Journal of the Royal College of Physicians of Edinburgh

Medical accidents, negligence, compensation, no-fault scheme

Non-tuberculous mycobacteria are opportunist pathogens increasingly recognised as a cause of pulmonary and extrapulmonary disease. Treatment is complicated, prolonged and potentially toxic, and due to a limited evidence base, potentially contentious and idiosyncratic. This is a retrospective review of nontuberculous mycobacteria cases in the NHS Borders Health Board between 1992 and 2010. We consider incidence, species identified, drug sensitivity testing and treatment outcome with reference to the British and American Thoracic Society guidelines. Thirty-eight cases of non-tuberculous mycobacteria isolates were identified; 84.21% were pulmonary and 42.11% were Mycobacterium avium complex. Incidence rose from 1.92/100,000 in 1993 to 4.43/100,000 in 2010. The British Thoracic Society guidelines were followed in 45.45% of cases. A total of 36.36% were successfully treated with another 36.36% still being treated with antimicrobials. There is a clear need for more research on treatment for this group of ‘emerging pathogens’ and it remains to be seen if concordance with current guidelines will improve treatment outcomes.

Background: Venous thromboembolism (VTE) prophylaxis is effective in the prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) in medical patients.

Methods: A retrospective chart review was performed on medical inpatients at two academic hospitals in Hamilton, Ontario to investigate if patients received VTE prophylaxis as per current guidelines.

Results: An analysis was performed on 762 patient charts and 170 met inclusion criteria for use of pharmacological VTE prophylaxis. Of these, 91 (54%) received pharmacological VTE prophylaxis. In 63 patients with a contraindication to pharmacological VTE prophylaxis, 16 (25%) received non-pharmacological VTE prophylaxis.

Conclusion: The provision rate of pharmacological VTE prophylaxis in hospitalised medical patients who met pre-defined clinical criteria for prophylaxis was 54%. The rate of prophylaxis increased with additional VTE risk factors to a peak rate of 67%. There is room for the development of strategies to improve the use of VTE prophylaxis in hospitalised medical patients.

We describe efforts made at Blackpool Victoria Hospital to implement the well-established international Surviving Sepsis guidelines. These included posters, pocket guides and stickers inserted in patient notes. All doctors and nurses in acute areas received specific information and education. Sepsis teams comprising both doctors and nurses were formed to encourage implementation and to audit and disseminate data. Data collection occurred from February to November 2009. Cases were considered prospectively at the time of initial assessment and 198 patients were identified; 169 (85%) had blood cultures taken; 146 (74%) had lactate levels measured; and 145 (74%) received antibiotics within the target time. We believe these results demonstrate relatively effective implementation of guidelines in the challenging environment of a district general hospital. Our results could be replicated easily and provide a good way of reducing patient mortality at minimal financial cost.

We report an unusual case of calcification of mitral valve annulus imaged with multiple non-invasive modalities in a patient who suffered a transient ischaemic attack, probably from thrombus overlying the mitral annular calcification. Both this mode of presentation and the imaging features of the annular calcification were relatively unusual, and the images obtained are remarkably clear and diagnostic.

Enteric granulomatous inflammation can be caused by a number of conditions including Crohn’s disease, sarcoidosis, enteric infections, chronic granulomatous disease and also by drug reactions. Granulomas have also been described in microscopic colitis associated with certain medications and autoimmune diseases. The association of granulomatous ileocolitis with coeliac disease is not common. We present a case of coeliac disease with granulomatous ileocolitis with follow-up and repeat histology on a gluten-free diet. We discuss the pathological mechanisms leading to the association of granulomatous ileocolitis with coeliac disease as well as other conditions.

It is widely established that vitamin D is critical for bone health. There is also an increasing body of evidence from observational studies that low levels of vitamin D are associated with a range of other disorders, including cancer and cardiovascular disease. People in temperate climates are often deficient in vitamin D, particularly in wintertime. The key question is whether there is sufficient evidence to justify supplementing vitamin D intakes for all. In this 'Controversy in Medicine', two international experts argue the case 'for' and 'against' universal vitamin D supplementation.

