Journal of the Royal College of Physicians of Edinburgh

The epidemiology of Lyme borreliosis (LB) in Tayside was studied and compared with Highland (an area of high endemicity) and the rest of Scotland. From April 2001 to March 2008 the incidence of LB in Tayside rose from an estimated 2.57 to 5.84 per 100,000 population. In 2008/09 the incidence of LB in Tayside increased further to an estimated 13.85 per 100,000 population. This rise was significant and, although numerically less than that in Highland (37.24 to 49.69 per 100,000 population), it was proportionally much larger (137% vs 33%) and confirmed that LB in Tayside has diverged from that in non-endemic Scottish regions. The dramatic rise of LB in Tayside cannot be accounted for by changes in laboratory protocol or changes in the number or demographics of patients tested. However, changes in climatic conditions and alterations in clinical presentations may have contributed to this significant rise.

The latest UK national human immunodeficiency virus (HIV) testing guidelines, released in September 2008, state that HIV testing should be offered to all patients with indicator conditions and considered in all general medical admissions in high-prevalence areas. We audited testing rates at Blackpool Victoria Hospital, a high-prevalence area, one year before and one year after the publication of the new guidelines. In the year after publication the rate of HIV testing in patients with indicator diseases was as follows: hepatitis B 6%, hepatitis C 28%, tuberculosis 9% and lymphoma 14%. The overall rate of HIV testing in acute medical admissions was 0.5%. Our results demonstrate that traditional methods of guideline dissemination did not lead to implementation. We are now assessing alternative methods such as marking all positive laboratory results for indicator diseases with the phrase ‘HIV testing should be considered’ and implementing universal opt-out screening in our Clinical Decisions Unit.

Background and aim: Pyogenic liver abscess (PLA) has been a condition of high mortality, improving over recent decades with combined antibiotic and percutaneous drainage. We aimed to identify the presenting features, diagnosis, microbiology, treatment and outcome for patients over a 15-year period at an inner-city hospital.

Methods: Patients with an appropriate discharge diagnosis were identified and case records retrospectively analysed.

Results: A total of 73 patient records were analysed. Common presenting features were anorexia, abdominal pain, fever, vomiting and weight loss with raised white cell count, C-reactive protein, alkaline phosphatase and hypoalbuminaemia. The delay following symptom onset to presentation was a mean of 17.3 days. The inclusion of PLA as a possible diagnosis on admission was only considered in 1% of cases. Positive blood or abscess culture was achieved in 63% of cases. We recorded a hospital mortality rate of 11%.

Conclusions: In this sample, PLA was rarely considered as a possible diagnosis at presentation. There are common presenting features, which should prompt early investigation. Our microbiological yield was lower than in some studies and may be due to the early empirical use of antibiotics, without microbiological guidance. Percutaneous drainage and antibiotic treatment remain the mainstay of management. The underlying cause for PLA is often not identified. Emerging septicaemia or underlying malignancy were strong predictors of mortality.

Current clinical practice is often heavily biased towards the exclusion of potentially serious, treatable diagnoses, such as deep venous thrombosis, rather than the positive diagnosis of the patient’s underlying illness which precipitates seeking medical attention. We report a case of leg swelling where deep venous thrombosis was repeatedly excluded as a cause of leg pain and swelling, but where arrival at the correct diagnosis was significantly delayed, in part due to protocol-driven practice.

An immunocompromised patient with non-specific neurological symptoms and signs, along with rapid cognitive decline evolving over three to four weeks, can present a diagnostic challenge. Here we report rapidly progressive dementia in a patient with systemic lupus erythematosus, who was subsequently diagnosed with sporadic Creutzfeldt-Jakob disease (sCJD). This case illustrates the need for prompt investigations to consider an alternative diagnosis where significant history fails to yield an explanation. A diagnosis of sCJD drastically alters the prognosis in a subject with a well-controlled connective tissue disease who is otherwise fit and well.

