bluuebunny/crossref_metadata_2025 huggingface dataset:
Non alcoholic fatty liver disease (NAFLD): an overview
Authors: McAvoy NC , Lockman A , Hayes PC
Published: January 2025

Non alcoholic fatty liver disease is an extremely common and underrecognised disorder.The term encompasses a spectrum of histological abnormality ranging from simple steatosis, through NASH to cirrhosis. Insulin resistance is central to its pathogenesis and is the liver manifestation of the Metabolic Syndrome. The natural history and the risk factors for disease progression are incompletely understood but the severity of insulin resistance and having multiple components of the Metabolic Syndrome appears important.Understanding the pathogenesis is crutial as it provides possible targets for therapeutic intervention. Management of the other components of the Metabolic Syndrome such as weight, hypertension and insulin resistance is important and helps both that component and the liver problem A general, rather than an organ-specific, approach to treating NAFLD and its comorbidity is essential.
The pros and cons of the SSRI antidepressants
Authors: Masterton G
Published: January 2025

The SSRIs have become the most heavily prescribed antidepressant drugs in North America and Europe. However, they have been dogged by controversy about withdrawal effects/drug dependence, heightened suicidal thinking and behaviour, and their use in children and adolescents who are depressed. This paper brings the reader up to date with developments, including opinion and guidance from the MHRA and NICE.
Polycythaemia: diagnosis and management
Authors: Kumar R , Prem S
Published: January 2025

Patients with raised haemoglobin or haematocrit need evaluation for the presence of polycythaemia. The term erythrocytosis should be used when only the red cells are affected, while polycythaemia is preferred for the clonal disorder involving all three haematopoietic cell lines, namely PV. Secondary erythrocytosis is far more common and is usually consequent to increased erythropoietin production. It is important to diagnose PV, as it has a high morbidity and mortality. The diagnostic criteria for PV are complex. Recently, an activating point mutation in the JAK2 gene (JAK2-V617F) has been detected in a majority of PV patients, but is not specific, and needs more evaluation. Patients may present with plethora, thrombosis in arterial or venous circulations, erythromelalgia, pruritus, haemorrhage, splenomegaly, gout, leucocytosis, or thrombocytosis.

Management consists of reducing haematocrit to below 0·45, primarily by venesection. Low-dose aspirin should be administered to all patients unless contraindicated. Cyto-reductive therapy is indicated only if venesection is not tolerated, for high-risk illness, extreme thrombocytosis, and progressive disease. Hydroxycarbamide (previously known as hydroxyurea) is the simplest and most effective medication, being preferred in all except young patients. Interferon is also effective, but is more toxic and inconvenient to use. Anagrelide may be used to control platelet counts, but hydroxycarbamide appears superior. In the very elderly, 32P or low-dose busulfan has a role because of the convenience, despite a greater risk of leukaemic transformation. With appropriate therapy, survival has improved from an average of two years to more than ten years. Special care is needed during pregnancy, prior to general surgery, and in the management of haemorrhage, pruritis, and splenomegaly.
Cardiovascular medicine – turning people into patients: has modern medicine gone too far?
Authors: Dear J
Published: January 2025

This hot topic meeting addressed the burning issue of the potential power of the medical profession and others to create disease out of cardiovascular risk factors. Cardiovascular disease remains the most common cause of morbidity and mortality in most of the western world, and in Scotland in particular. Clearly the reduction of cardiovascular disease is a critical goal but a side-effect of this can be the transformation of fit, healthy people with an increase in risk, into unwell patients labeled as suffering from disease. To prevent unnecessarily turning people into patients we need to understand the epidemiology of risk factors and have clear mechanisms for educating healthcare providers and the public. These topics were the focus of this well attended and stimulating meeting
Herceptin® – from laboratory to cure in breast cancer?
Authors: Cameron D
Published: January 2025

There has been considerable publicity surrounding the potential benefits of herceptin in treating early breast cancer and whether or not its benefits outweigh the costs of treatment. In this article, requested by visitors to the www.behindthemedicalheadlines.com site, Dr David Cameron provides an overview of the development of herceptin, its use in treatment and its safety profile.
End-stage renal disease in the very elderly
Authors: Selvarajah V , Isles C
Published: January 2025

The prevalence of end-stage renal disease in the UK looks set to increase for several more years. Since CKD is essentially a disease of older age, and because age is no longer seen as a contraindication for treatment, it follows that older people are now the fastest growing group of patients starting dialysis. Sadly this has not always been matched by an increase in services necessary to support them on dialysis. Expansion of dialysis facilities does not necessarily mean that all 80-year-old patients with end-stage renal disease should be offered treatment, which will often be inappropriate because of functional impairment, or will become inappropriate in the setting of severe dementia, advanced cancer or other serious co-morbid illness. Many questions about the management of older people with end-stage renal disease remain unanswered. Well designed prospective studies are required.
ANCA-associated systemic vasculitis (AASV)
Authors: Kluth DC , Hughes J
Published: January 2025

Anti-neutrophil cytoplasmic antibody-associated systemic vasculitis is a multi-system disease that can present to a number of medical specialties, and where early identification and treatment improves outcome. The vasculitides are commonly divided into WG, MPA, and CSS. This review will revise the common clinical presentations of these diseases and initial investigations. Anti-neutrophil cytoplasmic antibodies have provided a valuable test to aid in diagnosis and there is increasing clinical and experimental evidence that suggests they have an important role in the pathogenesis of disease. Anti-neutrophil cytoplasmic antibodies are directed at either MPO or PR3 which are present in the granules and on the cell surface of neutrophils. They can be detected by indirect immunofluoresence and ELISA-based assay, and both are essential when vasculitis is suspected. The antibodies are able to activate neutrophils and promote injury, and recent data have shown they can directly cause glomerulonephritis and systemic vasculitis in animal models.

