bluuebunny/crossref_metadata_2025_split huggingface dataset:
Key factors in developing and delivering interprofessional education
Authors: Reeves Scott , Summerfield Mann Lynn 
Published: May 2014

Interprofessional education (IPE) has been advocated in a number of policy documents for nearly 30 years as the main route to enhancing collaboration. Consequently, there has been a steady growth in IPE activity in this country and abroad. Despite this expansion, literature reveals that the planning and delivery of IPE remains a localized and rather haphazard affair with little understanding of the factors that influence its development or implementation. This article examines some of the key factors (conceptual, operational, educational and evaluative) that underpin the design and delivery of successful IPE and also presents a series of ideas to assist practitioners' work in this area.
An overview of the effect of ageing on hand function
Authors: Jones Nikki , Adams Jo 
Published: May 2014

Effective hand function involves many complex interrelated processes. Proprioceptive and sensory feedback mechanisms need to be complete, as well as sound hand to eye coordination. Intrinsic and extrinsic hand musculature needs to be well controlled before hand function can truly be smoothly coordinated and effective. In older people, there may be a decrease in hand function without evident trauma or disease. A natural decline in hand function is to be expected in the older population. However, this is not necessarily an irreversible loss – many of the conditions associated with loss of hand function are not a consequence of ageing so much as a consequence of inactivity. This article provides a critical review of the literature on the effect of the ageing process on hand function.
Emery–Dreifuss muscular dystrophy with cardiac manifestations
Authors: Cullington D , Pyatt JR 
Published: May 2014

An asymptomatic 40-year-old man attended clinic for cardiology assessment before cataract surgery. He had been diagnosed 9 years earlier with a ‘non specified limb-girdle muscular dystrophy’ following investigation for lower limb muscle weakness. Earlier electrocardiograms (ECGs) showed a bradycardic, junctional escape rhythm of 30–40 beats per minute (BPM). He had previously refused pacemaker insertion. He denied any syncope, shortness of breath or palpitations. He had muscle wasting to his upper arms and calves plus mild elbow contractures. He was normotensive, resting regular heart rate = 42 BPM and cardiorespiratory examination was unremarkable. His ECG showed atrial fibrillation, with a slow junctional escape rhythm of approximately 40 BPM and normal QRS width (Figure 1). Blood tests showed no haematological, electrolyte or thyroid dysfunction and no impaired glucose tolerance. Echocardiography showed good left ventricular function and 24-hour ECG Holter monitoring showed 8 pauses (longest 2.13s), with a heart rate varying between 29 and 79 BPM. He was commenced on clopidogrel to prevent thromboembolic complications and then he agreed for a VVIR system to be implanted to avoid bradyarrhythmic death. No complications ensued and he remains well at present. The patient also had two brothers, one died suddenly and the cause of death was not clearly determined. His elder brother was 52 years old and was diagnosed with a non-specific muscular dystrophy also associated with a junctional rhythm. He had a VVIR permanent pacemaker inserted in April 2003 following recurrent episodes of dizziness. An hereditary skeletal myopathy in association with pathognomic cardiac abnormalities suggested a diagnosis of Emery–Dreifuss muscular dystrophy (EDMD). Prognostically and therapeutically a definitive genetic diagnosis was required. Genetic testing confirmed that both siblings had inherited the X-linked form of EDMD involving a single base change of the emerin gene.
Importance of haemodynamic monitoring in cardiac tamponade
Authors: Mahajan Nitin , Thekkoott Deepak , Kabalkin Chaim , Hollander Gerald , Vaynblat Mikhail , Rankin Lydia 
Published: May 2014

