bluuebunny/crossref_metadata_2025 huggingface dataset:
Into the deep dark wood
Authors: Christie Sue
Published: May 2014

Traditional fairytales and modern classics can be enhanced beyond the page by helping children bring elements of performance, role-play and interpretation into their interaction with their favourite stories.
iPads in early education
Authors: Kucirkova Natalia
Published: May 2014

Natalia Kucirkova considers the benefits and some downsides of introducing tablet technology into an early years classroom, sharing experiences from settings that have found ways of utilising their features.
Invest in quality and affordability
Authors: Lawson Deborah
Published: May 2014

The government has recently made a number of grants available to those working in the early years, but does the money being made available really constitute an investment for parents and providers?
What we can learn from…India
Authors: Chapman Ailsa
Published: May 2014

This month we continue our series of articles that use practical activities to introduce young children to different countries from around the world; this month we focus on the diversity of India.
Babies and their bubbles
Authors: Clarke Jenni
Published: May 2014

The simple pleasure of blowing bubbles is one that is enjoyed by many people, not matter how small they are, however, babies have an added fascination in all things that float, shimmer and pop.
All the words are stages
Authors: Sydonie Laura
Published: May 2014

How can theatre practices and dramatic techniques help young children to learn, retain and use a foreign language? Laura Sydonie explores the use of drama in a kindergarten environment in China.
The power of knowledge
Authors: Jefferies Tina
Published: May 2014

True professionals make their work seem easy, but it is based on the momentum of an ever evolving blend of study, experience and reflection, which requires discipline and commitment to active learning.
Building conversations
Authors: Jones Michael
Published: May 2014

Communication and the intricacies of language are high on the political agenda, and while these can develop from sustained talking, it is important that we ensure the quality of these interactions is high.
Aiming high for early literacy
Authors: Connor Joyce
Published: May 2014

The REAL project is helping children to develop communication and language skills by linking the setting and home learning environments, and is now being adapted for disadvantaged two-year-olds.
Fruits of the imagination
Authors: Harries Judith , Astill Mel
Published: May 2014

The fourth in a six-part series that looks at different ‘objects’ in art and how artists explored their subject matter as a stimulus for providing practical early years activities – this month, we focus on food in art.
A series of movements
Authors: Finlayson Keri
Published: May 2014

Our ability to move and to interact with other people and objects in the environment around us relies heavily on a sequence of movements, and a combination of both fine and gross motor skills.
Colour coding road play
Authors: Sharpe Deborah
Published: May 2014

Young children tend be fascinated by vehicles and ride-on toys, which can help you plan an activity that uses traffic lights and signals as a basis for developing their knowledge and awareness about road safety.
Promoting thinking skills through visible routines
Authors: Lewis Helen , Grigg Russell
Published: May 2014

Thinking is an active process, but it is not a natural function, which means it needs to be worked at – practitioners can help children by developing routines that help them to make their thoughts explicit.
Non-competitive striking games
Authors: Robinson Sharon
Published: May 2014

Developing the skill of striking a ball along the ground with the hand through a noncompetitive game activity with a partner. Sharon Robinson is a former PE teacher and member of the Surrey inspectorate. She is now a freelance consultant, specialising in physical education from early years to key stage 5.
Criminal Records Bureau: It's now time to deliver!
Authors: Ford Fiona
Published: May 2014

Anyone involved in recruiting staff will instantly recognise an acronym that has caused us all so much trouble over the past six months, the CRB. By Fiona Ford, early years development manager, Select Education Plc.
A week IN THE LIFE OF
Authors: Jenkinson Ron
Published: May 2014

OfSTED, the fight to prevent school closure, redundancies, and a visit from a bishop. This is all part of one very hectic week in the life of head teacher, Ron Jenkinson, King Alfred's School, Shaftesbury, Dorset.
Talking about TERRORISM
Authors: Thornton Stephanie
Published: May 2014

Troubled times pose tricky questions for teachers. Can we protect the young from the anxieties of a tense political situation? Should we even try?
Creative design skill development
Authors: Rogers Maggie
Published: May 2014

Maggie Rogers, senior lecturer in D&T education at Goldsmith's College, University of London, has plenty of useful advice to ensure that children can get the most from their design experiences.
Inclusion is the name of the Brindishe game
Authors: Salmon Kathy
Published: May 2014

This article sets out a model for inclusive practices and gives examples of how these are put into operation in Brindishe School. By Kathy Salmon, a learning support co-ordinator at Brindishe, Lee, south east London.
Get your point over COMMUNICATION
Authors: Thornton Stephanie
Published: May 2014

Giving instructions is at the heart of managing a busy classroom. It is the core of teaching, says Stephanie Thornton. But why are our instructions so often misunderstood?
An area to get your head around
Authors: Walker Sam
Published: May 2014

Sam Walker a maths teacher from King's College Junior School, Wimbledon, shows how useful area and perimeter skills can be.
Learning the language of HAPPY TALK
Authors: Cosh Jackie
Published: May 2014

Children with speech or language difficulties benefit enormously from confidence-boosting activities. Jackie Cosh, a freelance writer from Glasgow who specialises in children and education, explains.
Just a touch of poetic licence
Authors: Strong Martin
Published: May 2014

