Massive levemir (long-acting) insulin overdose: case report.

A 52-year-old insulin-dependant diabetic man presented to the Emergency Department 2 hours after a deliberate massive overdose of 2100 units of long-acting Levemir insulin and a large quantity of whisky. On initial assessment, his GCS was 3/15 and his capillary blood sugar was 2.6 mmol/L.

Salivary duct carcinomas can be classified into luminal androgen receptor-positive, HER2 and basal-like phenotypes.

Aims: The aim of this study was to devise a molecular classification for salivary duct carcinomas (SDCs) based on the similarities between SDCs and breast carcinomas and on characteristics of the microarray-based gene expression profiling-defined molecular subtypes of breast cancer.

Methods And Results: Forty-two pure salivary duct carcinomas, 35 of which contained an in-situ component as defined by histological review and/or immunohistochemical analysis, were stained with antibodies for oestrogen receptor (ER), progesterone receptor (PR), androgen receptor (AR), human epidermal growth factor receptor 2 (HER2), epidermal growth factor receptor (EGFR) and cytokeratin (CK) 5/6. Based on these markers, tumours were classified into HER2, luminal androgen receptor-positive, basal-like, luminal and indeterminate phenotype.

The 'Silver Book' on elderly care in hospitals and community settings.

The number of people aged 85 and over is set to increase by two-thirds in the next 20 years, making it imperative that appropriate structures are in place and guidance is available for clinicians in every setting on best practice in caring for older people over the first 24 hours of an urgent care episode. This article discusses the launch of the Silver Book, which recommends ways in which emergency admissions can be reduced and the experience of those admitted improved.

Reconstruction for breast cancer in a nutshell.

Breast cancer is a disease many will experience. Depending on the size of the cancer, the size of the host breast, and whether it is multi-focal, a mastectomy may be recommended as part of the treatment. If this is the case, an immediate breast reconstruction may be offered.

Helping survivors to adjust after cancer.

The concept of "cancer survivorship" has received considerable attention over the past three years as increasing numbers of people live with and beyond cancer. Previously, attention may have focused more on treatments for cancer and the likelihood of their success. In recent years, interest has moved to the after-effects of treatment, and how people can return to their lives while recovering.

Atraumatic posterior dislocation of the native hip: an unusual presentation of septic arthritis.

We present a case of chronic posterior hip dislocation after severe joint destruction following septic arthritis. In the absence of trauma, infection must be considered in the differential diagnosis of a dislocated joint particularly in patients with risk factors such as intravenous drug abuse and immune compromise. Excision arthroplasty of the hip was performed with good pain relief and functional outcomes.

Nasal inspiratory flow: at rest and sniffing.

Background: This study quantifies the time-varying flow rate during inspiration at rest and in sniffing, both predecongestion and postdecongestion. It aims to provide a better understanding of nasal airflow mechanics, for application to the physiological modeling of nasal respiration and to therapeutic drug delivery.

Methods: The temporal profiles of nasal inspiration were measured at high fidelity in 14 healthy individuals using simultaneous bilateral hot-wire anemometry.

Clinical outcomes, quality of life, advantages and disadvantages of metal stent placement in the upper gastrointestinal tract.

Purpose Of Review: This review will discuss the immediate- and long-term success, complications and overall benefits of self-expandable metal stents (SEMSs) in malignant or benign obstruction of the oesophagus, stomach and duodenum. Over recent years, indications such as benign disease have expanded, as has SEMS diversity with self-expandable plastic stents (SEPSs) or fully covered and biodegradable stents, for example.

Recent Findings: SEMSs have been increasingly used in malignant upper gastrointestinal obstruction with many reports confirming efficacy, despite a significant complication rate.

Educating for integrated care.

In September 2012 the North West London Integrated Care Plot held a conference for clinical educators. The aim was to reach a consensus about what learning clinical staff needed in order to contribute to an integrated care system. The conference was attended by 81 clinical educators from a range of backgrounds.

Emollients, education and quality of life: the RCPCH care pathway for children with eczema.

Objectives: The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies. The eczema pathway focuses on defining the competences to improve the equity of care received by children with eczema.

Method: The eczema pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence.

Intramuscular cavernous haemangioma of the triceps.

