bluuebunny/crossref_metadata_2025 huggingface dataset:
‘Not just an ordinary bump to the head’: traumatic superficial temporal artery false aneurysm
Authors: Fassiadis Nicholas , Kuhanendran Damayanthi , M South Leah
Published: May 2014

A 79-year-old man who came to a general surgical clinic for evaluation of his asymptomatic bilateral inguinal herniae was noticed incidentally to have a swelling over his right temporal bone (Figure 1). The patient had injured his head 6 weeks previously following a fall, and this was thought by the GP to be a small haematoma that would eventually settle. Since then, the swelling had progressively become larger and tender. On examination, he had a 3 cm diameter pulsatile mass over his temporal bone, which on clinical grounds represented a superficial temporal artery pseudoaneurysm.

With the view that the aneurysm was likely to enlarge and rupture, it was arranged for the patient to undergo an urgent operation to remove it. A cervical block supplemented by 10 ml 1% lignocaine locally was used as the patient was unfit for a general anaesthetic. A transverse incision was made just anterior to the tragus in order to ligate the superficial temporal artery, thus gaining proximal control of the blood supply to the pseudoaneurysm. Excision of the pseudoaneurysm (Figure 2) was then undertaken through a second elliptical incision over the swelling. Distal ligation was not required as the lumen of the superficial temporal artery was obliterated. The patient recovered well from the operation and was discharged on the same day.
Hepatosplenomegaly in a patient returning from Spain
Authors: J Williams Michael , Korsheed Shvan , F Goddard Andrew , Venkatesan Pradhib
Published: May 2014

A 73-year-old man presented with a 1-month history of anorexia, malaise, fevers, night sweats and weight loss. He had no past medical history of note. Since his retirement, he spent the winter months in Spain. He often travelled around Spain and recalled sleeping on the ground while camping in the Mazarron region 8 months before his illness. In the vicinity he recalled seeing dogs. On examination, he was jaundiced with hepatosplenomegaly. His liver was palpable 20 cm below the costal margin in the mid-clavicular line, and the spleen 16 cm. There was no lymphadenopathy. Blood tests showed a pancytopenia with a haemoglobin of 10.3 g/dl, white cell count of 2.86 × 109/litre and platelets of 84 × 109/litre. His inflammatory markers were elevated with a C-reactive protein (CRP) of 231 mg/litre. His liver function tests were deranged with a bilirubin of 73 mmol/litre, alkaline phosphatase of 402 U/litre (reference range 40–130), alanine transaminase of 101 U/litre (reference range 0–45) and albumin of 26 g/litre.

During his admission, he spiked frequent fevers of up to 39.5°C. He was treated empirically with cefuroxime but with no improvement. Multiple sets of blood, urine and stool cultures were negative. Hepatitis B and C, Epstein–Barr virus and human immunodeficiency virus serology and blood films for malaria parasites were all negative. Serum electrophoresis showed a polyclonal increase in gammaglobulins.

A computed tomography scan of his chest and abdomen showed hepatosplenomegaly with no focal lesions and minimal lymphadenopathy. A bone marrow aspirate and trephine biopsy showed a reactive picture with increased immature myeloid cells, but no evidence of haematological malignancy. A liver biopsy showed an interface hepatitis, consistent with infection. No parasites were seen in either sample.

A sample of bone marrow sent for polymerase chain reaction analysis for Leishmania donovani was positive. He was referred to the local infectious diseases unit who started liposomal amphotericin 3 mg/kg for 5 days with a further dose at day 10. Three months later, he had regained 3 kg, his hepatomegaly measured 5 cm and his spleen was no longer palpable. His haemoglobin was 13.7 g/dl, white cell count 11.8 × 109/litre, platelets 616 × 109/litre, CRP < 5 mg/litre and albumin 38 g/litre.
Preimplantation genetic diagnosis
Authors: Grace Jan , Drakeley Andrew
Published: May 2014

Preimplantation genetic diagnosis is a treatment for genetic disease which uses assisted conception to create embryos free from disease, which are available for implantation. This article gives an up-to-date review of an increasingly important area of medicine.
Alcohol misuse: diagnosis and management
Authors: Ali Afia , Hassiotis Angela
Published: May 2014

Alcohol misuse is associated with a significant mortality and morbidity. Over 5000 people die each year of direct alcohol related deaths (Office of National Statistics, 2003). The cost to the NHS is estimated to be £3 billion a year (Royal College of Physicians, 2001). Around 29% of men and 17% of women drink more than the recommended limits (Office of National Statistics, 2001). Rates of dependency are estimated at 7.5% for men and 2% for women over the last 12 months (Office of Population Census and Surveys, 1996).
Assessment of clinical severity in Dupuytren's disease
Authors: Bayat A , Cunliffe EJ , McGrouther DA
Published: May 2014

Every clinician should be aware of the key features in the history and examination of the patient with Dupuytren's disease to know when surgical referral is appropriate and to inform the patient about causation and prognosis. This article outlines the most relevant questions to ask and provides a systematic approach to the clinical examination.
RIFLE classification of acute kidney failure in intensive care
Authors: Abosaif Nihal , Tolba Yasser
Published: May 2014

