bluuebunny/crossref_metadata_2025 huggingface dataset:
Bisphosphonates' use in metastatic
Authors: Hubner RA , houston SJ
Published: May 2014

Bisphosphonates already have an established role in the management of the skeletal complications of metastatic bone disease. The development of new, highly potent compounds has led to investigation into their use as preventive agents in the adjuvant setting. The aim of the paper is to evaluate the evidence for their use in prevention and treatment.
Should anaesthetists scrub? The cause for and against
Authors: Strachan Stephanie , Higgins Philippa
Published: May 2014

Hand hygiene is accepted as the leading measure in preventing the cross-transmission of microorganisms and in reducing the incidence of health-care associated infections. Anaesthetists use an ‘aseptic technique’ when performing invasive procedures, such as central venous lines, epidurals and spinals. However, there are a number of ideas as to what ‘asepsis’ involves, with differing views on which particular component is most important in the avoidance of infective contamination.
Ear, nose and throat problems in children with Down syndrome
Authors: Clarke RW
Published: May 2014

Down syndrome (trisomy 21) is a common childhood condition. As many of the features involve the head and neck, the diagnosis of Down syndrome has significant implications for the ear, nose and throat surgeon.
The pharyngeal pouch: clinical aspects and management
Authors: Bates Grant J
Published: May 2014

This article covers the management of patients who have a pharyngeal pouch. The condition of pharyngeal pouch is defined, together with discussion of the incidence, diagnosis, aetiology, pathology and treatment. These patients are often elderly and sometimes frail, so the newer minimally invasive endoscopic surgical techniques are especially important. The outcomes, complications and recurrence rate of endoscopic pouch surgery are discussed.
Long-acting user-independent contraceptives post abortion
Authors: Esen Umo I
Published: May 2014

Rising abortion rates in the UK could be reduced by promotion of the use of long-acting user-independent contraceptives in women for whom these could be the most appropriate methods of contraception; namely teenagers, young women, and women post delivery or termination of pregnancy who may not be contemplating a pregnancy for a couple of years or more.
Total risk factor management in patients with type 2 diabetes
Authors: Betteridge John
Published: May 2014

Type 2 diabetes is a multisystem metabolic syndrome. Its increasing prevalence therefore presents a major challenge not only in the management of diabetes but also in the treatment of cardiovascular disease.
Unusual presentation of Ramsay-Hunt syndrome without facial nerve palsy
Authors: Leong SCL , Karkanevatos A
Published: May 2014

A 65-year-old woman presented to the outpatient clinic with severe left earache associated with nausea, dizziness and left-sided hearing loss. Her symptoms, which started 5 days previously, had got progressively worse. There was no history of ear discharge or trauma. She was otherwise fit and healthy with no remarkable past medical history.

On examination, she was generally unwell. The left pinna was swollen and tender. The auditory canal was tight and inflamed with a small amount of discharge. These findings were initially thought to be otitis externa associated with perichrondritis of the pinna. She was admitted for symptomatic relief, aural toileting and intravenous antibiotics.

Her full blood count was normal and swabs taken revealed only normal skin flora. Her symptoms, however, did not improve as expected. Her dizziness and nausea had worsened although she did not have true rotatory vertigo or ataxia. She also complained of dysphagia to solids. There was no significant change to her speech but a fibreoptic endoscopy revealed sluggish movement of the left vocal cord and reduced sensation of the supraglottis. The rest of her neurological examination was otherwise normal.

At this stage, the possibility of Ramsay–Hunt syndrome was considered but there was still no evidence of herpetic lesions or facial palsy. Pure tone audiometry showed a sensorineural hearing loss of 30 dB in the left ear. Computed tomography scan of the temporal bones and magnetic resonance imaging of the brain were normal. Her symptoms gradually improved over the course of 1 week. On discharge, all her presenting symptoms had completely subsided except for mild intermittent nausea.

She was readmitted a week later with recurrence of left earache. However, both the nausea and the dizziness that presented themselves on initial admission were absent. The pinna was not swollen but there were now herpetiform vesicles in the left auditory meatus and tympanic membrane. Neurological examination was normal. Antibodies to varicella zoster virus (VZV) and VZV immunoglobulin M were positive.

These findings were consistent with VZV infection, which suggest that this may have been an unusual variant of Ramsay–Hunt syndrome. She was treated with acyclovir and gabapentin for post-herpetic neuralgia. The patient responded to treatment and was discharged 3 days later. Her follow-up examination revealed no evidence of residual symptoms.
Modernising Medical Careers: is it good for patients?
Authors: Paice Elisabeth
Published: May 2014

Postgraduate medical education and training is about to be overhauled in a way that will make the Calman reforms of specialist training seem modest in comparison. August 2005 sees the launch of a new structure and curriculum for the first 2 years, called the foundation programme.
So you want to be … a psychiatrist
Authors: Turner Trevor
Published: May 2014

Psychiatry is often known as ‘the other half of medicine’, and is the last truly clinical speciality. Thus psychiatrists take histories and conduct examinations, of both the physical and mental state, which in themselves substantially lead to the diagnosis.
Giving a presentation
Authors: Morris Ed
Published: May 2014

