bluuebunny/crossref_metadata_2025 huggingface dataset:
Is the ovary a sanctuary for non-Hodgkin's lymphoma? Successful surgical management
Authors: Anwer Saiyed , Murdoch John , Pawade Joya , Price Chris
Published: May 2014

In May 1999, a 30-year-old woman presented with a 2-month history of lower back pain and symptoms of sacral root compression. Systemic examination revealed a large right inguinal lymph node and a palpable right iliac fossa mass arising from the pelvis. A computed tomography scan showed bilateral hydronephrosis with some compression of the collecting systems, gross retroperitoneal and pelvic lymphadenopathy and an enlarged right inguinal lymph node. The lactate dehydrogenase level was raised at 665 iu/litre (normal range < 450 iu/litre). A lymph node biopsy confirmed the diagnosis of diffuse large B-cell non-Hodgkin's lymphoma. It was bulky stage 2 at presentation with an International Prognostic Index score of 1.

The patient received six courses of CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone). Following this there was no palpable disease but her computed tomography scan showed residual para-aortic lymphadenopathy with some calcification. A decision was taken to observe without further therapy.

She remained clinically very well until March 2000, when a right pelvic mass was palpable on clinical examination. She had an ultrasound scan followed by a computed tomography scan which showed pelvic lymphadenopathy and adnexal mass. In view of this she had two courses of mini BEAM (carmustine, etoposide, cytarabine and melphalan) (Chopra et al, 1992) in April–May 2000. A repeat ultrasound of the abdomen showed a reduction in right iliac fossa nodes. This was followed by high-dose therapy (BEAM) with autologous bone marrow transplantation in July 2000. This was consolidated with radiotherapy (40 Gray in 20 fractions) to the site of recurrence in the right pelvis in September and October 2000, and subsequent evaluation was consistent with remission.

Following mild elevation of lactate dehydrogenase levels in November 2002, she had an ultrasound and computed tomography scan which showed a complex ovarian mass of 7×4 cm on her right side, with no evidence of significant lymphadenopathy (Figure 1). A biopsy showed relapse of lymphoma and a bone marrow sample was normal. The pelvic mass was removed laparoscopically in June 2003, and turned out to be an ovary completely replaced by a solid lobulated tumour. Histology showed high-grade B-cell non-Hodgkin's lymphoma similar to her previous disease (Figures 2 and 3). She had three courses of adjuvant chemotherapy with R-ESHAP (Velasquez et al, 1994) (rituximab, etoposide, methylprednisolone, cytarabine and cisplatin) in July 2003. Following this she has remained in complete remission for more than 5 years.
Gingival overgrowth secondary to amlodipine
Authors: Dubrey Simon W , Grocott-Mason Richard
Published: May 2014

A 66-year-old Asian woman attended for optimization of blood pressure control. Prescribed medication included atenolol (50 mg once daily), bendrofluazide (2.5 mg once daily) and amlodipine (5 mg once daily). She complained of gingival overgrowth, occurring several months after starting amlodipine (Figure 1).
Should we admit patients with haematological malignancy to intensive care?
Authors: Jones Chris , Hewson Russ , Ramessur Suneil
Published: May 2014

Intensive care physicians are increasingly aware of the need to appropriately manage limited resources, so the admission of patients with haematological malignancy can be controversial because there is a perception of poor prognosis regardless of intervention. While this was true in the 1980s – one study showed an in-hospital mortality of 78% (Lloyd-Thomas et al, 1988), another an intensive care mortality of 90% for those requiring ventilation and renal replacement (Brunet et al, 1990) – survival rates are improving. Kroschinsky et al (2002) studied similar patients and showed an overall intensive care mortality of 44%, although the sub-group of ventilated patients still had a mortality of 74%.
A guide to surviving nights
Authors: Vamadeva SV
Published: May 2014

Since the introduction of the European Working Time Directive (EWTD) very few foundation year 1 trainees are expected to work night shifts. In the pre-EWTD era nights were induction by fire, a large amount of responsibility bestowed upon trainees just out of medical school with very little supervision provided. Although this meant trainees had little or no rest periods and minimal dedicated training during a shift, it did provide an excellent environment for self-directed on the job learning. Currently junior doctors are usually first exposed to night shifts from foundation year 2 onwards and are able to benefit from their extra year of work experience. Whether you're about to start a set of nights as a surgical or medical junior or those dreaded accident and emergency nights, the following advice is offered.
A guide to assisting at surgical operations 2: handling surgical instruments
Authors: Whalan Comus
Published: May 2014

During most operations, the instruments are kept on the scrub nurse's trolley. Here they can be kept regimentally clean and ordered. The surgeon (or assistant) can therefore simply ask for an instrument, hold out one hand without taking his or her eyes off the operation, and the instrument will appear in the hand, correctly oriented and ready for instant use. It is therefore bad practice to hoard instruments out of the scrub nurse's reach, just in case you might need them at some later stage of the operation. For the same reasons, you should also avoid helping yourself to instruments from the trolley: you are being treated to silver service, so don't turn it into a buffet.
A day in the life of an orthopaedic house officer
Authors: Ahmed Alia
Published: May 2014

Orthopaedics is a busy specialty with a high inpatient turnover and heavy outpatient workload. The orthopaedic team relies on its foundation doctors to manage ward patients effectively as well as dealing with on-call commitments. As a taster of what to expect, or as helpful tips for a current job, the following is a guide to a day in the life of an orthopaedic house officer.
Being a junior doctor today
Authors: Al-Shakarchi Israa
Published: May 2014

