changes could be made to improve the future care of pregnant women?
Say no to ‘Martini’ health care
Authors: Field Steve
Published: May 2014

Many column inches and much air time has been devoted to Lord Darzi's review of the NHS ( www.ournhs.nhs.uk /), with ‘polyclinics’ or ‘supersurgeries’ dominating the discussion.
Management of HIV:still a long way to go
Authors: Pozniak Anton
Published: May 2014

In June 1981 the US Center for Disease Control reported the occurrence, without identifiable cause, of an unusual pneumonia caused by Pneumocystis carinii (now jirovecii) in five apparently healthy men in Los Angeles. In that first year over 1600 cases of this new form of severe immunodeficiency were diagnosed with close to 700 deaths. Two years later, after much speculation, the human retrovirus HIV-1 was isolated and found to be the cause of this severe immune deficiency syndrome. Over a decade later effective treatment was discovered, so-called highly active antiretroviral therapy (HAART), consisting of usually three antiviral compounds. Ten years after the widespread introduction of HAART there are still 33.2 million people living with HIV globally and most have no access to antiviral treatment.
Modernising medical careers and factors influencing career choices of medical students
Authors: Al-Nuaimi Yusur , McGrouther Gus , Bayat Ardeshir
Published: May 2014

This article details medical students' views towards future career choices and factors that may influence this choice. The role of gender in career choice and the importance of structured career advice and management is highlighted and discussed.
Alfred Webb-Johnson: surgeon and administrator
Authors: Ellis Harold
Published: May 2014

May 28 2008 marks the 50th anniversary of the death of Baron Arthur Webb-Johnson GCVO, CBE, DSO, whose ability as a medical administrator has a lasting memorial in the modern Royal College of Surgeons of England in Lincoln's Inn Fields, London.
Ankle ligament injuries
Authors: Abbassian Ali , Thomas Rhidian
Published: May 2014

Ankle ligament injuries in the presence or in the absence of fractures are common. They often present a diagnostic challenge, and their management is poorly understood and subject to debate. This article reviews and discusses the current literature on the management and diagnosis of these injuries.
Charcot foot
Authors: Dattani Rupen , Patnaik Surendra , Lal Mohan
Published: May 2014

A 55-year-old man with insulindependent diabetes mellitus was referred by his GP with a 3-month history of a red, warm, swollen foot that can clinically mimicked cellulitis and had failed to respond to oral antibiotics. Plain radiographs (Figure 1) and magnetic resonance imaging (Figure 2) showed a dislocation of the tarsometatarsal joint with diffuse soft tissue oedema and destruction of the mid-tarsal joints.
Endotracheal tube or laryngeal mask for airway control during percutaneous dilatational tracheostom
Authors: Sabir Nadeem , Vaughan David
Published: May 2014

Percutaneous dilatational tracheostomy is a common procedure in the intensive care unit. It involves bronchoscope-guided tracheal puncture with a needle and guide wire followed by dilatation of the tract and placement of a tracheostomy tube. The bronchoscope helps ensure the puncture is midline and at the correct level in the trachea as well as avoiding serious complications such as perforation of the posterior tracheal wall. Airway maintenance during the procedure is traditionally via an endotracheal tube but studies suggest that using a laryngeal mask and its variants is more beneficial to the patient.
Cardiac resynchronization therapy in chronic heart failure
Authors: Petkar Sanjiv , Luckie Matthew , Khattar Rajdeep S
Published: May 2014

Cardiac resynchronization devices are used with increasing frequency in the treatment of chronic heart failure. This review focuses on the pathophysiological basis of cardiac dyssynchrony, and the rationale for resynchronization therapy.
Abdominoperineal excision of the rectum
Authors: Ellis Harold
Published: May 2014

With its vivid local symptoms and ready detection by inserting the finger into the patient's fundament, cancer of the rectum was well known (and much feared) even in ancient times. Its treatment, of course, until comparatively recently, was entirely palliative and mostly useless – warm baths, emollient enemas, bougie dilatation of stenosing growths. The first to amputate the rectum was Jaques Lisfranc (1790–1847) of Paris. In 1826, without the benefit of anaesthesia (ether was first introduced in 1846), he amputated the rectum through the perineum, leaving the patient with an uncontrollable perineal colostomy. In 1885, Paul Kraske (1851–1930) carried out a series of sacral resections of the rectum after removing the lower part of the sacrum, the sigmoid colon being brought down and sutured to the rectal stump.
The case for income protection
Authors:   Wesleyan Medical Sickness
Published: May 2014

