Journal of the Royal College of Physicians of Edinburgh

Background: Patients increasingly use the internet to access health information.Inadequate health literacy is common and frequently limits patient comprehension of healthcare literature. We aimed to assess the readability of online consumerorientated Parkinson’s disease (PD) information using two validated measures.

Method: We identified the 100 highest ranked consumer-orientated PD webpages and determined webpage readability using the Flesch-Kincaid and Simple Measure Of Gobbledygook (SMOG) formulae.

Results: None of the webpages analysed complied with current readability guidelines. Commercial websites were significantly easier to read (p=0.035). The Flesch-Kincaid formula significantly underestimated reading difficulty (p<0.0001). Ease of reading correlated weakly with search engine ranking (r=0.35, p=0.0004).

Conclusions: Only 1% of the top 100 PD information webpages are fully comprehensible to the average adult. Simple Measure Of Gobbledygook should be the preferred measure of webpage readability. Parkinson’s disease information websites require major text revision to comply with readability guidelines and to be comprehensible to the average patient.

The observation that hyperventilation was common in men involved in civil court actions compared with my non-medico-legal practice stimulated me to carefully assess 100 consecutively seen men with non-malignant asbestosrelated disease(s). A diagnosis of hyperventilation was made in 33 and probable hyperventilation in 12. The development of anxiety symptoms in these men could, in part at least, be prevented or greatly decreased if more emphasis was placed on the education of ex-asbestos workers by solicitors and organisations responsible for the initiation of civil actions.

The prevalence of proteinuria in patients presenting acutely with oedema due to heart failure has not been studied extensively. Recent evidence from the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) trial suggests that there is a high prevalence of albuminuria in chronic heart failure patients. We set out to investigate the prevalence of proteinuria in patients presenting with fluid retention secondary to heart failure. A random collection of urine albumin–creatinine ratios (ACRs) in successive patients was used to quantify proteinuria. Out of a sample of 19 patients, seven had no detectable albuminuria, eight had microalbuminuria and four had macroalbuminuria. We did not find any relation between urine ACR and age, serum urea or serum creatinine. Moreover, we did not find a higher prevalence of albuminuria with increasing age or the presence of diabetes mellitus. In conclusion, the clinical significance of this common finding in patients presenting with fluid retention is not clear, and further research is warranted to clarify its prognostic value.

In England the Department of Health has funded specialist clinical services aimed at diagnosing and managing the symptoms of chronic fatigue syndrome (CFS). These services are not available to those who do not fulfil the diagnostic criteria for CFS. This service evaluation examined the proportion of those referred to a specialist CFS service fulfilling the Fukuda diagnostic criteria for CFS and the alternative fatigue-associated diagnoses. The CFS database was interrogated to include every patient referred to the Newcastle service from November 2008 to December 2009. All medical notes were reviewed and the diagnosis, sex and age recorded. Data were compared to a previous service evaluation (2005–07). In 2008–09, 260 subjects were referred: 19 referrals per month (260/14), compared with 17 referrals per month in 2005–07 (375/24). The proportion of patients diagnosed with CFS increased significantly compared with 2007 (36% [20/56] vs 60% [157/260]; p<0.0001). Of the 40% of patients subsequently found not to have CFS the most common diagnosis was fatigue associated with a chronic disease (47% of all alternative diagnoses); 20% had primary sleep disorders, 15% psychological/psychiatric illnesses and 4% a cardiovascular disorder. Thirteen per cent remained unexplained (5.2% of the total referrals). This study found a significant increase in the proportion of patients referred to National Health Service (NHS) CFS services diagnosed with CFS. A large proportion of patients presenting with fatigue are not eligible for referral to the Department of Health specialist fatigue services, which represents an unmet need in terms of symptom management in current NHS services.

We present a case of a young man with Lemierre’s syndrome characterised by suppurative thrombophlebitis of the internal jugular vein and multiple septic embolic lesions with cavitations in both lungs resulting from an infected branchial cyst which was previously undiagnosed. Lemierre’s syndrome is a rare presentation, especially with pulmonary cavitations, but remains a serious illness with a high mortality rate. Early recognition and prompt treatment have significant impact on prognosis. We believe this to be the first case of Lemierre’s syndrome complicated by a previously undiagnosed, infected branchial cyst.