Being able to give a presentation is an essential part of a career in hospital medicine. This article gives advice on how to plan, research and deliver presentations in different situations and suggests ways in which you can learn to give talks which are well prepared, clear, and memorable.
Upper gastrointestinal bleeding
Authors: Rockall Timothy , Lewis Gareth
Published: May 2014

Acute gastrointestinal haemorrhage is classified according to whether it originates from the upper or lower gastrointestinal tract, the demarcation of which is the ligament of Treitz. This article will review the epidemiology, aetiology, assessment and treatment of acute upper gastrointestinal bleeding.
Interpretation of skull and facial radiographs
Authors: Allen Steve , Harvey Chris , O'Regan Declan
Published: May 2014

There are few indications for the skull X-ray as it has been superseded by head computed tomography (CT) as the initial investigation in head trauma (National Collaborating Centre for Acute Care, 2003). Facial radiographs remain the first-line investigation for facial trauma. This article provides a systematic approach to interpreting skull and facial films and describes the common traumatic conditions requiring these X-rays along with radiological signs.
Putting in central venous lines
Authors: Burdett Ed , Mythen Monty
Published: May 2014

Central lines are inserted for the following reasons:
How to carry out pericardial aspiration
Authors: Strike Philip C
Published: May 2014

Pericardial effusion is a potentially lifethreatening condition. Development of cardiac tamponade is a medical emergency requiring prompt and expert treatment with drainage of the pericardial fluid – pericardiocentesis.
A narrow complex tachycardia
Authors: Lambiase Pier
Published: May 2014

A 42-year-old woman presented to the accident and emergency department with a 3-month history of recurrent palpitations and breathlessness. She was otherwise fit and well and taking no regular medication. What are the abnormalities on the presenting electrocardiogram (ECG) in Figure 1 and what is the diagnosis?
Interpretation of the abdominal radiograph: 1
Authors: Harvey Chris J , Allen Steve , O'Regan Declan
Published: May 2014

Abdominal symptoms are a common presenting complaint in casualty departments and constitute a significant percentage of emergencies. The abdominal radiograph is still the commonest initial imaging investigation to exclude obstruction. Since many conditions may present with abdominal pain a rigorous analysis of the abdominal radiograph is essential to avoid missing important diagnostic radiological signs. This is the first of two articles which provide a systematic approach to interpreting the abdominal film and describe the common emergency conditions requiring abdominal radiographs along with radiological signs.
So you want to be … an otorhinolaryngologist
Authors: Swift Andrew
Published: May 2014

Ear, nose and throat surgery (ENT), now referred to as otorhinolaryngology, head and neck surgery (ORLHNS), offers a multitude of opportunities and has been described as having all surgical skills under one umbrella. Open surgery of the salivary and thyroid glands, reconstructive surgery and free flap surgery following excision of head and neck cancer, skull base surgery, microsurgery of the middle ear, endoscopic sinus surgery, facial plastics, functional and aesthetic nasal surgery, phonosurgery and the advances of lasers and navigational surgery are all included within ORLHNS.
A broad complex tachycardia
Authors: Dhinoja Mehul , Lambiase Pier
Published: May 2014

Figure 1a illustrates the electrocardiogram (ECG) of a 30-year-old man who presented to the accident and emergency department with a 2-hour history of palpitations and breathlessness.
Delirium
Authors: Bigham Sarah , Cock Hannah R
Published: May 2014

Delirium is the most common neurobehavioural problem encountered in general hospitals, yet is notoriously under-recognized. It is characterized by a disturbance of consciousness and change in cognition that cannot be accounted for by a prior history of dementia. This article reviews the pathophysiology, diagnosis and treatment of delirium.
Imaging of the pancreas
Authors: O'Regan Declan , Tait Paul
Published: May 2014

Imaging plays a major role in the investigation and management of pancreatic pathologies. A variety of invasive and non-invasive techniques can be used to characterize abnormalities and provide prognostic information. Diagnostic and therapeutic procedures may also be performed using image guidance.
Erythropoiesis-stimulating agents in kidney and cardiac disease
Authors: Fluck Richard
Published: May 2014

For the last 20 years, erythropoiesis-stimulating agents have transformed the lives of renal dialysis patients, and they are now being used to correct anaemia in chronic kidney disease and after renal transplantation. In future, these drugs may be used outside the renal clinic to improve outcomes in patients with chronic heart failure.
Pinnaplasty: the correction of the prominent, protruding or lop ear
Authors: Whitehead David , Watts Simon
Published: May 2014

This article gives an overview of the authors' approach to the pinnaplasty procedure including assessment of the defect, the procedure itself and aftercare with a synopsis of possible complications to be aware of.
Techniques of nasal reconstruction
Authors: Jones Nick
Published: May 2014

The contours of the nose have convex and concave surfaces in close contact with varying skin texture and colour. The human eye notices any asymmetry. Whole aesthetic subunits are often replaced for a better cosmetic result. The paramedian forehead flap gives consistently good results in major nasal reconstruction. Full thickness defects require all three layers to be replaced.
A computed tomography pictorial review of head injury imaging
Authors: Johnson Robert , Turnbull Ian
Published: May 2014

Computed tomography imaging of the head is commonly used in the investigation of traumatic brain injury. Emergency department personnel often need to interpret these images without expert radiological assistance. This article reviews the common computed tomography appearances of the head following traumatic brain injury.
Man and woman flu
Authors: Healy Brendan , Barnes Dr Rosemary , Hope-Gill Ben , Ramanujam Sangeetha , Baboolal Kesh
Published: May 2014