Diagnosis of AASV is made using clinical features, ANCA test, and relevant tissue biopsy. Treatment with cytotoxics has transformed the prognosis but until recently there has been limited trial evidence to determine which regime is best. This article will review a range of studies published over the last five years and preliminary evidence from ongoing studies to give an outline of current practice for immunosuppression and monitoring of disease. There is also now a range of biological therapies available including anti-TNF and anti-B-cell antibodies, which may have an increasing role as either adjunctive therapy or new regimes to induce remission.
What ACE inhibitor-induced changes in serum creatinine tell us about a possible diagnosis of renal artery stenosis
Authors: Main J
Published: January 2025

In renal artery stenosis, GFR becomes angiotensin II-dependent and therefore sensitive to ACE inhibitor. However, the effect of ACE inhibitor on SCr in the presence of RAS is complicated by several factors: serum creatinine is a poor indicator of GFR, RAS can affect one or both kidneys, GFR depends on systemic blood pressure and ACE inhibitor dose, and other conditions can render GFR ACE inhibitor-sensitive.

A basic understanding of the mechanism of glomerular filtration allows us to interpret ACE inhibitor-induced changes in SCr, and to decide whether they warrant further investigation of the renal arteries or exclude the possibility of RAS.
Diarrhoeal-associated haemolytic uraemic syndrome
Authors: Maxwell H
Published: January 2025

Diarrhoeal-associated HUS is a common cause of acute renal failure, particularly in young children. The diagnosis is made by the presence of the following triad of findings: haemolytic anaemia (<10 g/dl), thrombocytopenia (<150x109/l) and a creatinine value that is above the upper limit of normal for age. Ninety per cent of cases follow a diarrhoeal prodrome, and of these the majority are due to enterohaemorrhagic E. coli or VTEC. Sporadic and epidemic cases occur and sources of infection include undercooked meat, contact with farm animals and their faeces, and contaminated water, fruit, or vegetables.

Typically, children under three years of age are affected and present with abdominal pain and diarrhoea. The diarrhoea is often watery and soon becomes bloody. There may also be vomiting. The diarrhoea lasts on average for eight days, and the colitis can be so severe that children may present with an acute abdomen. Perforation, bowel infarction, and intussusception are rare complications. Rectal prolapse is a more common complication. Diagnosis of VTEC infection is by stool culture and serology.

Ten per cent of patients with VTEC infection go on to develop HUS. Of these, 50–60% will develop acute renal failure requiring dialysis. Extrarenal manifestations include seizures and somnolence, with cerebral infarcts and oedema being less common complications. Pancreatitis and altered glucose tolerance can occur and cardiac ischaemia has been reported. On average, dialysis is required for 8–10 days; those requiring dialysis for longer than four weeks are unlikely to make a full renal recovery. Acute mortality is 5–10%, being more common in patients with neurological involvement. End-stage renal failure develops in 3–5%, and up to 25% may be left with renal impairment. At one year after the illness, a normal GFR, normal BP, and absence of proteinuria are predictive of a complete recovery.
The modern management of asthma
Authors: Douglas JG
Published: January 2025

Asthma is among the most common of all chronic disorders at all ages. Despite increased understanding of cell biology and access to numerous drugs and inhaler, asthma is not under control. One in six people requiring emergency treatment for asthma will require emergency treatment again within two weeks and, sadly, in the UK one person dies of asthma every seven hours.

Modern management of asthma is supported by the rigorously evidence-based BTS/SIGN guidelines which are now are updated annually. There is increasing emphasis on starting inhaled steroid for milder cases and using lower doses, the usual starting adult dose is now 400 ug BDP or equivalent. Education using a written personalised Asthma Action Plan is central to good management and should be reinforced at every opportunity. For adults and older children with more troublesome symptoms a LABA is the most effective add-on therapy. Those not controlled at Step 3 should be considered for referral to a specialist hospital clinic.
Atrial fibrillation
Authors: Lip GYH , Lalukota K
Published: January 2025

Atrial fibrillation is the most common cardiac arrhythmia in everyday clinical practice, and has a significant morbidity and mortality related to it, either directly or indirectly. Atrial fibrillation results in a heavy burden on NHS services, in terms of both in-patient admissions, and out-patient care. Atrial fibrillation can be symptomatic or asymptomatic, yet morbidity and mortality are not much different in relation to symptom status. However, young patients with ‘lone AF’ (i.e. AF without ‘overt’ structural heart disease, as defined by essentially normal clinical history and examination, electrocardiogram, chest X-ray, and, in more recent series, the ECG) are often considered as being ‘at low risk’, although recent data have been less conclusive on this aspect.
Physician-assisted suicide in Oregon: a personal view
Authors: Jeffrey D
Published: January 2025

Proponents for the legalisation of PAS in the UK claim that it works well in Oregon in the US. About 30 patients have used PAS each year since it was legalised in Oregon in 1997. This paper reports the result of a visit to Portland in Oregon to listen to the views of healthcare professionals, hospice association leaders and proponents of PAS.