A55-year-old man presented to the emergency room (ER) with complaints of anorexia, feelings of being unwell and anuria from the previous day. He denied any chest pain, palpitations, dyspnoea on exertion or fever. He was recovering from a recent throat infection and had a past medical history of diabetes mellitus, hypertension and hypercholesterolaemia. He was pale-looking and his physical examination revealed hypotension (90/60 mmHg) and tachycardia. He appeared in mild respiratory distress. Examination of neck veins showed raised jugular venous pressure of 6 cm above the sternal angle. His chest was clear on auscultation and the intensity of heart sounds were diminished with no added sounds. He had a measured pulsus-paradoxus of 20 mmHg. His electrocardiogram showed diffuse low-voltage complexes with no evidence of electrical alternans. There were ST segment elevations in lateral leads with tall T-waves in anterior precordial leads suggestive of posterolateral myocardial infarction (Figure 1). Posterior changes were confirmed on a posterior electrocardiogram (Figure 2). Right-sided electrocardiogram failed to reveal any ST-T abnormalities suggestive of right ventricular infarction. The initial set of laboratory tests done in ER revealed high blood urea nitrogen (9.64 mmol/litre) and serum creatinine (150.28 μmol/litre). The first set of cardiac enzymes revealed high troponin I (23.05 μg/litre) with normal myoglobin and creatine kinase. An arterial line was placed that revealed pulsus-paradoxus of 20 mmHg. A Swan–Ganz catheter was placed and showed: right ventricle of 53/33 mmHg; right atrium of 28 mmHg; pulmonary artery of 50/32 mmHg; pulmonary capillary wedge pressure of 30 mmHg. The central venous pressure tracing showed complete obliteration of ‘y’ descent. Dopplerechocardiography was done. It showed mild-to-moderate pericardial effusion with possible thrombus overlying the right ventricular wall. Posterior and lateral walls were found to be hypokinetic. The patient underwent coronary angiography before emergency pericardiocentesis. Angiography revealed complete occlusion of the first obtuse marginal. Aortic-pulse tracing is shown in Figure 3. These pressure tracings were consistent with cardiac tamponade with a demonstrable pulsus-paradoxus of about 20 mmHg. Ventriculography was not performed because of a suspected subacute rupture of the myocardial wall. A cautious pericardiocentesis was performed. Examination of the pericardial cavity revealed 300 cm3 of blood clots. In the absence of an ongoing leak, a pericardial window was created and a drain was left in situ. The patient was dialysed once after the procedure. His haemodynamics improved significantly after surgery. He remained stable through the course of his stay in the hospital and was discharged 3 days after pericardiocentesis.
Secondary syphilis: a multisystem disease not to be forgotten
Authors: Thein Michael , Acland Katharine , Lightman Susan , Lynn William 
Published: May 2014

A42-year-old homosexual man presented with a 3-month history of painful mouth ulcers and a hyperkeratotic, erythematous scaly rash affecting his palms and soles (Figure 1). He also had a 2-month history of bilateral anterior tibial pain, balanitis and a panuveitis. There was a recent history of a non-specific urethritis and a past history of shingles. In addition to the rash affecting his palms and soles, he had facial seborrhoeic dermatitis, mucosal ulceration with leukoplakia, and a balanitis with phimosis. A tender firm lump was noted over his left anterior shin. He was apyrexial and there was no lymphadenopathy or hepatosplenomegaly. Routine investigations revealed a raised erythrocyte sedimentation rate of 42 mm/h, associated with a polyclonal rise of immunoglobulins with a normal full blood count and C-reactive protein. A plantar skin biopsy showed numerous plasma cells in addition to lymphocytes within the papillary dermis (Figure 2). A Warthin–Starry stain for bacteria was negative. At the same time as the skin biopsy his vision worsened with bilateral mid-peripheral retinitis in addition to panuveitis. The skin biopsy showing numerous plasma cells and the mid-peripheral distribution of the retinitis were highly suggestive of secondary syphilis. The diagnosis of secondary syphilis was confirmed by a positive venereal disease research laboratory (VDRL) titre of 1:256, in association with a positive fluorescent treponemal antibody (FTA) test and treponema pallidum haemagglutination assay. He was also found to be positive for human immunodeficiency virus with a CD4 (t-helper cell) count of 145 × 106/litre (10.5%), and a viral load of 115 305 copies/ml. X-rays of his tibial bones revealed bilateral lytic cortical lesions, in keeping with a syphilitic osteitis. The firm tender lump over his left shin corresponded to a cortical lesion with a marked periosteal reaction (Figure 3). He was given a 10-day course of high-dose intravenous benzylpenicillin, after which his skin and mucosal lesions had almost resolved. The initial ocular inflammatory reaction settled quickly but visual acuity deteriorated 2 days after the commencement of penicillin, thought to result from an intraocular Jarisch–Herxheimer reaction. This complication was treated with a tapering dose of oral prednisolone, starting at a dose of 60 mg/day. His visual acuity subsequently returned to normal leaving a residual typical ‘salt and pepper’ scarring in the fundus (Figure 4).
Intermittent gastric volvulus secondary to gall bladder adhesions: a rare cause of gastric outlet obstruction
Authors: Sultan J , Vassallo P , Davis P , Viswanath YKS 
Published: May 2014