The wide range of incidence of acute renal failure is partly the result of the lack of a reliable definition. The RIFLE classification allows acute renal failure to be stratified for severity, and different outcomes depend on the degree of severity. This review discusses how the RIFLE criteria fit into the whole picture.
The vocational crisis in medicine and nursing
Authors: Calne Roy
Published: May 2014

Unlike many occupations medicine and nursing are primarily and historically vocational professions. A wish to comfort, relieve pain and hopefully to cure other human beings who are ill should be the essential motivation to pursue these professions. Social status, remuneration and political bureaucratic compliance are of secondary importance. Both professions have traditionally been held in high regard by the public, but changes associated with advances in understanding disease processes and technological innovations have altered the nature of both medicine and nursing.
The child with recurrent abdominal pain: is it abdominal migraine?
Authors: Russell George , Symon David NK , Abu-Arafeh Ishaq A
Published: May 2014

Abu-Arafeh and Russell (1995) found that 72% of Aberdeen schoolchildren had had at least one episode of abdominal pain during the previous year. This pain was severe enough to interfere with normal activities in 32%, with severe pain occurring more than once in 8%. Other studies have identified recurrent abdominal pain in 10–15% of children.
Linking patients' trust in physicians to health outcomes
Authors: Lee Ying-Yang , L Lin Julia
Published: May 2014

Trust in the patient–physician relationship has been widely discussed, but in-depth and systematic analyses are scarce. A model is proposed to explore the trust–outcomes relationship by identifying the mediating effects of compliance, patient disclosure, placebo effect and physician's caring behaviour. The consequences of patients' trust in physicians and the practical implications of trust to quality patient care are presented.
Aortic regurgitation associated with cabergoline therapy
Authors: Lyons Kristopher , Flannery Danny
Published: May 2014

A 57-year-old man with a history of Lewy body dementia was referred for cardiac assessment with a history of exertional dyspnoea and orthopnoea. Symptoms developed 12 months after commencement of cabergoline by his neurologist. Transoesophageal echo demonstrated aortic regurgitation, which was moderate by vena contracta (0.6 cm) (Figure 1). The aortic valve was tricuspid and was not thickened or calcified. The leaflets appeared tethered and failed to coapt (Figure 2).

Other cardiac valves were normal. The appearance was typical of that associated with ergot-derived dopamine agonists, so the aortic regurgitation was considered to be secondary to treatment with cabergoline.
The clinical care of adult patients with sickle cell disease
Authors: Olujohungbe Adebayo , Howard Jo
Published: May 2014

Sickle cell disease is the most common inherited disease in the UK and is associated with significant morbidity and mortality. All health professionals should be aware of the common acute and chronic complications of sickle cell disease and the basic principles of their management.
The eye and Down's syndrome
Authors: Liyanage Sidath , Barnes Jonathan
Published: May 2014

Down's syndrome is a common genetic abnormality that can affect most parts of the eye. Common ocular features are described, as well as those which cause reduced vision, requiring referral to an ophthalmologist.
Assessment and treatment of pain in children
Authors: Snidvongs Saowarat , Nagaratnam Maya , Stephens Robert
Published: May 2014

Treating acute pain in the paediatric population poses challenges which include the lack of high levels of evidence and a universal pain measuring tool, contributing to the undertreatment of pain. A multimodal approach of topical and systemic analgesia, comfort measures and parental involvement remains the mainstay of pain management.
Management of first trimester miscarriage
Authors: Ankum Willem M
Published: May 2014

This article summarizes current knowledge about first trimester miscarriages from the clinician's perspective. The epidemiology of spontaneous miscarriage, its natural course and clinical findings are discussed together with the diagnostic management and therapeutic options, which include expectant, medical and surgical management.
Commotio cordis
Authors: Sharma Neel , Andrews Sam
Published: May 2014

A 22-year-old man, Mr X, and his friend, were playing a game of softball. His friend (as batsman) accidentally struck the ball into Mr X's chest. Mr X subsequently collapsed and lost consciousness. Cardiopulmonary resuscitation began following the arrival of paramedics. The patient was found in ventricular fibrillation and defibrillated to sinus rhythm. Upon arrival in the emergency department, the patient remained unresponsive but haemodynamically stable. An echocardiogram was performed which showed no structural abnormalities, pericardial effusions or valvular damage. The patient soon reverted back to ventricular fibrillation and despite the best efforts of the medical team could not be revived.

An autopsy was warranted which indicated no evidence of injury or natural disease to account for his death. A section from the autopsy report is as follows: ‘The heart weighs 316 g. The pericardial sac is free of significant fluid or adhesions. The coronary arteries arise normally and follow the distribution of a right dominant pattern with no significant atherosclerosis. The chambers and valves are proportionate. The valves are normally formed, thin and pliable and free of vegetations and degenerative changes. The myocardium is dark red brown, firm and free of focal or regional fibrosis, erythema, pallor or softening. The atrial and ventricular septa are intact and the septum and free walls are free of muscular bulges.'

Microscopic assessment of the heart as well as toxicological analysis of the blood proved unremarkable. The medical examiner assigned commotio cordis as the immediate cause of death.
Emergency laparoscopic repair of an obstructed Bochdalek hernia in an adult
Authors: Akhtar Kashif , Qurashi Kamran , Rizvi Arshad , Isla Alberto
Published: May 2014

A previously fit 27-year-old man presented to the authors' casualty department with a 24-hour history of severe vomiting, dizziness and lethargy. Examination was unremarkable except for marked dehydration. The patient was found to be hypokalaemic (K+ 2.8 mmol/litre) and in acute renal failure (urea 16.8 mmol/litre, creatinine 259 ¼mol/litre).