‘Can you write 1000 words on what it's like to be a hospital senior house officer by Monday?’ Prof enquired. Ironically he asked as my three fellow senior house officers and I were in a meeting with the hospital junior doctors welfare officer, discussing our miserable, overworked, under-paid, unappreciated lives. I did warn him that my input may be dark and jaded, but he wasn't listening. He was already gone, eyes glazed over with the warmth of nostalgia, recounting how much ‘fun’ he'd had when he was a senior house officer. After several minutes the glaze faded, and he slowly wandered off down the corridor muttering something about fun and frivolity before bestowing me with artistic licence to write as I pleased.
Subcuticular stitch: a review of various methods
Authors: Durai Rajaraman , Ng Philip CH
Published: May 2014

Subcuticular stitching was developed by several generations of surgeons (Fisher et al, 1980) and is often used to close the skin of various wounds. It has the advantages of being cosmetic and may not require removal, preventing a postoperative visit and any pain relating to stitch removal. It does not alter the size of the scar (Winn et al, 1977; Alam et al, 2006). In children removal of stitches may be traumatic (Wright, 1975), so subcuticular stitches are preferable. Subcuticular stitches are suitable for closure of various wounds ranging from laparotomy to laparoscopic port site wounds (Buchweitz et al, 2005).
So you want to be … a maxillofacial surgeon
Authors: D'Sa Sapna , Brennan Peter A
Published: May 2014

Maxillofacial surgery (or to give the speciality its full title oral and maxillofacial surgery) has long had a veil of mystery associated with it. Maxillofacial surgical trainees were seen as a rare breed of people who did a dental degree followed by a medical degree before embarking on their surgical training. However, changes have been afoot for several years and there are now increasing numbers of people in the speciality whose primary qualification is medicine with a secondary degree in dentistry.
Serum or plasma urea and electrolytes
Authors: Crook MA
Published: May 2014

Serum or plasma urea and electrolytes, sometimes called U/Es, is one of the most commonly requested test profiles from clinical biochemistry laboratories and is useful in many clinical situations. Although usually urea and electrolytes refer to urea (sometimes called blood urea nitrogen) as well as sodium and potassium, it often includes creatinine determination as well, although some laboratories require this to be ordered separately or instead of urea. For the sake of completeness creatinine will also be discussed in this article.
Types of research study: a guide for the foundation year doctor
Authors: Andreatta Walter , Kothari Alka , Trivedi Deepali , Hooke Rachel
Published: May 2014

In order to critically appraise a paper, a fundamental skill for practising evidencebased medicine, it is essential to be able to recognize whether the author(s) chose an appropriate study design (Sackett et al, 2000). This article gives the reader a general overview of the different types of studies and their significance.
Tuberculous psoas abscess mimicking soft tissue tumour
Authors: Wijesekera Nevin T , Riddell Angela M , Moskovic Eleanor
Published: May 2014

A 62-year-old Caucasian school dinner lady presented to her family doctor with a 2-year history of recurrent urinary tract infections. She was otherwise well, with no significant past medical history. Full blood count, urea and electrolytes, and bone biochemistry were normal. Urine culture was sterile. An abdominal ultrasound scan detected a left-sided mass in the iliolumbar region and scarring of the left kidney. The patient was referred to the authors' sarcoma unit with a suspected retroperitoneal soft tissue tumour causing obstructive renal damage.
Via the lungs or the veins?
Authors: John Sherine , Jigajinni Suyogi , Pushpanathan Ellile , Sultan Pervez
Published: May 2014

Volatile agents have been used in anaesthesia since the 1840s and intravenous anaesthetic agents were developed in the 1930s. The technique of using intravenous agents for induction and maintenance (total intravenous anaesthesia) has now gained popularity. This article explores some advantages and disadvantages of volatile (inhalational) based and total intravenous anaesthesia techniques.
Bare below the elbows policies: unnecessary bureaucracy
Authors: Sorene Elliot D
Published: May 2014

A knee-jerk reaction is defined in non-medical terms as ‘an automatic readily predictable response’, while the classical medical definition emphasizes that the outgoing message bypasses the core of the central nervous system. The current bare below the elbows policy, as advocated by the Health Secretary Alan Johnson in September 2007, seems to fit these definitions. It is an ill thought-out and evidence-deficient policy that was more of a response to the popular press than a true solution to the problem of hospital-acquired infections. This editorial looks at some of the key elements in that policy as well as some of the others that should have been included in the original package to tackle hospital-acquired infection.
Chylous ascites: an unusual case
Authors: Manikpure Gaurav , Hamlin Peter J , Tolan Damian , Edward Sara , Prescott Stephen
Published: May 2014

A 70-year-old man presented with 6 weeks' history of increasing abdominal distension and shortness of breath. He was completely independent before this admission. Relevant past medical history included a recent normal colonoscopy for altered bowel habit. Although abstinent for 1 year, his alcohol consumption had been up to 100 units/week for over 50 years. He was on no medications and had never smoked. Clinical examination revealed massive ascites. Bloods on admission showed a normal platelet count, mild anaemia, haemoglobin 11.4 g/dl and mild renal impairment, urea 10.4 mmol/litre and creatinine 140 umol/litre. Liver function tests and a full liver screen including hepatitis virus B and C, autoantibodies, alfa-fetoprotein and ferritin were normal. Ultrasound of the abdomen showed a nodular liver suggesting cirrhosis with widespread ascites. Chest X-ray was normal. Ascitic fluid aspiration revealed milky white ascitic fluid with a very high triglyceride content of 17.4 mmol/litre (normal <2.2 mmol/litre) in keeping with chylous ascites and negative for microbiology including acid-fast bacilli. The ascites did not respond to diuretic therapy.

