Journal of the Royal College of Physicians of Edinburgh

Background Telephone and video-based triage of dyspnoea has become commonplace and clinicians are faced with a new challenge in risk stratification of patients with dyspnoea due to suspected COVID-19. This review aimed to identify existing remote assessment modalities for acute dyspnoea which can be applied during pandemics.

Methods We conducted a systematic search of Medline, Embase, the Cochrane Library and medRxiv for studies of remote assessment of dyspnoea [PROSPERO ID: CRD42020202292]. A total of 3014 abstracts were screened independently by two reviewers and 32 studies were progressed to full text screening.

Results Five studies met the inclusion criteria. Commonly assessed clinical features included respiratory rate, work of breathing, counting time and mental status. All studies found remote triage modalities to be appropriate for detecting severe respiratory distress or the need for emergency level care.

Conclusions Evidence-based tools to remotely assess dyspnoea will reduce resource strain during current and future pandemics.

Background Increasing the uptake of HIV testing in people who may have undiagnosed HIV is essential to reduce the morbidity associated with late HIV diagnosis.

Methods We conducted a multicentre, longitudinal, mixed-methods study, surveying the attitudes, knowledge and practice of non-HIV specialist hospital physicians in South-East Scotland and North-East England with respect to HIV testing.

Results We found that although awareness of indications for HIV testing had improved over time, only 13% of clinicians recognised all of the surveyed HIV indicator conditions. Physicians were better at recognising the indicator conditions relevant to their specialty. The perception of working with a low-risk patient population was the most frequently cited barrier to offering an HIV test. Only a third of study respondents had requested more than 10 HIV tests in the preceding year.

Conclusions Our study supports a need for targeted and sustained educational initiatives to increase rates of HIV testing in secondary care.

Conventional disease-modifying antirheumatic drugs (DMARDs) have been used in the management of rheumatoid arthritis for a long time. Whereas methotrexate (MTX) is the anchor drug, leflunomide, hydroxychloroquine and sulfasalazine are used along with MTX either in combination or sequentially. Together these four drugs are the most commonly used DMARDs. They are also used in combination with biological DMARDs (bDMARDs) to enhance their efficacy and MTX in particular to reduce antibodies against anti-tumour necrosis factor. Despite their widespread use, concerns regarding their safety especially when used long-term hinder their optimum use in clinical medicine. In this narrative review we have critically appraised the available literature regarding the safety of these four DMARDs when used long-term.

Bell's palsy fully recovers in the great majority of cases. What may not be sufficiently appreciated is how distressing it can be. This Perspective recounts a personal experience; describes an unrecorded puzzling physical sign; and details the interest the experience generated in Charles Bell and in the infamous Robert Knox, whose paths crossed. Both deserve to be better known than just for a palsy or a murder-for-bodies scandal. Bell made a seminal contribution to neurophysiology, regarded by some as important as Harvey's discovery of the circulation of the blood. He was also a very accomplished artist, his paintings of wounded soldiers in the Napoleonic Wars among the best-ever artistic depictions of the mutilations of war. Knox published seven books and over 100 scientific papers and is a more multidimensional and interesting character than popularly portrayed.

Thyroiditis can be due to infection/autoimmunity with different clinical presentations. Correctly diagnosing and initiating treatment is a challenge to the treating physician. We present two cases of thyroiditis, who approached the physician for different complaints. The first was a female with a change in voice, foreign body sensation in throat, laryngoscopy showing left vocal cord paralysis, reduced thyroid stimulating hormone. An ultrasound neck was suggestive of thyroiditis, and a contrast enhanced computed tomography scan showed a bulky thyroid with enlarged cervical lymphadenopathy. The second patient was a female with high-grade fever, chills and the inability to take fluids-food. Assessment revealed bilateral enlarged, inflamed tonsils-membranous exudate, tender jugulo-digastric lymphadenopathy and a Technetium-99 thyroid scan suggestive of thyroiditis. Patients were admitted, treated with steroids, antipyretics, antibiotics, cured and discharged. At the three-month follow-up, they were asymptomatic, video laryngoscopy showed normal vocal cords with equal mobility in the first patient and the thyroid profile within normal range for both patients. These cases highlight that thyroiditis can co-exist with benign vocal cord palsy or occasionally also with inflammations of local tissues, such as the tonsils.

Haemoglobin (Hb) Cheverly is a rare, low oxygen affinity haemoglobinopathy. It is a result of point mutation at the 45 codon of the beta globin genes that leads to substitution of phenylalanine by serine. It is characterised by spuriously low peripheral oxygen saturation with normal arterial oxygen saturation. We describe a family of three with Hb Cheverly in Sarawak General Hospital, Malaysia. It was discovered through incidental finding during hospital admission for unrelated complaints. Laboratory testing revealed abnormal haemoglobin detected at the C window of the high performance liquid chromatography. Subsequent DNA analysis detected replacement of thymidine by cytosine at the beta globin genes. Hb Cheverly may or may not have clinical significance as most of the patients live a normal life; however, it is crucial for us to make early diagnosis to prevent unnecessary extensive investigations for hypoxaemia detected via pulse oximetry, especially in the midst of COVID-19 pandemic.