After admission the patient became pyrexial and began to vomit uncontrollably. Chest auscultation revealed decreased air entry at the left lung base and the chest radiograph was reported as showing cystic bronchiectasis for which antibiotic therapy was commenced (Figure 1).

The abdominal radiograph showed a paucity of intestinal gas. Upper gastrointestinal endoscopy to investigate the hyperemesis demonstrated an extremely dilated stomach containing 3 litres of fluid, with reflux oesophagitis. Computed tomography scans displayed a small left lung, a dilated stomach and herniation of abdominal viscera into the left side of the chest, with an empty abdominal cavity.

Laparoscopy confirmed the striking absence of small bowel, ascending and transverse colon, and spleen in the abdominal cavity, all of which had herniated into the left chest through a patent congenital Bochdalek foramen (8 × 10 cm), with no hernial sac. The defect was closed in a tension-free manner with a Goretex dual mesh patch, attached posteriorly with an anchoring device (Pro Tak) and secured with interrupted Ethibond sutures (Figure 2). At the end of the procedure the entire bowel was inspected from the duodeno-jejunal flexure and found to be correctly positioned.

Postoperative recovery was quick and uneventful and the patient was discharged home well on day 3 following a normal gastrograffin study (Figure 3).

Outpatient follow up at 18 months, examination and imaging confirmed no recurrence or complications.
Integrating assessment innovations in medical education
Authors: Burr Steven
Published: May 2014

The role assessment plays in driving learning should not be underestimated. An understanding of assessment processes is clearly important for all those involved in teaching, as well as examiners and candidates. So how do we best assess learning outcomes? This article provides a balanced foundation in the theory of modern medical education for those involved in assessment at any level.
Osseous sarcoidosis masquerading as metastatic disease
Authors: Barratt Shaney , Burn Paul R , Stone Robert
Published: May 2014

A 64-year-old woman presented with suspected malignancy, characterized by unexplained weight loss of 2 stone over the preceding year, lethargy and widespread musculoskeletal and back pain for which she was taking Zomorph 10 mg twice daily. She was iron deficient; endoscopy and colonoscopy were unremarkable. A bone scan showed widespread increase in uptake of radioisotope (Figure 1). A computed tomography scan showed multiple lytic lesions throughout the thoracolumbar spine, ribs and iliac blades, consistent with metastatic disease (Figure 2). There was no evidence of cord compression. There were multiple soft tissue nodules throughout both lungs, in tandem with small volume mediastinal lymph node enlargement.

Fine needle sampling of a small volume (7 mm) supraclavicular lymph node revealed no malignant cells but surprisingly the sample demonstrated well-formed non-caseating granulomata, staining negative for acid-fast bacilli. Serum angiotensin-converting enzyme levels were high (114 U/litre; normal range 16–53 U/litre), with a calcium level of 2.61 mmol/litre and normal creatinine levels.

There was concern that the patient might have dual pathology and so a vertebral body was additionally biopsied, the result again showing a non-caseating granuloma compatible with sarcoid (Figure 3).

The diagnosis was revised to systemic sarcoidosis with extensive bony involvement. Prednisolone and bisphosphonate were commenced. There was immediate symptomatic improvement, mirrored by declining serum angiotensin-converting enzyme levels. Interestingly, on commencing treatment there was an initial rapid rise in her alkaline phosphatase level (Figure 4), possibly related to increased bone turnover.

At her 2-month review she was virtually free of symptoms. Repeat computed tomography of the chest showed marked regression of the pulmonary nodules but persistence of the skeletal lesions.
Maternal congenital diaphragmatic hernia causing cardiovascular collapse during pregnancy
Authors: Hunter John D , Nimmagadda Jyothi , Quayle Anthony
Published: May 2014

A 31-year-old primigravid female presented to the obstetric department with severe left flank pain at 27 weeks' gestation. Her pregnancy had otherwise been straightforward and there was no significant past medical history. Physical examination was unremarkable apart from some vague tenderness and fullness in the left upper quadrant, and routine blood tests and urinalysis revealed no abnormalities. Obstetric ultrasound confirmed a 27-week gravid uterus with a single live fetus.

Analgesia was administered and an ultrasound scan of her abdomen requested for the next morning. Over the next few hours her abdominal pain got progressively more severe and the patient became increasingly distressed. Further examination revealed her to be hypotensive (blood pressure 85/40 mmHg), tachycardic and tachypnoeic with obvious central cyanosis (SpO2 88% on room air). Auscultation of her chest revealed decreased air entry over the left lung and tracheal shift to the right. An urgent chest X-ray suggested left diaphragmatic herniation of abdominal contents (Figure 1). Insertion of a nasogastric tube was attempted without success. Owing to increasing hypoxia and respiratory distress a decision was made to intubate and ventilate the patient before transfer to theatre.

Emergency laparotomy revealed at least 3.5 litres of blood within the peritoneal cavity and a large congenital defect in the postero-lateral portion of the left hemi-diaphragm (Bochdalek hernia). Most of the small bowel, the whole of the transverse colon and the stomach with the attached spleen had herniated through the defect causing the left lung to collapse. The abdominal contents were reduced back into the abdominal cavity, and the diaphragmatic defect repaired. A dead fetus was removed by caesarean section.

