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1.  SIADH and partial hypopituitarism in a patient with intravascular large B-cell lymphoma: a rare cause of a common presentation 
BMJ Case Reports  2013;2013:bcr2012007147.
Hyponatraemia is a very common electrolyte abnormality with varied presenting features depending on the underlying cause. The authors report the case of a 75-year-old, previously fit, gentleman who presented with weight loss, lethargy and blackouts. He required four admissions to the hospital over an 8-month period. Investigations revealed persistent hyponatraemia consistent with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion, macrocytic anaemia and partial hypopituitarism. Unfortunately, all other investigations that were performed failed to identify the underlying cause and a diagnosis of intravascular large B-cell lymphoma was only confirmed following postmortem studies. The authors recommend that endocrinologists should be involved at the outset in the management of patients with persistent hyponatraemia and that intravascular large B-cell lymphoma should be considered in the differential diagnosis of hyponatraemia.
doi:10.1136/bcr-2012-007147
PMCID: PMC3604444  PMID: 23362070
2.  Differences in level of confidence in diabetes care between different groups of trainees: the TOPDOC diabetes study 
BMC Medical Education  2014;14(1):191.
Background
There is an increasing prevalence of diabetes. Doctors in training, irrespective of specialty, will have patients with diabetes under their care. The aim of this further evaluation of the TOPDOC Diabetes Study data was to identify if there was any variation in confidence in managing diabetes depending on the geographical location of trainees and career aspirations.
Methods
An online national survey using a pre-validated questionnaire was administered to trainee doctors. A 4-point confidence rating scale was used to rate confidence in managing aspects of diabetes care and a 6-point scale used to quantify how often trainees would contribute to the management of patients with diabetes. Responses were grouped depending on which UK country trainees were based and their intended career choice.
Results
Trainees in Northern Ireland reported being less confident in IGT diagnosis, use of IV insulin and peri-operative management and were less likely to adjust oral treatment, contact specialist, educate lifestyle, and optimise treatment. Trainees in Scotland were less likely to contact a specialist, but more likely to educate on lifestyle, change insulin, and offer follow-up advice. In Northern Ireland, Undergraduate (UG) and Postgraduate (PG) training in diagnosis was felt less adequate, PG training in emergencies less adequate, and reporting of need for further training higher. Trainees in Wales felt UG training to be inadequate. In Scotland more trainees felt UG training in diagnosis and optimising treatment was inadequate. Physicians were more likely to report confidence in managing patients with diabetes and to engage in different aspects of diabetes care. Aspiring physicians were less likely to feel the need for more training in diabetes care; however a clear majority still felt they needed more training in all aspects of care.
Conclusions
Doctors in training have poor confidence levels dealing with diabetes related care issues. Although there is variability between different groups of trainees according to geographical location and career aspirations, this is a UK wide issue. There should be a UK wide standardised approach to improving training for junior doctors in diabetes care with local training guided by specific needs.
doi:10.1186/1472-6920-14-191
PMCID: PMC4175629  PMID: 25227271
3.  Unusual case of hyponatraemia 
BMJ Case Reports  2012;2012:bcr0320126143.
Hyponatraemia is the most common electrolyte abnormality, encountered in up to 30% of inpatients. Inappropriate management can have serious implications for patients; including demyelinating disease, coma and death. We have used a case report to identify the common problems, and provide useful strategies in management for which these can be avoided. The aim was to provide a framework which clinicians can adopt, in order to improve clinical practice and provide optimum outcome for the patient.
doi:10.1136/bcr-03-2012-6143
PMCID: PMC3624489  PMID: 22854232
4.  The Charcot Foot in Diabetes 
Diabetes Care  2011;34(9):2123-2129.
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
doi:10.2337/dc11-0844
PMCID: PMC3161273  PMID: 21868781
5.  The RANKL/RANK/OPG Signaling Pathway Mediates Medial Arterial Calcification in Diabetic Charcot Neuroarthropathy 
Diabetes  2011;60(8):2187-2196.