Circadian rhythm sleep disorders are poorly understood and often misdiagnosed. They are all related to the timing of sleep within the 24-hour day. This paper describes a patient with a long history of sleep disturbance whom we diagnosed as having delayed sleep phase syndrome by history and measurement of urinary melatonin metabolite excretion. Literature on the characteristics, diagnosis and management of this syndrome are briefly reviewed. In addition, the relation of the neurohormone melatonin to circadian rhythm and its other physiological roles are described.

Incidentally discovered adrenal masses (adrenal incidentalomas) found during radiological procedures are a by-product of modern-day medicine. Incidental findings of such adrenal masses pose uncertainties and dilemmas in evaluation and management. There is a paucity of comprehensive guidelines from professional societies, and current recommendations (based on expert opinions and the US National Institutes of Health statement, 2002) are open to debate with regards to cost and clinical benefit. We report two patients with ‘adrenal incidentalomas’ with different outcomes during the course of evaluation. We conclude with a simple guide to the evaluation and management of such masses based on the available literature.

The shifting age demographic of the adult population has affected every area of contemporary medical and surgical practice. Many more people are living well, not just into their 70s but into their 80s and beyond. Their expectations of treatment for every illness have shifted markedly upwards at the same time. Despite the decline in cases of rheumatic fever in Westernised populations in recent times, the ageing population has led to no decline in the prevalence of valvular aortic stenosis. This is now realised to be an active pro-inflammatory disease, rather than a degenerative process. Thus the condition has remained in the mainstream and continues to be responsible for considerable morbidity, hospitalisation and mortality among the elderly and very elderly.

Management has always been based on the triage of cases for direct intervention to the valve by surgery. Just as expectations have risen from patients, the techniques, application and monitoring of cardiac surgery have also made huge strides forward to meet this aspiration. More and more, surgeons are routinely asked to consider procedures in frailer, more elderly patients with more severe disease and co-morbidity. Managing the stenosis is rarely the only issue confronting the operating surgeon. Attempts to provide alternatives to open valve replacement surgery on cardiopulmonary bypass have now emerged. These are based around the transcutaneous placement of a valve prosthesis. While these technologies were initially highly selective in their application, they have now reached a stage to be compared with contemporary standards of cardiac surgical practice. In this debate we have invited two international experts from the fields of cardiac surgery (Professor Jahangiri) and interventional cardiology (Professor Kappetein and colleagues) to take deliberately opposing positions on the evolving management of valvular aortic stenosis in the very elderly. We have asked them to try to consider the strengths of each route. Both approaches provide options for patients who only a few years ago might have been regarded as essentially untreatable.

The use of cannabis is embedded within many societies, mostly used by the young and widely perceived to be safe. Increasing concern regarding the potential for cannabis to cause mental health effects has dominated cannabis research and the potential adverse respiratory effects have received relatively little attention. Studies on cannabis are challenging and subject to confounding by concomitant use of tobacco and other social factors, and while many of the studies referred to in this review are beset by the difficulties inherent in undertaking epidemiological research of the effects of cannabis, there is an emerging concern among many chest physicians who would suggest that habitual smoking of cannabis may contribute to the development of chronic obstructive pulmonary disease, pneumothorax and respiratory infections, including tuberculosis. Special attention should be given to the risk of lung cancer, particularly as biological plausibility may precede epidemiology.

Breast cancer is now the most common cancer of women in the UK and incidence is increasing. Because of major treatment advances and earlier diagnosis over the past 40 years, survival rates have been improving gradually and women diagnosed with breast cancer today are almost twice as likely to survive for 10 years or longer as women 40 years ago. However, breast cancer remains a major contributor to cancer morbidity and mortality in the UK. The majority of patients present with potentially curative disease and surgery is the mainstay of treatment. Many patients receive adjuvant (post-operative) therapy, which reduces the risk of loco-regional and distant disease recurrence. Treatment options include radiotherapy, chemotherapy, endocrine therapy and biological agents, with treatment increasingly tailored to the individual tumour and patient, aiming to provide maximum survival benefit with minimum toxicity. Many patients participate in clinical trials of radiotherapy, new agents, drug combinations or novel dosing regimens. Patients with metastatic disease can rarely be offered curative treatment, but improved quality of life and prolonged survival may be achieved with palliative treatment, including hormones, chemotherapy, radiotherapy, trastuzumab and bisphosphonates. This overview aims to summarise current knowledge and recent developments in the management of breast cancer.