The patient required several weeks of intensive therapy, and her recovery was complicated by pancreatitis which required laparotomy for desloughing of necrotic pancreatic tissue. She eventually went on to make a full recovery, and has subsequently had a healthy baby.
Mediastinal irradiation and its effect on the cardiovascular system
Authors: Tang David , Peng Edward WK , Giri Dheeraj , Chowdhary Manish , Sarkar Pradip
Published: May 2014

Mediastinal irradiation for various malignancies can cause radiation injury to mediastinal structures, most importantly the cardiovascular system. This article reviews the effect of radiation on cardiovascular structures and the manifestations of various radiation-induced heart diseases.
Nasal polyps: an update
Authors: McGarry Gerald , Melia Louise
Published: May 2014

Patients with nasal polyps suffer from a condition that, despite adequate treatment, runs a recurrent and remitting course, requiring long-term medication and often multiple operations. It is a condition in which the cause remains unknown.
‘I’m sorry but you've got cancer': the role of psycho-oncology
Authors: Chahl Pavan , Bond Ann
Published: May 2014

Patients struggling with cancer undergo significant psychological distress and have high rates of psychiatric morbidity. This article considers the psychological journey of a cancer patient. It looks at both the short-term and the long-term impact of cancer on the psychological health of patients.
The trainee in difficulty: a supportive structured approach
Authors: Black David , Kelleher Kevin
Published: May 2014

Trainees in difficulty provide a significant management challenge. This article describes the processes and outcomes of 4 years experience of a deanery-wide supportive structured approach based on the concept of trust and specialty-based local faculty groups.
The roles of doctors and health services in community violence prevention
Authors: Sivarajasingam Vaseekaran , Shepherd Jonathan
Published: May 2014

Violence control and prevention have traditionally been led by criminal justice services. During the last decade, tackling violence has become a multi-agency effort supported by government and regulated according to new legislation, reflecting recognition that health services and local government can contribute uniquely to this.
Paediatric endotracheal tubes: cuff or no cuff?
Authors: Jones Chris
Published: May 2014

Traditional teaching states that when an endotracheal tube is required for airway management of children under the age of about 8 years an uncuffed tube should be used. Cuffed endotracheal tubes were really only used in specific circumstances such as patients requiring ventilation with poorly compliant lungs.
Elizabeth Blackwell: a pioneer female medical graduate
Authors: Ellis Harold
Published: May 2014

This year marks the centenary of the death of Dr Elizabeth Blackwell, who died on 31 May 1910, the first woman in the English-speaking world to qualify as a doctor. She practiced both in England and the USA and did much to encourage, in the face of great opposition, medical training for women in both countries.
Managing the trainee in difficulty
Authors: Borkett-Jones Howard , Morris Clare
Published: May 2014

Trainees may encounter a range of difficulties during their training period. Supporting a trainee in difficulty can be extremely challenging, yet immensely rewarding.
Peritoneal mesothelioma
Authors: Berrill James , Haboubi Hasan , Duane Paul
Published: May 2014

A 59-year-old building surveyor presented with a 2-month history of lethargy and abdominal swelling. There was no associated abdominal pain, change in bowel habit or jaundice. There was no significant past medical history. His alcohol intake was approximately 60 units per week.

Examination revealed gross ascites, but no palpable masses, lymphadenopathy or stigmata of chronic liver disease. Blood tests revealed a microcytic anaemia (haemoglobin 9.3 g/dl, mean corpuscular volume 72.5 fl). Other abnormalities were high platelets (740 ×109/litre), raised erythrocyte sedimentation rate (101 mm/hr) and low albumin (30 g/litre). Other laboratory investigations were normal.

Computed tomography scan revealed calcified pleural plaques suggesting previous asbestos exposure (Figure 1) and extensive ascites with a sizeable omental mass (Figure 2).

Diagnostic tap of the ascitic fluid showed atypical mesothelial cells suspicious of malignancy (Figure 3). An omental biopsy was performed, and immunohistochemistry showed positive staining for calretinin (Figure 4a) and thrombomodulin (Figure 4b), and negative for carcinoembryonic antigen (CEA) (Figure 4c) and BerEP4 (Figure 4d). A diagnosis of malignant mesothelioma was made.

On further questioning regarding his occupational asbestos exposure he admitted to ‘throwing it around like snowballs’. His ascites was drained for symptomatic benefit, and after an oncology review he proceeded to a course of chemotherapy.
Moving young people with sickle cell disease from paediatric to adult services
Authors: Howard Jo , Woodhead Tanya , Musumadi Luhanga , Martell Alice , Inusa Baba PD
Published: May 2014

This article reviews data about transition from paediatric to adult services in patients with sickle cell disease, the most common inherited disease in the UK, and outlines how this has been addressed in a large UK sickle cell centre.
Has Bolitho affected assessment of the appropriate standard of medical care?
Authors: Perera Anthony
Published: May 2014

The courts' use of the Bolam test has been criticized for giving the medical profession deferential treatment and making it easier to defend a minority opinion. This article asks whether the shift to the Bolitho principle has gone too far or not far enough.
Medicines reconciliation: a guide for the foundation year doctor
Authors: Hooke Rachel
Published: May 2014

