Spedali Degli Innocenti, the Foundling Hospital in Florence, Italy.

The author reflects on a visit to the Ospedale Degli Innocenti, the former Renaissance foundling hospital in Florence, having escaped from an international clinical conference. He considers the symbolism of the architecture and artwork in relation to its function as a sanctuary for abandoned children.

What kind of doctor would you like me to be?

BACKGROUND: The modern medical school curriculum highlights the importance of good communication skills, although some clinicians still remain sceptical about the reduction of core science teaching in favour of these so-called softer skills. Previous studies into these topics are few and contradictory, with a heavy dependence on methodology and geographical source. METHODS: A semi-structured interview was conducted using the question 'I am about to qualify as a doctor in less than a year's time. As a patient, what advice would you give me? What kind of doctor would you like me to be if you came to me with an illness?' Responses were recorded anonymously on paper, verbatim. The responses were grouped into four broad classifications: personal qualities; communication skills; knowledge and intelligence; and manual skills. RESULTS: Data were collected from 51 patients. In total 118 attributes were identified and categorised. DISCUSSION: This education evaluation indicates that the patients we talked with in the UK counties of Shropshire and Staffordshire overwhelmingly sought doctors with good personal qualities and communication skills. Of the attributes recorded, 92 per cent were related to such qualities, with only 8 per cent emphasising knowledge and intelligence, and with no comments on manual skills. The results support the current emphasis in UK medical schools on communication skills and professionalism, and the development of personal qualities through the promotion of humanities teaching. The modern medical school curriculum highlights the importance of good communication skills.

The flip test: a reappraisal.

STUDY DESIGN: Diagnostic study. OBJECTIVE: To assess the construct validity of the flip test as a sign of nerve root tension. SUMMARY OF BACKGROUND DATA: The flip test is commonly performed in patients with sciatica to confirm or otherwise nerve root tension evidenced by a restricted supine straight leg raise (SLR). Passive extension of the knee with the patient in the erect position and the hip flexed is reported to cause a sudden falling or flipping back of the trunk. Although widely known there are no research articles validating this test. METHODS: Sixty-seven patients with sciatica and magnetic resonance imaging scans confirming disc protrusion and nerve root compression underwent the flip test. The response of the patient was recorded, compared with the supine SLR, and subjected to statistical analysis. RESULTS: Thirty-three percent of patients felt no pain, 39% felt pain on full extension of the knee, and 28% resisted full extension of the knee due to pain. Only one-third of patients demonstrated a "flip." The response was related to the supine SLR, such that patients with high SLRs tended not to show a painful reaction whereas all patients with a supine SLR below 45 degrees showed a painful response. CONCLUSION: We consider that the flip test has been substantially misinterpreted in the past. However, it remains a useful check of nerve root tension but only for patients with supine SLRs below 45 degrees . The most reliable response was not a flip but the demonstration of pain on extension of the knee. We would recommend the term "sitting SLR test," as a more accurate and less misleading name.

Low back pain on passive straight leg raising: the anterior theca as a source of pain.

STUDY DESIGN: A prospective clinical and radiologic investigation of two groups of patients presenting with either acute back pain only or acute leg pain only, yet similar restriction in straight leg raising (SLR). OBJECTIVES: To highlight a group of patients presenting with acute low back pain only, yet a restricted SLR normally associated with leg pain (sciatica) caused by a posterolateral disc prolapse. To determine the anatomic source of the pain in the low back pain only group. SUMMARY OF BACKGROUND DATA: A restricted SLR is commonly associated with leg pain (sciatica) due to compression of a nerve root by an intervertebral disc prolapse. Previous studies investigating pain patterns on SLR have suggested that central disc prolapses tend to induce back pain whereas the more lateral prolapses induce leg pain. Such research work has involved patients presenting with typical sciatic pain investigated by myelography and undergoing decompressive surgery. There are no studies specifically investigating patients presenting with low back pain only and reduced SLR. METHODS: Two groups of patients, one with acute low back pain only and one with acute leg pain only, yet showing similar restriction in SLR underwent MR imaging. The scans were reviewed "blind" by an experienced spinal radiologist and imaging features recorded according to a detailed protocol. The MR findings were then compared. RESULTS: Significant disc prolapses were seen equally in both groups. The disc prolapses in the back pain only group were more likely to be central, smaller, to compress the theca only, and to be at a higher lumbar level as compared with the leg pain only group. CONCLUSIONS: Acute low back pain associated with significant restriction in SLR is likely to be caused by a disc prolapse compressing the anterior theca.

Paediatric post-traumatic cortical defects of the distal radius.

Paediatric post-traumatic cortical defects, although rare, are predominately seen affecting the distal radius following a greenstick or torus fracture. We review the literature and present a further two cases supported by CT and MRI. Images from an acute greenstick fracture are also presented to help understand the pathogenesis. Defects are typically solitary on plain radiographs and are usually noticed late, proximal to the site of compression. They are non-expansile in an otherwise healthy child. CT and MRI may reveal smaller multiple subperiosteal defects. Typical defects require no further management other than reassurance and advice that they may occasionally cause discomfort but resolve with time.