A51-year-old man presented with a history of intermittent epigastric pain over a course of 18 months, associated with feeling bloated, and episodic nausea and non-bilious vomiting, which relieved the pain. During recent months vomiting had been replaced by severe retching. Ultrasound scan of the gall bladder revealed gallstones. Clinical examination was unremarkable. Routine haematological and biochemical investigations were also normal. Two gastroscopies were incomplete, since on both occasions the endoscope could not be negotiated beyond the antrum and the pylorus could not be visualized. A water-soluble contrast swallow revealed a ‘cup and fill’ configuration (Figure 1), suggesting mesenteroaxial gastric volvulus. A repeat ultrasound scan revealed a thick-walled gall bladder with several calculi. Laparoscopy confirmed the presence of the gastric volvulus, with the stomach adherent to the body of a chronically-inflamed gall bladder. At initial intraoperative gastroscopy the endoscope failed to pass beyond the antrum. Following adhesiolysis, cholecystectomy and anterior suture gastropexy, a gastroscope could easily be passed into the pylorus and duodenum. He made an uneventful recovery and remains asymptomatic 1.5 years after the operation.
Nicotine replacement therapy and ischaemic stroke
Authors: Ang Richard , Wroe Stephen , Manji Hadi , Sharma Pankaj 
Published: May 2014

A52-year-old right-handed businessman developed sudden onset of non-fluent dysphasia, weakness and sensory disturbance on the right side of his body 3 weeks after starting Nicorette patches (21 mg). He continued to smoke 3–5 cigars a day while on these patches. The patient had a history of depression and excessive alcohol intake. Examination confirmed an expressive dysphasia with verbal fluency limited to five words beginning with ‘C’ or ‘S’ but with no problems in comprehension, naming or praxis. Rapid alternating movements were impaired on the right and reflexes were brisker on the right side, although both planters were flexor. Cardiovascular and general examination was unremarkable. Magnetic resonance imaging (MRI) brain scan confirmed a left anterior cerebral artery territory infarct. The following blood tests were normal or unhelpful: erythrocyte sedimentation rate (ESR), C-reactive protein, protein culture and sensitivity, antithrombin, antiphospholipid coagulant, treponemal serology, thyroid screen and autoantibody screen. The patient was found to have mildly raised triglyceride (2.42 mmol/l) and low density lipoprotein (LDL) cholesterol (4.61 mmo/l). Electrocardiogram (ECG), echocardiography and carotid Dopplers were all normal. Two previous cases of stroke following nicotine patches have been reported by Jackson (1993) and Pierce (1994). In addition, the Medicines and Healthcare products Regulatory Agency (MHRA) have received 12 further cases of cerebrovascular disorders following nicotine replacement (Table 1).
A case of neonatal testicular torsion
Authors: Wong Chee-Yeng , Yong Sin-Chuen , Boo Nem-Yun , Phang Koon-Seng 
Published: May 2014

A Malay male infant of 3000 g was delivered via spontaneous vaginal delivery to a primigravida mother. His Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. His mother had an uneventful antenatal and intrapartum period. Physical examination performed at 1 hour of life detected an enlarged, hard and tender right testis with discolouration of his right scrotal skin. There was a left cystic hydrocoele and the left testis was of normal consistency and size. A clinical diagnosis of torsion of the right testis was made. Ultrasonography of the testes showed absence of Doppler signal within the right testis, which measured 1.46 × 0.91 cm with the presence of an ill-defined hypoechoic area in its superior pole, suggesting an area of infarction. The left testis was of normal size and Doppler signal. Intraoperatively, the right testis was found to be gangrenous with torsion of the right testicular artery. The left testis was normal. Right orchidectomy and a left orchidopexy were performed. Postoperatively the infant recovered uneventfully and was discharged home on the fourth day of life. On follow-up, the left testis was growing well. Histopathological examination (Figures 1 and 2) of the right testis confirmed the presence of testicular torsion with infarction.
Unusual presentation of Ramsay-Hunt syndrome without facial nerve palsy
Authors: Leong SCL , Karkanevatos A 
Published: May 2014