Cytological features suggesting herpes simplex virus (HSV) infection in samples obtained at bronchoscopy have been described only very rarely in routinely processed samples. We report four cases where evidence of HSV infection was identified morphologically in samples processed using thin-layer techniques, with polymerase chain reaction confirmation of the presence of virus in three cases. We suggest that the increased morphological clarity provided by this technique for processing these cytology samples may result in the morphological features of viral infection being seen more frequently. Pathologists reporting such samples need to be aware of this possibility in order to avoid potential misinterpretations. In addition, however, respiratory and intensive care physicians unused to receiving cytology reports indicating ‘HSV infection’ need to be aware that the significance is uncertain and in most cases it is likely to indicate the reactivation of a latent infection.

The epidemiology of arterial hypertension and its treatment has been underlined by a huge research literature. Consistently raised arterial blood pressure in a clinic or home setting is a simple clinical observation that marks a predilection to a variety of fatal and non-fatal vascular disease events. Over the past 50 years tolerable, safe and effective primary and secondary medicines to offset a substantial amount of the associated morbidity and mortality risk of elevated blood pressure have emerged. Due to the nature of the population-relative risk and low absolute risk of this phenomenon it has often taken very large numbers of patients recruited from multiple centres in several countries and huge financial investment to define these profiles. Few national clinical research funds have invested in this process and it has often been left to a relatively small group of investigators to work closely with the commercial producers of new medicines to complete the essential outcome trials on which much of contemporary cardiovascular medical practice is based. Currently there are few, if any, significant new drug entities relevant to raised blood pressure under development. Most of the underlying clinical management principles and associations are clear. Achieved blood pressure, through patient adherence and variable prescriber practice, defines outcomes for individuals. The theoretical likelihood of a major step forward in the understanding of raised arterial blood pressure or a preferred means for population management is low. Moreover, with few new drug entities, investment in major outcome trials is unlikely to be proposed and the target for new trials is perhaps less apparent. While there can be no doubt that few areas in recent medical practice have benefited more from such huge achievements in underlining treatment, is it time to move on from the cardiovascular mega trial in hypertension? In this controversy we have asked two international authorities in blood pressure care to address the case for and against further mega trials in this area of practice.

Functional neurological symptoms refer to neurological symptoms that are not explained by disease. They may also be called psychogenic, nonorganic, somatoform, dissociative or conversion symptoms. The most common functional neurological symptoms are non-epileptic attacks and functional weakness. These are common in neurology and general medical practice, especially in emergency situations, where they can be mistaken for epilepsy or stroke. Many studies have shown that these symptoms often persist, are associated with distress and disability and, in the right hands, have a low rate of misdiagnosis. Physicians are often uncertain how to approach patients with these problems. Are patients making up the symptoms? How can the diagnosis be made confidently? What is the best way to explain the diagnosis to the patient? Does treatment ever help? This review takes readers through these questions with practical tips for avoiding common pitfalls, both in diagnosis and management. There is no good evidence that these symptoms are any more ‘made up’ than irritable bowel symptoms or chronic pain. The diagnosis should usually be made by a neurologist on the basis of positive signs of inconsistency such as Hoover’s sign or the typical features of a non-epileptic attack. A ‘functional’ model of the symptoms is useful both in thinking about the problem and when explaining the symptoms to the patient. There are many useful steps in management that do not require a detailed understanding of aetiology in an individual patient.

The neuromuscular junction is vulnerable to autoimmune attack both at the pre-synaptic nerve terminal and at the post-synaptic muscle membrane. Antibodies directed to the nicotinic acetylcholine receptor at the muscle surface are the cause of myasthenia gravis in the majority of cases. Myasthenia gravis is an acquired condition, characterised by weakness and fatigability of the skeletal muscles. The ocular muscles are commonly affected first, but the disease often generalises. Treatment includes symptom control and immunosuppression. The thymus gland plays an important role in the pathogenesis of myasthenia gravis and thymectomy is indicated in certain subgroups. Lambert-Eaton myasthenic syndrome is associated with antibodies directed to the voltage-gated calcium channel antibodies at the pre-synaptic nerve terminal. It is an acquired condition and, in some cases, may be paraneoplastic, often secondary to underlying small cell lung carcinoma. Clinical presentation is distinct from myasthenia gravis, with patients often first presenting with lower limb muscle fatigability and autonomic symptoms. Congenital myasthenic syndromes are inherited neuromuscular disorders due to mutations in proteins at the neuromuscular junction. Various phenotypes exist depending on the protein mutation. Treatment is directed towards symptom control and immunosuppression is not indicated.