Martin Strong, literacy co-ordinator at Ulcombe CE Primary School in Kent, outlines a touchy-feely approach to writing poetic sentences with a year 1 class.
My Sikh Faith
Authors: Eades Jennifer
Published: May 2014

Use Sikh stories to provoke reflection, and awareness of other opinions, as well as to develop strategies important to literacy and religious education. By Jennifer Eades, a writer and education consultant.
Warm welcome, then the Ofsted bombshell
Authors: Nixon Sam
Published: May 2014

Columnist Sam Nixon started this term as a newly qualified teacher. He teaches a year 6 class at St Saviour's Primary School in Larkhall, Bath, while not writing for Five to Eleven.
Write your very own pop song
Authors: Iannuzzelli Paul
Published: May 2014

In this lesson, children get to write songs and stage their very own pop TV show. By Paul Iannuzzelli, a songwriter and education consultant for Dante Rhymes, Walton-On-Thames, Surrey.
Nowhere to run, nowhere to play
Authors: Rhodes Liz
Published: May 2014

Is the well-being of children being damaged by an over-protective culture?
Pupils getting some perspective: ARTScool makes art cool
Authors: Ross Emily
Published: May 2014

ARTScool 2005 is a unique festival celebrating the creativity of children in Crewe. Emily Ross spoke to Sharon Ayres, the art development manager who organised the event
Going to a new frontier
Authors: March Ally
Published: May 2014

What is the best way to ensure a smooth transition when the new children come from foundation stage into year 1? Ally March discusses
Clever Anansi and Boastful Bullfrog
Authors: Rhodes Liz
Published: May 2014

This is a traditional African tale which helps teach moral standards to children. Liz Rhodes, a primary school consultant from Exeter, discusses ways to teach this fable to year 2
Using your whiteboard
Authors: Biggins Yvonne
Published: May 2014

In this month's guide, Yvonne Biggins outlines some cross-curricular literacy activities using an interactive whiteboard
I am the Music Man
Authors: Rhodes Liz
Published: May 2014

Explore instruments with your children! Liz Rhodes shows how this can be done with this exuberant book in a Year 2 class
An electronic village
Authors: Palmer Sue
Published: May 2014

In the next part of her series on how modern life is damaging children, Sue Palmer looks at the effects of a screen-based lifestyle on the developing brain
A tuneful inclusion
Authors: Lea Zoe
Published: May 2014

Music is a great way to help children understand cultural differences. Music can also control behaviour, encourage group work and most importantly – it's great fun
Understanding faiths
Authors: Johnson Emma
Published: May 2014

Emma Johnson, an RE co-ordinator and key stage 1 teacher from Hampshire, suggests how to teach the basics about some key religious texts for your year 2 class
Repairing self-esteem
Authors: Thornton Stephanie
Published: May 2014

What should a teacher do, when a child has low self-esteem? What, for that matter, can a teacher do?
Coughs in the classroom
Authors: Steele Chris
Published: May 2014

Teachers come into contact with a variety of common illnesses in the classroom. But where is the line drawn between a letter home and more serious action?
Codes and ciphers
Authors: Hynson Colin
Published: May 2014

Elizabeth Hoad uses maps to help children with compound words and prefix words.
Story-time: a pleasurable public moment
Authors: Rosen Michael
Published: May 2014

Michael Rosen is presenting a new series on the benefits of reading aloud to children. 5TO7 interviews him on his opinion of how literacy is taught in schools
You can use ICT to …
Authors: Cogill Julie
Published: May 2014

The whiteboard revolution is here. It is transforming learning in schools. Julie Cogill gives you some hints which will help you create inspiring, fun lessons
Weight of the world
Authors: Kern Merilee
Published: May 2014

Childhood obesity is fast becoming a nationwide epidemic, and far too many educators don't have adequate information or resources when it comes to teaching
Working with the IT crowd
Authors: Mill Patsy
Published: May 2014

Is education ready for the implications of the information technology revolution? Do we even understand what those implications actually are?
Wash to beat the worms!
Authors: Smith Elaine
Published: May 2014

Almost one in two children under the age of 10 get threadworms. Effective hand washing is key to help prevent threadworms from spreading between children
The Lion, the Witch and the Wardrobe
Authors: Eades Jenny Fox
Published: May 2014

This classic tale by CS Lewis can be used with children in key stage 1 to help them develop thinking and speaking skills
When to start school?
Authors: Thornton Stephanie
Published: May 2014

Are five-year-olds too young to start formal schooling? Stephanie Thornton discusses whether there is a perfect age to start
Number assessments
Authors: Dabell John
Published: May 2014

John Dabell explores different exercises as ways of practicing with children time, counting and symmetry
Making a class book
Authors: Cruickshank Sarah
Published: May 2014

Most young children love books and find the idea that they can make their own very exciting. Sarah Cruickshank introduces this lesson for year 1 children
National smile month
Authors: Hammond's Paula
Published: May 2014

Paula Hammond's science activities focus on what we can do to look after our teeth, reduce the build up of plaque and help to stop decay
Chocolate everything day
Authors: Hammond Paula
Published: May 2014

This assembly reminds children how important it is to be good to others-and good to themselves
Snakes, ducks, silences
Authors: Kriworuchko John
Published: May 2014