He suffered a sudden respiratory arrest and was resuscitated and transferred to the high dependency unit. Therapeutic abdominal paracentesis was performed, draining 5 litres of chylous fluid. Urgent computed tomography of the chest, abdomen and pelvis showed a right pulmonary artery embolus and bilateral femoral vein thrombosis. Bony metastases were also identified throughout the axial skeleton, with para-aortic lymphadenopathy and a large nodal mass in the small bowel mesentery (Figure 1). The radiological differential included prostate cancer and lymphoma. Prostate-specific antigen was elevated at 1611 ug/litre (normal < 5 ug/litre) and subsequent computed tomography-guided biopsy of the mesenteric mass revealed fibro-fatty connective tissue infiltrated by tumour cells with immunohistochemistry positive for prostate-specific antigen, consistent with extensive metastatic prostate cancer with nodal and bony metastases (Figure 2). Hormonal treatment with leuprorelin acetate and bicalutamide was started on transfer to urology but unfortunately his clinical condition deteriorated, and he died 2 months later.
Treating restless legs syndrome with rotigotine
Authors: Reading Paul
Published: May 2014

Restless legs syndrome has attracted increasing interest as a clinically significant, common and treatable disorder. Good evidence suggests that dopaminergic drugs are the most effective first-line agents when symptoms are severe.
Assuring and maintaining quality in clinical education
Authors: Barrow Mark , McKimm Judy
Published: May 2014

Clinical teachers need to evaluate the quality and effectiveness of their teaching. Evaluation of teaching and learning generally occurs within quality assurance frameworks that have common features. Understanding quality assurance systems and evaluation methods will help clinical teachers to improve the student learning experience.
Follicular lymphoma: managing an indolent malignancy
Authors: Hallam Simon , Montoto Silvia
Published: May 2014

Follicular lymphoma is by far the most common indolent non-Hodgkin lymphoma worldwide. Management is complicated by difficulty in accurately predicting individual outcomes and judging whether, when and how best to intervene. This article illustrates key issues in the management of this fascinating and enigmatic disease.
Anaesthetic consent: how much information and when?
Authors: Combeer Elizabeth
Published: May 2014

Autonomy refers to an individual's right to ‘self-govern’, to run one's own life and make one's own decisions. Respect for autonomy (along with justice, beneficence and non-maleficence) is one of the moral principles underpinning medical ethics (Beauchamp and Childress, 2001). The Association of Anaesthetists of Great Britain and Ireland regards autonomy as the most important of the four principles (Association of Anaesthetists of Great Britain and Ireland, 2008; Wee, 2009).
Should all patients be placed head down for internal jugular vein catheter insertion?
Authors: Carle C , Ashworth A , Gavin N
Published: May 2014

Traditional teaching states that all patients undergoing internal jugular vein catheterization should be placed in the head-down position so that the site of cannulation is below the level of the right atrium. The resulting internal jugular vein distension allows easier identification of the vessel and reduces cannulation-associated complications (carotid puncture, pneumothorax or venous air embolism).
Intensive therapy of the patient with liver disease
Authors: Rylah B , Vercueil A
Published: May 2014

Liver disease is a subject of increasing importance in the UK, with a steadily rising incidence. It is an important cause of death in young adults, and the initial presentation of liver disease is frequently complicated by critical illness.
National Association of Clinical Tutors UK: 40 years of achievement
Authors: Nathavitharana KA
Published: May 2014

The National Association of Clinical Tutors UK continues to be pivotal in shaping medical education, with relevance to trainers and trainees alike. This review examines the development of the National Association of Clinical Tutors UK, highlighting its accomplishments in supporting medical teachers in the NHS.
Cranial computed tomography 1: technical aspects for clinicians
Authors: Thomas Robert H , Burke Christopher J , Howlett David
Published: May 2014

The importance of cranial computed tomography in the diagnosis and follow up of intracranial pathology cannot be underestimated. Clinicians at every level should have a basic understanding of this technique. This first of two articles looks at the technical strengths and weaknesses of cranial computed tomography, and cranial anatomy.
Spontaneous intracerebral haemorrhage: a clinical review
Authors: Gupta RK , Jamjoom AAB , Nikkar-Esfahani A , Jamjoom DZA
Published: May 2014

This article provides a clinical overview of spontaneous intracerebral haemorrhage, focusing on clinical aspects of the aetiology, diagnosis and management (both in the emergency department and in a critical care environment) of this important and devastating condition.
Cerebral venous sinus thrombosis: a diagnosis not to be missed
Authors: Imtiaz Komal E , Rajpara Sanjay , Majeed Tahir
Published: May 2014

A 47-year-old woman was admitted with a severe headache of 5 days' duration, vomiting and collapse with transient loss of consciousness in December 2002. She had been taking black cohosh, a herbal preparation containing plant oestrogen for menopausal symptoms, for 2 years. Her father had a history of pulmonary embolism and her sister had systemic lupus erythematosus. Clinical examination was normal except for slight neck stiffness and photophobia. Brain computed tomography was normal and lumbar puncture revealed normal CSF; CSF pressure was not recorded. Her symptoms improved slowly and she was discharged home with an appointment with the neurologist arranged as an outpatient.