Despite global efforts to reduce maternal mortality, maternal deaths from bacterial sepsis have actually risen in the UK. The group A streptococcus, also known as Streptococcus pyogenes, is the leading cause of infection-related death in pregnancy and the puerperium. Many clinicians remain unaware of the risks posed to this particular group of otherwise fit, healthy patients despite the fact that S. pyogenes has been the leading infective cause of puerperal deaths since records began. S. pyogenes has a specific but unexplained predilection for the recently pregnant woman, and has an attributable mortality greater than many other invasive bacteria. Here, the epidemiology, aetiology, and management of severe peripartum sepsis are discussed, as are potential approaches to reduce risks. While fundamental changes in healthcare access can lead to dramatic reductions in maternal deaths in developing countries, an improvement in maternal sepsis deaths in the UK will require heightened awareness among both hospital and community-based clinical staff.

To date, women have been a minority of the medical workforce. Recent data have shown that this situation will soon change, with the numbers of women in medical practice exceeding the numbers of men in the near future. This article outlines the history of women in medicine; it explores some of the data published by the Royal College of Physicians of London report Women and Medicine: The Future,1 and other recent reports to highlight some key issues, in order to support sensible and appropriate policy decisions in relation to the changing demographic of the medical workforce.

Roger McNeill was born in 1853 on Colonsay in the Inner Hebrides, the son of a cattle herder. He graduated with a degree in medicine from Edinburgh University, where he studied with Joseph Lister, among others. After working in London during a smallpox epidemic, he received a gold medal and honours for his M.D. thesis in 1881. McNeill returned to Scotland as the Resident Medical Officer at Gesto Hospital on the Isle of Skye. From there, he launched and published the first statistical research about the health of Highland crofters. His was an illustrious yet understated career in public health: he was the first president of the Caledonian Medical Society (1881–82), he earned a Diploma in Public Health from Cambridge University (1889), he was the first Medical Officer of Health for Argyll (1890–1924), wrote The Prevention of Epidemics and the Construction and Management of Isolation Hospitals (1894), and was the first witness before Parliament’s Dewar Committee in Oban in 1912. McNeill and other members of the Caledonian Medical Society testified about medical services in remote Scotland, encouraging a revolution in healthcare throughout the Highlands and Islands. The committee’s report led to the foundation of the Highlands and Islands Medical Service, a forerunner of the National Health Service established in 1948.

This paper traces the understanding of angina pectoris over two centuries from its first description by William Heberden, emphasising the Scottish dimension in this process. Such a retrospect is appropriate at a time when natural disasters in several parts of the world are drawing attention to their effect in increasing the incidence of heart attacks.

Karl Gebhardt (1897–1948) had a distinguished career as professor of sports medicine before the Second World War. He developed sports for the disabled at a specialised orthopaedic clinic at Hohenlychen and was President of the Red Cross in Germany. During the war, Gebhardt also acted as Heinrich Himmler’s personal physician and was responsible for medical experimentation on prisoners in the concentration camps at Auschwitz and Ravensbrück. In his capacity as SS consultant surgeon, he treated Reinhard Heydrich (a high ranking Nazi official, also known as ‘the Hangman’1) after an attempt was made on his life. When Heydrich died, Gebhardt was accused of failing to treat him with sulphonamides. To prove his innocence he carried out a series of experiments on Ravensbrück concentration camp prisoners, breaking their legs and infecting them with various organisms in order to prove the worthlessness of the drugs in treating gas gangrene. He also attempted to transplant the limbs from camp victims to German soldiers wounded on the Russian front. He was tried after the war and executed for these crimes in 1948. This paper explores the paradox of a gifted doctor who was also the perpetrator of inhuman crimes.