A steady income is something we generally take for granted until we find ourselves unable to work as a result of illness or injury. Then the question of how to cover outgoings, such as the mortgage or children's school and university fees, comes sharply into focus. You may think that NHS sick pay will be enough to cover all your regular outgoings, but in fact there are few, if any, employers who will replace 100% of what someone earned if they become incapacitated. So there is always going to be a financial shortfall that needs to be filled, which is why every professional should consider income protection.
Access to cancer drugs: local autonomy or local tyranny?
Authors: Waxman Jonathan
Published: May 2014

In cancer we have seen an incredible change in the way malignancy is treated, from a time where the only prospect for patients was chemotherapy, and the only diseases that were considered responsive were leukaemias, testicular cancer and lymphoma. We are now in a situation where there have been major improvements in survival for many solid cancers. These improvements have been multifactorial in origin, with benefits from screening and reduced cigarette smoking, as well as from chemotherapy and hormonal therapy, given as adjuvant treatments for the major groups of solid tumours.
Anal fissure: a review
Authors: Wray D , Ijaz S , Lidder S
Published: May 2014

Patients often present to general and colorectal clinics with symptoms of anal fissures and can even present acutely to hospital. Conservative remedies have healing rates of up to 85% and have largely replaced surgery as first-line management. This review highlights the cardinal points in the aetiology, pathogenesis and treatment of anal fissures.
Welsh not so rarebit
Authors: Jones R Mathew , Robinson Mark , Williamson Ian
Published: May 2014

A 69-year-old man was hospitalized with a compound tibial fracture following a fall. During his admission, he developed an episode of acute breathlessness with associated hypoxaemia. A plain chest radiograph displayed right lower lobe consolidation. Computed tomography pulmonary angiography showed no evidence of pulmonary emboli, but demonstrated a 7 mm, soft tissue density mass in the right bronchus intermedius (Figure 1). Fibreoptic bronchoscopy revealed a pea at the right upper lobe orifice (Figure 2), which was wholly removed with operating forceps.
The ethical basis of making decisions about cardiopulmonary resuscitation
Authors: Randall Fiona
Published: May 2014

This article outlines the clinical ethical concerns around decision making regarding cardiopulmonary resuscitation and how they resulted from lack of clarity in the formulation of the previous guidance. It then reviews new guidance and discusses its wider implications for doctors and patients.
Academic foundation programmes
Authors: Banham Lindsay , Beck Daniel , Rutter Paul
Published: May 2014

Academic foundation programmes allow newly graduated doctors to experience work in the academic sphere alongside the core clinical training that the foundation programme provides. Having just completed such programmes, the authors outline why they were developed and what they involve. This article discusses some pros and cons and, for those who may consider applying, suggests some useful next steps.
NHS jargon buster
Authors: Vamadeva SV
Published: May 2014

Have you ever wondered what the difference is between a PCT or SHA or indeed, even what these terms mean? In the year of the sixtieth anniversary of the foundation of the NHS this article aims to make its structure and function a little clearer.
A guide to assisting at surgical operations 1: general principles
Authors: Whalan Comus
Published: May 2014

This short series of articles is intended to help junior doctors in their attempts to be good surgical assistants. It does not describe specific operations, but instead describes some general principles of assisting that apply to most surgical operations.
Safeguarding your health: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Maintaining good mental and physical health is important for anyone, but particularly so for foundation year doctors. Many will never have worked such long hours or taken on such responsibility before.
Management of common problems in patients with chronic liver disease: a practical guide
Authors: Bhamidimarri RS Kumar
Published: May 2014

Chronic liver disease is becoming an increasing problem with the majority of cases the result of alcohol-induced liver damage. Other causes include infection with hepatitis B or C virus, autoimmune liver disease, haemochromatosis, primary biliary cirrhosis, and cirrhosis complicated by non-alcoholic steatohepatitis. This list is by no means a complete one.
Conflict resolution: a guide for the foundation year doctor
Authors: Trivedi Deepali , Singh Savita , Hooke Rachel
Published: May 2014

Conflict is bound to arise in a huge organization like the NHS, where many individuals with different thoughts, ideas and aspirations work together. Conflict is usually looked upon quite negatively as it creates an atmosphere of dissatisfaction and unhappiness, making the working environment difficult. However, conflict can help to bring some important issues to the surface, or help to recognize hard feelings that might prevail among fellow colleagues.
Anti-tumour necrosis factor-α therapies in Crohn's disease
Authors: Sprakes MB , Hamlin PJ
Published: May 2014

This article reviews the limitations of existing Crohn's disease therapies and the efficacy and safety of anti-tumour necrosis factor-α drugs. Trying to determine which patients may benefit from these therapies while minimizing toxicity is key. Special treatment situations and future developments are also briefly discussed.
Mycetoma of the foot
Authors: Oddy MJ , Blundell CM , Suvarna SK , Greig JM
Published: May 2014

A 22-year-old Eritrean woman, who had been resident in the UK for 6 years, presented with a 3-year history of a slowly growing mass over the dorsolateral aspect of her right foot. A previous incisional open biopsy performed by the regional bone tumour unit demonstrated fungal hyphae.