Five days post-discharge from the hospital, she was readmitted because of the persisting headache and was found to have papilloedema on neurological examination. Chest X-ray, full blood count, erythrocyte sedimentation rate, clotting screen, urea and electrolytes, liver function tests, serum glucose, immunoglobulins, complement and autoantibody screening were normal or negative. Magnetic resonance imaging and venogram showed deep venous thrombosis in the superior sagittal sinus (Figure 1). She was anticoagulated with heparin followed by warfarin. Her headaches settled and she was discharged home 8 days later.

Further investigations confirmed heterozygosity for the prothrombin gene variant (G20210A). She continued to describe ‘pressure headaches’ with tinnitus. Repeat brain magnetic resonance imaging and venogram was normal in 2004. Her headaches recurred and the diagnosis of secondary intracranial hypertension was made and acetazolamide and bendrofluazide were commenced. Further magnetic resonance imaging of the brain with venogram in September 2007 revealed a hypoplastic left transverse sinus and patent superior sagittal sinus. She was referred to the neurosurgeons and had a lumbo-thecal peritoneal shunt insertion in November 2007 with improvement in her symptoms, despite a small frontal subdural collection on brain computed tomography postoperatively, which had resolved on repeat magnetic resonance imaging in March 2008. She is regularly followed up in the neurology and ophthalmology clinics for residual bilateral papilloedema and left amblyopia and continues on ramipril, bendrofluazide and warfarin.
Radiology of acute skull and facial injuries
Authors: Counsell A , Khan SHM
Published: May 2014

Facial trauma is frequently seen in day-to-day practice as a casualty doctor, often resulting from road traffic accidents, sporting injuries and assaults.
Cubital tunnel syndrome
Authors: Anderton Michael , Webb Mark
Published: May 2014

Cubital tunnel syndrome is the second most common peripheral entrapment syndrome after carpal tunnel syndrome (Fernandez et al, 1998). It is a chronic neuropathy of the ulnar nerve, resulting in a sensory, motor or mixed neuropathy. It is most commonly seen in adults and affects twice as many men as women. The incidence is thought to be rising, in part as a result of the use of mobile phones, during which the elbow is held in sharp flexion for prolonged periods (Darowish et al, 2009).
An approach to assessing the chest radiograph
Authors: Sethi R , Khan SHM
Published: May 2014

The chest X-ray is the most commonly requested radiological investigation but remains one of the most difficult to interpret. The spectrum of disease encountered within the thorax is vast and too extensive for this review. However, with a systematic approach, most of the crucial abnormalities on a chest film can be assessed. This article gives a basic approach to evaluating the chest radiograph and illustrates common and important conditions that are encountered in everyday practice.
Radiology of acute ankle injuries
Authors: Gummow AD , Khan SHM
Published: May 2014

Ankle injuries are extremely common conditions presenting to the emergency department. Ankle radiographs account for 10% of all plain films requested by the emergency department, fewer only than chest and cervical spine radiographs. Although most of these are sprains, typically from inversion injuries, several fractures are described.
Radiology of acute injuries to the hand and fingers
Authors: Porter NA , Khan SHM
Published: May 2014

As humans, our daily activities rely on our ability to perform intricate movements with our hands and fingers, as well as being able to perform powerful gripping actions. Consequently even seemingly minor injuries to the hands can have a significant impact on activities of daily living. Minor injuries to the hands and fingers are a very common cause of attendance of the accident and emergency department.
Recognizing advanced disease
Authors: Gadoud Amy , Johnson Miriam
Published: May 2014

Recognition of advanced disease is a key, but difficult, skill required by all clinicians; lack of competence has serious consequences for patient, caregivers and health service. This article summarizes features of advanced disease and the impact of realistic prognostication.
Doctor as professional and doctor as leader: same attributes, attitudes and values?
Authors: O'sullivan Helen , McKimm Judy
Published: May 2014

This article examines the links between medical professionalism and medical leadership and discusses how the values that are required to be a ‘good doctor’ are the same as a ‘good leader’. The potential of this overlap to inform the debate on developing and assessing both medical leadership and professionalism is evaluated.
Urinary tract obstruction
Authors: Iyasere Osasuyi , Xu Gang , Harris Kevin
Published: May 2014

Renal obstruction remains a common cause of renal failure. This article reviews the aetiopathogenesis, clinical features, investigations and management of urinary tract obstruction. It highlights the importance of prompt intervention to prevent long-term complications.
Infections in biological agents used in rheumatic disease
Authors: Byng-Maddick Rachel , Ehrenstein Michael
Published: May 2014

Immunosuppression and biological therapies are being used exponentially to treat inflammatory arthritis and connective tissue diseases. This article discusses the potential infectious complications of these therapies.
Managing impulse control behaviours in Parkinson's disease: practical guidelines
Authors: Macphee Graeme JA , Chaudhuri K Ray , David Anthony S , Worth Paul , Wood Brian
Published: May 2014