Prostate cancer incidence is rising due to the ageing population and increased public and doctor awareness. The role of screening is still not clear due to the large number of asymptomatic men who would need to be screened and treated to prevent one death. Discussion of all treatment options should be undertaken, with the patient having the opportunity to meet a clinical oncologist and urological surgeon. Treatment options include active surveillance, external beam radiotherapy, brachytherapy and surgery. Low-dose rate brachytherapy involves the permanent insertion of radioactive seeds (half-life 60 days) under ultrasound guidance. It is a good option for many men as impotence and incontinence rates are lower than for surgery and it has reduced hospital costs and time off work and high rates of relapse-free survival (90–95% in low-risk disease). External beam radiotherapy offers a good treatment for men with more locally advanced disease and men who do not want to undergo an anaesthetic. New developments allow higher doses of radiotherapy to be given with reduced relapse rates and reduced toxicity to neighbouring structures such as bowel and bladder. High-dose rate brachytherapy involves the temporary insertion of applicators into the prostate so that a high energy source can temporarily be fed into different positions in the prostate, ensuring a high dose to the prostate gland but minimising dose to the bladder and bowel. It can be used as monotherapy or in combination with external beam radiotherapy.

Head and neck cancer is traditionally thought of as being a disease associated with alcohol and tobacco abuse and deprivation. It was the fourth most common cancer in males in Scotland in 2000 and just over 1,000 cases were diagnosed in 2007. As smoking becomes less prevalent, a fall in the incidence of head and neck cancer could be anticipated; however, increasing evidence of other aetiological factors contributing to the diagnosis of head and neck cancer, particularly oropharyngeal cancer in non-smoking, little-drinking populations, is impacting on that perception. This review will aim to look at current aetiological factors for head and neck cancer, along with current therapeutic modalities in treatment of this disease.

Older people have much to gain from surgery, but pose a significant challenge not only in emergency surgery but also in elective surgery. Despite significant progress in the care of older surgical patients, they remain more likely to ‘fail’ pre-assessment and have higher rates of post-operative complications than younger people. The evidence suggests that this is a consequence of agerelated increases in co-morbidities and reduction in physiological reserve. Numerous studies have demonstrated improvements in outcome when individual co-morbidities are appropriately assessed and optimised. However, current models of care do not allow for the translation of this evidence into routine clinical practice, particularly in those with complex co-morbidities and functional dependence. This article explores the reasons for poor outcome in older people and describes an alternative model of care for the older elective surgical patient.

Surveillance of the serotypes causing invasive pneumococcal diseases in the UK has indicated increasing incidence of serotype 1- and serotype 3-related disease in recent years. The introduction of a pneumococcal conjugate vaccine to the paediatric vaccination schedule in 2006, which did not cover these serotypes, has been regarded as a contributing factor. Serotypes 1 and 3 were perhaps the most extensively studied pneumococcal serotypes in the early twentieth century when pneumococcal serotyping began. Such historical observations are pertinent to our understanding of contemporary disease manifestations for these serotypes as many parallels can be seen between their behaviour in the early twentieth century and the early twenty-first century. There are many relevant lessons to be learned from these pre-antibiotic era descriptions and the observations of our predecessors.

This paper examines the association between Winston Churchill and Charles McMoran Wilson, later Lord Moran, who was made personal physician to Churchill in 1940 at the instigation of the Cabinet when Churchill became prime minister of wartime Britain.

Lord Howe Island and the St Kilda archipelago have many similarities, yet their communities had totally disparate outcomes. The characteristics of the two islands are compared and contrasted, and it is hypothesised that the differences in health and diseases largely explain the success of one society and the failure of the other.