Journal of the Royal College of Physicians of Edinburgh

Acute upper gastrointestinal bleed (AUGIB) is one of the most common medical emergencies in the UK, with roughly one presentation every 6 min. Despite advances in therapeutics and endoscopy provision, mortality following AUGIB over the last two decades has remained high, with over 9,000 deaths annually in the UK; consequently, several national bodies have published UK-relevant guidelines. Despite this, the 2015 UK National Confidential Enquiry into Patient Outcome and Death in AUGIB highlighted variations in practice, raised concerns regarding suboptimal patient care and released a series of recommendations. This review paper incorporates the latest available evidence and UK-relevant guidelines to summarise the optimal pre-endoscopic, endoscopic, and post-endoscopic approach to and management of non-variceal and variceal AUGIB that will be of practical value to both general physicians and gastroenterologists.

We investigated the effects of reinforced audit and feedback on the medical record documentation (MRD) of 35 surgical residents at a tertiary university hospital. In three phases (pre intervention, 3 and 9-month post intervention), 525 medical records were assessed. An educational guideline assisting residents to record more accurate MRD was developed. The MRD rate in the pre-intervention and immediate post-intervention phases had changed significantly. The MRD rate in the pre-intervention and 9 months after cessation of intervention was not statistically significant. Reinforced audit and feedback had only a short term effect on MRD. To achieve long lasting change, we suggest residents’ MRD behaviour must be integrated in their periodic clinical performance evaluation and reinforced through positive feedback including incentive mechanisms.

Gadolinium-based contrast agents have greatly expanded the capability of magnetic resonance imaging and have been used extensively in neuroradiology over the past 30 years. When initially developed they were thought to be relatively harmless; it was later discovered they are associated with nephrogenic systemic fibrosis and should be used with caution in certain patient groups, especially those with renal failure. Lately it has been found that the use of these contrast agents may result in deposition of gadolinium in the brain even in patients with an intact blood-brain barrier. While this has not been shown to be associated with any clinical effects, a precautionary approach has been advised by the regulatory authorities. Here we review the development of the gadolinium contrast agents, their use and the advice related to this new information.

Patients with intra-cerebral metastases often receive glucocorticoids, particularly in the presence of peri-lesional vasogenic cerebral oedema. We present a case of presumptive lung carcinoma with cerebral metastases where central diabetes insipidus was unmasked after glucocorticoid administration and correction of undiagnosed central hypocortisolism.

Successive governments of the UK have strongly supported two policies: an NHS free at the point of delivery, and the encouragement of consumer choice. It was natural for governments to think that amalgamating the policies would increase patient satisfaction, improve efficiency and save money. There are many reasons why this has not been well-received by patients and doctors and has not saved money, but the underlying problem is that there is a conceptual misfit between healthcare as public policy and as individual responsibility.

Patients in the NHS cannot become consumers and doctors cannot become suppliers of goods and services.

The medical profession has adopted a cognitive model of empathy, or detached concern, in its professionalism and practice. As a consequence there is now an empathy gap which has been demonstrated by lapses in patient care in the UK. There may also be an empathy gap developing in medical students during their training. This paper argues for the adoption of a relational view of empathy which embraces emotional and moral dimensions of the concept, acknowledges the importance of the clinical context and prioritises the relationship between the doctor and patient. A relational model extends to encompass the patient's family and all members of the healthcare team. By exploring the process of empathising in clinical practice I develop a relational model that is more appropriate for modern patterns of patient care and medical education than detached concern. Adoption of a relational model of empathy in training and practice can help bridge the empathy gap.

Magnetic resonance imaging has become a widely used clinical tool for the assessment of neurologic symptoms, as well as being increasingly used in neuroscience research. White matter hyperintensities are common findings on brain imaging and their discovery leads to questions about best management, especially when findings are incidental or not considered relevant to the patient's presentation. This review will discuss the varied causes of white matter hyperintensities, consider how best to distinguish between them radiologically, and when they might have potential clinical relevance.

Since the 18th century tuberculosis has been a major cause of death throughout the world. It is a highly infectious disease that spreads by droplet infection and finding effective treatment to combat tuberculosis took a great deal of time. One of the first treatments to have some real success was a stay in a sanatorium. Sanatoria were homes that provided patients with good food and fresh air (and therefore sunlight). The first sanatorium to use sunlight therapy (heliotherapy) seriously was founded in Leysin, Switzerland, by Auguste Rollier. Patients built up their sun exposure gradually to prevent sunburn or skin damage. We suggest that heliotherapy was more successful in treating tuberculosis than was appreciated once chemotherapy became available. The birth of heliotherapy coincided with an increased appreciation of the association of sunlight and health among the general public. The secret of its success is the combined effects of sunlight on the skin inducing the production of nitric oxide and vitamin D. Nitric oxide is not only a messenger in the cardiovascular system and responsible for relaxation of vascular muscle but is also involved in the innate immune system. Vitamin D is responsible for immune system functions and multiple studies have found an association between tuberculosis immunity and high vitamin D levels. Therefore, it is understandable that providing tuberculosis patients with sunlight may have boosted their immune system and aided them in the fight against tuberculosis. In view of the high level of resistance to all drug regimens in some patients, perhaps it is time to revive the use of sanatoria in the fight against tuberculosis.

The ‘McNamara fallacy’ (also known as quantitative fallacy) is named after the US Secretary of Defense during the Vietnam War. The fallacy consists of over-reliance on metrics, and may be summarised as: ‘if it cannot be measured, it is not important'. This paper describes the McNamara fallacy as it applies to medicine and healthcare, taking as examples hospital mortality data, NHS targets and quality assurance.

This paper reviews Churchill's illness in Carthage in December 1943. It was characterised by fever that lasted 6 days, left lower lobe pneumonia and two episodes of atrial fibrillation. He was managed in a private villa by Lord Moran, his personal physician, with the assistance of two nurses and the expert advice of colleagues. Sulphadiazine and digitalis leaf were precribed and Churchill recovered. It is remarkable that, despite the severity of his illness, he continued to direct the affairs of State from his bed.

By the mid-19th century about 200,000 miners were employed in a UK coal mining industry still growing with the advances of the Industrial Revolution. Coal miners were long known to suffer poor health but the link to inhaling dust in the mines had not been made. In 1813 George Pearson was the first to suggest that darkening of lungs seen in normal individuals as they aged was caused by inhaled soot from burning oil, candles and coal, which were the common domestic sources of heat and light. In 1831 Dr James Craufurd Gregory first described black pigmentation and disease in the lungs of a deceased coal miner and linked this to pulmonary accumulation of coal mine dust. Gregory hypothesised that the black material seen at autopsy in the collier's lungs was inhaled coal dust and this was confirmed by chemical analysis carried out by Professor Sir Robert Christison. Gregory suggested that coal dust was the cause of the disease and warned physicians in mining areas to be vigilant for the disease. This first description of what came to be known as ‘coal worker's pneumoconiosis’ sparked a remarkable intellectual effort by physicians in Scotland, culminating in a large body of published work that led to the first understandings of this disease and its link to coal-blackened lungs. This paper sets out the history of the role of Scottish physicians in gaining this understanding of coal worker's pneumoconiosis. It describes Gregory's case and the lung - recently discovered in the pathology collection of the Surgeons’ Hall Museums, Edinburgh, where it has lain unnoticed for over 180 years - on which Gregory based his landmark paper.