Journal of the Royal College of Physicians of Edinburgh

Medical treatments for patients with type 2 diabetes mellitus and class II and above obesity (body mass index greater than 35 kg/m2) are currently limited to treatment of diabetes and prevention of its vascular complications. Bariatric surgery is by far the most effective treatment not only for weight loss, but also for improvement or remission of diabetes. This editorial examines the current evidence for the impact of bariatric surgery on weight loss and type 2 diabetes.

Background: The high sensitivities and specificities reported for blood biomarkers as a supportive test in the diagnosis of acute stroke do not correspond with their performance for decision-making in emergency situations.

Methods: Seventy-two patients with suspected stroke were recruited: 44 with ischaemic stroke, 17 with haemorrhagic stroke and 11 stroke mimics, as well as a high-risk control group of 79 individuals. Serum neuron-specific enolase (NSE) and S100 calcium binding protein B (S100B) biomarker levels were determined on admission, using immunoassay kits. The sensitivities and specificities of NSE and S100B for distinguishing acute stroke from stroke mimics and high-risk controls were calculated.

Results: For cut-off values (NSE ≤14 micrograms per litre and S100B ≤130 nanograms per litre) the sensitivity was 53% and 55% respectively. Specificity was 64 for both versus the stroke mimic group. Specificity was higher (79% and 86% respectively) when calculated on the basis of the control group.

Conclusions: This study supports the evidence indicating that serum levels of NSE and S100B do not improve the diagnosis of acute stroke.

Background: The prevalence of hypertension in a population is the sum of those individuals with a blood pressure (BP) exceeding 140/90 mm Hg plus those with normal BP on antihypertensive therapy (this is usually about 20–30% of the population). Rest normally reduces BP but the frequency and extent of the fall remains unclear.

Methods: This study analysed the results of 1,008 consecutive life assurance examinations in which BP was recorded twice, before and after a ten minute period of recumbent rest.

Results: Two hundred and twelve subjects had initial BPs of more than 140/90 mm Hg (21%). When all those receiving antihypertensive treatment but with normal BPs were included, this was 26.5%. Of the 212 subjects, BP was at a normal level in 147 (69%) after ten minutes at rest.

Conclusion: BP measurement after a ten minute period of standardised rest could more accurately identify true hypertension.

Background: Our Trust developed a clinical guideline to improve the prescribing and use of intravenous (IV) fluids based on the British consensus guidelines on IV fluid therapy for adult surgical patients. We audited the effect of targeted interventions to improve performance against this guideline.

Method: There were 53 IV fluid prescription charts in the pre-intervention audit and 48 in the post-intervention audit. Data was collected on the seven local practice standards (‘local gold standards’) in the clinical guideline; compliance with all of them was necessary to meet the IV fluid prescribing bundle of care.

Results: The proportion of prescriptions which met the IV fluid prescribing bundle of care increased (3.8% to 22.9% [p=0.004]) and the legibility of the IV fluid prescription increased (28.3% to 56.3% [p=0.004]).

Conclusion: We have shown that the process of prescribing, administering and monitoring IV fluid use can be significantly improved through a range of targeted multi-disciplinary interventions.

Computed tomography (CT) coronary angiography is now a widely available and reliable test accessible on basic CT platforms that can exclude coronary heart disease with confidence. It is fast, cheap and, if properly carried out by trained and accredited staff in carefully selected patients, useful information can be obtained with acceptably low radiation exposure in some cases.

Paradoxical coronary artery embolism is a rare but under-diagnosed cause of acute myocardial infarction (AMI) and requires a high level of clinical suspicion to make an early diagnosis. We describe the case of a young woman who presented with a severe cough and chest pain who was subsequently found to have a paradoxical embolus in the right coronary artery. Echocardiography showed a patent foramen ovale (PFO) and an atrial septal aneurysm (ASA). The patient was found to be a heterozygous carrier of the factor V Leiden mutation that increases the risk for venous-thromboembolism. The association between a PFO and an ASA is a risk factor for systemic embolisation. This is the first reported case of paradoxical coronary artery embolus causing AMI in a non-pregnant patient with factor Leiden thrombophilia. Identification of this clinical phenotype is vital as the risk of future embolic events can be reduced by anticoagulation and closure of anatomical cardiac defects.

We present the case of a female patient with a subacute paraneoplastic brainstem neurological syndrome associated with breast cancer and the development of anti-Ri antineuronal antibodies (ANNAs). It is an important syndrome to identify because of the need for urgent investigation and management to reduce progressive and irreversible neurological deterioration and to recognise the associated risks of bulbar and central respiratory failure. Diagnosis can be confounded if the anticipated normality of imaging and cerebrospinal fluid (CSF) studies is not appreciated. Positive antineuronal screening can provide rapid support for a paraneoplastic aetiology. Urgent and extensive investigation to identify the underlying tumour is imperative since neurological outcome is dependent on the rapidity of commencement and efficacy of tumour therapy. We discuss the symptoms, pathophysiology, diagnosis, treatment and prognosis of paraneoplastic neurological syndromes.