Impulse control behaviours are increasingly recognized as serious complications of dopaminergic therapy in Parkinson's disease. This article outlines a set of practical guidelines for management of these behaviours which have been developed by five experts from neurology, psychiatry and care of the elderly.
Mortality in a teaching hospital during junior doctor changeover: a regional and national comparison
Authors: Sharma Vijay , Proctor Ian , Winstanley Alison
Published: May 2014

Concerns about whether the junior doctor changeover in the UK is associated with an increased risk of death have been reawakened by a retrospective study ( Jen et al, 2009 ). Examination of overall mortality data has consistently failed to demonstrate any increase in mortality during the changeover. However, regional and national trends may mask this increase, so a study was undertaken to compare mortality in a busy London teaching hospital with regional and national trends. No evidence of an increase in mortality in August was found for any of the time periods examined, even after comparison with regional and national trends. The authors conclude that examination of overall mortality data is a blunt and impractical instrument for settling the question of whether an increase in morbidity and mortality occurs. Preventable morbidity and mortality should be audited.
Extra-levator abdomino-perineal excision in advanced low rectal cancer surgery
Authors: Dayal Sanjeev , Moran Brendan
Published: May 2014

The anatomy of the lower rectum can pose anatomical and technical challenges that can make excision of cancers in this region difficult. It is proposed that extra-levator abdomino-perineal excision optimizes the surgical treatment of advanced low rectal cancer.
Management of osteoporosis in patients with chronic kidney disease
Authors: Gupta Abhaya
Published: May 2014

Osteoporosis and chronic kidney disease are common in old age and often occur together. Both diseases lead to increased bone fragility and fractures but with different pathophysiological backgrounds. This article reviews the challenges in diagnosis, evaluation and management of osteoporosis in patients with chronic kidney disease.
Self-regulation: what is the future?
Authors: Patterson Linda J
Published: May 2014

These last few months have been an extraordinary time for the medical profession. No-one can be unaware of the media interest in doctors, and their clinical performance (much coverage being highly critical), and also of the government's statements concerning the regulation of the profession. As the British Medical Journal leader put it, after the verdicts of the General Medical Council (GMC) on the Bristol heart surgeons were announced, ‘All changed, changed utterly’ (Smith, 1998a).
Lanreotide and beyond: extending the therapeutic horizons
Authors: Culler M
Published: May 2014

Thirty years after the growth hormone inhibiting effects of somatostatin were first described, greater understanding of its activities is opening the door to potential treatments for diabetes, cancer and other disorders. Recent identification of five somatostatin receptor subtypes is allowing treatment to be carefully targeted in order to maximize efficacy, and minimize unwanted effects.
The influenza virus
Authors: Stockton JD , Zambon MC
Published: May 2014

Influenza is a severe cause of morbidity and mortality throughout the world, resulting in annual outbreaks in all age ranges of the population. With an extensive animal reservoir the threat of emergence of a novel influenza virus, capable of causing a pandemic, has spurred research into novel therapies with which to fight the virus.
Dornase alpha and survival of patients with cystic fibrosis
Authors: McIntyre Ann-Marie
Published: May 2014

Dornase alpha can offer substantial clinical benefits to cystic fibrosis patients, but its long-term impact is as yet unknown. This article attempts to model the impact of continuous dornase alpha use on patient survival and its cost implications for the health-care provider.
Insulin lispro for the treatment of type 2 diabetes
Authors: Fisher Miles
Published: May 2014

Tight control can prevent complications in type 2 diabetes, and many patients will require insulin therapy to achieve this. Newer insulin formulations may offer some advantages with regard to patient convenience and a reduction inhypoglycaemia.
Use of apomorphine in Parkinson's disease
Authors: O'Sullivan John D , Lees Andrew J
Published: May 2014

Apomorphine is a dopamine agonist administered subcutaneously as intermittent injections or in a continuous infusion. It is useful in managing advanced Parkinson's disease, and provides an alternative to neurosurgical procedures. This review summarizes indications and practical guidelines for its use.
Measuring Surgical Outcome
Authors: Reeves Barnaby C , Browne John
Published: May 2014

A surgical outcome is any event or measure of a patient's health that may occur or change, for better or worse, as a result of an operation. The introduction of clinical governance has led to debate about how to monitor the quality of surgical services in the NHS. One method that has been proposed is the publication of data on surgical outcomes for named hospitals and surgeons (Dobson, 1998).
Quality assurance and locum doctors in NHS trusts
Authors: Heard SR
Published: May 2014

The Audit Commission has recently published its findings on the use of locums to provide service in the NHS. Cover Story: the Use of Locum Doctors in NHS Trusts (Audit Commission, 1999) considers the question of how to provide care for patients in the absence of permanent medical staff who, the report recognizes, are the optimum providers of medical care. Some 3 500 locums are employed throughout NHS trusts everyday for short-term absences relating to study leave, annual leave and sickness and long-term absences relating largely to unfilled vacancies and maternity leave.
Squamous cell carcinoma
Authors: Cook Chris , Watura Roland
Published: May 2014

An 85-year-old man was initially admitted with left-sided pleuritic chest pain and associated rib cage tenderness. Mild ankle oedema was the only other clinical finding. A chest X-ray at this time showed what appeared to be a simple and isolated rib fracture. The lungs were otherwise clear (Figure 1).
Psychiatric aspects of alcohol misuse
Authors: Dunn Nick , Cook Chris CH
Published: May 2014