‘Palliative care’ and ‘hospice’ mean different things in the US and the UK. ‘Hospice’ in the US means end-of-life care at home, and many of those ‘eligible’ patients receive this only for the last two or three weeks of life. ‘Palliative care’ tends to be delivered by hospital support teams and is largely concerned with the last days of life in the acute hospital setting. There are no specialist palliative care inpatient units in Oregon. It is commonly assumed that those patients who carry out PAS must be suffering terrible pain or are depressed. However, the experience in Oregon suggests that the small number of patients who carry out PAS are not depressed, nor are they in pain. They all share an overpowering need for control and they simply want to be able to choose when they should die.

Although PAS is legal in Oregon, only a small number of doctors take part in the process. No hospitals permit PAS to be carried out on their premises. Hospice home care programs adopt an ambivalent moral stance, distancing themselves from the act of PAS whilst continuing to support the patient and their family. The implications of these findings for notions of autonomy and moral agency are discussed here.
Primary spontaneous pneumothorax: why all
Authors: Mackenzie SJ , Gray A
Published: January 2025

The management of PSP continues to be a source of debate. There are few randomised control trials comparing treatment options, and current guidelines based on specialist opinion vary in their recommendations. Initial management options include observation, aspiration, intercostal drainage with and without pleurodesis, and video-assisted thoracoscopic surgery. Primary spontaneous pneumothoraces arise in patients without clinically apparent lung disease, and no obvious precipitating factor. It is a relatively common presentation with a reported incidence of 18 to 28 per 100,000 men per year and 1·2 to 6 per 100,000 women per year. Primary spontaneous pneumothorax usually occurs in young, tall males between the ages of 15 and 34.

The BTS and ACCP have both published guidelines on the treatment of PSP. While they agree on the management of small asymptomatic PSP (observation and outpatient review) and clinically unstable PSP (intercostal drain insertion and admission), they differ on the management of symptomatic small PSP and clinically stable large PSP. The ACCP advise that simple aspiration is rarely appropriate in the treatment of PSP, while the BTS recommend simple aspiration as a first-line treatment. A 2007 Cochrane report, which systematically reviewed all published randomised control trials comparing aspiration to intercostal drain insertion, concluded that there was no difference in the immediate success rate, early failure rate, or one-year success rate between the two interventions. However, aspiration resulted in a lower number of patients requiring admission, and decreased the duration of hospital stay. Current evidence supports the 2003 BTS guidelines, and simple aspiration as first-line treatment in clinically stable pneumothoraces. Until a large randomised control trial is performed, and provides a conclusive evidence base for the most appropriate management of spontaneous pneumothorax, confusion will remain over first-line treatment.
Cutaneous applications of medical lasers and intense pulsed light systems
Authors: Wright PA , Ahmed S , Cole RP , Moore JC , Royston SL , Widdowson DC
Published: January 2025

Medical lasers and IPL systems are currently used for a wide variety of cutaneous applications, such as the treatment of vascular lesions, unwanted hair, tattoos, scars, melanocytic and other skin lesions.1 Accordingly, with the emergence of numerous new facilities from the hospital to the high street, it is important that healthcare professionals and patients should have appropriate awareness of treatments with these modalities. The aim of this review is to discuss the efficacy of commonly used skin lasers and IPL systems together with the indications for their use in treatment.
Lucy Wills (1888–1964):The life and research of an adventurous independent woman
Authors: Bastian H
Published: January 2025

Lucy Wills was one of a pioneering generation of women in medicine and medical research in England. After a double first honours degree in botany and geology from Cambridge in 1911, she travelled to South Africa, where she worked as a nurse during the First World War. Wills then gained a medical degree in London in 1920. By the late 1920s she had developed an interest in haematology and began travelling to India to investigate pernicious anaemia in pregnancy.There she identified a substance often called ‘the Wills’ factor’, which was later recognised as folic acid. Wills undertook a placebo trial of routine iron supplementation in pregnant women during the Second World War, hampered, but not stopped, by bombing. In retirement, she continued to study nutritional effects on health in South Africa and Fiji.
Diabetes and endocrinology symposium: genes, environment and emerging therapies
Authors: Zammitt Nicola
Published: January 2025

This symposium provided an update in various areas within the fields of diabetes and endocrinology. Topics included the effects of diet and exercise on the metabolic syndrome and cardiovascular disease; programmes to decrease the incidence of diabetes; updates in the genetics of phaeochromocytoma, obesity and type 2 diabetes; the use of pegvisomant in acromegaly and incretin-based therapies in type 2 diabetes; and the relative strengths and weaknesses of bisphosphonates and HRT as treatment for post-menopausal osteoporosis.
Exercise for obesity – how much is enough?
Authors: Haboubi N , Axe K
Published: January 2025

Exercise is an important part of weight management, particularly in the long term. However, there is conflicting evidence about how much exercise obese subjects need to perform. Diet, genetic or other factors may contribute to the difference in weight between normal and obese subjects if physical activities are equal between groups. Obese subjects may therefore need to be more active and perform more exercise than their normal weight counterparts in order to lower or maintain their weight.