OBJECTIVE
The receptor activator of nuclear factor-κB (RANK), RANK ligand (RANKL), and osteoprotegerin (OPG) signaling pathway (RANKL/RANK/OPG signaling) is implicated in the osteolysis associated with diabetic Charcot neuroarthropathy (CN); however, the links with medial arterial calcification (MAC) seen in people with CN are unclear. This study aimed to investigate the role of RANKL/OPG in MAC in patients with CN.
RESEARCH DESIGN AND METHODS
Enzyme-linked immunosorbent assay and Bio-plex multiarray technology were used to quantify a range of cytokines, including RANKL and OPG in sera from 10 patients with diabetes, 12 patients with CN, and 5 healthy volunteers. Human tibial artery segments were immunohistochemically stained with Alizarin red and human RANKL antibody. Human vascular smooth muscle cells (VSMCs) were also explanted from arterial segments for in vitro studies.
RESULTS
We demonstrate colocalization and upregulation of RANKL expression in areas displaying MAC. Systemic levels of RANKL, OPG, and inflammatory cytokines (interleukin-8, granulocyte colony–stimulating factor) were elevated in those with CN compared with diabetic patients and healthy control subjects. Human VSMCs cultured in CN serum showed accelerated osteoblastic differentiation (alkaline phosphatase activity) and mineralization (alizarin red staining) compared with cells treated with diabetic or control serum (P < 0.05). Coincubation with OPG, the decoy receptor for RANKL, attenuated osteogenic differentiation of VSMCs and was independent of a high calcium-phosphate milieu. The accelerated mineralization induced by RANKL and CN serum correlated with nuclear translocation of nuclear factor-κB, a process abrogated by OPG.
CONCLUSIONS
Our data provide direct evidence that RANKL/RANK/OPG signaling is modulated in patients with CN and plays a role in vascular calcification. This study highlights this pathway as a potential target for intervention.
doi:10.2337/db10-1220
PMCID: PMC3142088  PMID: 21659498
6.  Role of Quantitative Bone Scanning in the Assessment of Bone Turnover in Patients With Charcot Foot 
Diabetes Care  2009;33(2):348-349.
OBJECTIVE
To assess the new quantitative bone scan parameters as markers of Charcot neuroosteoarthropathy (CNO) activity.
RESEARCH DESIGN AND METHODS
Forty-two patients with acute (n = 21) and nonacute (n = 21) CNO underwent quantitative bone scanning. Patients with acute CNO were followed for 3–12 months and bone scans were repeated after treatment. New quantitative parameters were assessed and compared with markers of bone turnover and with skin temperature difference (STD).
RESULTS
Significant correlations between quantitative bone scan parameters and bone turnover markers were observed (all P < 0.05). These parameters decreased after treatment of CNO, and its reduction to the baseline value correlated with differences of bone turnover markers and STD (all P < 0.05).
CONCLUSIONS
Our study suggests that bone scanning can be used not only for diagnosis of CNO but also for monitoring disease activity by quantitative bone scan parameters.
doi:10.2337/dc09-0950
PMCID: PMC2809280  PMID: 19933988
7.  Protocol for a national audit on self-reported confidence levels, training requirements and current practice among trainee doctors in the UK: The Trainees Own Perception of Delivery of Care in Diabetes (TOPDOC) Study 
BMC Medical Education  2010;10:54.
Background
As the incidence and prevalence of diabetes increases across the world, resource pressures require doctors without specialist training to provide care for people with diabetes. In the UK, national standards have been set to ensure quality diabetes care from diagnosis to the management of complications. In a multi-centre pilot study, we have demonstrated a lack of confidence among UK trainee doctors in managing diabetes. Suboptimal confidence was identified in a number of areas, including the management of diabetes emergencies. A national survey would clarify whether the results of our pilot study are representative and reproducible.
Methods/Design
Target cohort: All postgraduate trainee doctors in the UK.