Alcohol and psychiatric disorder have a complicated relationship. Certain important psychiatric syndromes arise from the toxic effects of alcohol and thiamine deficiency. Liver disease and hypoglycaemia are also associated with their own psychiatric syndromes. Many psychiatric patients also turn to alcohol as an easily available ‘medication’.
Treatment of psychiatric aspects of alcohol misuse
Authors: Naik PC , Brownell LW
Published: May 2014

Psychiatric disorders and alcohol misuse often coexist. This article outlines the clinical management of these comorbid disorders. It discusses and suggests therapeutic recommendations.
Effective gynaecological practice and evidence-based medicine
Authors: Maresh Michael JA , Semple David M
Published: May 2014

Today we are all expected to practice evidence-based medicine. However, there are many problems with regard to this in gynaecology, as in many areas, because the evidence base is sadly lacking. Obstetrics is much more advanced, with evidence based on randomized controlled trials being promoted heavily by Iain Chalmers, particularly in 1989 with the publication of Effective Care in Pregnancy and Childbirth.
Thyrotoxicosis and abdominal pain: atypical presentation in a middle-aged man
Authors: Bhattacharyya A , Tymms DJ
Published: May 2014

A45-year-old man was referred to the surgical assessment unit by his GP with a 1-week history of vomiting and severe abdominal pain. Marked tenderness was noted in the epigastrium and umbilical region. He was dehydrated with blood pressure 100/70 mmHg and pulse of 110/min. The rest of the initial examination was normal. Abdominal and chest X-ray, electrocardiogram, routine blood tests, including full blood count, liver and kidney functions, cardiac enzymes and serum amylase were normal as were the ultrasound scan of the abdomen and endoscopy of stomach and duodenum. Serum calcium was very high at 3.11 mmol/litre (normal 2.10–2.60) with a normal serum phosphate level.

Treatment with normal saline, frusemide and pamidronate (three daily doses of 30 mg each) reduced the serum calcium to 2.94 mmol/litre with little symptomatic improvement. He also had tremor and a small goitre when thyrotoxicosis was suspected and confirmed (free thyroxine 57.5, normal 9–24 pmol/litre; triiodothyronine 8.9, normal 0.8–2.7 nmol/litre; and undetectable thyroid- stimulating hormone, normal 0.4–4 mu/litre). Serum parathyroid hormone subsequently was reported as low (<5, normal 12–81pg/ml). He was treated with carbimazole 40 mg daily with remarkable improvement. Subsequently alternative causes of hypercalcaemia were excluded by a normal serum and urine electrophoresis, and bone scan. Serum calcium returned to normal in 3 weeks time. He received radioactive iodine, and became hypothyroid 5 months later. He had done well on follow-up with 75 μg thyroxine daily and serum calcium remained normal.
The junior doctor manager
Authors: Hooke Rachel L
Published: May 2014

Several organizations are employing junior doctor managers to help them implement and maintain controls on the hours worked by their colleagues, and to improve conditions. A person who has worked as a junior doctor is in a good position to understand these issues.
Violence towards doctors: prevalence and effects
Authors: Zahid MA , Al-Sahlawi KS , Shahid AA , Al-Ajmi MT , Awadh JA
Published: May 2014

Violence against doctors has already been identified as a matter of particular concern. Both the severity and the psychological sequelae of violence are difficult to quantify. This study was aimed at measuring the rates and severity, and determining the effects, of violence in doctors working in a general hospital.
Clinical governance: opportunity or Pandora's box?
Authors: Heard Shelley
Published: May 2014

This edition of Hospital Medicine begins an important series on clinical governance (p. 505). ‘Ho hum!’ you might say — surely not again! It seems that every journal and every conference has this subject as its primary focus. My response to this is ‘so they should’. The reasons for this come through clearly from the articles in this series. Four perspectives are covered — the historical and cultural context by Phil Ayres, the educational perspective by Peter Hill, a specialty perspective from Peter Connelly and a trust perspective by Ian Haslock. Different views but, in fact, the same message — clinical governance is the opportunity to get quality services addressing patients' needs to the top of the NHS agenda.
Training to treat cancer: future developments
Authors: Gerrard Georgina , Kiltie Anne E , Macdonald Rosemary G
Published: May 2014

Both medical and clinical oncologists treat patients with cancer, but these specialties receive markedly different training. A questionnaire was sent to all UK oncology trainees regarding training. Rotation to other cancer-related specialties was successfully piloted. Such rotations might enhance interprofessional working.
Diogenes syndrome: a case report
Authors: Sikdar Sudip
Published: May 2014

A rare syndrome, variously known as Diogenes syndrome (Clarke et al, 1975), senile breakdown (MacMillan and Shaw, 1966) and senile squalor, ischaracterized by extreme self-neglect, domestic squalor, social withdrawal, apathy, tendency to hoard rubbish and a blissful unconcern about one's living condition. It is periodically encountered among the elderly, and debate continues regarding the exact cause of the condition. A typical case with severe frontal lobe atrophy is presented.
An unusual cause of iron deficiency anaemia in an intravenous drug user
Authors: Younis N , Casson IF
Published: May 2014

A40-year-old intravenous drug user was admitted to the department of medicine with a painful swollen left leg. He freely admitted to injecting heroin (diamorphine) intravenously and had recently injected into his left leg. He had a 10-year history of illicit drug use and had previously attempted to stop with the use of methadone. There was no history of hepatitis, human immunodeficiency virus (HIV) infection or the sharing of syringes used for injection.

