Scottish Medical Journal

A 14-year-old girl developed dental pain and was treated for acute infected pulpitis of her right upper lateral incisor with drilling and filling. The pain continued and was helped by analgesia, sucking ice cubes and drinking cold water. Forty-eight hours later, she became confused and disoriented. She started to vomit and complained of headache. Investigations revealed hyponatraemia with normal serum potassium levels and initially normal urinary sodium excretion. Over the next 24 hours, she passed 5.45 L of urine and her serum sodium rose from 125 to 143 mmol/L. Self-induced water intoxication has been described during drinking games and initiation ceremonies, but this would appear to an unusual cause. Conservative management proved successful in allowing this girl to recover without sequelae.

Carcinoid tumours are rare tumours of the neuro-endocrine system. They most commonly present in the gut; however, they can present in other organs. In all, 0.3% of carcinoid tumours are ovarian in origin. Subsequently, very few cases of ovarian carcinoid affecting the heart have been reported and this case adds to the literature on this. There are very few reports in the literature of ovarian carcinoid and even fewer on cardiac failure due to carcinoid. Generally, carcinoid heart disease only affects the right-sided valves, sparing the mitral and aortic valves. We present the case of a patient who had an ovarian carcinoid tumour excised successfully and had been asymptomatic for 14 years prior to an incidental finding of right valvular signs on echocardiography, before subsequently right heart failure deemed to be secondary to ovarian carcinoid heart disease. The diagnosis is generally made on the findings of right-sided heart failure and the valvular abnormalities on echocardiogram (isolated pulmonary and tricuspid involvement). If the tumour is present at the same time as the development of heart failure, cardiac function can improve with timely tumour resection; however, cardiac disease can occur despite tumour removal.

This is the first reported case of medial cystic degeneration of the popliteal artery presenting as distal embolization and contains a high-definition photo of the cyst in situ. Duplex ultrasound and magnetic resonance angiography are useful adjuncts to diagnosis. Based on the published literature, resection and interposition grafting appears to be the most efficacious treatment modality.

We present the case of a patient with an adenocarcinoma of the colon associated with an oncocytoma of the kidney. A left colonic cancer was diagnosed at colonoscopy and an incidental finding of a left renal mass was noted, with a staging computerized tomography scan. Following a left hemicolectomy and a left nephrectomy, the pathological report confirmed the presence of a colonic adenocarcinoma and revealed that the left renal mass was an oncocytoma. This case report reviews the management decisions associated with incidental renal masses as well as the treatment of synchronous neoplasia.

A 67-year-old trout fisherman presented with a six-week history of polyuria, polydipsia, dyspnoea on exertion and the development of subcutaneous extensor surface skin nodules. He was hypercalcaemic with acute renal impairment. Parathyroid hormone was suppressed and vitamin D levels were within normal limits. The patient had a past history of hypothyroidism, but thyroid replacement was adequate. Hypoadrenalism, myeloma and metastatic malignancy were excluded. Biopsy of a subcutaneous nodule revealed dermally based non-caseating granulomata, consistent with sarcoidosis. Serum angiotensin-converting enzyme was elevated, and computerized tomography scanning of the chest and abdomen revealed widespread lymphadenopathy with multiple lung nodules and splenomegaly. Prednisolone therapy produced rapid resolution of his skin lesions and normalization of his bone and renal biochemistry. The mechanism of hypercalcaemia in sarcoidosis is poorly understood but is thought to involve parathyroid hormone-independent 1-hydroxylation of 25-hydroxyvitamin D within sarcoid lesions. This process may be exacerbated by exposure to UV light and it is of interest that this patient developed symptoms after a period of intense trout fishing in the good weather of April and May 2007.

Malignancy often results in clotting abnormalities. The aetiology of haemostasis problems in cancer is complex, and is still not completely understood. We describe a case of a patient with malignant mesothelioma, who was found to have elevated activated partial thromboplastin time, due to lupus anticoagulant. We suggest that patients with malignancy should have their coagulation checked prior to any invasive procedures.