A 21-year-old woman was admitted to the authors' hospital with symptoms of breathlessness, pleuritic chest pain and haemoptysis having been unwell for 1 week with a flu-like illness. Clinical examination revealed a rapid respiratory rate (36/min), tachycardia (134 beats per minute), pyrexia (39°C), bibasal coarse crepitations and bronchial breathing. Investigations showed hypoxia (PO2 12.4 on 100% oxygen), raised inflammatory markers (C-reactive protein 324 mg/litre), thrombocytopenia (platelets 144 × 109/litre), leucopenia (2 × 109/litre) and neutropenia (0.88 × 109/litre). Chest X-ray revealed bilateral air space shadowing (Figure 1). The patient was admitted to the high dependency unit and started on intravenous co-amoxiclav (1.2 g three times per day) and clarithromycin (500 mg twice daily). Blood cultures at 24 hours grew Staphylococcus aureus resistant to penicillin and fusidic acid. The patient was switched to intravenous flucloxacillin. Admission was complicated by the development of a small pleural effusion. The patient was managed with high flow oxygen therapy, did not require ventilatory support at any stage and was discharged home after 17 days. The patient received flucloxacillin for a total of 4 weeks. The S. aureus isolate carried enterotoxins G and I and the Panton-Valentine leucocidin gene. Throat swab was positive for influenza B by a molecular method.
To routinely preoxygenate or not?
Authors: Holmes Michael V
Published: May 2014

A recommendation that preoxygenation should be mandatory, and a routine ‘minimum standard’ of care for all patients undergoing anaesthesia (Bell, 2004), has created much debate. Traditionally, preoxygenation has been used:
Chronic obstructive pulmonary disease: time to ditch the old mindset
Authors: Burns Graham , Bianchi Stephen
Published: May 2014

Chronic obstructive pulmonary disease (COPD) has long had a negative public image, seen as a largely untreatable condition. New therapies and rigorously evidence-based guidelines now provide treatment strategies which can have a major impact on the disease.
Obsessive-compulsive disorder, the brain and electroconvulsive therapy
Authors: Cybulska Eva M
Published: May 2014

Obsessive-compulsive disorder, classified as an anxiety disorder, arises from malfunctioning of the fronto-striatalpallido-thalamic-frontal circuit in the brain. As well as perseverative thoughts and acts, there are other signs of ‘organicity’. Delay in treatment is often a result of patients' reluctance to seek help, and doctors' insufficient knowledge and experience in this clinical area. Electroconvulsive therapy is effective in severe and refractory cases.
An unusual cause of paraplegia
Authors: Saravanan Venkatesh , Janakiram Murali , Bankar Rajesh N , Kumar Sampath , Nasar Abu
Published: May 2014

A 40-year-old man was admitted to hospital with an acute onset of paraplegia of 5 days' duration, preceded by vague back pain in the interscapular region for 2 months. The pain was intermittent and was relieved by rest and analgesics. He had no significant past medical history. Physical examination revealed a gibbus at the level of the thoracic (T4–T6) vertebrae and signs of extramedullary cord compression at T7 level. Cardiovascular, respiratory, abdominal and ophthalmological examination was unremarkable and there were no Marfanoid features. Full blood count, biochemical and lipid profile, and electrocardiogram were within the normal range. Sputum examination was negative for acid-fast bacilli. Chest X-ray (Figure 1) showed mediastinal widening and X-ray of dorsolumbar spine showed scoliosis at T5–T8 with convexity to the right. Magnetic resonance imaging revealed gross dilatation of the arch of aorta and two large saccular aneurysms with size of 11.3 cm × 10.8 cm and 9.4 cm × 10.2 cm, causing destruction of T6–T9 vertebrae and spinal cord compression (Figure 2). A positive serum VDRL (venereal disease research laboratory test) and TPHA (Treponema pallidum haemaglutination assay) confirmed that the patient had syphilis. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was negative. CSF analysis was normal and the CSF VDRL and TPHA were non-reactive. A diagnosis of cardiovascular syphilis was made and oral prednisolone was started followed by 2.4 million units of benzathine penicillin G. While awaiting surgery the patient's condition deteriorated rapidly as a result of a rupture of the aneurysm and he died despite aggressive resuscitation efforts. Autopsy confirmed syphilitic aortic aneurysm with destruction of vertebrae and direct spinal cord compression.
Improving maternal safety in future: learning from the Confidential Enquiries
Authors: Tuffnell Derek , Rathod Medha
Published: May 2014

The lessons from reviewing maternal deaths reinforce the need for multidisciplinary working and continuing education of all practitioners who are in contact with pregnant women. Identification of the highest risk group of women should allow targeted care.
An unexpected finding during gastroscopy
Authors: Kamaruddin Shafie , Ramachandran Subramanian , Turner Graham B , Yousaf Mohammed , McConville Paul , Wilson Carol , Clements W Barry
Published: May 2014

At the age of 3 years, the patient had undergone surgery for repair of an atrial septal defect and had an epicardial pacing system placed for congenital atrioventricular block. This was replaced with an endocardial dual chamber pacemaker at the age of 15 years. The epicardial pulse generator and leads were left in situ.