Clinical examination revealed a thin, unkempt, middle-aged gentleman, who had pallor of the skin and the mucous membranes. He had evidence of drug ‘tramline’ marks, venous thrombophlebitis in his groins and both upper and lower limbs (Figure 1). There was no evidence of lymphadenopathy or signs of endocarditis. Chest and abdominal examination revealed no abnormalities. He had evidence of swelling, erythema and tenderness in the anterior lower left leg and there was no calf tenderness. The signs in his leg were consistent with cellulitis. Initial investigations revealed a severe hypochromic microcytic anaemia, a haemoglobin level of 4.3 g/dl with low serum iron, low ferritin and raised iron binding capacity consistent with iron deficiency anaemia. Electrolytes, liver function tests and clotting were normal.

He was transfused four units of red packed cells and treated with intravenous antibiotics. He denied any history of maleana, haematemesis, rectal bleeding or haematuria. He denied usage of non-steroidal inflammatory drugs or aspirin. A Doppler ultrasound of his leg revealed no evidence of thrombus. A chest X-ray revealed no abnormalities. A transoesophageal echocardiogram showed no evidence of endocarditis. Tests for HIV, hepatitis B or C revealed no abnormalities. A gastroscopy revealed no abnormality and duodenal biopsies revealed no evidence of coeliac disease. Colonoscopy revealed no abnormality. Red cell isotope scanning using 51-chromium-labelled red cells and mesenteric angiography revealed no cause for blood loss. Repeated samples of urine revealed no red blood cells. He eventually admitted to injection with syringes into his groin, often hitting his femoral artery rather than the femoral vein, with concomitant loss of arterial blood on multiple occasions. We assumed that this was the most likely cause of his iron deficiency anaemia.
Issues in measurement
Authors: Davies Huw TO
Published: May 2014

Measurement lies at the heart of all quantitative methods in clinical, epidemiological and health services research. If the measures employed lack the essential features of validity and reliability then the conclusions drawn from empirical findings may mislead. This short article explains and explores the desirable features of measurement instruments used in health-care research.
Severe postoperative nausea and vomiting in a Parkinsonian patient
Authors: O'Brien Brian , Harmon Dominic
Published: May 2014

A 74-year-old woman was reviewed 6 hours postoperatively following a mastectomy and axillary clearance as she was vomiting and feeling nauseous. She had experienced a severe episode of emesis after surgery more than 10 years previously, which, she recalled, had lasted several days.
Medical publishing: how does it affect you?
Authors: Richardson Peter , Tinker Jack , Linssen Rebecca
Published: May 2014

Writing and publishing are an integral part of doctors' training alongside their clinical work with patients. This issue sees the start of a new series of articles for doctors covering various aspects of publishing and accessing information (p. 736). Here, over the next few months, you will be able to find expert advice on topics as diverse as writing a grant application, publishing a CD-ROM and finding health information on the Internet.
The management of alcohol-related seizures: an overview
Authors: Ahmed S , Chadwick D , Walker RJ
Published: May 2014

Alcohol-withdrawal seizures are one of the common medical emergencies. The seizures are generalized and usually occur abruptly between 6–8 hours after cessation of alcohol use (peak 12–24 hours). These patients are often uncooperative and therefore need careful assessment. Lorazepam is the first-line drug for termination and prophylaxis of alcohol-withdrawal seizures.
Disulfiram revisited
Authors: O'Shea Brian
Published: May 2014

Disulfiram can be important in helping motivated alcoholics to remain abstinent. Prescribers should be aware of disulfiram’s toxicity, and how to recognize and manage reactions. A number of other agents are available to help alcoholics remain sober, although these do not necessarily obviate use of disulfiram. Also, disulfiram may have a wider role in the management of the addictions, e.g. in cocaine use.
Repaglinide: a novel oral antidiabetic agent
Authors: Nattrass Malcolm
Published: May 2014

Repaglinide is a novel oral antidiabetic agent, marking the development of a new class of drugs for type 2 diabetes. This article examines repaglinide and its position in the treatment of type 2 diabetes.
Modern approaches to management of menorrhagia
Authors: Rogerson Lynne , Duffy Sean , Hawe Jed
Published: May 2014

Menorrhagia and its management is a common problem in both the primary health-care setting and in hospitals. There is an increasing number of options for management of menorrhagia and these will be discussed in this article.
Quadruple primary neoplasms in a 27-year-old woman
Authors: Wai HPS , Yau TK , Sze WM , Yeung MW , Lee AWM
Published: May 2014

A27-year-old woman was referred to our department on 3 February 1998 with a diagnosis of malignant melanoma associated with cystic teratoma of ovary. She had had a laparotomy and bilateral salphingo-oophorectomy on 5 January 1998. Pathology revealed tumour involvement of left ovary, left parametrium and malignant ascites, the right ovary showed polycystic disease, the uterus showed simple hyperplasia of endothelium, the omentum had no tumour and subdiaphragmatic scrapping was negative. On histological examination of the tumour, the cystic portion was basically a cystic teratoma with presence of skin, glial and bony tissue, the solid portion consisted of sheets of undifferentiated tumour cells, which on immunohistochemical staining shown strong positivity to HMB 45 and S-100. Ultrastructual examination confirmed melanocytic differentiation.