A case report of a patient presenting with painless arm swelling, which provides diagnostic challenge and interesting imaging on the conditions of syringomyelia and neuropathic osteoarthropathy, conditions with distinguishing clinical features and disabling consequences if misdiagnosed.

Pyomyositis is a primary pyogenic infection in skeletal muscle, often progressing to abscess formation. It is rare in temperate climates and generally deep-seated within the pelvis with nonspecific clinical features, making diagnosis difficult. Magnetic resonance imaging (MRI) is highly sensitive for muscle inflammation and fluid collection, and with its increasing availability is now the investigation of choice. Treatment of pyomyositis abscess has traditionally been with incision and drainage or guided aspiration followed by a prolonged course of antibiotics, although there are sporadic reports of cases treated successfully with antibiotics alone. Our aim was to describe our own experience with the treatment of pyomyositis abscess in children. From our 20-year database of over 16,000 paediatric orthopaedic admissions, we identified only three cases with MRI-confirmed pyomyositis abscess. These were all in boys (aged 2-12 years) and affected the gluteal, piriformis and adductor muscles. Despite the organisms not being identified, each patient was treated successfully with a short (4-7 days) course of intravenous antibiotics followed by 2-6 weeks of oral therapy. There were no recurrences or complications and all made a full recovery. In conclusion, we propose that uncomplicated pyomyositis abscess in children may usually be managed conservatively without the need for open or percutaneous drainage.

Ultrasonography has been used to detect fetal congenital heart disease since the 1980s, although there has been little uniformity in policy. In the UK, data published for 1993-1995 found an average detection rate of 23.4% with a Scottish rate of 9.6%. At the time of this study, 10 out of the 14 health boards in Scotland were implementing the 16-22-week fetal anomaly scan (FAS). The aims of this study were to determine the rate of antenatal diagnosis of major congenital heart disease (MCHD) throughout Scotland during 1 January to 31 December 2006, to document the regional differences in detection and to determine if implementation of a FAS significantly improved rates. Retrospective data were collected from the centralized Paediatric Cardiac Services in Edinburgh and Glasgow. The database contains information on all infants with cardiac disease in Scotland. All infants requiring cardiac intervention or dying in the first year of life were included. The results showed that the antenatal diagnosis rate for Scotland was 28% (95% CI 21.2%, 34.9%). The Scottish health boards that had implemented the FAS had a significantly higher antenatal detection rate (χ² test P = 0.037). In conclusion, antenatal detection rate of MCHD varies widely throughout Scotland. Implementation of the FAS has made a significant difference to antenatal diagnosis

This study aimed to describe the demographic and clinical characteristics of consecutive referrals to a liaison psychiatry outpatient clinic, based within a National Health Service (NHS) general hospital. All outpatient referrals to the service between January 2005 and January 2008 were subjected to retrospective completion of a proforma for post hoc data collection. Data relating to characteristics of the referral, patients, diagnosis, and nature and extent of contact were extracted for scrutiny. The majority (60.2%) of referrals to the service came from physicians based within the general hospital. Where conveyed, depression (26.7%) was the most commonly cited reason for referral. Diagnoses of both mood (affective) disorders (32.9%) and neurotic, stress-related and somatoform disorders (54.7%) were common. Cognitive behaviour therapy (56.1%) was the most commonly used intervention followed by pharmacological therapy (25.4%). In conclusion, the study provides a description of the nature of the work encountered in a liaison psychiatry setting and demonstrates the extent of services provided for medical specialties within the general hospital.

Physician assistants (PAs) have medical training and work supervised by a doctor. In 2006-2008 the Scottish Government piloted use of USA-trained PAs. The aim of the paper is to evaluate the impact and contribution made by PAs to delivering effective health care in National Health Service (NHS) Scotland. Mixed methods, longitudinally, including interviews, feedback forms and activity data collection. Data analysis used nVivo, SPSS and Excel. Participants were 15 USA-trained PAs, medical supervisors and team members, 20 patients, four NHS senior managers and three trade union representatives. Settings were four Scottish NHS Boards where PAs worked in primary care, out of hours clinics, emergency medicine, intermediate care and orthopaedics. Two minor patient safety issues arose. Patients were satisfied with PAs. Scope of practice did not replicate US working. Inability to prescribe was a hindrance. PAs tended to have longer consultations, but provided continuity and an educational resource. They were assessed to be mid-level practitioners approximating to nurse practitioner or generalist doctor. Valued features were generalism, medical background, confidence differential diagnosis and communication. Interviewees suggested PAs could fulfil roles currently filled by medical staff, potentially saving resources. In conclusion, there is potential for PAs to fulfil distinctive mid-level roles in the Scottish NHS adding value in continuity, communication and medical approach.