Most doctors are familiar with the concept of taking a patient's drug history on admission. Medicines reconciliation is about obtaining up-to-date, accurate and reliable information on patients' medication. According to the National Institute for Health and Clinical Excellence and the National Patient Safety Agency (2007), in their joint guidance, ‘the aim… is to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission’. This is an important aspect of patient safety, so that patients receive all the correct medication, with none omitted and nothing additional administered by mistake. Medicines reconciliation has the potential to reduce medication errors (National Prescribing Centre, 2008).
So you want to be…a geriatrician
Authors: Singh Iqbal , Vilches Arturo , Manku Lakhveer , Wallace Jane
Published: May 2014

The improvement in health and social care over the preceding century is reaping its reward in longer and healthier lives, making the over-80s the fastest growing population group. Most elderly individuals are living independent lives, but as their number grows and chronic disease sets in, so does the need for experts in the prevention, treatment and rehabilitation of illness in older patients… geriatricians!
Can an understanding of transactional analysis improve postgraduate clinical supervision?
Authors: Siva Manoj , McKimm Judy , Held Sam
Published: May 2014

Clinical supervision in postgraduate medical training is vital in producing competent and safe health-care practitioners. Effective communication between supervisors and trainees at an interpersonal and professional level determines the quality of the supervision process. Transactional analysis, a theory of personality, can be used to enhance understanding of interpersonal interactions and improve the outcomes of clinical training.
The eye in haematological disease
Authors: Shalchi Zaid , Taylor Simon RJ , Lightman Sue
Published: May 2014

The eye allows living functioning blood vessels to be observed and is thus ideal for the study of haematological disease. Disorders of the blood have significant ocular manifestations and pose a real threat to vision, making knowledge of the subject essential to ophthalmologists, haematologists, oncologists and general physicians.
Pathogenesis of hepatitis B virus infection and potential for new therapies
Authors: Peppa Dimitra , Maini Mala K
Published: May 2014

Chronic hepatitis B virus infection leads to about 1 million deaths per year, making it one of the top ten causes of death worldwide. An improved understanding of defective antiviral responses in chronic hepatitis B virus infection could allow specific immunotherapeutic interventions, enhancing the immune response to hepatitis B virus.
Protocol-guided hip fracture management reduces length of hospital stay
Authors: Kumar Gautam
Published: May 2014

Objective: To see if protocolised hip fracture care led to an improvement in patient management and more standardized treatment with the aim of reducing wait for surgery and postoperative length of stay.

Design: Following the introduction and establishment of a care pathway a retrospective, observational audit was conducted with patient data and pathway compliance obtained from analysing medical notes and accessing electronic patients' records.

Setting: The audit analysed all patients who sustained a fractured hip admitted to University College London Hospital over an 18-month period between August 2009 and February 2011.

Measurements: In addition to demographic data, a comparison was made between those who were and were not managed with the care pathway. Investigations, preoperative management, time to surgery, length of stay and mortality were all evaluated.

Results: Patients managed via the care pathway had significantly more investigations and preoperative interventions, and subsequently had a reduced length of hospital stay (a mean average of 13 compared to 17 days). There was no significant difference in time from admission to surgery, and 30-day mortality.

Conclusions: Using a care pathway to manage those patients sustaining fractured femur appears to make preoperative management more consistent. This, in turn, leads to a reduction in length of hospital stay.
Diagnosis, epidemiology and treatment of inflammatory neuropathies
Authors: Baig Fahd , Knopp Michael , Rajabally Yusuf A
Published: May 2014

This article reviews the main diagnostic, epidemiological and therapeutic issues relating to the three main inflammatory neuropathies: Guillain–Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy and multifocal motor neuropathy. The current knowledge base and recent developments are described.
New oral anticoagulants: an alternative to warfarin
Authors: Wilkinson Peter
Published: May 2014

New agents have been introduced for the prevention of inappropriate thrombosis in the vascular tree and the heart. This article reviews, compares and contrasts the newer agents which inhibit activated factor X (Xa) or activated factor II (thrombin).
National Joint Registry data inaccuracy: a threat to proper reporting
Authors: Kosy Jonathan D , Kassam Al-Amin M , Hockings Michael
Published: May 2014

Introduction: The authors set out to investigate the accuracy of the information their unit was inputting onto the National Joint Registry. This is important both in relation to implant surveillance and also to the use of these data to monitor the performance of surgeons.

Method: A single consultant's arthroplasty patients were audited over 12 months. Data taken from the National Joint Registry were compared to the operation notes and the hospital's computer system.

Results: Of 78 cases inputted, 27 (35%) were incorrect. Sixteen cases (21%) had the incorrect ‘consultant in charge’ recorded, eight cases (10%) had the incorrect ‘operating surgeon’ recorded and three cases (4%) had both errors. The most frequent inaccuracies resulted from listing by another consultant and incorrectly recorded trainee supervision. These errors were highlighted to the unit and a corrected process was designed. The intervention was to implement this process by presenting to the involved groups and displaying posters to prevent the error-producing process. The audit was repeated (after 6 months) showing eradication of the problem.