Domains Studied: The self reported online survey questionnaire has 5 domains: (1) confidence levels in the diagnosis and management of diabetes, (2) working with diabetes specialists, (3) perceived adequacy of training in diabetes (4) current practice in optimising glycaemic control and (5) perceived barriers to seeking euglycaemia.
Assessment tools: Self-reported confidence is assessed using the 'Confidence Rating' (CR) scale for trainee doctors developed by the Royal College of Physicians. This scale has four points - ('not confident' (CR1), 'satisfactory but lacking confidence' (CR2), 'confident in some cases (CR3) and 'fully confident in most cases' (CR4).
Frequency of aspects of day-to-day practice is assessed using a six-point scale. Respondents have a choice of 'always' (100%), 'almost always' (80-99%), 'often' (50-79%), 'not very often' (20-49%) and 'rarely' (5-19%) or never (less than 5%).
Discussion
It is anticipated that the results of this national study will clarify confidence levels and current practice among trainee doctors in the provision of care for people with diabetes. The responses will inform efforts to enhance postgraduate training in diabetes, potentially improving the quality of care for people with diabetes.
doi:10.1186/1472-6920-10-54
PMCID: PMC2921101  PMID: 20659349
8.  Treating painful diabetic polyneuropathy 
BMJ : British Medical Journal  2007;335(7610):57-58.
As consensus is lacking, protocols need to be devised and implemented locally
doi:10.1136/bmj.39261.687650.47
PMCID: PMC1914521  PMID: 17626918
9.  Infective endocarditis caused by Staphylococcus aureus in a patient with atopic dermatitis: a case report 
Introduction-
Atopic dermatitis (AD) is a common condition in the United Kingdom with the prevalence varying from 21% in infants aged 0–6 months to 6.4% at the age of 16 years. Patients with AD experience high rates of colonization of their skin surfaces by Staphylococcus aureus (S. aureus). In severe AD there is a potential risk of staphylococcal bacteremia and invasive infection such as acute endocarditis.
Case presentation-
We report a case of acute endocarditis with mitral valve destruction caused by S. aureus in a 30-year-old man with severe AD. The patient received intensive inpatient treatment with antibiotics and underwent successful mitral valve replacement and skin treatment for AD.
Conclusion-
Patients with severe AD are at higher risk of staphylococcal bacteremia and endocarditis. Staphylococcal endocarditis has to be considered in the differential diagnosis of febrile illness in patients with uncontrolled atopic dermatitis.
doi:10.1186/1752-1947-2-143
PMCID: PMC2390575  PMID: 18454875
10.  Training tomorrow's doctors in diabetes: self-reported confidence levels, practice and perceived training needs of post-graduate trainee doctors in the UK. A multi-centre survey 
Objective
To assess the confidence, practices and perceived training needs in diabetes care of post-graduate trainee doctors in the UK.
Methods
An anonymised postal questionnaire using a validated 'Confidence Rating' (CR) scale was applied to aspects of diabetes care and administered to junior doctors from three UK hospitals. The frequency of aspects of day-to-day practice was assessed using a five-point scale with narrative description in combination with numeric values. Respondents had a choice of 'always' (100%), 'almost always' (80–99%), 'often' (50–79%), 'not very often' (20–49%) and 'rarely' (less than 20%). Yes/No questions were used to assess perception of further training requirements. Additional 'free-text' comments were also sought.
Results
82 doctors completed the survey. The mean number of years since medical qualification was 3 years and 4 months, (range: 4 months to 14 years and 1 month). Only 11 of the respondents had undergone specific diabetes training since qualification.
4(5%) reported 'not confident' (CR1), 30 (37%) 'satisfactory but lacked confidence' (CR2), 25 (30%) felt 'confident in some cases' (CR3) and 23 (28%) doctors felt fully confident (CR4) in diagnosing diabetes. 12 (15%) doctors would always, 24 (29%) almost always, 20 (24%) often, 22 (27%) not very often and 4 (5%) rarely take the initiative to optimise gcaemic control. 5 (6%) reported training in diagnosis of diabetes was adequate while 59 (72%) would welcome more training. Reported confidence was better in managing diabetes emergencies, with 4 (5%) not confident in managing hypoglycaemia, 10 (12%) lacking confidence, 22 (27%) confident in some cases and 45 (55%) fully confident in almost all cases. Managing diabetic ketoacidosis, 5 (6%) doctors did not feel confident, 16 (20%) lacked confidence, 20 (24%) confident in some cases, and 40 (50%) felt fully confident in almost all cases.