In most countries in the Western world, more than 50% of adults are overweight or obese putting them at increased risk of hypertension, type 2 diabetes, coronary heart disease, stroke and other chronic disorders. It is not clear what impact increasing prevalence of overweight and obesity has on hospital admissions. The objective of this study was to examine the relationship between body mass index (BMI) and number of days spent in hospital. The study was designed as a retrospective and prospective cohort study using nationally representative Health Survey data linked to NHS hospital admissions data. The study was set in Scotland. The participants were a nationally representative sample of 6968 (45%) men and 8700 (55%) women, of 16-74 years of age, living in private households whose BMI was recorded in the 1995 and 1998 Scottish Health Surveys. The outcome measure was the number of days spent in hospital between 1981 and 2004. The results showed that the proportion of participants in both normal weight (BMI 20-24.9 kg/m²) and overweight (BMI 25-29.9 kg/m²) categories was 37%, with 21% in the obese (BMI ≥30 kg/m²) and 5% in the under-weight (BMI <20 kg/m²) categories. The median number of days spent in hospital between 1981 and 2004 was six. The odds ratios (95% confidence intervals) for spending above the median numbers of days in hospital adjusted for age, sex, socioeconomic status and behavioural factors (i.e. smoking, alcohol drinking and physical activity) were 1.29 (1.06-1.56) for the <20 kg/m² group, 1.00 (0.91-1.11) for the 25-29.9 kg/m² group and 1.24 (1.10-1.38) for the ≤30 kg/m² group compared with the 20-24.9 kg/m² group. In conclusion, extremes of BMI category identified at a single point in time are associated with spending above the median number of days in hospital over a 20-year period after adjusting for demographic, behavioural and socioeconomic exposures.

Electronic patient health information in secondary care is often stored on different IT systems and not accessible to doctors involved in clinical decision-making. The Scottish Government will support clinical portal implementation in all Scottish Health Boards, which will present information from different sources as a virtual electronic patient record. An online survey was developed and sent to secondary care doctors, who were asked to rank the importance of different types of patient-centred information, knowledge support sources, and information to support appraisal and continued professional development that a clinical portal could deliver. Subgroup analysis was performed to investigate whether expectations differed between senior clinicians and doctors in training. Replies were received from 677 senior doctors and 137 trainees. Patient-centric information such as current medication and allergies, clinical alerts, past medical history, diagnostic test results and clinical letters were ranked as most important. Doctors would also like access to knowledge support, such as clinical guidelines. Eighteen of the top 20 ranked information types were consistent between senior doctors and those in training grades. In conclusion, senior doctors and trainees consistently want to see similar information in the clinical portal which is largely patient-centred with some provision for knowledge support.

To our knowledge there have been no previous studies that have examined the effect of short messaging service (SMS) text messaging reminders to both mobile and landlines on the ‘did not attend’ (DNA) rate in adult hospital clinic attendees. Our aim was to determine the effectiveness of a text messaging reminder in improving attendance in return general ophthalmology clinic patients. Ophthalmology clinic patients requiring a follow-up appointment were invited to enter the study. An information leaflet was provided and patients were contacted two weeks before their scheduled appointment by way of a customized text message to either the mobile phone or landline. The non-attendance rate compared with historic non-attendance rate was recorded. Two hundred and one patients were recruited. The historic DNA rate was 12%. The DNA rate in the SMS text reminder group was reduced to 5.5% (11 patients). The historic ‘Could not attend’ (CNA) rate of 6% had been reduced to 2% (4 patients). Forty-seven percent of patients used mobile phone technology with text messaging capability and 69% responded to the text reminder. In conclusion, routine SMS texting is a cost-effective means of reducing DNAs and should become standard practice. In addition, two-way messaging could allow for further efficiency as advance notification of patient cancellations facilitates re-scheduling of alternative patients.