Discussion: It is the surgeon's duty to ensure data recorded under his/her name are accurate and justify any discrepancies when compared to other surgeons. Pooling of patients and supervision of trainees are sources of potential error.
How to appraise a randomized controlled trial
Authors: Hussain Jamilla A , Gadoud Amy , Taylor Paul
Published: May 2014

Critical appraisal is an essential skill for evidence-based practitioners. It involves the systematic examination of research in order to assess its trustworthiness and relevance to specific situations. This article gives an overview on how to approach critical appraisal of randomized controlled trials.
Personality, self development and the compassionate leader
Authors: McKimm Judy , O'Sullivan Helen
Published: May 2014

This article discusses how the recent publication of the Francis Report aligns with contemporary thinking on leadership development and professionalism, and that development and demonstration of appropriate personal qualities is central to effective medical leadership.
Imaging and neurobiological changes in late-life depression
Authors: Allan Charlotte L , Zsoldos Enikő , Ebmeier Klaus P
Published: May 2014

Depression was previously thought of as a ‘functional’ illness, without demonstrable pathology, but the advent of sophisticated neuroimaging techniques has changed this perspective. This article reviews the latest structural and functional brain imaging studies, describing the neurobiological changes which underlie this common condition.
Finding the perfect match: the living donor paired exchange system
Authors: Hunter Jennifer , Heetun Mohammad , Sinha Sanjay
Published: May 2014

Patients on the kidney transplant waiting list can often face substantial waiting times for an organ from a deceased donor. Furthermore, the number of patients requiring a kidney transplant is increasing. This article discusses an emerging solution – the living donor kidney exchange system.
Uncommon presentations of non-Hodgkin's lymphoma
Authors: Charalambous Haris , Simpson Joanna
Published: May 2014

In this issue of Hospital Medicine, a case of a primary adrenal lymphoma (PAL) and a primary cutaneous B cell lymphoma (PCBCL) are presented (p. 759). These extranodal lymphomas are uncommon presentations of B cell non-Hodgkin's lymphoma.
A case of mistaken identity: primary cutaneous lymphoma presenting as venous ulceration
Authors: Tumman Jonathan , Coggins Ron
Published: May 2014

A 88-year-old woman was referred to the surgical outpatient department with a recurrent, long-standing leg ulcer. On examination she was found to have signs of chronic venous hypertension (varicose veins, varicose eczema and lipodermatosclerosis), and a 10 mm ulcer which was thought to be a benign venous ulcer. Four-layer bandaging was instituted, but the ulcer failed to heal. A punch biopsy was therefore performed which supported the clinical diagnosis of a stasis ulcer. Three months later healing had not taken place, and the ulcer had grown in size and taken on a sinister appearance (Figure 1). A presumptive diagnosis of Marjolin's ulcer was made, and she subsequently underwent wide local excision and skin grafting. Histology revealed a high grade cutaneous B cell lymphoma. Excision was complete, with no evidence of regional or distant disease, and no further treatment was undertaken. She unfortunately died soon afterwards from an unrelated problem.
Group B streptococcal meningitis in a previously healthy adult
Authors: Kelly J , Hayman G , Philpott-Howard J
Published: May 2014

Group B streptococcus (GBS; Streptococcus agalactiae) has emerged in recent years as an important cause of invasive infection in non-pregnant adults. However, GBS meningitis in this group is rare. The majority of cases reported previously have been in patients with underlying immunosuppression. Here we report a case of GBS meningitis in a previously healthy adult.
Thyrotoxicosis in old age: a different clinical entity?
Authors: Bhattacharyya Arpandev , Wiles Philip G
Published: May 2014

Thyrotoxicosis generally presents with classic signs and symptoms in younger people. Among the elderly population atypical presentation is recognized, although this has not been well quantified or characterized. To avoid misdiagnosis or delay in diagnosis, clinical suspicion needs to remain high.
Paroxetine and its uses in psychiatry
Authors: Bell Caroline , Nutt David
Published: May 2014

Paroxetine is one of the specific serotonin-reuptake inhibitor antidepressants which is used in a variety of psychiatric disorders. It has recently gained considerable publicity because of its use in social anxiety disorder and its subsequent labelling by the media as a ‘lifestyle drug’. This review summarizes current indications for paroxetine and outlines doses and duration of treatment for each condition.
Recent trends in breast reconstruction
Authors: Rainsbury Dick M
Published: May 2014

The rising popularity of breast reconstruction is closely linked to patient expectation, improved techniques and a better understanding of the risks and benefits of reconstructive procedures. Innovative new approaches can conceal the scars of mastectomy and extend the role of breast-conserving surgery, leading to improved outcomes.
BAL fluid cytology in the assessment of infectious lung disease
Authors: Jacobs Jan A , De Brauwer IGB
Published: May 2014

The need for rapid laboratory results has marked the application of bronchoalveolar lavage (BAL) fluid cytology as a valuable tool in the assessment of infectious lung conditions. The techniques of BAL fluid processing presented here can be performed in a microbiological laboratory. The diagnostic value of BAL fluid cytology for the prediction of ventilator-associated pneumonia is discussed.
The role of the surgeon in the intensive care unit
Authors: Scheeren CIE
Published: May 2014

Trauma management and postoperative care require active input from surgeons in the intensive care unit, yet there appears to be diminishing surgical involvement in the care of the critically ill. A formal postgraduate training programme in intensive care medicine for several disciplines has been introduced in the Netherlands, which may lead to greater participation of surgeons in intensive care medicine.
Age and the cardiovascular system
Authors: Rehman HU
Published: May 2014