The mass measured 3 × 4 cm with intact overlying skin and no sinus formation (Figure 1). Plain X-rays were normal and a magnetic resonance image showed the mass to contain discrete rounded opacities of intermediate signal. Bone marrow oedema was seen but no bony infiltration or destruction (Figure 2).

She underwent wide excision including the previous biopsy tract (Figure 3). No organism was cultured under routine laboratory conditions. Histological examination showed dense fibrous connective tissue with a granulomatous component, with pigmented brown and black material surrounding central hyphae. The infection was identified as Madurella mycetomatis (Figure 4). Oral voriconazole was given for 3 months and there was no evidence of recurrence 6 months post-operation, either clinically or on magnetic resonance imaging.
Prenatal treatment of fetomaternal thrombocytopenia
Authors: Vatopoulou Theodora , Sorinola Olanrewaju
Published: May 2014

A 34-year old Caucasian woman (gravida 2, para 1) with a history of fetomaternal alloimmune thrombocytopenia presented for antenatal care in her second pregnancy at 12 weeks' gestation. Her first baby was severely affected by fetomaternal alloimmune thrombocytopenia (platelet count < 3×109/litre) and presented with neonatal purpura and fits caused by intracranial haemorrhage. Fetomaternal platelet incompatibility and presence of maternal anti-HPA-1b antibodies was demonstrated (Table 1) and the baby treated successfully, with platelet transfusions (HPA-1 negative).

During her second pregnancy, the mother's booking platelet count was 250 × 109/litre. Fetal platelet typing via amniocentesis at 16 weeks showed fetal platelet genotype HPA 1a1b. The modified direct monoclonal antibody-specific immobilization of platelet antigens (MAIPA) test showed that the mother was still positive for anti-HPA-1b antibodies (Table 1), indicating a high risk of fetomaternal alloimmune thrombocytopenia in this pregnancy. Starting at 16 weeks, she received weekly intravenous immunoglobulin 1 g/kg. The anomaly scan at 20 weeks was unremarkable. Further monitoring included weekly cranial scans to detect intracranial haemorrhage, and monthly growth scans. These were all normal. The mother declined fetal blood sampling to assess the fetal platelet count. Steroids were given at 33 weeks and baby delivered by planned caesarean section at 34 weeks. The boy weighed 2.75 kg and had no signs of bleeding. His platelet count was 100 × 109/litre and he has been well since.
The management of alcoholic hepatitis
Authors: Forrest Ewan H
Published: May 2014

Alcoholic hepatitis is an increasingly common reason for hospital admission which carries a high mortality. This review describes a clinical approach to the definition, assessment and management of this condition.
Sudden cardiac death: history, aetiology and management
Authors: Mudawi Telal O , Albouaini Khaled , Kaye Gerald C
Published: May 2014

Despite being a relatively common medical condition, sudden cardiac death suffers a widespread lack of knowledge and understanding among general physicians. This article fills this knowledge gap, outlining risk factors, causes and preventative strategies.
Cocaine-induced myocardial infarction: not your average acute coronary syndrome
Authors: Behar Jonathan M , Lindsay Alistair C , McEwan Jean R
Published: May 2014

A 31-year-old woman presented to accident and emergency at 03.20 hrs complaining of central chest pain since the preceding evening. She denied any significant medical history or family history and initially denied taking any medication or drugs of abuse. On examination her pulse was 110 beats per minute and her blood pressure 126/82 mmHg but there were no other abnormal physical findings. Her initial electrocardiogram showed multiple ventricular ectopics with periods of idioventricular rhythm but no acute ST segment elevation that met thrombolysis criteria (Figure 1).

She was initially treated with aspirin, low molecular weight heparin and intravenous nitrates. Although her symptoms of pain resolved overnight, the electrocardiogram evolved Q waves suggesting a significant anterior myocardial infarction (Figure 2). This was confirmed by a raised cardiac troponin T level at 12 hours.

It was not until some 15 hours after admission, and only after direct questioning, that she admitted to being a regular cocaine user, often using up to 3 g per week. She had smoked a pipe containing crack cocaine the preceding evening, and then immediately afterwards injected cocaine into a femoral vein. She described a euphoric rush followed by a non-resolving severe chest pain.