Now aged 23 years old, the patient presented with a 48-hour history of right shoulder tip pain, palpitations, rigors and subsequent melaena. On examination she was pyrexic (40°C) with vague upper abdominal tenderness. She had no overt features of bacterial endocarditis. Her chest X-ray shows both the endocardial and epicardial pacing system in situ (Figure 1). Preliminary haematological investigations revealed a microcytic hypochromic anaemia (7.4 g/dl), neutrophilia (25x109/ml), an erythrocyte sedimentation rate of 121 mm/hr and a C-reactive protein of 272 mg/litre. Repeated blood cultures were negative. Transoesophageal echocardiography showed no evidence of valvular or pacemaker lead vegetations. Gastroscopy revealed the redundant epicardial pacemaker generator inside the stomach with evidence of gastric ulceration (Figure 2).

After initial resuscitation with blood products and parenteral antibiotics she underwent surgery where through a gastrostomy the pulse generator was retrieved. At laparotomy the left lobe of the liver appeared unhealthy and subsequent computed tomography scan of the abdomen confirmed the presence of multiple intrahepatic abscesses (Figure 3). It was decided that the hepatic abscess were not suitable for percutaneous drainage as they were multiple and predominantly in the left lobe of the liver. She continued on a protracted course of intravenous antibiotics and made a full recovery thereafter.
Jejunojejunal intussusception as a result of submucosal lipoma
Authors: Naidu Leena S , Aslam Mansoor
Published: May 2014

An 81-year-old man presented to a surgical take with a 4-day history of abdominal pain, distension and inability to open his bowels. Previous medical history included ischaemic heart disease, hypertension, atrial fibrillation and gout. On examination, the abdomen was distended with visible peristaltic bowel loops in the upper abdomen. It was soft and non-tender on palpation with tinkling (increased) bowel sounds on auscultation.
Does total intravenous anaesthesia increase the risk of awareness?
Authors: Bould MD , Kasanda C
Published: May 2014

Total intravenous anaesthesia (TIVA) with propofol given by repeated boluses, manual infusion or target controlled infusion is associated with a low incidence of postoperative nausea and vomiting. It is also useful in certain types of surgery, e.g. when administration of volatile anaesthetics is difficult. One reason for reluctance to use TIVA is the belief that the incidence of awareness under anaesthesia is greater than with volatile anaesthetic agents.
Polymyalgia rheumatica and giant cell arteritis
Authors: Subrahmanyam Peddasomayajula , Dasgupta Bhaskar
Published: May 2014

Polymyalgia rheumatica and giant cell arteritis are the commonest inflammatory rheumatic conditions seen in the elderly. This review focuses on the diagnostic processes and complications of disease and treatment; and the safe management of these conditions with careful consideration of balance between benefits and long-term risks of glucocorticosteroid therapy.
Robert Graves: 1796–1852
Authors: Ellis Harold
Published: May 2014

Every medical practitioner in this country knows the eponym Graves' disease (although in continental Europe it is more often referred to as Basedow's disease), yet few know much at all about the man apart from the fact that he was a Dublin physician. The reason for this is probably that, apart from his carefully recorded clinical contributions, his personal details have been less than fully documented. The year 2006 marks the 210th anniversary of his birth.
Laparoscopic-assisted oesophagectomy for adenocarcinoma in an AIDS patient
Authors: Botha Abrie , Kochhar Suneeta
Published: May 2014

A 44-year-old man with known AIDS (acquired immunodeficiency syndrome) presented with an 18-month history of progressive dysphagia, occasional reflux, reduced appetite and significant weight loss. There was no odynophagia, haematemesis or haemoptysis. Upper gastrointestinal endoscopy and endoscopic ultrasound demonstrated a tumour 41–44 cm from the incisors. Two 6 mm regional paraoesophageal lymph nodes were seen at 34 cm and there were two 5 mm splenic artery nodes. Endoscopic staging was of a T3 N1 tumour at the gastro-oesophageal junction and biopsy findings revealed poorly differentiated adenocarcinoma. Computed tomography confirmed endoscopic findings and showed no evidence of metastatic disease.

The patient had previously been treated for oesophageal candidiasis, an AIDS-defining illness. He was diagnosed with human immunodeficiency virus (HIV) 4 years ago and was currently taking zidovudine, lamivudine and efavirenz or highly active anti-retroviral therapy (HAART). At presentation his viral load was less than 50 copies (Roche polymerase chain reaction assay, Amplicor HIV-1 Monitor) and his T-cell count was approximately 200/mm3.

The patient received three cycles of neoadjuvant chemotherapy for tumour regression. This was complicated by the development of peripheral neuropathy. Despite ongoing nausea the patient was able to continue with HAART.

After completing the course of chemotherapy, the patient underwent a laparoscopic-assisted Ivor Lewis oesophagectomy. This is a two-stage procedure where a laparotomy is performed followed by thoracotomy and an anastomosis of the stomach to the upper oesophagus in the chest. He had a brief stay on the high dependency unit as a result of shortness of breath. Chest X-ray showed bilateral infiltrates suggestive of acute lung injury. Pneumocystis carinii pneumonia was deemed unlikely as a result of septrin prophylaxis. Nutritional status improved and he was discharged on day 16. Peripheral neuropathy is an ongoing issue.