This multi-purpose lesson for year 1 aims to develop a number of important skills at the same time. John Kriworuchko explains
Whatever the weather
Authors: Hammond Paula
Published: May 2014

February 5 is Weather Man Day. Therefore, this month, we will be giving the children the chance to become classroom weather boys and girls. During the course of the week, they will have the chance to:
Creating an outside space Playgrounds and gardens
Authors: Baker Shari
Published: May 2014

Do you have a dull and grey flat piece of tarmac, instead of a creative outdoor play space? Shari Baker looks at the various grants available to help your school turn that space into a fun and stimulating play area.
How can charity registration help your PTA?
Authors: Galbraith Jane
Published: May 2014

Jane Galbraith from the National Confederation of Parent Teacher Associations (NCPTA) explains the benefits of charity status and offers a guide on how to acheive this.
what the journals say
Authors: Williams Julia
Published: May 2014

It is widely acknowledged that patients awaiting major surgery experience feelings of vulnerability. This becomes more apparent in patients with cancer as their fears of the unknown intensify. These concerns include the outcome of surgery, the hospital experience, lose of control, both physically and psychologically, and fear of what they might be told with regard to their prognosis. Previous studies have highlighted how patients stress that an important aspect of their care is for nurses to have opportunities to listen to and understand their needs. This illustrates the importance of information, coping strategies and the need to reduce anxiety and stress in relation to surgery. The way in which nurses meet patients, communicate the extent of understanding of their suffering, including their existential suffering, is an important aspect of nursing care.
The lived experience of stigmatisation in patients after stoma reversal
Authors: Owen John , Papageorgiou Alexia
Published: May 2014

Aim: This small−scale, exploratory, qualitative study was conducted to investigate how the experiences of having a stoma and subsequent stoma reversal affected the lives of the participants.Method: Five participants were interviewed about their experiences. Manual thematic analysis, using Interpretive Phenomenological Analysis (IPA), was employed to interpret the data. Results: Common themes were identified as emerging from the data. Themes before reversal were: acceptance and coping; social impact; and anticipation of returning to normal. Post−reversal themes were: returning to normal; interference with anticipated return to normal; and ongoing social impact. Conclusion: This exploratory study provides a rich account of the experiences of stoma patients who underwent reversal operations. It enhances our understanding of the transition encountered when changing from a person with a stoma into someone without one. This research has found that the anticipated return to normal can be hampered by a mix of physical and psychological processes.
Back to basics: Teaching gastrointestinal anatomy and physiology to qualified nurses
Authors: Boyles Anna
Published: May 2014

As expert practitioners, clinical nurse specialists are ideally placed to improve the knowledge and skill levels of other professionals. They carry out this aspect of their role in a variety of arenas from large formal sessions to one-on-one teaching in the clinical area. In this article, Anna Boyles examines a new method of maximizing the effectiveness of learning experiences provided by the stoma care department at King′s College Hospital. She discusses pertinent theories of adult learning and how this has led to the development and delivery of a new, experiential approach to teaching gastrointestinal anatomy and physiology, a topic that remains at the centre of good nursing practice.
Promoting innovation
Authors: Cooper Joanne
Published: May 2014

When you hear or read the word 'research', what do you feel? Excitement, interest, or perhaps a sense of anxiety or dread? From my own experience and within my current role at United Lincolnshire Hospitals NHS Trust, it is the latter feelings that are often felt by staff when attemping to raise the profile of nursing research and innovation. However, with relevant education, training and support, I am convinced that nurses are not only well able to undertake high quality health-care research, but are uniquely positioned to identify and apply clinically relevant research questions.
Using patient reported outcome measures to improve patient care
Authors: Whiteing Nicola , Cox Carol
Published: May 2014

Patient reported outcome measures (PROMs) are an effective mechanism for gauging the patient experience as well as whether patients perceive their health outcomes have been achieved. Gastrointestinal nurses need to understand and determine the type of PROM to be used with their patient population in order to help improve the patient experience, argue Nicola Whiteing and Carol Cox.
Tried and tested: Ten years' experience of infliximab in inflammatory bowel disease
Authors: Greveson Kay
Published: May 2014

Medical treatment for Crohn’s disease and ulcerative colitis aims to provide rapid, effective relief from symptoms, modify the disease process and improve quality of life. Where disease is refractory or resistant to first-line medical therapy, biological therapies are used. Kay Greveson considers the use of anti-tumour necrosis factor alpha (anti-TNFα) therapies in inflammatory bowel disease, focusing on infliximab and examining the breadth of clinical data that has emerged which can provide specialist nurses with confidence in recommending its use
Stoma and peristomal complications: Predisposing factors and management
Authors: Boyles Anna
Published: May 2014

Studies have suggested that 21–70% of people living with a stoma and undergoing stoma-forming surgery will experience complications (Leenen and Kuypers, 1989; Bass et al, 1997; Shellito, 1998), with the likelihood of problems increasing over time following surgery. Anna Boyles outlines what is considered normal in terms of stomal and peristomal appearance and function, and examines the predisposing factors that may make complications more likely. Methods of preventing and treating complications are also considered.
How nurse specialists can demonstrate their worth
Authors: Leary Alison
Published: May 2014