She underwent coronary angiography 36 hours after presentation which revealed a thrombus in the proximal left anterior descending artery (Figure 3). The coronary arteries were angiographically normal, with no evidence of angiographic atheromatous disease. She was treated with intravenous heparin and abciximab, and thereafter remained pain free and haemodynamically stable. An echocardiogram showed severe left ventricular impairment (ejection fraction 30%) with gross apical dyskinesis. She was discharged on aspirin and an angiotensin-converting enzyme inhibitor and given strong advice to cease using cocaine. She failed to return for pre-arranged follow up, was not registered with the GP she indicated and could not be traced through the NHS database.
Theodor Kocher: the first surgeon to be awarded the Nobel Prize
Authors: Ellis Harold
Published: May 2014

A century ago, in 1909, the Swiss surgeon Theodor Kocher became the first of only a handful of surgeons to be awarded the Nobel Prize, rightly regarded – at least in medicine – as the highest achievable accolade in its six fields.
The principles of symptom control
Authors: Johnson Miriam J
Published: May 2014

The core medical skills of history taking, examination and investigation form the heart of every patient encounter. Undergraduate and postgraduate curricula have this process as the bedrock of medical training. The core competencies outlined in the generic postgraduate training curriculum (Federation of the Royal Colleges of Physicians, 2006a) have good clinical care with good history taking and examination as the first area of expertise. Thus doctors are taught and trained, quite rightly, to diagnose the underlying pathology.
Management of pain
Authors: Cawley Declan , Bennett Michael I
Published: May 2014

Pain is a common symptom that patients describe and clinicians have to manage. Management plans are tailored to the complexity of the pain. This may require a multi-modal approach while involving the wider multidisciplinary team.
Two eponymous surgeons: William Cowper and François Poupart
Authors: Ellis Harold
Published: May 2014

This year marks the tricentenary of the deaths of two surgeons who are immortalized by the anatomical structures they described but about whom few would otherwise know anything more.
Lifelong learning for the modern day clinician
Authors: Stephenson Paul , Brigden David , Dangerfield Peter
Published: May 2014

The General Medical Council has a clear requirement for all doctors to ‘keep their skills up to date’; this is the essence of lifelong learning. This article identifies qualities of a lifelong learner and discusses the key activities which will help the clinician meet lifelong learning objectives seamlessly within common clinical settings.
HIV-related psychosis
Authors: Honey Helen , Bolton Jim , Attard Doreen
Published: May 2014

A 35-year-old Ugandan man was escorted to the emergency department by his family following 2 days of uncharacteristic behaviour. He had presented himself to a police station believing that he was guilty of terrorist acts. He had no psychiatric history and no history of illicit drug use. The patient was responding to auditory hallucinations and lacked insight into his symptoms.

Preliminary blood investigations and a computed tomography brain scan were normal. The patient was able to give informed consent for an HIV test, which was positive. He was admitted to a psychiatric ward and was successfully treated with antipsychotic medication.
Should anaesthetists be involved in prehospital care?
Authors: Boet S , Siu L
Published: May 2014

Across the world, there are basically two types of prehospital emergency medical service systems. In Anglo-American countries, acute out-of-hospital care for critically ill patients is provided by paramedics, while in most European countries, this role is filled by anaesthetists or emergency specialists. Intuitively, prehospital anaesthetists seem to be a useful adjunct for improved patient outcome but at greater expense. Which system provides the best medical care for critically ill patients in the prehospital setting? Is it purely an economic issue?
Adding insult to injury: care of patients with acute kidney injury
Authors: Stewart JAD
Published: May 2014

Acute kidney injury, formerly known as acute renal failure, is both a prevalent and serious problem among hospitalized patients. Although no definitive studies have been undertaken in the UK the prevalence among inpatients in the USA is 4.9% (Waikar et al, 2007). Associated mortality rates have been wide ranging.
Managing immunosuppression in medical patients
Authors: Pritchard CW , Hawthorne AB
Published: May 2014

Immunosuppressive drugs are increasingly widely used. Safe use requires knowledge of the side-effect profile, contraindications and precautions before starting, and the monitoring regimen, and patients should be fully informed of the risks and benefits before starting.
When headaches are not neurological: an unusual presentation of Ebstein's anomaly
Authors: Cook C , Carpenter JP , Longcroft-Wheaton G , Wong Y-K
Published: May 2014

A 16-year-old male was admitted following a loss of vision. Baseline observations demonstrated SpO2 80% on air, tachycardia of 180 beats per minute (bpm) and hypotension of 90/50 mmHg. He reported bilateral visual disturbance while sitting in bed together with breathlessness, chest discomfort and dizziness but had not had palpitation or syncope. He had been prescribed propranolol for recurrent migraines of increasing frequency with similar visual disturbances, nausea and vomiting but with no perceived benefit. He was otherwise well, a non-smoker who drank minimally and denied recreational drug use.