Dementia occurs after stroke in 25% of patients but also can arise from covert cerebrovascular disease (CVD). ‘Silent’ lacunes occur in 25% of the elderly, often associated with focal or confluent hyperintensities on T2-weighted magnetic resonance imaging, which are detected in 95% of seniors. These covert infarcts predict future stroke and faster cognitive decline. Best practice guidelines advocate screening for cognitive impairment in all phases of overt stroke, when covert CVD is uncovered, when vascular risk factors are present and if patients present with cognitive complaints. Standardised testing is recommended, emphasising executive function and speed of processing. Cholinesterase inhibitors have cognitive enhancing effects in vascular dementia, but the major thrust is still aggressive management of vascular risk factors and healthy lifestyle choices. Given that mixed Alzheimer’s dementia and CVD is likely the most common substrate for dementia and that they share common vascular risk factors, a major goal for vascular medicine is cerebrovascular protection, not just to prevent heart attack and stroke, but also to maintain brain health and delay dementia.

While viral hepatitis is a global problem its prevalence in the UK is often underestimated. Chronic infection with the hepatitis B and/or C virus causes significant morbidity and mortality. New treatments that attenuate viral replication or induce immunity against infection have transformed the management of these conditions, but their effectiveness comes at some cost – both in financial terms and in the side-effect profile associated with treatment. Viral resistance promises to be an ongoing problem, particularly in patients who have an inadequate response to antiviral therapy or are non-adherent with treatment protocols. This article explores new developments in the treatment of chronic hepatitis B and C infection, and describes current protocols for managing patients with these conditions.

At a time when the role of the laboratory in clinical medicine and in medical research was evolving rapidly, a young Chinese graduate of the Hong Kong College of Medicine and the University of Edinburgh undertook a period of intensive training at the laboratory of the Royal College of Physicians of Edinburgh that was to play a pivotal role in determining his future career as the first Professor of Pathology at the University of Hong Kong and its first professor of Chinese descent. Chung Yik Wang’s subsequent achievements over a span of ten years were a testament to the solid foundation that had been laid during that early period, and was an excellent example of how the skills of medical science could be transferred across continents to best effect. Tragically, Wang’s career was cut short when he succumbed to tuberculosis, the disease he had spent many years studying.

The first dynasty in Greece after its independence in 1830 was founded in 1833 with Otto, the son of Ludwig I of Bavaria. In 1836 Otto married Amalia, the daughter of the Grand Duke of Oldenburg. The people of Greece anticipated that the marriage would result in an heir to the throne, establishing the new dynasty. The failure of the royal couple to produce an heir was a major reason for their subsequent abdication. For many years both were subjected to repeated examinations by Greek and German physicians, especially Amalia, who was considered to be largely responsible for the infertility. In this paper we discuss possible diagnoses and describe the various treatments suggested for, and applied to, the infertility. We also review the consequent political controversies and the problems created among the royal families of Europe who wanted to replace the Wittelsbach dynasty with another royal line – a situation that led, in 1863, to the succession of the Danish Schleswig-Holstein-Sonderburg-Glücksburg dynasty to the Greek throne.

Ephedra is a Chinese shrub which has been used in China for medicinal purposes for several thousand years. The pure alkaloid ephedrine was first isolated and characterised by Nagai in 1885. It was then forgotten until it was rediscovered by Chen and Schmidt in the early 1920s. Its actions on the adrenoceptors could be classified into separate alpha and beta effects – a defining moment in the history of autonomic pharmacology. Ephedrine became a highly popular and effective treatment for asthma, particularly because, unlike adrenaline (until then the standard therapy), it can be given by mouth. Ephedrine as a treatment for asthma reached its zenith in the late 1950s, since when there has been a gradual and inevitable decline in its therapeutic use. From mainstream medicine, ephedrine moved into the twilight zone of street drugs and nutritional supplements. Ephedra and ephedrine products are now banned in many countries, as they are a major source for the production of the addictive compound methamphetamine (crystal meth).