A 65-year-old woman presented to the outpatient clinic with severe left earache associated with nausea, dizziness and left-sided hearing loss. Her symptoms, which started 5 days previously, had got progressively worse. There was no history of ear discharge or trauma. She was otherwise fit and healthy with no remarkable past medical history. On examination, she was generally unwell. The left pinna was swollen and tender. The auditory canal was tight and inflamed with a small amount of discharge. These findings were initially thought to be otitis externa associated with perichrondritis of the pinna. She was admitted for symptomatic relief, aural toileting and intravenous antibiotics. Her full blood count was normal and swabs taken revealed only normal skin flora. Her symptoms, however, did not improve as expected. Her dizziness and nausea had worsened although she did not have true rotatory vertigo or ataxia. She also complained of dysphagia to solids. There was no significant change to her speech but a fibreoptic endoscopy revealed sluggish movement of the left vocal cord and reduced sensation of the supraglottis. The rest of her neurological examination was otherwise normal. At this stage, the possibility of Ramsay–Hunt syndrome was considered but there was still no evidence of herpetic lesions or facial palsy. Pure tone audiometry showed a sensorineural hearing loss of 30 dB in the left ear. Computed tomography scan of the temporal bones and magnetic resonance imaging of the brain were normal. Her symptoms gradually improved over the course of 1 week. On discharge, all her presenting symptoms had completely subsided except for mild intermittent nausea. She was readmitted a week later with recurrence of left earache. However, both the nausea and the dizziness that presented themselves on initial admission were absent. The pinna was not swollen but there were now herpetiform vesicles in the left auditory meatus and tympanic membrane. Neurological examination was normal. Antibodies to varicella zoster virus (VZV) and VZV immunoglobulin M were positive. These findings were consistent with VZV infection, which suggest that this may have been an unusual variant of Ramsay–Hunt syndrome. She was treated with acyclovir and gabapentin for post-herpetic neuralgia. The patient responded to treatment and was discharged 3 days later. Her follow-up examination revealed no evidence of residual symptoms.
An unexpected finding during gastroscopy
Authors: Kamaruddin Shafie , Ramachandran Subramanian , Turner Graham B , Yousaf Mohammed , McConville Paul , Wilson Carol , Clements W Barry 
Published: May 2014

At the age of 3 years, the patient had undergone surgery for repair of an atrial septal defect and had an epicardial pacing system placed for congenital atrioventricular block. This was replaced with an endocardial dual chamber pacemaker at the age of 15 years. The epicardial pulse generator and leads were left in situ. Now aged 23 years old, the patient presented with a 48-hour history of right shoulder tip pain, palpitations, rigors and subsequent melaena. On examination she was pyrexic (40°C) with vague upper abdominal tenderness. She had no overt features of bacterial endocarditis. Her chest X-ray shows both the endocardial and epicardial pacing system in situ (Figure 1). Preliminary haematological investigations revealed a microcytic hypochromic anaemia (7.4 g/dl), neutrophilia (25x109/ml), an erythrocyte sedimentation rate of 121 mm/hr and a C-reactive protein of 272 mg/litre. Repeated blood cultures were negative. Transoesophageal echocardiography showed no evidence of valvular or pacemaker lead vegetations. Gastroscopy revealed the redundant epicardial pacemaker generator inside the stomach with evidence of gastric ulceration (Figure 2). After initial resuscitation with blood products and parenteral antibiotics she underwent surgery where through a gastrostomy the pulse generator was retrieved. At laparotomy the left lobe of the liver appeared unhealthy and subsequent computed tomography scan of the abdomen confirmed the presence of multiple intrahepatic abscesses (Figure 3). It was decided that the hepatic abscess were not suitable for percutaneous drainage as they were multiple and predominantly in the left lobe of the liver. She continued on a protracted course of intravenous antibiotics and made a full recovery thereafter.
Laparoscopic-assisted oesophagectomy for adenocarcinoma in an AIDS patient
Authors: Botha Abrie , Kochhar Suneeta 
Published: May 2014