On examination, the jugular venous pressure was elevated but there were no other cardiorespiratory findings of note. Arterial blood gas analysis revealed profound hypoxia and a compensated metabolic acidosis. A 12-lead electrocardiogram demonstrated a supraventricular tachycardia with broad QRS (Figure 1). Carotid sinus massage and intravenous adenosine had no effect. Electrolyte levels were abnormal (potassium 2.7 mmol/litre, magnesium 0.45 mmol/litre, corrected calcium 1.60 mmol/litre) and a central venous line was inserted to allow electrolyte replacement. During this procedure, he spontaneously reverted to sinus rhythm at a rate of 70 bpm.

A repeat electrocardiogram showed sinus rhythm with normal axis but T wave inversion in the inferior leads and evidence of pre-excitation with a short PR interval and classical delta waves (Figure 2). As a result, Wolff–Parkinson–White syndrome was diagnosed. The chest radiograph showed an abnormal, globular cardiac silhouette (Figure 3).

Following return to sinus rhythm, the blood pressure and acid–base status normalized. Routine transthoracic echocardiography demonstrated Ebstein's anomaly with an associated atrial septal defect and small membranous ventricular septal defect.
Should patients be manually ventilated during rapid sequence induction of anaesthesia?
Authors: Clements Paul , Washington Stephen J , McCluskey Anthony
Published: May 2014

Pulmonary aspiration of gastric contents has been recognized as a cause of significant morbidity and mortality during anaesthesia since the classic publication by Mendelson in 1946. The introduction of suxamethonium 5 years later allowed tracheal intubation to be achieved under complete muscle relaxation within 1 minute of induction of anaesthesia. In 1961 Sellick described the use of cricoid pressure to prevent gastric regurgitation.
Solving the quality conundrum in the NHS: will public reporting help?
Authors: Ali Adam M
Published: May 2014

Public outcome reporting has been hailed as a magic bullet for improving quality in the NHS. Is this optimism justified or will the scheme simply create confusion?
Professionalism: what it means to doctors today
Authors: Nicholson Sandra , Raval Devina
Published: May 2014

Current political, institutional and societal expectations have challenged the meaning of medical professionalism. This article summarizes the debates concerning what constitutes medical professionalism, how professionalism develops in doctors and the critical importance of professionalism within good medical practice.
Should we be using activated protein C to treat severe sepsis?
Authors: Eve RL , Duffy MR
Published: May 2014

Sepsis and septic shock are common syndromes occurring in the intensive care unit and are associated with a high mortality. Levels of endogenous activated protein C are reduced in sepsis and linked with poor outcome. This led to the development of recombinant human activated protein C (rhAPC, drotrecogin alfa (activated), Xigris) for the treatment of patients with severe sepsis. Its use in this condition has been recommended by the National Institute for Clinical Excellence (NICE), and the Surviving Sepsis Campaign guidelines (Dellinger et al, 2008) suggest that adult patients with sepsis-induced organ dysfunction associated with a clinical assessment of high risk of death, most of whom will have an APACHE II score ≥25 or multiple organ failure, receive this therapy.
Medical schools 100years ago
Authors: Ellis Harold
Published: May 2014

What were our medical schools and our medical students like a century ago? Of course the buildings were usually rather stately Victorian edifices, the teaching hospitals imposing, often ancient structures with their Nightingale wards. Look at the old faded group photographs of the student classes and ‘firms’; the numbers are much smaller, the sex entirely male in most schools, the vast majority are white and the dress uniformly a suit and tie.
Diuretics
Authors: Baig MAH , Shakur R , Scott D
Published: May 2014

Diuretics enhance the rate of excretion of sodium ions (Na+) and water. They are usually taken in the morning so that diuresis does not intrude upon sleep. Diuretics are divided into groups based on their mechanism and site of action: loop, thiazide, potassium-sparing, osmotic, mercurial and carbonic anhydrase inhibitors (Figure 1). Only the first three types will be discussed here as they are the ones commonly used.
So you want to be … a medical oncologist
Authors: Gore Martin
Published: May 2014

We are all influenced in our choice of career by senior doctors that we come into contact with as medical students or junior doctors. I had such an influential encounter as a student at Barts. Professor Gordon Hamilton- Fairley was a new breed in a fledgling specialty which was burgeoning in the USA as a result of dramatic advances in the treatment of patients with haematological malignancies, especially Hodgkin's disease. His appeared to be a rather maverick world, the treatments could not be found in any textbook and patients were scattered the length and breadth of the hospital.
The survivor's guide to working in trauma and orthopaedics
Authors: Singisetti Kiran
Published: May 2014

It is only normal to be anxious when starting work in a new specialty, and trauma and orthopaedics is no exception. This anxiety can be eased with a bit of preparation before you start the job.
Lateral thinking: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

In these days of evidence-based medicine, doctors are relatively discouraged from thinking laterally. In the past, they had to rely on clinical acumen, ‘sixth sense’, intuition and experience. This was partly because there were fewer guidelines, but there was also a lower level of sophistication of investigations, and paucity of access to what few tests were available. Medicine was traditionally portrayed as an art rather than a science.
Dictation: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