Conclusion
There is a lack of confidence in managing aspects of diabetes care, including the management of diabetes emergencies, amongst postgraduate trainee doctors with a perceived need for more training. This may have considerable significance and further research is required to identify the causes of deficiencies identified in this study.
doi:10.1186/1472-6920-8-22
PMCID: PMC2358901  PMID: 18419804
11.  Non-European Union doctors in the National Health Service: why, when and how do they come to the United Kingdom of Great Britain and Northern Ireland? 
Background
As many as 30% of doctors working for the National Health System (NHS) of the United Kingdom of Great Britain and Northern Ireland (UK) have obtained their primary qualifications from a country outside the European Union. However, factors driving this migration of doctors to the UK merit continuing exploration. Our objective was to obtain training and employment profile of UK doctors who obtained their primary medical qualification outside the European Union (non-European doctors) and to assess self-reported reasons for their migration.
Methods
We conducted an online survey of non-European doctors using a pre-validated questionnaire.
Results
One thousand six hundred and nineteen doctors of 26 different nationalities completed the survey. Of the respondents, 90.1% were from India and over three-quarters migrated to the UK mainly for 'training'. Other reasons cited were 'better pay' (7.2%), 'better work environment' (7.1%) and 'having family and friends in the UK' (2.8%). Many of the respondents have been in the UK for more than a year (88.8%), with 31.3% having spent more than 3 years gaining experience of working in the NHS. Most respondents believe they will be affected by recent changes to UK immigration policy (86.6%), few report that they would be unaffected (3.7%) and the rest are unsure (9.8%).
Conclusion
The primary reason for many non-European doctors to migrate to the UK is for training within the NHS. Secondary reasons like better pay, better work environment and having friends and family in the UK also play a role in attracting these doctors, predominantly from the Indian subcontinent and other British Commonwealth countries.
doi:10.1186/1478-4491-5-6
PMCID: PMC1817649  PMID: 17326841
12.  A new pressure ulcer conceptual framework 
Journal of Advanced Nursing  2014;70(10):2222-2234.
Aim
This paper discusses the critical determinants of pressure ulcer development and proposes a new pressure ulcer conceptual framework.
Background
Recent work to develop and validate a new evidence-based pressure ulcer risk assessment framework was undertaken. This formed part of a Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research. The foundation for the risk assessment component incorporated a systematic review and a consensus study that highlighted the need to propose a new conceptual framework.
Design
Discussion Paper.
Data Sources
The new conceptual framework links evidence from biomechanical, physiological and epidemiological evidence, through use of data from a systematic review (search conducted March 2010), a consensus study (conducted December 2010–2011) and an international expert group meeting (conducted December 2011).
Implications for Nursing
A new pressure ulcer conceptual framework incorporating key physiological and biomechanical components and their impact on internal strains, stresses and damage thresholds is proposed. Direct and key indirect causal factors suggested in a theoretical causal pathway are mapped to the physiological and biomechanical components of the framework. The new proposed conceptual framework provides the basis for understanding the critical determinants of pressure ulcer development and has the potential to influence risk assessment guidance and practice. It could also be used to underpin future research to explore the role of individual risk factors conceptually and operationally.
Conclusion
By integrating existing knowledge from epidemiological, physiological and biomechanical evidence, a theoretical causal pathway and new conceptual framework are proposed with potential implications for practice and research.
doi:10.1111/jan.12405
PMCID: PMC4263098  PMID: 24684197
conceptual framework; nursing; pressure ulcer; risk factors; tissue viability

Results 1-12 (12)