In these difficult times it is essential that you, as a nurse specialist, understand your value both financially and in terms of the quality of work you undertake and are able to communicate your value in your Annual Report or to your managers. In this article, Alison Leary discusses the importance of understanding and demonstrating your value as a nurse specialist, and provides tips on how to do so.
Impact of stoma care on enhanced recovery after colorectal surgery
Authors: Burton Julie , Allison Joanna , Smart Neil , Francis Nader
Published: May 2014

A stoma has a substantial impact on patient quality of life and within the enhanced recovery protocol; all efforts are made to improve patient care, reduce complications and shorten hospital stay after colorectal resection. In this article, Julie Burton, Joanna Allison, Neil Smart and Nader Francis discuss the literature surrounding the impact of stoma formation on enhanced recovery after elective colorectal resections. The factors that influence this are discussed including type of surgery, type and site of stoma, early complications and preoperative stoma training. Practical stoma education, optimum communication and patient motivation are outlined as essential components of pre-operative care. Strategies to reduce stress after early discharge are also addressed, alongside the impact of early stoma complications on length of stay. Optimum support from the stoma care nurse specialist both in secondary care and the community are also explored.
Endoscopist’s thumb and other injuries
Authors: Mair Sheila
Published: May 2014

The demand for gastrointestinal endoscopic examinations has increased as a result of various factors including the advent of bowel screening and advances in endoscopic therapeutic treatment. The risks to patients are now well known. Less, however, is known about the risks to the staff carrying out these procedures. In this article, Sheila Mair discusses repetitive stress injury as a risk to endoscopists.
National Institute for Health Research leading the way for GI research
Authors: Rhymes Christopher
Published: May 2014

Clinical research is important to ensuring evidence-based care, which is why in 2006, the Department of Health set up the National Institute of Health Research (NIHR). In this article, Christopher Rhymes describes the role of the NIHR and the development of the Clinical Research Networks. The work of the networks and the gastrointestinal research portfolio is discussed. The benefits for patients, researchers and organizations in participating in NIHR portfolio research is described and how working with your local network can help you unblock the blocks in getting your study open and recruiting.
Management of acute upper gastrointestinal bleeding
Authors: Vikramjit Mitra Dr. , Benjamin Marrow Dr. , Manu Nayar Dr.
Published: May 2014

Acute upper gastrointestinal bleeding (AUGIB) is a major medical emergency. In 2007, a UK-wide GI bleed audit showed an overall mortality of 10% in patients admitted with AUGIB. Following results of this audit, both SIGN (Scottish Intercollegiate Network Guidelines) and NICE (National Institute for Health and Clinical Excellence) have published guidance on the management of this common and challenging gastroenterological condition to improve the standard of care for people with AUGIB. In this article, Vikramjit Mitra, Benjamin Marrow and Manu Nayar describe an evidence-based approach to the management of this common and life-threatening condition and review the literature around this topic.
The impact of stoma formation and enhanced recovery in the elderly
Authors: Lowther Claire
Published: May 2014

By 2031 the number of people aged 65 and over in the UK is expected to be more than 15 million—nearly a quarter of the population (Office of National Statistics, 2010). Caring for older people has always been one of the top priorities for hospitals, yet it requires special expertise (Royal College of Nursing, 2004). In this article, Claire Lowther focuses on how age can affect a person’s health and recovery, with particular reference to enhanced recovery and stoma care.
Buried bumper syndrome: a challenging complication of PEGs
Authors: Ramdass Debra , Mann Steven
Published: May 2014

Percutaneous endoscopic gastrostomy (PEG) feeding is the standard technique for long-term administration of enteral feeding to patients with an intact gastrointestinal tract. Its use is widespread and the procedure is technically straightforward in most cases. Buried bumper syndrome (BBS) is a complication that has been widely reported to be associated with sub-optimal post-procedure care. The condition is a challenge to manage. Debra Ramdass and Steven Mann describe a case of BBS and review the literature for its prevention and management.
An overview of inherited intestinal polyposis syndromes
Authors: Neale Kay , Cuthill Vicky
Published: May 2014

Inherited intestinal cancer syndromes are more commonly known as ‘polyposis’ or ‘hereditary non-polyposis colorectal cancer’ (HNPCC; commonly referred to as Lynch syndrome). They include familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome (PJS), juvenile polyposis syndrome (JPS), MYH associated polyposis (MAP), and serrated polyposis syndrome (SPS). This article will provide a history of and an introduction to the genetics of polyposis syndromes, which will be discussed in greater detail in a series of articles that will follow this one and will end with an article on Lynch syndrome. The term ‘inherited’ refers to the fact that these syndromes are caused by genetic mutations inherited from one generation to the next. In the last 20 years, genetic testing has revolutionised the clinical care of patients. With modern technology, an increasing number of conditions are shown to have a genetic cause. It is therefore vital that gastrointestinal nurses have a working understanding of this science and how it affects the care of patients.
Partnership or privatisation? An NHS Trust's experience of sponsorship
Authors: Burton Julie
Published: May 2014