Regarding the amount of exercise, duration has a greater effect on weight loss than intensity. Moderate-intensity exercise is as beneficial as high-intensity exercise for weight loss and, as it appears to be more attractive to obese subjects, leads to a greater adherence to exercise programmes.

Preservation of lean body mass is greater when exercise is performed as part of a weight management programme. If diet only is used for weight loss, lean tissue is lost. Combining aerobic and resistance exercise appears to preserve lean tissue, so both types of exercise should be encouraged. Aerobic exercise has a greater effect on weight loss, but resistance exercise could potentially increase lean tissue. High-intensity exercise may spare more lean tissue than moderate exercise, but the benefits of greater adherence of subjects to moderate exercise outweigh those of high-intensity exercise.

When barriers to exercise exist, lifestyle changes combined with diet should be advised. In general, obese subjects should be encouraged to start off with lowintensity exercise and gradually progress to a higher level.
Prostate cancer – reasonable approaches to a confusing problem
Authors: Howard G , McLaren D
Published: January 2025

Prostate cancer is the most common cancer in men. While progress has been made in understanding the disease’s natural history and in developing more effective treatments, this has not clarified the disease’s diagnosis and management – about which uncertainties have actually increased. In this article Dr Grahame Howard and Dr Duncan McLaren provide an overview of the current treatment options and their benefits.
Gastroenterology for the generalist and the specialist
Authors: Masson S
Published: January 2025

This symposium provided an update in aspects of gastroenterology that are of relevance and interest to both the general physician and specialist gastroenterologist. Everyday practical dilemmas, such as the investigation of iron deficiency anaemia, consideration of PEG feeding and the management of IBS,were considered alongside updates in the management of variceal bleeding and alcoholic and non-alcoholic fatty liver disease. Looking to the future, developments in endoscopy safety and quality, with particular reference to the colorectal cancer screening programme, were outlined.
Inspirational people and care for the deprived: medical missionaries in Kashmir
Authors: Mir NA , Connell Mir V
Published: January 2025

Lieutenant Robert Thorpe, a soldier in the British Army in India, visited Kashmir and witnessed the suffering and sorrows of the people there in the nineteenth century; his appeal to British soldiers raised enough funds for the Church Missionary Society to send medical missionaries to the Kashmir Valley. Thus began a process that would see the opening of a 150-bed British Mission Hospital in Srinagar and the start of a new wave of educational and healthcare reforms in the region. As the medical missionary work progressed so did the avenues of research, which led to pioneering work on skin cancer.The missionary doctors and nurses made a significant difference to the lives of the people of Kashmir and their pioneering work continues to live on.
Barium aspiration, not observed during videofluoroscopy but confirmed incidentally on routine chest X-ray
Authors: Ripley DP , Noble DD , Bella A
Published: January 2025

The authors present a case of barium aspiration during videofluoroscopy that was not diagnosed at the time of the procedure, but on a chest X-ray five months later.
Clopidogrel therapy in coronary heart disease: reviewing the evidence and assessing the practice
Authors: Mudawi TO , Morrison L
Published: January 2025

Since its introduction as a new anti-platelet agent a decade ago, clopidogrel has been shown to be a useful drug in the treatment of non-ST elevation acute coronary syndromes. Its use in such conditions has been advocated by national UK, European and international guidelines issued by a number of professional regulatory authorities. However, in the past few years, new evidence has emerged from a number of clinical trials supporting the expansion of clopidogrel use to include ST elevation myocardial infarction and patients undergoing both urgent and elective percutaneous coronary interventional procedures in the form of an initial loading dose followed by a daily maintenance dose, usually for a period of 12 months. This review paper aims to highlight areas in clinical practice where clopidogrel use does not follow the agreed guidelines. It also compares the published UK, European and international guidelines with the up-to-date evidence that recently became available from clinical trials. The paper also outlines some suggested recommendations to be considered when issuing any new clopidogrel-related guidance documents.
Management of Clostridium difficile infection
Authors: Ewan V , Newton JL
Published: January 2025

Clostridium difficile-associated diarrhoea is the most common cause of nosocomial diarrhoea and has a high morbidity and mortality among infected patients. Its prevalence and recurrence rates increase with age. Influencing local antibiotic practice can have an impact on infection rates, and this and other specific strategies to reduce the incidence and relapse rates of C. difficile-associated diarrhoea are needed. Reduction of C. difficile-associated diarrhoea rates would have enormous positive resource implications for health services, primarily by reducing length of hospital stay, and would also reduce mortality and morbidity in hospital inpatients.
The risks and benefits of the combined oral contraceptive pill
Authors: Russell R , Kingsland C
Published: January 2025