A 20-year-old male presented with acute lower limb oligoarthritis and enthesitis followed by acute onset redness, watering, pain and decreased vision in the right eye. He had recent history of diarrhoea with fever. Erythrocyte sedimentation rate and high-sensitivity C-reactive protein (hsCRP) were raised and human leukocyte antigen-B27 was positive. The best corrected visual acuity (BCVA) in the right eye was 20/120 and it showed a paracentral shallow corneal ulcer of size 3 x 4 mm with underlying dense stromal infiltrates and haze. Microbiological evaluation of corneal scrapings was reported as Staphylococcus hominis. The epithelium healed on topical antibiotics in one week, but there were persistent punctate erosions and pleomorphic anterior stromal infiltrates and haze. The residual keratitis healed completely on topical steroids in ten days, with BCVA improving to 20/20. A diagnosis of reactive arthritis with immune-mediated keratitis was made.

Premature ventricular contractions (PVCs) are heart beats initiated in the ventricles instead of in the sinoatrial node. A high burden of PVCs can lead to a cardiomyopathy, characterised by reduced left ventricular (LV) systolic dysfunction. We present a case of PVC-related cardiomyopathy where the 65-year-old male was initially seen by his primary care provider for recent onset chest pain and dizziness. His transthoracic echocardiogram showed mild concentric LV hypertrophy and mildly reduced systolic function (LV ejection fraction 43%). There was also mild right ventricular (RV) systolic dysfunction. He was started on a beta-blocker and an angiotensin-converting enzyme inhibitor. A 24-hour Holter monitor showed a very high burden of PVCs (32% of all beats). He continued to have frequent PVCs and his echocardiogram did not improve. He was eventually referred for a PVC ablation. Following the ablation, a repeat Holter monitor showed a marked reduction in PVC burden (<1% of beats) and his echocardiogram had normalised.

Mutations in the HNF4A gene are associated with hyperinsulinaemic hypoglycaemia in infants, frequently evolving into relative deficiency of insulin in adulthood as maturity onset diabetes of the young (MODY). A 69-year-old male with a strong family history of adult-onset diabetes was referred with lifelong hypoglycaemia, found to be due to a pathogenic HNF4A mutation. HbA1c levels were low, continuous glucose monitoring demonstrated frequent low glucose events in the early morning, and he was successfully treated with diazoxide. This case represents a new phenotype of a known mutation associated more commonly with MODY. The same mutation in one family led to profoundly different manifestations. Genetic causes of hyperinsulinaemic hypoglycaemia can present late in life and identifying such cases is important to allow the correct treatment to be established.

Isolated convexity cortical subarachnoid haemorrhage (cSAH) is a rare form of non-traumatic subarachnoid haemorrhage localised to one or few cortical sulci of the brain without involving the adjacent brain parenchyma or spreading to sylvian fissure, interhemispheric fissure, basal cisterns and ventricles. cSAH has multiple aetiologies described in medical literature. Intracranial high-grade stenosis is rarely presented as cSAH, especially in young adult patients. Patients presenting with cSAH warrant appropriate diagnostic work up to identify and treat the underlying aetiology.

Background During the COVID-19 pandemic, care home residents and staff were identified as being at risk of infection. Their safety was important, but equally important was safe delivery of healthcare to those who needed it. The Welsh Government provided care homes with video consulting (VC) to deliver safe healthcare to the vulnerable, combat isolation and protect the residents and staff.

Methods To understand the use, value, benefits and challenges of using VC in care homes across Wales, telephone interviews were conducted between September and November 2020.

Results From 101 interviews, findings suggest that while care homes are responsive to VC, there is a need for further awareness, better training and support for care home staff.

Conclusions Interestingly, issues around connectivity, lack of equipment and technical literacy were highlighted as minimal barriers. VC should be encouraged as a long-term service to support the health and wellbeing of care home staff and residents.

Reactive arthritis (ReA) is a form of inflammatory arthritis triggered by a remote antecedent infection, usually in the genitourinary or gastrointestinal tract. It is part of the spondyloarthropathy (SpA) spectrum, an umbrella term for a group of distinct conditions with shared clinical features. Typically, it presents with an asymmetric oligoarthritis of the lower limb joints, and patients may also have sacroiliitis, enthesitis and dactylitis. Other features often seen include anterior uveitis, urethritis and skin manifestations such as pustular lesions on the plantar areas. Although ReA was characterised initially as a sterile arthritis, the detection of metabolically active Chlamydia species in the joint fluid of some affected patients has generated further questions on the pathophysiology of this condition. There are no formal diagnostic criteria, and the diagnosis is mainly clinical. HLA-B27 can support the diagnosis in the correct clinical context, and serves as a prognostic indicator. The majority of patients have a self-limiting course, but some develop chronic SpA and require immunomodulatory therapy.

This is the first of two papers which examine a series of portraits of patients at the Royal Edinburgh Asylum (REA) which were undertaken in the 1880s by John Miles, who, as well as being a professional painter, was also an inmate of the Morningside institution. The portraits by John Miles are of interest for several reasons. They are an example of patient art, only a small portion of which has survived from nineteenth century asylums. They are also in the tradition of patient portraiture. Miles's work is of interest because he was both a professional artist and a patient. His portraits also provide some insight into the patients’ world: their appearance, demeanour, posture, clothing and their surroundings in the asylum. The patients in the portraits have been identified and their case notes examined. This information complements Miles's portraits and helps to build up a fuller picture of individual patients and their life in the Morningside Asylum. The case notes also reveal the symptomatology and behaviour of the patients. Alongside the portraits by Miles, we discuss a second series of portraits of the same patients and contained in a collection entitled ‘Bruised Reeds'. We discuss if these portraits were also by Miles.