Postoperative histology demonstrated a poorly differentiated adenocarcinoma of the gastrooesophageal junction that had penetrated through gastric serosa. The pathological stage was pT3 N2. Ten out of 26 lymph nodes were found to be positive for adenocarcinoma.
Irritable bowel syndrome: anxiety in gastroenterology
Authors: Bortha Claude , Libby Gerald
Published: May 2014

Irritable bowel syndrome is in many ways still a famous ‘heartsinker’ but over the past half century a significantly better understanding of the pathophysiology has evolved, improving overall treatment.
Chronic obstructive pulmonary disease, inflammation and PDE4 inhibitors
Authors: Halpin David MG
Published: May 2014

Chronic obstructive pulmonary disease is a treatable and preventable condition caused mainly by tobacco-induced pulmonary inflammation. Significant advances have been made in the pharmacological and non-pharmacological management of chronic obstructive pulmonary disease but the next challenge is the development of effective anti-inflammatory therapies. Phosphodiesterase-4 (PDE4) inhibitors are candidates for this role.
The evolving role of exemestane in the management of breast cancer
Authors: Bundred Nigel
Published: May 2014

The role of therapies in the management of breast cancer is continuously changing. As research and development furthers, newer and more effective treatments are beginning to take the lead in cancer care, changing the role of tamoxifen.
Building patient confidence through effective communication
Authors: Gupta Romesh , Gupta Rajeev
Published: May 2014

In order to achieve these, increasing emphasis and importance must be given to clear and effective communication. Doctors fit to practice in the 21st century need not only be clinically competent but must also be effective communicators, managers, teachers and lifelong learners while remaining aware of the health needs of a multicultural society.
Aspiration of the elbow joint
Authors: Oussedik Sam , Haddad Fares
Published: May 2014

The technique described below can be used for any of the above conditions. Aspiration of the elbow joint following radial head fracture will form the focus of this discussion.
So you want to be … a radiologist
Authors: O'Regan Declan , Bloomley Martin
Published: May 2014

Radiologists are doctors who use a variety of imaging methods to diagnose and treat patients. The specialty has dramatically progressed over the last two decades with the development of sophisticated new imaging technology. Conventional radiography, ultrasound (US), computed tomography (CT), magnetic resonance imaging and radionuclide medicine are techniques which the radiologist may use to provide anatomical and functional information about disease processes.
Responding to a request for a report: a guide for foundation year doctors
Authors: Clements Nick
Published: May 2014

A 46-year-old man is admitted to the accident and emergency (A&E) department, following a serious road traffic accident. He had multiple injuries and signs of internal haemorrhage. Despite all attempts at resuscitation and transfusion he dies from internal blood loss within 3 hours of admission. It subsequently transpires that the last unit of blood was intended for another patient in A&E with the same surname.
Reflections on foundation year 1
Authors: Hegarty Anne
Published: May 2014

As I approach the end of my foundation year 1 (FY1) I look back on what has been an interesting but at times difficult year. August 2005 heralded the start of working as a junior doctor, but along with many others I was now classed as an FY1 junior doctor. I was now one of many newly-qualified doctors becoming part of history as the first set of doctors embarking on the reformed postgraduate medical education and training programme as encompassed in Modernising Medical Careers (MMC) (Department of Health, 2005).
Principles of paediatric injuries
Authors: Jenabzadeh AR , Haddad FS
Published: May 2014

Paediatric injuries differ from those in adults in many respects. This article discusses why this is the case and outlines the general principles of treating paediatric injuries. It will also look at non-accidental injury (NAI), which should always be considered when reviewing a child with a fracture.
Why good communication is worth the effort
Authors: Bown Stephanie
Published: May 2014

Developing good interpersonal and communication skills improves your clinical effectiveness as a doctor and reduces your medicolegal risk, resulting in both better patient satisfaction and improved personal wellbeing.
The clinical anatomy of the antecubital fossa
Authors: Ellis Harold
Published: May 2014

To the anatomist, the antecubital fossa is the space through which the principal vascular and nervous trunks pass into the forearm. To the surgeon it is also the site of possible injury to the brachial artery in fractures around the elbow, with the risk of Volkmann's ischaemic contracture constantly in mind. It is here where the surgeon is tempted to use the large superficial veins for venous access, but knows only too well the dangers of inadvertent intra-arterial or intraneural injection – something that may well be encountered in a ‘main-line’ drug addict. It is also a convenient site for arterial cannulation and for anaesthetic blocks of the nerves to the forearm.
Urgent complications of thyroidectomy
Authors: Cornish JA , Smellie WJB
Published: May 2014

In the late 19th century the mortality rate of thyroidectomy was reported as being as high as 20% and it was suggested that thyroidectomies should only be performed to save life and never for discomfort or deformity (Bliss et al, 2000). Theodore Kocher pioneered surgical advances in thyroidectomies and since the early 20th century the mortality and morbidity have been dramatically reduced (Bergamaschi et al, 1998). Despite the low mortality complications can still occur that have the potential to be life threatening and this article will focus on these complications.
Suturing for foundation doctors
Authors: Foong DPS , Bidwai ASC , Lauffer GL , Kanitkar S
Published: May 2014