The combined oral contraceptive pill has been used by an estimated 300 million women worldwide since it was first developed. In recent years it has been linked with both an increased risk of some forms of cancer and a protective effect against other cancers – leading to considerable confusion for women. In order to provide much-needed clarity, Dr Richard Russell and Mr Charles Kingsland provide an overview of the risks and benefits of the combined oral contraceptive pill.
Edward Harrison and the treatment of spinal deformities in the nineteenth century
Authors: Weiner M-F , Silver JR
Published: January 2025

At the beginning of the nineteenth century, doctors and lay practitioners became interested in the treatment of spinal deformity, but it took two centuries for the specialty to become established. The provision of care was fragmented, and treatment was in the hands of physicians, surgeons, mechanics, masseurs and bonesetters. In 1837, Dr Edward Harrison founded the first infirmary for spinal diseases in London with only six beds. Harrison was a forceful character who had trained in Scotland. He held no voluntary hospital appointment and faced great opposition from the London Royal Colleges and the orthodox establishment, including Sir Charles Bell and John Shaw. This paper describes Harrison’s treatment of patients afflicted by spinal deformity and analyses the medical environment of the time as well as Harrison’s legacy.
Palliative management of advanced cancer
Authors: Hauser K , Walsh D
Published: January 2025

The goal of this article is to review important developments in symptom management, drugs, complications and communication pertaining to the palliative management of advanced cancer. Pain and fatigue are the most common symptoms of advanced cancer. Pain is often well controlled with analgesics, although some cancer pain is more difficult to control. Risk factors for refractory pain include breakthrough and neuropathic pain, both of which will be discussed in this review. Methadone and gabapentin both have a role in the management of neuropathic pain and will be discussed in detail. Complications of advanced cancer amenable to medical treatment include delirium and bowel obstruction. Good communication is paramount in the management of advanced cancer. The issues of how to deliver prognostic information and hold a family conference will be covered by this review.
Medical advertising: The Family Encyclopaedia of Medicine scandal of 1914
Authors: Jellinek EH
Published: January 2025

The past 100 years have seen a transition from a total ban in Britain on all advertising by doctors to the laity to almost total freedom of medical information, with probable benefit to public health but also a risk of loss of privacy. The Family Encyclopaedia of Medicine, written by Dr Hugh Howard Riddle and published by Lord Northcliffe’s Daily Mail in 1914, started a flood of medical journalism in the press and the newer media. The lavishly advertised misattribution of its authorship to ‘thirty eminent specialists’, including Clifford Allbutt and William Osler, caused a major rumpus in the London Royal College of Physicians, but the fortnightly publication continued and became a four-volume book, popular with a public avid for more and more medical information.
Malnutrition: the spectre at the feast
Authors: McKinlay AW
Published: January 2025

It seems impossible that malnutrition could be a problem in a modern Western country, particularly when obesity has been identified as the major public health challenge of the twenty-first century. Despite this, hospital malnutrition remains a major problem in the UK’s National Health Service, and there have been repeated calls for this to be addressed as a matter of urgency. In this article Dr Alastair McKinlay provides a detailed analysis of the problem of hospital malnutrition and how it should be tackled.
Bisphosphonate prescribing in chronic kidney disease
Authors: Courtney AE , Leonard N , McCloskey MC , Smyth JS , Maxwell AP
Published: January 2025

Osteoporosis and chronic kidney disease (CKD) are both increasingly prevalent with advancing age. Bisphosphonates are licensed for use in osteoporosis, but the appropriateness and safety of this class of drug in CKD is uncertain. This study assessed the use of bisphosphonates for persons with CKD in clinical practice. The prescribing pattern of bisphosphonates in all 595 persons attending renal services in one UK hospital was analysed. The mean estimated glomerular filtration rate (eGFR) of the population was 44 + 23 ml/min/1.73m2. Bisphosphonate treatment was prescribed for 32 patients (5%), of whom 13 had an eGFR <30 ml/min/1.73m2 and two patients received maintenance dialysis therapy. Thirty-nine (7%) patients were prescribed corticosteroid therapy; 9/23 with an eGFR >30 ml/min/1.73m2 were not prescribed bisphosphonate medication. Twenty-two (4%) patients had osteoporosis; 5/9 with an eGFR >30 ml/min/1.73m2 were not prescribed bisphosphonate medication. Bisphosphonate medication was not prescribed to a proportion of persons with early CKD (stages 1–3) who could potentially benefit from such therapy; conversely such treatments were used in some patients with severe CKD (stages 4 and 5). This pattern of bisphosphonate prescribing arguably reflects the uncertainty about the efficacy and safety of such treatment for persons with CKD.
Intercostal chest drains: a wake-up call from the National Patient Safety Agency rapid response report
Authors: Akram AR , Hartung TK
Published: January 2025