Approximately two third of stoma care departments in hospitals in England are sponsored, but what does this mean in practical terms to ostomists, stoma nurses, and the commissioners? This article explores the journey of Yeovil District Hospital Foundation Trust and the sponsorship process, examining the benefits and pitfalls experienced. The process of successfully negotiating the sponsorship included (1) understanding the implications of government policy and the ethical and legal issues surrounding the sponsorship process; (2) understanding the tender process, working effectively with procurement, and overcoming pitfalls; and (3) ensuring freedom of product choice in line with clinical judgment. The outcome of the process was successful, and the increased staffing levels have led to significant improvements in patient care. Given the recent political and media debate surrounding sponsorship, stoma care nurses have a responsibility to share their experience and take the lead in discussions and advocate on behalf of ostomists and the gold standard in clinical practice.
The management of vulval pain syndromes
Authors: Innamaa Anni , Nunns David
Published: May 2014

Vulval problems are common in gynaecological practice. Pain syndromes of the vulva should be considered once infection and dermatological causes of vulval symptoms have been excluded. This article covers vulval vestibulitis and dysaesthetic vulvodynia, the two subgroups of vulval pain syndromes.
The role of deliberate hypotension
Authors: Dutton Richard P
Published: May 2014

Treatment of haemorrhagic shock consists of finding the source of bleeding and correcting it, and restoring normal intravascular fluid volume (American College of Surgeons Committee on Trauma, 1997). There is general consensus that fluid administration is ultimately required for successful resuscitation. In the long run, restoration of fluid volume is required to support systemic perfusion and restore aerobic metabolism. Failure to do so is associated with poor clinical outcomes (Abramson et al, 1993). For this reason, the advanced trauma life support curriculum recommends administration of up to 2litres of intravenous fluids early in resuscitation, followed by continued blood and fluid therapy to support a normal systolic blood pressure.
Endotracheal intubation in the field: con position
Authors: Wigginton Jane G , Benitez Fernando L , Pepe Paul E
Published: May 2014

Endotracheal intubation (ETI) is considered by most clinicians to be the definitive approach to airway control for most critically ill and injured patients, be they in the operating theatre, in the early phases of an intensive care unit hospitalization, or in the out-of-hospital setting (Pepe et al, 1985; American College of Surgeons Committee on Trauma, 1997; American Heart Association Emergency Cardiovascular Care Committee, 2000). The likely presence of significant physiological derangements (e.g. hypoxaemia, hypercarbia, hypoperfusion) and other clinical care imperatives (e.g. airway protection) have driven a strong philosophy that emergency medical services (EMS) personnel should attempt to provide a definitive airway as soon as possible in the out-of-hospital setting for cardiopulmonary arrest, severe trauma and other critical emergencies (Miller et al, 1978; Pepe et al, 1985; Fowler, 1988; Pepe et al, 1993; American College of Surgeons Committee on Trauma, 1997; American Heart Association Emergency Cardiovascular Care Committee, 2000).
Antibiotic prescribing as a risk factor for MRSA
Authors: Wilcox Mark H
Published: May 2014

There is accumulating evidence to support the role of specific antibiotic classes as risk factors for selecting meticillin-resistant Staphylococcus aureus (MRSA). Crucially, however, controlled studies of antimicrobial prescribing interventions are lacking. The evidence for the association between antimicrobial prescribing and expansion of MRSA is reviewed here.
Late presentation of choanal atresia
Authors: Gratero JF , Hobbs CGL , Youngs RP
Published: May 2014

A 21-year-old man was referred to the ear, nose and throat outpatients with a 2-month history of sore throat and a right-sided neck lump, which had persisted despite antibiotics. On direct questioning, he was found to have a long history of right-sided nasal congestion and rhinorrhoea. He had previously had a nasal polyp removed from the right side 10 years before, but with no resolution in his nasal blockage. On examination there was a 1.5 cm soft, mobile, non-tender mass in the right anterior triangle. Direct inspection of the oral cavity and oropharynx was normal, while anterior rhinoscopy revealed a deviated nasal septum to the right. Blood tests were normal and an infectious mononucleosis screen was negative.

Following a further course of antibiotics, he was reviewed in clinic showing some improvement in his throat symptoms while the neck mass remained unchanged. Flexible nasendoscopy was normal on the left side, but the scope could not be passed on the right. He was offered surgery for his nasal obstruction and under general anaesthesia, a rigid scope was introduced into the right nasal cavity and the diagnosis was made. A subsequent computed tomography (CT) scan confirmed right-sided choanal atresia (Figure 1).
Diabetes and sport: managing the complex interactions
Authors: Gallen Ian
Published: May 2014

Many people with diabetes will want to perform sports, some at a competitive level. However, the changes in physiological responses with exercise seen in diabetes, combined with the effect of diet, tablet or insulin treatment, may impact on glycaemic control and increase the risk of hypoglycaemia. This article reviews these issues so that they can be managed effectively.
Fifty years of the Confidential Enquiry into Maternal Deaths
Authors: Drife James
Published: May 2014

Detailed analysis of maternal deaths in the UK has stimulated many improvements in pregnancy care. Recent reports, however, have identified groups at disturbingly high risk. Lessons learned in Britain are now being applied in other countries.
An unusual case of polyuria in a lithium-treated patient
Authors: Green A , Clark JDA
Published: May 2014

A 60-year-old woman, who had been taking lithium for 36 years for bipolar affective disorder, was referred to an endocrinologist by her psychiatrist for investigation of polydipsia and polyuria. Water deprivation did not concentrate her urine, nor did desmopressin, indicating the diagnosis of nephrogenic diabetes insipidus (NDI).