As a doctor, at some point you will have to dictate letters or other documents to be typed up. Dictation is an essential skill that is not automatically taught. It is advisable to get into good habits, to make it easier for the staff typing your correspondence as well as yourself and your team.
Registries and databases in trauma and orthopaedics
Authors: Singisetti Kiran
Published: May 2014

Registries and databases have proven to be a great help to medical progress. They provide clinicians and researchers with real-time information about certain diseases and treatment methods (Ingelfinger and Drazen, 2004). Although much of the information is observational, they help us look at current practice and trends and thereby introduce changes as necessary (Lyratzopoulos et al, 2008).
So you want to be … a dermatologist
Authors: Ogden Stephanie , Griffiths Christopher
Published: May 2014

Dermatology is a highly visual specialty with more than two thousand diagnoses. Pattern recognition is a key skill, which often permits diagnosis on clinical observation alone. Owing to the wide range of diagnoses and relative lack of dermatology training at undergraduate level colleagues in other specialties often require dermatology input, thus ward consults are an integral part of most dermatologists' work.
Managing upwards: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

The concept of managing your boss sounds peculiar, as people usually only think of managing staff under them. Nevertheless, adept management ‘upwards’ can reap dividends. It is not manipulative or sly – it is about good working relations. This article is mainly about dealing with consultants. However, the same principles can apply to other doctors more senior than you in the team.
Extending palliative care to patients with dementia
Authors: Jordan Alice
Published: May 2014

Palliative care should be available to all with a life-limiting illness, including those with dementia. This article examines the palliative needs of those with dementia and how these needs might be met.
Improving communication in acute care
Authors: Burns Eileen
Published: May 2014

When asked, most people say that they would like to die at home. However, in the UK, most people die in acute hospitals, usually in old age and following chronic illness (National Confidential Enquiry into Patient Outcomes and Death (NCEPOD), 2009). An NCEPOD report, Caring to the End, highlighted the need for significant improvement in end-of-life care in the acute setting (NCEPOD, 2009). A whole systems approach across health and social care, and society in general, is also required both to improve our preparedness for death and also the quality of end-of-life care that we can expect to receive in the place of our choice (Department of Health, 2008).
What is new in the third edition of the Foundation Programme Curriculum?
Authors: Nathavitharana KA
Published: May 2014

The third edition of the Foundation Programme Curriculum (UK Foundation Programme Office, 2010a), produced by the Academy of Royal Colleges Foundation Programme Committee, was published in April 2010. This replaces the previous editions of 2005 and 2007. The simultaneously published Foundation Programme Reference Guide (UK Foundation Programme Office, 2010b) was produced by the national coordinating body for curriculum delivery, the UK Foundation Programme Office. Central to the new edition is the switch in emphasis from competencies to outcomes which form the basis of the curriculum. This article analyses the key messages in the revised curriculum.
The immune reconstitution inflammatory syndrome and antiretroviral therapy
Authors: Lorent Natalie , Conesa-Botella Anali , Colebunders Robert
Published: May 2014

Although generally mild, severe immune reconstitution inflammatory syndrome may complicate antiretroviral therapy, and it may be difficult to differentiate from treatment failure or toxicity. This article looks at diagnostic and therapeutic challenges of severe infectious manifestations of immune reconstitution inflammatory syndrome.
Biochemical basis of the amyloid diseases
Authors: Gibbs Simon DJ , Hawkins Philip N
Published: May 2014

Amyloidosis is a heterogeneous group of diseases characterized by normally soluble proteins deposited extracellularly in an abnormally folded, insoluble fibrillar form. This can lead to organ impairment and premature death. This article discusses the pathogenesis, classification system and means of diagnosis of the amyloid diseases.
Lithium toxicity: the importance of clinical signs
Authors: Dunne Francis J
Published: May 2014

Although there appears to be a decline in its use, lithium is still used extensively in the UK to treat bipolar disorder. However, lithium can be quite toxic and lead to long-term problems, rarely death. Therefore, doctors need to carefully monitor patients taking lithium and seek appropriate advice whenever concerns are raised.
The World Health Organization Surgical Safety Checklist
Authors: Sparkes David , Rylah Barnaby
Published: May 2014

The World Health Organization produced the Surgical Safety Checklist to improve patient safety. This review examines the supporting evidence, the results of a study of its worldwide trial and discusses the possible mechanisms of its effects.
Parotid incidentaloma detected during thoracic PET imaging: how should these lesions be managed?
Authors: Thomas Robert , Sharma Neel , Burke Chris , Maxwell David , Howlett David C
Published: May 2014

Three patients (two female, one male) were aged between 60 and 78 years with no significant previous medical history. In all three cases the patients had histopathological and radiological diagnosis of non-small cell lung cancer and the staging computed tomography scans showed no evidence of metastatic disease. These patients were considered to be potential surgical candidates in view of their spirometry and general health, and therefore proceeded to positron emission tomography as part of the preoperative work-up. In each patient unilateral intense focal uptake was reported in the parotid gland (with no evidence of other metastases) and this was deemed to be of uncertain significance (Figures 1 and 2).