Intercostal chest drains have been well established in the management of pneumothorax and pleural effusion, and explicit guidelines exist for the indications for inserting a chest drain. In May 2008 the UK’s National Patient Safety Agency issued a rapid response report entitled Risks of chest drain insertion, highlighting significant complications directly related to intercostal chest drain insertions. A systematic search of the National Reporting and Learning System database for chest drain-associated patient safety incidents revealed 12 deaths and 15 cases of serious harm out of a total of 2,152 incidents between January 2005 and March 2008. In response to these alarming incidents the report called for six action points to be implemented by NHS hospitals and the independent sector by 17 November 2008. This review aims to summarise the National Patient Safety Agency recommendations and provide a brief review of the literature on chest drain-related complications.
Medicine in extreme environments: danger and opportunity
Authors: Baillie JK
Published: January 2025

The problems encountered by expedition doctors are diverse and can be immensely challenging. They range from decompression sickness to highaltitude cerebral oedema, and from immersion hypothermia to the management of multiple trauma patients without any medical kit. Advice was presented on how to deal with these problems and many more. Our understanding of the pathophysiology of high-altitude cerebral oedema is still incomplete, but there is hope that work currently under way may identify genes that predispose individuals to altitude illness. There is active debate among experts about what factors limit exercise performance at high altitude. The accepted explanation has been that a failure of bulk oxygen delivery to the tissues is the limiting factor, but it has been proposed that alternatives such as inefficient microvascular flow or alterations in mitochondrial function may be more important.
Placental site trophoblastic tumour – a rare cause of recurrent spontaneous pneumothoraces and conjunctival metastasis
Authors: Chatterjee S , Hancock BW , Suvarna SK , Mudhar HS , Matthews S , Tejwani DH , Tan J , Everard J , Hannigan B , Woolfall P
Published: January 2025

Spontaneously occurring primary pneumothorax in the young is uncommon but well documented as a complication of primary or secondary lung malignancy. We report the case of a 24-year-old female patient with placental site trophoblastic tumour presenting as recurrent pneumothorax, despite initial surgery and chemotherapy. Later, despite further chemotherapy, she developed conjunctival metastasis. To the best of our knowledge, this is the first case of a placental site trophoblastic tumour metastasising to the conjunctiva to be reported in the literature. Clinicians should keep in mind the possibility of pneumothorax due to lung metastasis when no obvious primary lung disorder is apparent.
Insulin delivery devices
Authors: Graveling AJ , McIntyre EA
Published: January 2025

Insulin therapy remains the cornerstone of treating patients with diabetes mellitus. All patients with Type 1, and many with Type 2, diabetes are treated with insulin. This article describes the discovery and evolution of insulin preparations and discusses current analogue, standard human and animal insulin preparations available for prescription in the UK, highlighting the advantages and disadvantages of the various preparations. An overview of initiating insulin therapy and typical insulin doses and regimes is given. To update general physicians, the necessary adjustments of insulin therapy for intercurrent illness are briefly considered. There is an array of different insulin delivery devices for subcutaneous insulin injection, which can be confusing, and the general advantages and disadvantages of such devices are examined. Recent insulin delivery device advances include the modern continuous subcutaneous insulin infusion devices or external insulin pumps. Advances in this field are rapid and strive towards the development of a closed loop insulin delivery device. Continuous subcutaneous insulin infusion devices are discussed along with the existing guidelines for their use in the UK. Currently continuous subcutaneous insulin infusion therapy is more widely used in other countries compared with the UK. Finally, future possible methods and routes of insulin delivery are reviewed, including inhaled, closed loop pump or oral.
The diagnosis and treatment of acute pulmonary thromboembolism
Authors: Martin TN , Brady AJB
Published: January 2025

Acute pulmonary embolism is a common major medical condition and is frequently poorly managed. There has been wide variation within and between countries, and even within hospitals, on how to diagnose and treat this frequently encountered medical emergency. This review examines the current status and advances now available in most acute centres, and reveals how the new European Society of Cardiology guidelines simplify this complex and poorly understood condition. Particular emphasis is placed on the new role of biochemical markers of myocardial stress and on the definition of right ventricular dysfunction as key determinants of severity and risk of death and for specific therapy.
Syncope: to admit or not to admit
Authors: Can I , Benditt DG
Published: January 2025

Syncope is one element of the broader issue of ‘transient loss of consciousness’, but is nevertheless a very common clinical problem. Emergency department physicians and general practitioners are often the first physicians to evaluate the patient. After ensuring that any serious injury is treated, the most important task is to decide whether to admit patients to hospital. Physicians usually take the ‘safe’ approach and, as a result, admit both high- and intermediaterisk patients to hospital. This is understandable, but has implications for both the patient and for the management of the healthcare system. The European Society of Cardiology guidelines and several clinical studies provide helpful advice regarding ‘risk stratification’ of patients for hospital admission versus discharge from the emergency department or clinic with subsequent outpatient subspeciality evaluation. Syncope management units and a guideline-based approach tend to reduce the number of undiagnosed cases and the hospital admission rate. This review describes this approach for managing these patients effectively.
SINGLE- VS DOUBLE-CHAMBER PACEMAKERS
Authors: Petrie Colin J , MacDonald Michael R
Published: January 2025