She was started on chlorthalidone, a treatment for NDI, and her symptoms improved dramatically. Her polyuria was well controlled on chlorthalidone for 4 years, until she started feel tired and weak and her polyuria worsened. Initially these symptoms were attributed to her depression and lithium therapy. However, routine blood testing revealed a random blood glucose of 18.5 mmol/litre, thereby confirming the diagnosis of type 2 diabetes, and a corrected calcium of 3.02 mmol/litre (normal range 2.1–2.6 mmol/litre). She was started on a diabetic diet, resulting in good diabetes control (confirmed by haemoglobin A1c) and her symptoms improved.

The patient's chlorthalidone was stopped as thiazide diuretics can cause hypercalcaemia and her calcium was repeated. The repeat value was higher at 3.07 mmol/litre and her parathormone was alsoelevated at 11.24 pmol/litre, confirming hyperparathyroidism. A parathyroid adenoma was sought but a nuclear medicine scan (Tc99m ssesta-MIBI; technetium 99m-sesta 2-methoxy isobutyl isonitrille) and ultrasound examination of the neck failed to localize an adenoma. It was felt that she had developed parathyroid hyperplasia secondary to chronic lithium therapy (Mallette and Eichhorn, 1986), so her lithium was withdrawn and replaced with sodium valproate. Her NDI and hyperparathyroidism resolved on withdrawal of lithium.
Laryngeal tuberculosis: not the usual suspect
Authors: Street I , Gillett D , Sawyer A , Weighill J
Published: May 2014

A 40-year-old Caucasian male patient of Irish origin residing in Brighton and of no fixed abode presented to the ear nose and throat outpatient clinic with dysphonia and dyspnoea for approximately 3 months. He consumed about 110 units of alcohol per week and smoked about 40 cigarettes each day. On examination, he had two palpable nodes in the right posterior triangle. Flexible nasal endoscopy showed an immobile left vocal cord and a transglottic mass. A chest X-ray resulted in a picture consistent with infection, although metastases could not be excluded (Figure 1). Blood test results showed a normal white cell count and an erythrocyte sedimentation rate of 118.

Eleven days later, laryngoscopy and biopsy from the left supraglottis was performed; a mass with an irregular surface and without ulceration was noted over the left arytenoid cartilage and false cord. After 4 days a staging computed tomography (CT) scan of the neck and chest was done.

The patient was seen in the outpatient clinic within 2 weeks: histology showed only mild subepithelial chronic inflammation; no specific mention of granulomata was made. The CT scan showed extensive cervical lymphadenopathy, the lungs showed multiple poorly defined soft tissue lesions with cavitation consistent with multiple metastases, while laryngeal appearances were consistent with a T2/T3 supraglottic lesion (Figure 2).

The possibility of pulmonary tuberculosis was realized. The respiratory physicians reviewed his chest CT and, on further questioning, he had no history of intravenous drug abuse or other risk factors for immunodeficiency. Human immunodeficiency virus testing was not performed. A repeat biopsy was arranged the next day to search for acid-fast bacilli. However, this was cancelled preoperatively because the patient was dyspnoeic and had a pyrexia of 38°C. The next morning, his sputum sample showed acid-fast bacilli. The patient was isolated and started on once-daily doses of rifampicin, isoniazid, pyrazinamide and ethambutal. These were given as a 6-month course consisting of 2 months of treatment with the four drugs, followed by a 4-month period of daily treatment with isoniazid and rifampicin.

The patient remained as an inpatient under the care of the respiratory medicine department for 2 weeks and improved on the antituberculous medication regimen – at that point, he went to theatre for a repeat laryngoscopy and biopsy. This was taken from the left arytenoid region, where a defined mass was noted.

His next appointment was less than a fortnight later in the outpatient clinic. The histology report showed that there was only chronic inflammation; there were no acid-fast bacilli on staining and no granulomata were seen. The original biopsy specimen was re-examined and stained with a view to finding acid-fast bacilli, which were definitively identified within the laryngeal tissue.

On longer-term follow-up, he was seen in clinic 3 months later. His voice had improved, his vocal folds were moving normally and the left arytenoid mass was no longer present.
Surveillance and screening of Barrett's oesophagus
Authors: Lao-Sirieix Pierre , Fitzgerald Rebecca
Published: May 2014

The management of patients with Barrett's oesophagus is a controversial topic which needs attention in view of the alarming increase in oesophageal adenocarcinoma. Current surveillance methods are not cost-effective and better methods for risk stratification are needed. The majority of Barrett's patients are undiagnosed and this has prompted a discussion about a screening programme aimed at detecting all Barrett's patients.
Snoring: referral, investigation and treatment
Authors: Trotter Matthew I , Morgan David W
Published: May 2014

Snoring is a common problem and the incidence increases with age. The significance of snoring as a symptom of sleep disordered breathing must not be overlooked in assessing this complaint. This article aims to highlight some of the important aspects in the investigation and management of a snoring patient.
Splenosis: a management conundrum in acute abdominal pain
Authors: Burger AEE , Stuart S , Rasheed A
Published: May 2014

A 38-year-old woman presented with a 4-day history of left upper quadrant pain and nausea, on the background of occasional mild left upper quadrant pain over the previous year. She gave a history of emergency splenectomy 18 years previously following a jet skiing accident, and was otherwise fit and well. On admission she was in pain, lying in the right lateral position with normal vital signs, a blood pressure of 126/60 mmHg, pulse rate of 72 beats per minute and respiratory rate of 16 breaths per minute. Examination confirmed tenderness in the left upper quadrant and left flank, with no signs of peritonism.