Oliguria is a common feature of acute kidney injury (AKI), but should be interpreted in the context of other biochemical markers when diagnosing and monitoring AKI or considering the need for renal support. We report an unusual case of apparent severe oliguria arising as a result of complex urological pathology and discuss how an understanding of creatinine kinetics raised suspicions of an alternative diagnosis. We discuss the problems caused by an over-reliance on urine output or serum creatinine alone when diagnosing and staging AKI and highlight the need for a more holistic approach.

The management of coronary disease has moved forward with the application of more sensitive blood biomarkers for early detection alongside more structured symptom assessment, examination and serial ECG measures. However every episode of exertional chest pain isn’t symptomatic coronary disease and given massive public awareness campaigns we now face a different management issue with undiagnosed chest pain sent as a ‘rule-out’ activity. These urgent referrals are often justified based on the management of the minority with unstable coronary disease without preliminary medical review or examination. Avoiding delay which is valuable in coronary patients may be irrelevant to the majority. The overall effectiveness of this pathway is unclear where the patient does not have coronary disease but also where superficial interpretation can be misleading through non-specificity. Do biomarker assays become the answer to every chest pain patient and has the basic assessment of the individual patient and a prior probability of disease no role to play? Does this activity represent a burden or an irrelevant dead end for non-coronary patients? We have asked for comment from two leading authorities on the evolving role and application of cardiac biomarker technologies in managing this considerable and common clinical dilemma.

This article covers public health aspects of the investigation and management of people who are infected with tuberculosis (TB). It contains a brief overview of the recent epidemiology of TB in Scotland, focusing on changes in Scottish TB incidence and describing some epidemiological associations. We then describe the initial public health assessment of those with suspected TB and responses that should be initiated. It does not address issues relating to the clinical treatment of patients with TB.

Pharmacogenetics, the study of genetic variation relevant to drug metabolism, is a rapidly evolving area of medicine. This brief review will consider some of the recent advances where inherited genetic variants have been associated with either drug efficacy or toxicity. Examples of where pharmacogenetic testing has been adopted into clinical practice will be provided as well as a look at its likely development over the next decade. Finally, the large increase in genetic testing of tumour tissue samples to predict response to molecularly targeted treatments in cancer will be considered.

National Institute for Health and Clinical Excellence guidance for the clinical management of hypertension, published last year, proposes a step change in UK clinical practice.1 Although broadly helpful, there are some concerns about its implementation. Ambulatory blood pressure monitoring for diagnosis of hypertension, though logical, will place an additional financial burden on primary care at a time of austerity. Home blood pressure measurement may be a more practical option. Previous guidance recommended the used of thiazide diuretics as a first-line treatment option.2 Five years later, the new guidelines propose a major change, with an initial emphasis on the use of calcium channel blockers and angiotensin converting enzyme inhibitors/angiotensin receptor blockers, moving the use of thiazide-like diuretics to a third-line option. In addition, bendroflumethiazide, the mainstay of treatment in the UK over many years, has been replaced with chlortalidone, the starting doses of which are not readily available in this country. Cost-effectiveness analysis and a presumed risk of metabolic disorders has guided the rationale for these changes to the therapeutic algorithm, however this may not be robust. Importantly, unless there are special circumstances, reducing the blood pressure in hypertensive patients is more important than the means used to lower it. In future, it will be important to ‘personalise’ treatment more effectively and base management on lifetime risk.

Dr James Barry, a surgeon in the British Army from 1813 until his retirement in 1859, became famous after his death following the revelation that he was in fact a woman who had masqueraded as a man for no less than 56 years. This paper reviews Margaret Bulkley’s student years at the University of Edinburgh from the time of her adoption of the identity of the youth calling himself James Barry. The deception was perpetrated in order to obtain a medical degree and the three year MD curriculum was completed without discovery. Few facts are known about these years (1809–1812) and the work of Lisa Rosner has been invaluable as a source of prosopographical information to apply to our knowledge of James Barry’s experiences during his time at Edinburgh. Contemporary letters and an Army document also assist in developing this unique and extraordinary story, revealing much that was previously unknown as well as some data, which in earlier work were incorrectly reported.

General paralysis of the insane (GPI) was one of the most devastating diseases observed in British psychiatry during the century after 1840, in terms of the high number and type of patients diagnosed, the severity of its symptoms and, above all, its utterly hopeless prognosis. With particular reference to the physicians and patients of the Royal Edinburgh Asylum, this article explores the diagnostic process and the social and medical significance of the ‘death sentence’ that accompanied the GPI diagnosis.

On 12 May 1857, Edward Sieveking read a paper on epilepsy to the Royal Medical and Chirurgical Society in London. During the discussion that followed Sir Charles Locock, obstetrician to Queen Victoria, was reported to have commented that during the past 14 months he had used potassium bromide to successfully stop epileptic seizures in all but one of 14 or 15 women with ‘hysterical’ or catamenial epilepsy. This report of Locock’s comment has generally given him credit for introducing the first reasonably effective antiepileptic drug into medical practice. However examination of the original reports raises questions as to how soundly based the accounts of Locock’s comments were. Subsequently, others using the drug to treat epilepsy failed to obtain the degree of benefit that the reports of Locock’s comments would have led them to expect. The drug might not have come into more widespread use as a result, had not Samuel Wilks provided good, independent evidence for the drug’s antiepileptic efficacy in 1861.