We read with interest the article by Choo WK et al. in the June edition of the Journal (WK Choo, L Tilling, S Gupta. The selection of pacing modalities according to NICE recommendations. J R Coll Physicians Edinb 2009; 39:113–6). In their study they correctly state NICE guidelines currently recommend dual-chamber pacemakers for those with high-degree atrioventricular (AV) block, and their current practice reflects this. It is noteworthy that the UKPACE investigators randomised 2,021 patients over the age of 70 years with second- or third-degree AV block to a single-chamber pacemaker (n = 1,009) or dual-chamber pacemaker (n = 1,012) and followed them up for a median of 4.6 years.1 They found no significant clinical benefit from dual-chamber pacemaker, but in fact an increased risk of complications in the dual-chamber group. The authors conclude that in subjects older than 70 years of age with high degree AV block, single-chamber pacemakers are warranted.
Stockton-on-Tees symposium: Recent advances in medicine
Authors: Mountford CG , Dwarakanath AD
Published: January 2025

This symposium provided an update on recent advances in medicine relevant to the general physician. The opening session on respiratory medicine session focused on lung cancer and lung transplantation. Everyday practical issues of dealing with abnormal liver function tests were considered in session two as well as the challenges in improving end-of-life care. Clinically orientated presentations in the third session covered case-based discussions on severe metabolic acidosis and the management of Parkinson’s disease. The final session on gastroenterology included an update on Clostridium difficile and an overview of risk assessment for upper gastrointestinal bleeding and the use of risk assessments as a tool in clinical practice to avoid unnecessary hospital admission.
OTHER CORRELATES OF THE DECLINE IN AUTOPSY RATE
Authors: Jolobe OMP
Published: January 2025

The decline in the autopsy rate (Horowitz RE. Autopsies: an exercise in futility? J R Coll Physicians Edinb 2009; 39:l94-5) might well be a manifestation of the increasing reliance on technological advances in imaging so as to arrive at a diagnosis. Although imaging techniques have led to huge improvements in the quality of healthcare, the paradox is that there has not been a corresponding improvement in the quality of the content of the undergraduate medical curriculum because the decline in autopsy rate has resulted in an atrophy of the skills of clinico-pathological correlation, the latter skills being ones traditionally taught in tandem with skills in eliciting physical signs.

Even bedside teaching of clinical skills is ‘unfortunately in steady decline’,1 and it has now also become a ‘badge of honour’ to arrive at a diagnosis without the benefit of performing a clinical examination.2 The latter development is a fortunate one for the National Health Service because in the new era of nurse-led consultations (a third of consultations in general practice in England in 2008 were with nurses3) it is much less labour-intensive to bypass the clinical examination altogether when teaching diagnostic skills to prospective nurse practitioners. Only in non-Western rural societies such as that in the Eastern Cape province in South Africa, where I practised medicine for seven years, was there an expectation among members of the public that the ingredients of the ‘complete package’ of a medical consultation should comprise, in this order, history taking, clinical examination, diagnosis (articulated in terms which the patient could understand) and treatment. Fortunately, highly sophisticated patients in the West have no such expectations when they attend clinics in primary as well as in secondary and tertiary care, where stripping down to the waist to have a full clinical examination has become increasingly anachronistic, thanks to the advent of high-tech imaging.

The ‘downside’ is the inappropriate use of laboratory tests and imaging, as shown in a study where ‘selecting tests based on history and [clinical] examination and prioritising less expensive and higher yield tests’ would have been more cost-effective.4 In that study postural blood pressure recording, performed in only 38% of episodes, had a higher yield with respect to affecting diagnosis and management and determining aetiology of the syncopal episode than head computed tomography scans, which were performed in as many as 63% of instances.4 The wastefulness (in this era of economic stringency) of bypassing the clinical examination is compounded by the scant respect with which the results of high-tech tests are themselves treated, exemplified by the traditional disorder prevailing in the health record, where ‘anything’ is filed ‘anywhere’ and ‘anyhow’,5 and no audit is made either of the quality and content record-keeping or of the quality and content of discharge summaries and clinic letters.
Affective Influences on the Intensity of Mental Effort: 25 Years of Programmatic Research
Authors: Gendolla Guido H. E.
Published: January 2025

This article highlights the systematic impact of experienced and implicit affect on the intensity of mental effort. The key argument is that both consciously experienced affect and implicitly activated affect knowledge can influence responses in the cardiovascular system reflecting effort intensity by informing individuals about task demand—the key variable determining resource mobilization. According to the motivational intensity theory, effort rises with experienced demand as long as success is possible and the necessary effort is justified. Twenty-five years of programmatic research have provided clear evidence that both consciously experienced affect and implicitly activated affect knowledge systematically influence the intensity of effort. Importantly, affect's impact on effort is moderated by task context variables, like objective task difficulty, incentive, and other general boundary conditions.
Identifying Cladribine prescription pattern in MS: an Italian multicentre study
Authors: Zanghì Aurora , Fantozzi Roberta , Foschi Matteo , Signoriello Elisabetta , Inglese Matilde , Lus Giacomo , Centonze Diego , Surcinelli Andrea , Sirito Tommaso , Bonavita Simona , Avolio Carlo , D’Amico Emanuele
Published: January 2025

Background:

Characterizing Cladribine tablets prescription pattern in daily clinical practice is crucial for optimizing multiple sclerosis (MS) treatment.