Microscopic haematuria was noted; however, intravenous urogram was normal. The patient continued to complain of pain and developed peritonism in the left subcostal region. All haematological and biochemical indices remained normal. An abdominal computed tomography (CT) was performed to rule out any unexpected pathology. This revealed extensive intra-abdominal nodules thought to represent splenosis, based on the history of traumatic splenic rupture and subsequent splenectomy. Splenosis is defined as autotransplantation of splenic tissue to unusual sites after splenic trauma. Two large nodules were located close to the splenic vein (Figure 1). There were no features to suggest either haemorrhage in or infarction of these presumed splenunculi, nor other radiological abnormalities to account for her pain.

In light of normal blood indices and equivocal CT result, an active observation strategy of repeated examination, haematological and biochemical testing was adopted. On day three post-admission her left upper quadrant pain became refractory to morphine patient-controlled analgesia, and arterial blood gases on this occasion confirmed a metabolic acidosis with a base deficit of 8.4.

The decision was taken to proceed to laparotomy looking for devitalized or ischaemic tissue. Except for adhesions and extensive splenic implantation as per CT findings, this was unremarkable. Multiple spenunculi were noted throughout the abdomen, none appeared to have bled or infarcted.

Postoperatively the pain did not settle, requiring increasingly large doses of morphine and necessitating high dependency unit admission. A repeat CT scan, however, showed no change from the previous scan. As the pain failed to resolve or be alleviated by any analgesia, the patient was taken for re-laparotomy 48 hours later. A decision was made to resect the largest splenunculi, which coincided with the anatomical site of the pain. One large splenunculus, lying against the diaphragm, was resected from the splenic vein, another from the omentum and two smaller splenunculi from the region of the pancreatic tail (Figure 2).

Postoperatively the patient improved dramatically, was mobilizing well by day 5 and was discharged home pain free 8 days after the second laparotomy. Although the large splenunculus was dusky at resection, histology revealed congestion of the red pulp with no other significant abnormalities.
Bone bruises: definition, classification and significance
Authors: Punwar Shahid , Hall-Craggs Margaret , S Haddad Fares
Published: May 2014

The increasing use of magnetic resonance imaging in the diagnosis of musculoskeletal injuries has alerted clinicians to the phenomenon of bone bruising. This article will outline the current knowledge and treatment implications of these interesting radiological findings.
New drugs for the treatment of type 2 diabetes
Authors: Chowdhury Tahseen A , Hossain Belayet
Published: May 2014

Insights into the pathogenesis of type 2 diabetes has led to increasing therapeutic targets for intervention, and improvements in peptide delivery technology have lead to non-injection methods of insulin delivery. This article reviews new drugs which are likely to become available for use by people with diabetes over the coming year.
Dealing with bullying: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Bullying is something normally associated with assault or name-calling in the school playground. As a child, you assume that adults do not experience it. However, this is far from the truth. Bullying in the workplace can be subtle, insidious and hard to prove. It is sometimes psychologically more difficult to handle than blatant verbal taunts or physical brutality.
Optimal reperfusion strategy for acute myocardial infarction
Authors: Dzielicka Ewa , Swanton Howard
Published: May 2014

Primary percutaneous coronary intervention has proved to be a superior intervention strategy for acute myocardial infarction than pre-hospital thrombolysis. Both strategies are being used in the UK in parallel, and time to intervention is crucial with both strategies. The Myocardial Infarction National Audit Project registry is showing a gradual move towards percutaneous coronary intervention as the strategy of choice when available.
Analysis of selection tools for appointment of specialty trainees in histopathology in Scotland
Authors: Johnston Peter W , French Fiona H
Published: May 2014

This study explores possible benefits of structured selection methods in the employment of specialty trainees in histopathology in Scotland. It examines methods used in 2007 demonstrating novel approaches and discusses the positive reaction of consultants involved in the process.
Ignaz Semmelweis: tragic pioneer in the prevention of puerperal sepsis
Authors: Ellis Harold
Published: May 2014

5 his year marks the 190th anniversary of the birth of Ignaz Semmelweis, born in Budapest, then part of the Austro-Hungarian empire, in 1818. From earliest times, infection of the genital tract, often resulting in peritonitis, septicaemia, pyaemia and death – ‘child-bed fever’ or ‘puerperal fever’ – was a feared complication of delivery or abortion. With the establishment of lying-in hospitals, the disease often assumed epidemic proportions; it was safer to be delivered at home than in hospital.
Facial nerve palsy: assessment and management
Authors: Syed Irfan , Bhutta Mahmood
Published: May 2014