There was diagnostic uncertainty as to whether the uptake represented another malignancy, metastasis or benign parotid disease. In each case high-resolution ultrasound was undertaken for further evaluation of the parotid gland combined with ultrasound-guided core biopsy (18G needle) of the focal lesion demonstrated. Ultrasound confirmed focal hypoechoic lesions in the parotid gland in each case, corresponding with the location on positron emission tomography imaging. Sonographic differences between patients were noted, as demonstrated in Figures 3 and 4. Histology from the core biopsy confirmed a diagnosis of Warthin's tumour in two patients and pleomorphic adenoma in the third. The patients were referred to ear, nose and throat surgery for further management of these lesions.

All patients were deemed to have resectable lung cancer and were referred on for thoracic surgical assessment.
Transition: a rheumatology perspective
Authors: Tattersall Rachel , McDonagh Janet E
Published: May 2014

This article reviews the evidence regarding the process of transition which young people experience when moving from paediatric to adult care. Rheumatology has championed this process and this article prioritizes the perspective of adult physicians.
Structured assessments of clinical competence
Authors: Boursicot Katharine AM
Published: May 2014

Clinical teachers are often involved in assessing clinical competence in the workplace, in universities and colleges. Assessments commonly used to formally assess clinical competence include long and short cases and the objective structured clinical examination which, if well designed, is a fair and reliable method of assessing clinical competence.
Gluteus medius tears: an under-diagnosed pathology
Authors: El-Husseiny Moataz , Patel Shelain , Rayan Faizal , Haddad Fares
Published: May 2014

Tears of the gluteus medius tendon contribute to greater trochanteric pain syndrome, but they are often overlooked as a cause of lateral hip pain and tenderness. This review presents the relevant anatomy, pathophysiology, diagnostic workup, differential diagnosis and management of these tears.
Developing clinical leadership capacity among UK foundation trainees
Authors: McKimm Judy , Wong Junie , Wright Richard , O'Sullivan Helen
Published: May 2014

This article provides a guide to how junior doctors can act as leaders within their workplace using various leadership and management tools, and discusses a novel academic foundation programme in clinical leadership and management.
Anaesthesia in obese patients
Authors: Kirkham L , Thomas M
Published: May 2014

With an increasing number of obese patients requiring surgery, this article outlines important factors in preoperative assessment, the impact obesity has upon intraoperative anaesthetic technique and which surgeries are currently recommended for weight loss.
Ketamine cystitis: an emerging diagnostic and therapeutic challenge
Authors: Gray Thomas , Dass Meena
Published: May 2014

Ketamine abuse is increasingly common in the UK. Ketamine-induced cystitis can cause serious damage to the urinary tract. This emerging problem presents a new diagnostic challenge and is very likely to increase in incidence over the coming years.
Fibromyalgia syndrome and depression: common pathways
Authors: Dunne Francis J , Dunne Ciaran A
Published: May 2014

Fibromyalgia is a musculoskeletal pain disorder which predominantly affects women and is often associated with depression. Both conditions have much in common, so assessment and treatment of physical and mental health symptoms with dual-acting medications and other appropriate interventions would seem advantageous.
Depression in Parkinson’s disease: diagnosis and management
Authors: Latoo Javed , Mistry Minal , Dunne Francis J
Published: May 2014

Parkinson's disease has a high prevalence of psychiatric comorbidity including depression. This review highlights the epidemiology, aetiology and diagnosis of depression in patients with Parkinson's disease. Recommendations are made on treatment and a closer partnership between neurology and psychiatry.
The training needs and career intentions of staff grade and associate specialist doctors
Authors: Brown Jeremy , Kirton Jennifer , Shaw Nigel J , Murphy Philip , Clarke Raymond
Published: May 2014

This article outlines the results of a study which used an online survey to explore the career intentions of staff grade and associate specialist doctors in one region and their training needs to inform those managing the continued professional development of staff grade and associate specialist doctors.
The acute prescription of oxygen in orthopaedic trauma patients
Authors: Young AF , Kostalas M
Published: May 2014

Background:

In trauma and orthopaedic surgery high flow oxygen can save lives by preventing severe hypoxaemia. Conversely, excessive oxygen can cause harm, and inadequate monitoring of its use has been reported in both pre-hospital and hospital audits. In 2008 the British Thoracic Society published guidelines on the use of emergency oxygen in adults.