Her chest X-ray was clear. Computed tomography of abdomen and pelvis suggested bilobar liver metastasis and significant para-aortic lymphadenopathy. The alpha-fetoprotein (αFP) and beta-human chorionic gonadotrophin (β-hCG) were within normal limits. The diagnosis was a malignant melanoma arising in cystic teratoma of ovary, stage IV disease.

Her past medical history included multiple primary neoplasms. She had right thigh cutaneous histiocytoma at the age of 20 years, with complete excision performed. She developed poorly differentiated invasive ductal carcinoma of left breast (stage pT2N0M0) at the age of 21 years and had a left mastectomy and left axillary clearance; no postoperative adjuvant treatment was given. She also recently had multiple thyroid nodules which shown atypical cells, suggestive of a follicular neoplasm, and total thyroidectomy was contemplated.

Evaluation of her family revealed a strong family history of malignancy. Her twin sister died of a primary brain tumour at the age of 8 years. Her father died of lung cancer at the age of 45 years. Her paternal grandfather died of lung cancer in his 60s. Her paternal grandmother died of primary liver cancer in her 60s. One of her paternal half-uncles (mutual grandfather, different grandmothers) died of a primary brain tumour in his 50s while another died of lung cancer in his 70s. There was no positive family history of malignancy on her maternal side (Figure 1).

She was treated with combination chemotherapy using cisplatin (75 mg/m2) and cyclophosphamide (750 mg/m2). However, she deteriorated rapidly after the first cycle of chemotherapy and died on 16 March 1998.
The role of entacapone in the management of Parkinson's disease
Authors: Brooks David J , Forsyth Duncan , Playfer Jeremy R , Williams Adrian C
Published: May 2014

Catechol-O-methyltransferase (COMT) inhibition is an important advance in the treatment of Parkinson's disease. This consensus statement provides guidelines for the optimal use of the only currently available COMT inhibitor, entacapone (Comtess®, Orion Pharma (UK) Ltd, Newbury, Berkshire).
Continuous ambulatory peritoneal dialysis and uterovaginal prolapse
Authors: Dickson Malcolm J , Railton Angela
Published: May 2014

It has been estimated that 50% of parous women have some degree of genital tract prolapse and that 10–20% of these cause symptoms. Approximately 20% of women on gynaecological waiting lists for major surgery have prolapse and this rises to 60% of elderly women undergoing major gynaecological surgery (Cardozo, 1995). As the condition is very common it is extraordinary that there is so much uncertainty regarding the natural history of genital tract prolapse.
Developments in cardiac ultrasound
Authors: Plein Sven , Williams Gordon J
Published: May 2014

This article gives an overview of recent developments in cardiac ultrasound for the general hospital physician. It discusses contrast echocardiography, harmonic imaging, three-dimensional echocardiography, Doppler tissue imaging and perfusion imaging and give an outlook on future perspectives.
Effective transition from paediatric to adult services
Authors: Viner Russell
Published: May 2014

The effective transfer of adolescents from paediatric to adult services is a new quality issue confronting all health services. This article reviews current knowledge in the field and outlines good practice.
Educational supervision for PRHOs: getting it right?
Authors: Challis Maggie , Batstone Gifford
Published: May 2014

The New Doctor highlights aspects of educational supervision for preregistration house officers that may serve as a lesson for improving the educational experience of all doctors in training. On the basis of research carried out in mid-Trent, this article highlights some of the issues relating to the training of educational supervisors and how these need to be put into context if further advances in education and training are to take place.
Radical cystectomy and bladder substitution
Authors: Whittlestone TH , Persad R
Published: May 2014

The incidence of bladder cancer is rising. The main treatment for superficial bladder cancer is local resection and judicious use of intravesical agents. Radical cystectomy can cure organ-confined, invasive disease. The ileal conduit remains the gold standard following cystectomy. Newer methods of bladder substitution and nerve-sparing techniques have resulted in better tolerance of this treatment.
Chronic pancreatitis
Authors: Isla Alberto M
Published: May 2014

Chronic pancreatitis causes destruction of the pancreatic gland which leads to diabetes and malabsorption. Its principal cause is alcohol abuse, and intractable pain is the main clinical feature. The incidence of pancreatic carcinoma is increased among patients with chronic pancreatitis.
Magnetic resonance cholangio-pancreatography
Authors: Lomas David J , Gimson Alex
Published: May 2014

Magnetic resonance imaging can now offer a robust and non-invasive diagnostic alternative to the established imaging investigations of the biliary and pancreatic ducts. This article briefly reviews the underlying principles, technique, pitfalls and clinical applications.
Topical tacalcitol treatment for psoriasis
Authors: Harrison PV
Published: May 2014

Multiple studies have shown the benefit of topical tacalcitol treatment for chronic plaque psoriasis. Tacalcitol ointment 4 μg/g is efficacious and well tolerated as both monotherapy and in combination with other treatments such as ultraviolet light therapy. It can be used all over the body including the face and scalp.
Sources of hospital cross-infection and other problems: observations of an inpatient
Authors: Tylden Elizabeth
Published: May 2014

This article gives the patient's viewpoint of a recent stay in hospital. The author highlights a number of issues and discusses the implications of her observations for hospital practice in the UK.