A 44-year-old man with known AIDS (acquired immunodeficiency syndrome) presented with an 18-month history of progressive dysphagia, occasional reflux, reduced appetite and significant weight loss. There was no odynophagia, haematemesis or haemoptysis. Upper gastrointestinal endoscopy and endoscopic ultrasound demonstrated a tumour 41–44 cm from the incisors. Two 6 mm regional paraoesophageal lymph nodes were seen at 34 cm and there were two 5 mm splenic artery nodes. Endoscopic staging was of a T3 N1 tumour at the gastro-oesophageal junction and biopsy findings revealed poorly differentiated adenocarcinoma. Computed tomography confirmed endoscopic findings and showed no evidence of metastatic disease. The patient had previously been treated for oesophageal candidiasis, an AIDS-defining illness. He was diagnosed with human immunodeficiency virus (HIV) 4 years ago and was currently taking zidovudine, lamivudine and efavirenz or highly active anti-retroviral therapy (HAART). At presentation his viral load was less than 50 copies (Roche polymerase chain reaction assay, Amplicor HIV-1 Monitor) and his T-cell count was approximately 200/mm3. The patient received three cycles of neoadjuvant chemotherapy for tumour regression. This was complicated by the development of peripheral neuropathy. Despite ongoing nausea the patient was able to continue with HAART. After completing the course of chemotherapy, the patient underwent a laparoscopic-assisted Ivor Lewis oesophagectomy. This is a two-stage procedure where a laparotomy is performed followed by thoracotomy and an anastomosis of the stomach to the upper oesophagus in the chest. He had a brief stay on the high dependency unit as a result of shortness of breath. Chest X-ray showed bilateral infiltrates suggestive of acute lung injury. Pneumocystis carinii pneumonia was deemed unlikely as a result of septrin prophylaxis. Nutritional status improved and he was discharged on day 16. Peripheral neuropathy is an ongoing issue. Postoperative histology demonstrated a poorly differentiated adenocarcinoma of the gastrooesophageal junction that had penetrated through gastric serosa. The pathological stage was pT3 N2. Ten out of 26 lymph nodes were found to be positive for adenocarcinoma.
Drug-induced QT prolongation: consequences and current dilemma
Authors: Dubrey Simon W , Grocott-Mason Richard 
Published: May 2014

An 86-year-old woman was admitted with falls. She was taking no medication and had no family history of long QT syndrome. An electrocardiogram (ECG) revealed atrial fibrillation at 160 beats per minute. Rate control was commenced with digoxin and metoprolol, to a total dosage of 625 μg and 137.5 mg respectively. On day 8, the therapy was changed to attempt chemical cardioversion with sotalol at a dosage of 40 mg daily. After a cumulative sotalol dosage of only 120 mg, given over 3 days, the ECG showed extreme QT interval prolongation (800 msec) and bizarre T, or TU wave inversion (Figure 1). Blood tests were normal (K+ 5.3 mmol/litre, Mg++ 0.97 mmol/litre, Ca++ 2.45 mmol/litre) and troponin T was negative. An echocardiogram showed normal dimensions and function. The patient experienced numerous runs of polymorphic ventricular tachycardia (torsade de pointes) precipitated by repeated ‘R on T’ events (Figure 2). Intravenous magnesium had no effect. Temporary pacing was used to overdrive pace the patient. The patient was commenced on a low dose of bisoprolol and made a complete recovery to sinus rhythm and a normal QT interval.
Phantom limb claudication
Authors: Corfield L , Gurprashad R , Halawa M , Yusuf SW 
Published: May 2014

A fit and well 29-year-old man underwent a right above-knee amputation in 1976 as a result of severe trauma sustained in a road traffic accident. After rehabilitation, he remained well and mobilized independently with his prosthesis. Twenty nine years later he was admitted to hospital for an infection of his stump following minor trauma. There was no history of diabetes, hypertension or smoking. He was taking aspirin and lipid-lowering medication. During his admission and subsequent follow up, he gave a clear history of not only right stump (thigh) claudication but also claudication in his absent right calf when mobilizing with his prosthesis after walking 50 yards. The pain was relieved quickly by ceasing to walk. The claudication persisted after the stump was well healed. At re-presentation, both the arterial duplex scan and magnetic resonance angiogram showed occlusion of the right external iliac artery (Figure 1). His stump healed well with no surgical intervention or complication. He was advised to exercise to improve the claudication. After 4 months he was able to walk 100 yards without claudicating.