Method:

Data were collected before, 3 months after and 12 months after the introduction of an oxygen prescription chart and education of junior doctors and ward staff.

Results:

A total of 84 patients were recorded in the first study, 76 in the second and 72 in the third. After education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments correctly prescribed increased from 10/84 (12%) to 56/76 patients (74%, P<0.001) at 3 months. Twelve months after education and introduction of an oxygen prescription section on the drug charts the number of oxygen treatments prescribed decreased to 37/72 (51%, P<0.001).

Conclusions:

Education and the use of oxygen prescribing charts significantly improved the prescription of oxygen. The effect of the intervention fell at 12 months, suggesting poor sustainability. Continued education and feedback to ward staff is vital to maintain change and improve sustainability.
Colorectal disorders during pregnancy: a review
Authors: Thomas GP , dos Santos IM , Ouro SM , Thomas-Gibson S , Vaizey CJ
Published: May 2014

The management of colorectal problems can be difficult during pregnancy. This review summarizes the treatment options available for these patients.
Prevention of tissue hypoperfusion in the trauma patient: initial management
Authors: Kaczynski Jakub
Published: May 2014

This article outlines the challenges of identification and management of tissue hypoperfusion as a consequence of haemorrhagic shock in civilian polytrauma cases. It also describes damage resuscitation, but does not cover specific trauma cases such as pregnancy, burns, head injuries, children and elderly trauma.
Traumatic injuries to the biliary tree
Authors: Williamson JML
Published: May 2014

Traumatic biliary injuries are uncommon and frequently associated with damage to other viscera. Some injuries are immediately recognized, but others are occult and present with a postoperative bile leak or more insidiously. Biliary trauma requires a multidisciplinary approach: radiological, endoscopic and operative interventions all play a role.
Barrett's oesophagus: diagnosis, surveillance and treatment
Authors: Bornschein Jan , Fitzgerald Rebecca C
Published: May 2014

Barrett's oesophagus is a premalignant condition with rising incidence in the UK. Technological progress in endoscopic imaging and rapid development of endoscopic treatment modalities for early neoplastic lesions have altered patient management and highlighted the need for more structured screening and surveillance schemes.
‘The patient is medically cleared’
Authors: Beale Chloe , Turner Trevor
Published: May 2014

It is standard practice for psychiatric nurses and junior doctors working in emergency departments to ask that patients be 'medically cleared' before psychiatric admission or even assessment. However, there is a lack of agreement over what this process should entail.
Improving the quality of prescribing in the emergency department
Authors: Barnett Joe , Rees Richard , Jani Yogini , George Marc
Published: May 2014

Prescribing errors are common and can have a significant negative impact on patients. This article presents an audit and intervention which aimed to improve prescribing safety, documentation and handover in the emergency department. The authors identified shortcomings in the emergency department drug chart, which were subsequently confirmed by audit. To address these shortcomings, a new drug chart was designed and introduced, before repeating the audit. This intervention resulted in significantly more frequent documentation of key aspects of the prescription including date and time, and rate and volume for infusions. This low cost intervention is applicable to other emergency department settings.
Hospital-based work experience for applicants to medicine
Authors: Dubrey Simon W , Shah Shreena , Ghonim Sarah
Published: May 2014

An appreciation of a future career is an invaluable experience and almost an obligatory prerequisite in the process of applying to enter medical school. This article describes the benefits, process and cautions associated with hospital-based work experience programmes.
Perioperative management of elderly patients suffering a hip fracture
Authors: Hili Stephanie , Dawe Edward JC , Lindisfarne Edward AO , Stott Philip M
Published: May 2014

Preparing elderly patients for emergency hip fracture surgery is a significant challenge for hospital staff. This article discusses the principles of preoperative care in these patients, and the rationale for such strategies, based on evidence and current guidelines. Such guidance increasingly reflects a national standard of care.
Cystic fibrosis presenting in adults
Authors: Mallia Patrick
Published: May 2014

Cystic fibrosis is a common genetic disease occurring in children. Milder forms of cystic fibrosis are increasingly being recognized as presenting in adults as well. This article describes the various ways in which cystic fibrosis can present in adult patients.
Therapeutic trends in cutaneous melanoma
Authors: Hall PN , Javaid M , de Takats PG
Published: May 2014

Many advances in the management of melanoma have occurred in the last few years. These make this an exciting time for clinicians and allows them to offer glimmers of hope for patients with this disease. This article looks at the therapeutic aspects of the treatment of cutaneous melanoma.
Modernizing medical education
Authors: Bacon Neil CM
Published: May 2014

Continuing medical education, continuing professional development and the increasing importance of clinical governance all add to the challenge of delivering life-long learning to the profession. Use of the Internet to deliver this education provides a number of solutions and potential cost savings.