Congestive heart failure is a common cause of morbidity and mortality in the elderly population. Important changes occur in the structure and function of the cardiovascular system with advancing age. An understanding of these changes is vital for optimum management of these patients.
Delivery of non-surgical oncology care
Authors: Dodwell D , Sebag-Montefiore D , Collinson M , Selby P
Published: May 2014

The changes and options for future change in the provision of non-surgical oncology care within the UK are discussed in the context of the recommendations of the Calman report, the drive towards site specialization and the changing nature of the specialties of clinical and medical oncology. Options for the creation of an improved and more flexible service are discussed.
To paralyse or not to paralyse?
Authors: Howell Tanya K , Walker Robert
Published: May 2014

The Pierre Robin syndrome occurs in 1 in 50 000 live births and is characterized by congenital micrognathia with glossoptosis. An associated cleft palate is found in more than 50% of patients, and cardiac and skeletal defects are present in 25-30% (Stehling, 1992).
Antiplatelet therapy
Authors: Gershlick AH
Published: May 2014

Within the last few years antiplatelet therapy has developed exponentially, with new agents being tested in an increasing number of clinical scenarios. The mechanism of action of these newer agents and evidence of benefit is prevented in this review.
The acute abdomen and its management
Authors: Carter Paul
Published: May 2014

Emergency referrals represent nearly 50% of general surgical practice. The acute abdomen makes up the bulk of these emergency referrals. As in all branches of medicine a number of seemingly straightforward questions need to be answered.
Management of toxic epidermal necrolysis
Authors: Craven Nicholas M
Published: May 2014

Toxic epidermal necrolysis and Stevens–Johnson syndrome are rare, life-threatening drug reactions. Widespread epidermal necrosis and mucosal erosions lead to complications similar to those developing after extensive burns. Treatment is supportive. The role of steroids and other potential disease-modifying agents remains to be established by controlled studies.
Human parvovirus B19 in pregnancy
Authors: Brennand JE , Cameron AD
Published: May 2014

Parvovirus B19 infection can result in an adverse outcome when acquired during pregnancy. However, in the majority of cases a successful outcome can be anticipated. Public awareness of this condition is essential and obstetricians should be familiar with the options available to them if they are presented with this clinical problem.
Travel and the immunocompromised host
Authors: Conlon Christopher P
Published: May 2014

Increasing opportunities for travel and advances in medicine mean that immunocompromised patients may venture to potentially risky parts of the world. This article examines the risks faced by such travellers. Some limitations of standard travel vaccines are discussed and suggestions are made as to how best to advise such travellers.
Weakness of the pelvic floor: urological consequences
Authors: Thakar Ranee , Stanton Stuart L
Published: May 2014

The pelvic floor comprises three compartments: anterior, posterior and middle. Weakness of the pelvic floor can lead to prolapse, urinary or faecal incontinence. This article deals with the defects in the anterior compartment which lead to urological consequences. The anatomy and management of stress incontinence are discussed.
Provision of an electronic library at the clinical frontline: evaluation of impact on hospital medical staff
Authors: Freeth DS , Weist A , Roberts CM
Published: May 2014

Doctors need convenient access to the latest information if they are to meet the demands of clinical governance and evidence-based medicine. Forest Healthcare NHS Trust used its intranet to provide clinical areas with direct 24-hour access to library materials.
The future of pathology in the UK: modernization or rationalization?
Authors: Lilleyman John
Published: May 2014

Since its beginning the NHS has profoundly affected the way pathology services are configured, staffed and delivered in the UK, and will continue to do so. But it is only one influence on the shifting patterns of laboratory work that are also continually being re-shaped by the evolutionary forces of advancing medical knowledge and increasingly sophisticated laboratory technology.
Gelclair: managing the symptoms of oral mucositis
Authors: Smith Tom
Published: May 2014

Oral mucositis, ulceration and inflammation are common complications in patients receiving radiotherapy or chemotherapy, and human immunodeficiency virus (HIV) patients, and they are also primary symptoms of Behçet's disease.
Almotriptan: a balanced approach to migraine
Authors: Cull Roger
Published: May 2014

Effective acute treatment of migraine is possible with the 5HT1B/1D agonists (triptans), but their use has been limited in the UK because of concerns about limited efficacy, recurrence of attacks, adverse events, and cost. Almotriptan (Almogran, Lundbeck Ltd, Milton Keynes), the most recently available member of the class, offers some advantages over previously available agents.
Tropical infections can mimic common Western European diseases
Authors: Hershman MJ
Published: May 2014

With increasing international travel and migration, clinicians must have an increased awareness of tropical illnesses. Four case reports in this issue emphasize that these conditions can be difficult to diagnose and can mimic common Western European diseases, including disseminated carcinoma.
Pneumococcal disease in childhood
Authors: Mohan PV , Heath PT
Published: May 2014

Streptococcus pneumoniae is the most common cause of serious bacterial infections in children worldwide. Problems with antibiotic resistance have lead to changes in antibiotic policies for children with possible pneumococcal disease. Demonstration of the efficacy of a pneumococcal conjugate vaccine has lead to consideration of its inclusion in routine infant vaccination schedules.
Long-acting β2-agonists in chronic obstructive pulmonary disease
Authors: Llewellyn-Jones Carol
Published: May 2014

