These guidelines update previous guidance published in 2005. They have been revised by a group who are members of the UK and Ireland Neuroendocrine Tumour Society with endorsement from the clinical committees of the British Society of Gastroenterology, the Society for Endocrinology, the Association of Surgeons of Great Britain and Ireland (and its Surgical Specialty Associations), the British Society of Gastrointestinal and Abdominal Radiology and others. The authorship represents leaders of the various groups in the UK and Ireland Neuroendocrine Tumour Society, but a large amount of work has been carried out by other specialists, many of whom attended a guidelines conference in May 2009. We have attempted to represent this work in the acknowledgements section. Over the past few years, there have been advances in the management of neuroendocrine tumours, which have included clearer characterisation, more specific and therapeutically relevant diagnosis, and improved treatments. However, there remain few randomised trials in the field and the disease is uncommon, hence all evidence must be considered weak in comparison with other more common cancers.

This 6-month, open, non-controlled, multicenter, dose-titration study evaluated the efficacy and safety of 28-day prolonged-release (PR) lanreotide in the treatment of carcinoid syndrome. Eligible patients had a carcinoid tumor with ≧3 stools/day and/or ≧1 moderate/severe flushing episodes/day. Six treatments of 28-day PR lanreotide were administered by deep subcutaneous injection. The dose for the first two injections was 90 mg. Subsequent doses could be titrated (60, 90, 120 mg) according to symptom response. Seventy-one patients were treated. Flushing decreased from a mean of 3.0 at baseline to 2.3 on day 1, and 2.0 on day 2, with a daily mean of 2.1 for the first week post-treatment (p < 0.05). Diarrhea decreased from a mean of 5.0 at baseline to 4.3 on day 1 (p < 0.05), and 4.5 on day 2, with a daily mean of 4.4 for the first week post-treatment (p < 0.001). Symptom frequency decreased further after the second and third injections, and reached a plateau after the fourth injection. By month 6, flushing and diarrhea had significantly decreased from baseline by a mean of 1.3 and 1.1 episodes/day, respectively (both p ≤ 0.001); 65% of patients with flushing as the target symptom and 18% of diarrhea-target patients achieved ≧50% reduction from baseline. Median urinary 5-hydroxyindoleacetic acid and chromogranin A levels decreased by 24 and 38%, respectively. Treatment was well tolerated. 28-day PR lanreotide was effective in reducing the symptoms and biochemical markers associated with carcinoid syndrome.

Doctors need to identify and understand the professional behaviours of both themselves and others. In order for students to think critically about these issues we encouraged them to use the tenets of the General Medical Council's Duties of a Doctor as a framework in which to reflect on the actions of healthcare professionals at work. Although the critical incident technique is a well-known process for encouraging reflection, little is known about its usefulness for assessment purposes in this setting. We aimed to discover the validity, feasibility and educational impact of the critical incident as an assessment method for first year students undertaking guided reflection in the context of their first exposure to multi-professional health and social care experiences. First year medical students submitted two critical incidents they had observed during multi-professional health and social care attachments and an evaluation of their experiences. Students engaged in the reflective cycle on the professional behaviours of others providing evidence of a varied range of situations. With adequate preparation, junior students are able to reflect on social and healthcare experiences using the Duties of a Doctor as a framework. Critical incidents are a valid and feasible method for assessing students' reflections on professionalism, with good educational impact.

1 The effects of two (8-adrenoceptor antagonists (propranolol and metoprolol), and of the 38-adrenoceptor agonist, terbutaline, on the plasma kinetics of antipyrine were studied in five normal subjects. In addition, the influence of propranolol on the clearance of antipyrine to three of its major metabolites was investigated.2 At the same level of j8-adrenoceptor blockade, assessed by lowering of exercise tachycardia, propranolol decreased antipyrine clearance by 37.3 + 9.9 s.d. % (P < 0.001) and metoprolol decreased it by 18.0 ± 4.7 s.d. % (P < 0.01). Terbutaline had no effect on antipyrine clearance. The volume of distribution of antipyrine was unchanged following treatment with all three drugs. 3 Only the metabolic clearance of antipyrine to its 3-hydroxymethyl product was impaired to a statistically significant degree by propranolol. However, four of the five subjects also showed impaired clearance to 4-hydroxyantipyrine and three of the five to norantipyrine after propranolol treatment. In four of the five subjects propranolol lowered the renal clearance of antipyrine. 4 Inhibition of the metabolism of antipyrine by 3-adrenoceptor antagonists may be related to their lipid-solubility and extent of metabolism and is independent of their effect on ,1-adrenoreceptors.

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