Suturing a wound is a useful skill for foundation doctors, especially those working in the emergency department. The main purpose of suturing is to secure the wound edges in close opposition to provide a favourable environment for wound healing resulting in minimal scarring. This article outlines the basic steps involved in assessment of a wound and then, if it is suitable, how to go about suturing it in the emergency department.
Management of acute stroke
Authors: Salih Isam M , Myint Phyo K
Published: May 2014

Stroke is a common condition worldwide. It is the third leading cause of death and the leading cause of disability in the UK. Acute management of stroke plays an important role in reducing its mortality and morbidity. This article outlines the practical management of acute stroke patients in a UK hospital setting. Secondary prevention, which is usually initiated in acute phase, is beyond the scope of this article.
Reduction of the dislocated shoulder
Authors: Oussedik Sam , Haddad Fares
Published: May 2014

The glenohumeral joint is the most commonly dislocated major joint of the body. Patients presenting with a suspected dislocation should be fully assessed as previously described. Of clinical importance are the distal neurovascular status, including axillary nerve function as examined through ‘regimental patch’ sensation, and the type of dislocation, anterior, posterior or inferior (luxatio erecta). The protocols described below apply to the reduction of the commonest type of injury, anterior dislocation. Posterior and inferior dislocations warrant discussion with the on-call orthopaedic team.
The role of the coroner: what you need to know for the foundation years
Authors: Knapman Paul A
Published: May 2014

Very many doctors are likely to qualify with very little knowledge of the coroner or indeed forensic medicine. After all, it is highly likely that in London medical schools at any rate, there are no lectures on forensic medicine since there are no university departments of forensic medicine. In times past, a lecture or two on the coroner was part of the undergraduate programme.
So you want to be … a gastroenterologist
Authors: Hunter John
Published: May 2014

Why be put off by jealous colleagues who make school-boy jokes about bums and bottoms? True, detailed enquiries into bowel habits are necessary for the resolution of many patients' complaints, but actual faeces play a small part in the life of the well-organized gastroenterologist. Discussions of bowel habit should be as detached and cerebral as su-doku, and modern bowel preparations leave the colon as clear as crystal.
Time management
Authors: Clark Celia Ingham
Published: May 2014

There is never enough time for a doctor to do everything that he/she wants to do. Time management is a challenge for every grade of doctor. However, it is often hardest for the most junior doctors, since they have the least control over their work.
The ischaemic leg
Authors: Sritharan Kaji , Davies Alun H
Published: May 2014

Peripheral vascular disease often affects the lower limb and the resulting ischaemia can be a considerable source of morbidity and mortality. Presentation may either be acute, chronic or acute on chronic, and accurate history and examination is key to successful management of the patient.
ST elevation and atypical chest pain
Authors: Lewis Clive , Lambiase Pier D
Published: May 2014

Figure 1 illustrates the electrocardiogram (ECG) of a 42-year-old man who presented with sharp central chest pain that initially worsened with inspiration but did not appear to vary with his position. Describe the key features of the ECG and the differential diagnosis.
Blood transfusion: a practical guide
Authors: Burdett Edward , Stephens Robert
Published: May 2014

Over 2 million units of red cells are transfused in the UK every year, half of which are used for surgical patients. A successful transfusion is the appropriate provision of blood cells or other blood components in a safe and timely manner. This article gives a practical guide to transfusion medicine.
Interpretation of cervical spine radiographs
Authors: O'Regan Declan , Harvey Chris J , Allen Steve
Published: May 2014

Patients who present to emergency departments following neck trauma are frequently investigated with plain radiographs. The great majority of radiographs will be normal, but interpreting these films can be a daunting task for a junior doctor as the findings may be subtle and the consequences of missing an injury may be catastrophic. The process can be made simpler by understanding which patients require X-rays, developing a systematic approach to reading the films and being able to decide whether further investigation is required. A basic comprehension of the types of cervical spine trauma is useful as well as understanding the principles of stable and unstable injuries.
Recognizing and managing severe community-acquired pneumonia
Authors: Kamath Ajay V , Myint Phyo K
Published: May 2014

Community-acquired pneumonia (CAP)is a common condition. It results in 50 000–83 000 hospital admissions in the UK annually. It is particularly common in the very young and the elderly. Between 22 and 44% of patients with CAP are admitted to hospital (Woodhead et al, 1987; Guest and Morris, 1997). In hospitalized patients, the overall mortality is between 5 and 12%. However, in the older age group (≥65 years) the mortality is around 20% (Myint et al, 2005) and in those patients admitted to the intensive care unit (ICU), it is as high as 50%. Hence it is important to assess patients on admission, to identify those with severe CAP and manage them appropriately.
Psychiatry in the general hospital: hints from the shop floor
Authors: Lawrence-Smith Geoff , Ali Afia , Hassiotis Angela
Published: May 2014

With the advent of the foundation programme, junior doctors will hopefully find themselves with many more opportunities for exposure to aspects of medicine that previously were not so readily accessible. The art of psychiatry is one such important aspect, and one that is intricately linked to the care of patients in the general hospital setting.
The need to build a strong foundation: a return to the basics
Authors: Summers SA , Laing C , Kelly PA , Marshall D
Published: May 2014