Objectives:

To describe efficacy, safety profile and new disease-modifying therapy (DMT) prescriptions following Cladribine treatment.

Design:

Independent retrospective cohort study in patients followed at six Italian MS centres.

Methods:

Patients diagnosed with relapsing MS (RMS) according to 2017 McDonald criteria, who initiated Cladribine between January 2019 and May 2023, were included. A generalized linear regression model was built for the outcome DMT after Cladribine course. Heatmaps were generated based on weighted pivot tables to visualize the proportion of patients requiring DMT post-Cladribine.

Results:

A total cohort of 352 patients was enrolled, 134 naïve to any DMT, 218 switchers from other DMTs. The last DMT was an injectable first-line DMT for 48 (22%) patients, oral first-line DMT for 141 (64.7%) patients, SP1 inhibitor-Fingolimod for 23 (10.6%) patients, and Natalizumab for 6 (2.7%) patients. Overall, Cladribine was efficacious and well tolerated, 12% of patients required a new DMT prescription after a median time of 24 months. The regression model revealed that patients aged >40 years at Cladribine prescription had a 16% decrease in likelihood of receiving a new DMT. Heatmaps showed patients previously on Fingolimod had a lower rate (72.2%) of being free from therapy after Cladribine.

Conclusion:

In our multicentric real-world Italian study, Cladribine therapy is generally effective during the investigated follow-up period. Understanding key characteristics of patients responding best to Cladribine can help tailor therapeutic strategies for optimal outcomes.
The missed opportunity of Poland's implementation of parental leave provisions
Authors: Latos – Miłkowska Monika
Published: January 2025

The purpose of this article is to prove that the provisions on parental leave that have been implemented into the Polish legal system have been implemented in such a way that does not meet the goals of European legislator. The first goal of the European legislator has been achieved – reconciliation of work and family life. It can be argued that this parental leave is an important means of achieving work-life balance. But this is not the only objective of the European legislator. It is rather doubtful that the second objective – improving the situation of women in the labour market and increasing the use of parental leave by men – will be achieved. The way the Polish legislator has implemented the provisions on parental leave means that the Polish practice of taking this leave is unlikely to change much and will still be used mainly by women. Thus, it can be asserted that the Polish legislator has missed the opportunity to make more profound changes in the Polish childcare model.
A prospective study to evaluate high dose daptomycin pharmacokinetics and pharmacodynamics in Staphylococcus spp. infective endocarditis
Authors: De Gregori Simona , De Silvestri Annalisa , Capone Mara , Monzillo Vincenzina , Giordani Paola , Bruno Raffaele , Seminari Elena
Published: January 2025

Background:

Daptomycin pharmacokinetics and pharmacodynamics data relative to higher doses in patients are necessary for clinical practice.

Objectives:

A monocentric, prospective study that enrolled patients with a diagnosis of Staphylococcus spp. infective endocarditis treated with daptomycin according to clinical practice, to evaluate the pharmacokinetics/pharmacodynamics of different daptomycin daily doses (group A: 8–10 and group B: 11–12 mg/kg).

Design and methods:

A monocentric, prospective, cohort study that enrolled patients with a diagnosis of Staphylococcus spp. infective endocarditis treated with daptomycin. Daptomycin was administered by intravenous infusion over a 30-min period for at least five consecutive days before PK study.

Results:

Twenty-two patients were included. Native valve infectious endocarditis (IE) was diagnosed in 9 patients, prosthetic valve IE was diagnosed in 10 patients and 3 patients had concomitant intracardiac device infections. All patients showed a microbiologic response with negative blood cultures by day 5 (1–3 interquartile rate (IQR) 3–8). The median calculated AUC0–24 was 1298 (1–3 IQR 1069–1484) and 1459 (1–3 IQR 1218–1711) µg*h/mL, with the corresponding clearance of 0.49 (1–3 IQR 0.37–0.57) and 0.57 (1–3 IQR 0.40–0.71) L/h, respectively. A value of area under the curve/minimum inhibitory concentration (AUC/MIC) > 666 was reached by all patients; however, 4 out of 15 patients in group A and 1 out of 14 patients in group B did not reach the pharmacokinetic/pharmacodynamic (PK/PD) target of 1061; therefore, AUC/MIC equal to or above 1061 was reached by 73.3% in group A and 92.9% in group B.

Conclusion:

From a PK/PD point of view, all patients reached the value of AUC/MIC > 666, while roughly 70% of patients in group A and 90% in group B reached the target value of AUC/MIC>1061. Even if this cut-off value is arbitrary, 11–12 mg/kg daily dose could be taken into consideration in case of serious infections characterised by a high inoculum or in cases of prosthetic valve infections.