The facial nerve (cranial nerve VII) is the most common site of unilateral cranial nerve palsy. Patients with facial nerve palsy may present in either the emergency department or primary care setting and it is important to be familiar with appropriate assessment and management. The most common cause of facial palsy is idiopathic (otherwise known as Bell's palsy), accounting for around 50% of cases. This is essentially a diagnosis of exclusion and therefore a systematic approach to history, examination and investigation is required to ensure that the correct diagnosis is made.
Triplane fractures of the ankle
Authors: Patel Shelain , Haddad Fares
Published: May 2014

Triplane fractures are fractures that occur in three planes. They occur in the adolescent population, with the ankle joint most frequently involved. Early recognition of the complex fracture pattern and appropriate treatment thereafter will maximize the chances of a favourable outcome.
The management of abdominal aortic aneurysms
Authors: Symons NRA , Gibbs RGJ
Published: May 2014

Abdominal aortic aneurysms cause about 6000 deaths per year in England and Wales, predominantly from rupture. Significant progress has been made in recent years in developing minimally invasive, endovascular methods of treatment. This review evaluates the current management options for abdominal aortic aneurysm.
Curriculum and course design
Authors: McKimm Judy , Barrow Mark
Published: May 2014

Clinical teachers may be involved in planning and developing courses and teaching sessions for different groups of students or trainees. Understanding the principles of curriculum development and design can help teachers provide the most appropriate educational interventions for their learners.
Open surgery for hip impingement
Authors: Norton Mark , Fern Edwin D , Williams Mark
Published: May 2014

Mechanical impingement of the proximal femur against the acetabular rim is now recognized as a common cause of labral tears and degenerative changes in the hip. Open surgery is successful in treating this condition if damage to the articular cartilage surface is minimal.
Integrating teaching innovations in medical education
Authors: Burr Steven
Published: May 2014

Teaching is changing, but the goal remains the same. This article provides a balanced foundation in the theory of modern medical education for those involved in teaching at any level.
Antidepressants, thiazide diuretics and alcoholism: central pontine myelinolysis waiting to happen?
Authors: Crosland Lucy , Longcroft-Wheaton Gaius , Fraser Jocelyn , Stone Adam
Published: May 2014

A 50-year-old man, with a known weekly alcohol intake of almost 100 units, presented to his GP feeling drowsy. Routine blood tests revealed a profound hyponatraemia of 100 mmol/litre, and he was referred to hospital for investigations. On admission he was drowsy, but had a Glasgow Coma Scale score of 15, an abbreviated mental test score of 10/10 and an entirely normal neurological examination. Liver function tests were consistent with excessive alcohol consumption. He had been prescribed bendroflumethazide and clomipramine (a tricyclic antidepressant) by his GP. In view of their potential tocause hyponatraemia these were subsequently withheld and he was fluid restricted to 1.5 litres per day. His sodium level rose gradually and on day 5 of admission it had increased to 122 mmol/litre. He was discharged on day 8 having been advised to stop drinking.

Less than a week after discharge he represented to his GP with symptoms of excessive sweating, shaking, constipation, disorientation and dysarthria. He was febrile at 38.6°C , and had a blood pressure of 180/90 mmHg. Electrolytes were normal (Na+ 135 mmol/litre). Although he denied consuming any alcohol since his initial admission, his symptoms were consistent with acute alcohol withdrawal and he was treated accordingly. He failed to improve on two attempts at reducing doses of chlordiazepoxide. His dysarthria progressed until his speech was difficult to understand and his swallow became unsafe. He continued to spike temperatures throughout the admission and although a catheter specimen of urine was positive for enterococcus, treatment with a prolonged course of antibiotics had not resolved his fever.

A computed tomography scan of his head and a lumbar puncture were performed. Other than cortical atrophy in keeping with alcohol abuse, neither investigation provided any answers. It was considered that his symptoms could be explained by autonomic dysfunction. In view of his corrected hyponatraemia, central pontine myelinolysis was suggested and a magnetic resonance imaging head scan was performed (Figure 1). This confirmed the presence of central hyperintensity on the water sensitive sequences within the central pons, in keeping with an osmotic demyelination syndrome. Additionally these changes were identified within the caudate nuclei, possibly accounting for the patient's inability to fully control voluntary movement. The ongoing temperatures without sepsis suggested hypothalamic involvement.

Following diagnosis this patient failed to improve. Treatment became supportive, and he died 7 weeks later.
ABC don't ever forget glucose
Authors: Brooks HD , Harger SP , Twomey PJ
Published: May 2014

This article summarizes the diagnosis and acute management of glucose-based emergencies for the foundation year doctor, principally focusing on hypoglycaemia and the hyperglycaemic emergencies of diabetic ketoacidosis and hyperglycaemic hyperosmolar state. The causes of hyperglycaemia and hypoglycaemia are given in Table 1.
Facilitating learning in the workplace
Authors: Morris Clare
Published: May 2014

Workplace-based learning has been at the heart of medical education and training for centuries. However, radical reform of the NHS means we have to re-think traditional approaches to apprenticeship and find new ways to ensure that students and trainees can learn ‘on-the-job’ while doing the job.