Recent years have seen considerable advances in diagnostic investigations. However, there is often misuse of these techniques and resources, and this is reflected in persistently high rates of misdiagnosis, iatrogenic illness and rising health-care costs.
Metatarsal fractures
Authors: Patel Rahul , Haddad Fares
Published: May 2014

The human foot combines mechanical complexity and structural strength.
Interpretation of paediatric trauma
Authors: Harvey Chris , Bhakoo Pradeep , Allen Steve , O'Regan Declan
Published: May 2014

Fractures in children differ from those in adults in a number of ways. The immature skeleton is more elastic resulting in incomplete fractures (torus and greenstick) as well as fractures without cortical disruption. In addition the periosteum is more elastic and thicker than in adults. Also children's bones heal quicker and remodel more readily. However, there are areas of structural weakness, which adults do not possess, in the epiphyseal growth plates and zones of cartilage hypertrophy. Therefore fractures at these sites are common.
So you want to be … a geriatrician
Authors: Singh Iqbal , Vilches Arturo , Watt Jenny
Published: May 2014

Those interested in a tranquil existence, stop reading now.
Oxygen therapy in adults
Authors: Booth Helen
Published: May 2014

Oxygen therapy is the provision of oxygen in greater inspired concentrations (FiO2) than room air (21%) to prevent tissue hypoxia. Oxygen is used widely in acute and elective situations across a range of specialties, by ambulance personnel, nurses and medical staff. In the emergency or acute setting it is important to appreciate that each professional group may work to different oxygen protocols as their patients are at different stages of the patient pathway. This article outlines the indications and hazards of oxygen therapy and emphasizes the importance of individualized oxygen prescribing, depending on the diagnosis and objective measurement of oxygenation (widely available with pulse oximetry).
Interpretation of knee radiographs
Authors: O'Regan Declan , Harvey Chris , Allen Steve
Published: May 2014

The knee is particularly susceptible to traumatic injury because of the variety of compressive, load-bearing and rotational forces that may act upon it. Injuries may be the result of high-impact trauma such as falls from a height or road traffic accidents, or a result of low-velocity sporting injuries. They may be associated with significant complications such as vascular injury, compartment syndrome, bony non-union, avascular necrosis and osteoarthritis. The majority of fractures are visible on plain radiographs although detectable injuries are sometimes subtle. Simple guidelines are available in order to help decide which injuries do not require investigation with radiographs.
Cardiac axis measurement on electrocardiograms
Authors: Maung Aye Khin
Published: May 2014

Although cardiac axis measurement causes more confusion and difficulty than any other aspect of electrocardiogram (ECG) assessment for many doctors, it can be easily worked out in a few seconds using the simple method outlined in this article.
Ankle fractures
Authors: Oussedik Sam
Published: May 2014

The ankle joint comprises three bones, the tibia, fibula and talus, together with the ligamentous structures which bind them together. Three groups of ligaments can be distinguished: the deltoid ligament medially, between tibia and talus; the lateral collateral ligaments laterally, comprising anterior talofibular, calcaneofibular and posterior talofibular ligaments; and the syndesmosis complex, comprising the interosseous membrane between tibia and fibula, anterior tibiofibular, posterior tibio-fibular, inferior transverse and interosseous ligaments (Figure 1). Together, these structures allow movement of the talus within the mortise joint formed by tibia and fibular of 30° of dorsiflexion and 45° of plantar flexion.
So you want to be … a hepatopancreatobiliary surgeon
Authors: Williamson Robin
Published: May 2014

HPB or hepatopancreatobiliary surgery means looking after patients with ‘surgical’ diseases of the liver, pancreas, gall bladder and biliary tree. By extension, HPB surgeons also operate frequently on the spleen, stomach, duodenum and jejunum; for example, we are well accustomed to creating a defunctioned (Roux) loop of bowel to act as a conduit or bypass in pancreatobiliary surgery. For the most part the day is spent in theatre dealing with stones, cysts and tumours, but there are other difficult conditions to manage such as portal hypertension and pancreatitis, both acute and chronic.
The NICE hypertension guideline update 2006: a welcome revision
Authors: Lewis S Philip
Published: May 2014

Hypertension affects up to 40% of the adult population (Wolf-Maier et al, 2003). In this situation, any guidance which improves outcomes and cost-effectiveness is particularly important, especially when increases in stroke, coronary artery disease and heart failure resulting from inadequate blood pressure control are themselves major consumers of NHS costs.
Botulinum toxin and the overactive bladder
Authors: Woodhouse JB , Patki P , Patil K , Shah J
Published: May 2014

Botulinum toxin is now a treatment for many conditions. It is undergoing increasing use in several different unlicensed urological clinical situations which are outlined in this article. The article discusses the available evidence relating to its use, effectiveness and safety.
Diagnosis and management of renal (ureteric) colic
Authors: Ahmed Hashim U , Khan Azhar A , Bafaloukas Nikos , Shergill Iqbal S , Buchholz Niels-Peter N
Published: May 2014

Renal (ureteric) colic is a common surgical emergency. It is usually caused by calculi obstructing the ureter, but about 15% of patients have other causes, e.g. extrinsic compression, intramural neoplasia or an anatomical abnormality. This review will focus on calculus-related renal or ureteric colic, its assessment and subsequent management.
Otosclerosis: a review of aetiology, management and outcomes
Authors: Siddiq MA
Published: May 2014