Haemangiomas are one of the most common soft tissue tumours comprising 7% of all benign tumours. Vascular malformations are often confused with haemangiomas. The etiology is unknown.

Workplace-based assessments of junior doctors: do scores predict training difficulties?

Objectives: Workplace-based assessment (WPBA) is an increasingly important part of postgraduate medical training and its results may be used as evidence of professional competence. This study evaluates the ability of WPBA to distinguish UK Foundation Programme (FP) doctors with training difficulties and its effectiveness as a surrogate marker for deficiencies in professional competence.

Methods: We conducted a retrospective observational study using anonymised records for 1646 trainees in a single UK postgraduate deanery.

Productivity gains by specialist nurses.

Workload analysis showed that the specialist nursing service in lung cancer in an acute hospital was being used primarily to support processes and administration rather than providing holistic cancer care. An analysis of the inpatient population showed that many people were being admitted for non-acute problems, such as symptom control in advanced disease. As the key workers for patients with lung cancer, the clinical nurse specialists negotiated away the administrative burden and adopted standard, proactive case management in line with national standards.

Breast awareness and screening.

Breast cancer is the most commonly diagnosed cancer in the UK. Breast awareness and screening, along with better treatment, can significantly improve outcomes, and more women than ever are now surviving the disease. This article discusses breast awareness and screening, symptoms and risk factors for breast cancer, and how nurses can raise breast awareness and screening uptake.

Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease.

Background: Clostridium difficile (C. difficile) infection in hospitals in developed countries continues to be a major public health hazard despite increased control measures including review of antibiotic policies and hygiene measures. Patients with colitis are thought to be particularly vulnerable to C.

A clinical information system reduces medication errors in paediatric intensive care.

Purpose: To determine the effect of electronic prescribing (EP) with a clinical information system (Intellivue Clinical Information Portfolio, Philips, UK) on prescribing errors and omitted doses in a paediatric intensive care unit (PICU).

Methods: Prospective audit of prescribing errors and omitted doses for 96 h periods in three epochs: (1) before implementation of EP, (2) 1 week and (3) 6 months later.

Results: There was a non-significant reduction in prescribing errors: 8.

Analysis of risk scoring for the outpatient management of acute upper gastrointestinal bleeding.

Objective: To determine whether the Glasgow-Blatchford bleeding score (GBS) or pre-endoscopy Rockall score was better at accurately identifying patients with acute upper gastrointestinal bleeding (AUGIB) who were at low risk of the need for clinical intervention and death and therefore suitable for outpatient management.

Design: Retrospective database and case note review of all patients admitted to the emergency departments with AUGIB from 1 January 2008 to 31 December 2009.

Setting: Two tertiary centre teaching hospitals.

The Role of PET/CT in Advanced Malignant Melanoma.

Positron emission tomography/computed tomography (PET/CT) with fluorodeoxyglucose demonstrates a high sensitivity and specificity for detecting both locoregional and distant metastases in patients presenting with AJCC stages III and IV disease. PET/CT also plays an important role in the detection of recurrence particularly in high-risk group patients, and this should be the modality of choice in investigating patients for suspected recurrence. The role of PET/CT in response assessment and follow-up still has to be defined, and cost-effectiveness analysis is required to strengthen its role.

Correction for effect of cold storage on immature platelet fraction.

It is common practice to store samples and measure the immature platelet fraction (IPF) only when the initial standard complete blood count and the blood smear indicate thrombocytopenia. However, the cold storage introduces an inherent error in the %IPF. A falsely elevated %IPF carries the risk of potentially misleading the clinicians' interpretation of the thrombopoietic activity, thus hindering the clinical utility of this parameter.

Selective reduction and termination of multiple pregnancies.

The substantial increase in high order multiple pregnancies in the last two decades as a result of assisted reproductive techniques has necessitated the development of multifetal pregnancy reduction as a management tool to decrease fetal number and improve perinatal survival. The evidence in favour of reduction in pregnancies with more than four fetuses to twins is undisputed. Despite the recent improvements in expectant management of triplets with reasonable perinatal outcomes, the evidence suggests that reduction to twins significantly reduces the risk of preterm delivery without an increase in miscarriage rates.