Until recently, the use of long-acting β2-agonists in chronic obstructive pulmonary disease has been understated. There is now evidence that they may offer benefits beyond bronchodilation. This article reviews the management of chronic obstructive pulmonary disease and looks at the place of long-acting β2-agonists as a first-line treatment option.
Advances in the management of CSF rhinorrhoea
Authors: Swift Andrew C , Foy Patrick
Published: May 2014

Cerebrospinal fluid fistulae are under-diagnosed, difficult to locate and often clinically silent. They are potentially lethal and carry a long-term cumulative risk of meningitis. They should be fully investigated and treated aggressively. Current endoscopic techniques combined with intrathecal fluorescein dye enable most defects to be located and sealed with minimal morbidity.
Testicular cancer: current update and controversies
Authors: Lee Frank , Hamid Rizwan , Arya Manit , Patel Hitendra RH
Published: May 2014

Testicular cancer is an important disease affecting young men. The overall 5- year survival has improved to 95%. The goal now is to maintain the efficacy of treatment in advanced disease while reducing the associated side effects.
Common injuries of the foot and ankle
Authors: Coull R , Williams RL
Published: May 2014

This article is aimed at accident and emergency and orthopaedic senior house officers. It emphasizes key points of the safe initial management of common foot and ankle injuries.
Management of skeletal metastases
Authors: Radford M , Gibbons CLMH
Published: May 2014

Bone is a frequent site of tumour metastasis and is the third most common site of metastatic carcinoma. With advances in the use of immunotherapy, hormonal manipulation, chemotherapy and radiation for the palliation of patients with metastatic bone disease, significant improvements in survival, wellbeing and overall quality of life have been achieved.
Smart handles and red flags in neurological diagnosis
Authors: Hawkes Christopher
Published: May 2014

Eliciting a full history and undertaking a complete neurological examination is time consuming. Knowledge of diagnostic short cuts (smart handles) and caveats (red flags) can speed up this process but care is needed as many tips given here have not been validated scientifically.
eSTEP: a web-based learning resource for basic surgical trainees
Authors: Amin Amit , Amen Furrat
Published: May 2014

A website has been set up by the Royal College of Surgeons of England for trainees registered on the Surgeons in Training Education Programme (STEP). eSTEP has been designed to provide an interactive component to the course and looks to have added a new dimension to basic surgical training.
Bony skull neoplasms masquerading as giant cell arteritis
Authors: J Thomas , IM Morris , Mattingly PC
Published: May 2014

Giant cell arteritis can be difficult to diagnose, and temporal artery biopsy is not always helpful. This paper reports five patients who were initially thought to have giant cell arteritis but proved to have another diagnosis. Four patients had bony skull metastases, while the fifth had multiple myeloma. These cases highlight the importance of carefully considering the differential diagnosis of giant cell arteritis before making a firm diagnosis.
Inflammatory responses after surgery
Authors: Herroeder Susanne , Durieux Marcel E , Hollmann Markus W
Published: May 2014

The inflammatory response after major surgery is of great importance for patients, physicians and perioperative medicine in general. This article, although not intended to be comprehensive, provides an overview of present knowledge about inflammatory mechanisms, predictive parameters and therapeutic approaches.
Unusual neurological signs complicating epidural analgesia
Authors: Crowe Suzanne
Published: May 2014

Subdural blockade occurs in 0.82% of epidural catheter attempts (Lubenow et al, 1988). It complicates epidural analgesia, and produces a wide variety of neurological signs. Presentation may include delayed, extensive sensory block, sparing of sacral dermatomes, and varying degrees of motor nerve blockade. The spectrum of clinical signs has been well characterized, and can be explained by the anatomy of the dural and arachnoid spaces.
Epidemiology of meningococcal disease
Authors: Cartwright Keith AV
Published: May 2014

In the UK, serogroup A strains disappeared 50years ago, but in the 1990s, numbers of cases rose again to a 50-year high. Following the very successful introduction of conjugated meningitis C vaccines, effective meningitis B vaccines are now the highest priority.
Treating meningococcal infections in children
Authors: Welch Steven B , Nadel Simon
Published: May 2014

Aggressive early treatment of meningococcal disease in children can reduce mortality. This relies on prompt recognition of septicaemia and meningitis, and treatment of the complications of shock and raised intracranial pressure.
Isolated B-cell lymphoma of the pituitary region: a rare clinical entity
Authors: Stephens JW , Morganstein DL , McLaughlin JE , Dorwood N , Vanderpump MP
Published: May 2014

Metastatic carcinoma in the pituitary region is a well-recognized clinical entity (Teears and Silverman, 1975), and lymphomatous involvement as part of systemic disease is well documented (Mathiasen et al, 2000). This article describes the unusual case of a B-cell lymphoma localized to the pituitary region without systemic involvement.
Diagnosis and immediate care of injuries to the elbow and forearm
Authors: Phillips NJ , Stanley D
Published: May 2014

Commonly presenting to accident and emergency departments, the upper limb is often involved in trauma, either directly or as a result of a fall. Injuries associated with simple fractures may significantly affect outcomes. Accurate diagnosis of patterns of injury is vital.