Otosclerosis is an autosomal dominant condition affecting the temporal bone. It presents predominantly with deafness in a young population. This review looks at the aetiological theories, present treatment strategies and surgical outcomes of this condition.
Intestinal failure
Authors: Williamson Robin
Published: May 2014

The small bowel is a marvellous organ. First, it absorbs nutrients on behalf of all the other organs of the body. This function is not entirely ‘altruistic’: enteric (small-bowel) epithelium is itself nourished by luminal nutrients, which explains its disproportionately severe atrophy in starvation or total parenteral nutrition. Second, it has an enormous functional reserve. In the era of jejunoileal bypass for morbid obesity, most patients with 85–90% of the small bowel taken out of circuit could still maintain a body weight above normal. Third, the fact that diarrhoea after a major enterectomy diminishes with time indicates the adaptive power of the remnant small intestine. The lining of the jejunum and ileum is normally shed every few days as cells migrate from crypt base to villus tip, yet the process can be further accelerated to compensate for loss of tissue mass.
Drug-induced QT prolongation: consequences and current dilemma
Authors: Dubrey Simon W , Grocott-Mason Richard
Published: May 2014

An 86-year-old woman was admitted with falls. She was taking no medication and had no family history of long QT syndrome. An electrocardiogram (ECG) revealed atrial fibrillation at 160 beats per minute.

Rate control was commenced with digoxin and metoprolol, to a total dosage of 625 μg and 137.5 mg respectively. On day 8, the therapy was changed to attempt chemical cardioversion with sotalol at a dosage of 40 mg daily. After a cumulative sotalol dosage of only 120 mg, given over 3 days, the ECG showed extreme QT interval prolongation (800 msec) and bizarre T, or TU wave inversion (Figure 1). Blood tests were normal (K+ 5.3 mmol/litre, Mg++ 0.97 mmol/litre, Ca++ 2.45 mmol/litre) and troponin T was negative. An echocardiogram showed normal dimensions and function.

The patient experienced numerous runs of polymorphic ventricular tachycardia (torsade de pointes) precipitated by repeated ‘R on T’ events (Figure 2). Intravenous magnesium had no effect. Temporary pacing was used to overdrive pace the patient. The patient was commenced on a low dose of bisoprolol and made a complete recovery to sinus rhythm and a normal QT interval.
Phantom limb claudication
Authors: Corfield L , Gurprashad R , Halawa M , Yusuf SW
Published: May 2014

A fit and well 29-year-old man underwent a right above-knee amputation in 1976 as a result of severe trauma sustained in a road traffic accident. After rehabilitation, he remained well and mobilized independently with his prosthesis. Twenty nine years later he was admitted to hospital for an infection of his stump following minor trauma.

There was no history of diabetes, hypertension or smoking. He was taking aspirin and lipid-lowering medication. During his admission and subsequent follow up, he gave a clear history of not only right stump (thigh) claudication but also claudication in his absent right calf when mobilizing with his prosthesis after walking 50 yards. The pain was relieved quickly by ceasing to walk. The claudication persisted after the stump was well healed.

At re-presentation, both the arterial duplex scan and magnetic resonance angiogram showed occlusion of the right external iliac artery (Figure 1).

His stump healed well with no surgical intervention or complication. He was advised to exercise to improve the claudication. After 4 months he was able to walk 100 yards without claudicating.
Bowen disease of the conjunctiva treated by Mohs resection
Authors: Sheth Hiten G , Jain Rajni , Joshi Naresh
Published: May 2014

A previously healthy 61-year-old Caucasian woman was referred with a recurrent right upper eyelid lesion. She had first presented to her local ophthalmic service with a 6-month history of an eyelid lump which was initially diagnosed as a presumed chalazion and treated by incision and curettage.

On examination visual acuities were 6/6 in either eye and anterior and posterior segment examination was unremarkable. Eversion of the right upper lid revealed a 4 mm lesion arising from the marginal palpebral conjunctiva around the lateral third of the eyelid (Figure 1) and a shave biopsy was performed. This revealed enlarged and atypical keratinocytes with numerous mitoses, consistent with Bowen disease.

The patient had no ophthalmic history, was a controlled hypertensive (atenolol 25 mg), and had no risk factors for immunosuppression and no history of lid trauma, other skin cancers or excess sun exposure.

The lesion was surgically excised using the Mohs method, frozen section histology confirming clear margins with complete removal. The site was closed directly without the need for lid augmentation or reconstruction and the appearance 2 weeks post-procedure was functionally and cosmetically acceptable(Figure 2). At 6-month follow up there was no clinical evidence of recurrence.
Postoperative cognitive decline, dementia and anaesthesia
Authors: Ballard Clive , Clack Hannah , Green David
Published: May 2014

The potential for older people to develop cognitive impairment as a consequence of major surgery with anaesthesia has been increasingly recognized over the last 10 years. This article reviews the evidence regarding the incidence, outcome and potential mechanisms of cognitive impairment and considers the specific implications for people with dementia.
Screening women at moderate risk of breast cancer
Authors: Moyle Penny , Warren Ruth
Published: May 2014

Breast cancer risk is grouped into high risk, moderate risk and woman at or near population risk. Who are moderate-risk women? How is their risk assessed? What is the evidence and best practice for screening moderate-risk women?