The Scottish Diabetes Foot Action Group (SDG) has developed and introduced a national strategy plan for diabetic foot care across Scotland. This has involved the implementation of an evidence-based national foot screening and risk stratification programme that has already covered 61% of the population in just the first two years. Nationally agreed patient information foot leaflets and professional education material have been introduced, and a consensus for antibiotic use in the diabetic foot has been published. Information on multidisciplinary specialist foot services has been collected, indicating that 58% of Health Board areas have consultants with dedicated sessions in their job plan to a foot clinic, and 42% had integrated orthotic involvement. The SDG aims to increase these figures. Work has been undertaken to support local podiatry networks and improve communication between the specialist centre and the community. At a national level the SDG is working with Foot in Diabetes UK (FDUK) to recognize key podiatry skills by developing core competencies and a competency framework for the diabetes podiatrist and diabetes orthotist. The annual Scottish Diabetes Survey indicates some improvement in amputation rates with prevalence decreasing from 0.8% to 0.5%, and improved recording of foot ulceration at a national level. This national strategy has helped highlight the importance and difficulties facing diabetes foot care and should help to continue to improve the quality of care of people with diabetes who have foot-related problems.

Knee stiffness following anterior cruciate ligament (ACL) reconstruction remains a common complication, which can substantially impair knee function. The aim of this study was to assess the effectiveness of arthroscopic arthrolysis, in conjunction with manipulation under anaesthetic (MUA), in treating stiffness post-ACL reconstruction. We reviewed the records of 18 patients who underwent arthroscopic arthrolysis to treat established stiffness following primary isolated ACL reconstruction. Eight of these patients underwent concomitant MUA at time of arthrolysis. The median time between reconstruction and arthrolysis was nine months. Seven patients had arthrolysis performed within eight months of reconstruction, while 11 patients underwent arthrolysis greater than eight months postreconstruction. Following arthrolysis, the mean extension loss improved from 7° to 1°. In patients with mild extension stiffness (prearthrolysis extension deficits <10°), the mean improvement to extension was 3°. In patients with severe extension stiffness (prearthrolysis extension deficit ≥10°), the mean improvement to extension was 10°. Arthroscopic arthrolysis was significantly more effective in restoring extension loss if carried out within eight months of the primary reconstruction (P < 0.03). In the patients who underwent MUA at time of arthrolysis, the mean flexion loss improved from 16° to 4°. In conclusion, arthroscopic arthrolysis, in conjunction with MUA, is an effective treatment for knee stiffness post-ACL reconstruction but ideally should be carried out within eight months.

An occupational hazard peculiar to fishermen, is an injury from a sharp fish spine. Such spines can cause envenomation injury, infectious sequelae or trauma to anatomical structures. The management of two fishermen with penetrating ratfish (Chimaera) spine injuries to the lower limb is described. Both were managed by removal of the spine under general anaesthesia. In the second patient, the spine was embedded adjacent to the left femoral artery, highlighting the potential for major haemorrhage and supporting the use of surgical wound exploration when important structures may be involved. Herein, we describe the first report in English of Chimaera spine injury. In addition, we surveyed nine northeast Atlantic deep-sea fishermen to gain information on exposure to, and injuries from, this type of fish. The most commonly identified species was Chimaera monstrosa. Five fishermen reported injuries to their feet or hands from Chimaera spines and two had sought medical attention. The evidence indicates that deep-sea trawler fishermen of the northeast Atlantic frequently encounter Chimaera species and can suffer dangerous penetrating wounds from its dorsal spine.

A highly contagious behavioural affliction is now endemic in highland areas of Scotland. Pretravel advice ought to include a health warning to sport-lovers venturing north into wild, highlands of Gaeldom. It particularly affects young adults and predominates in men, although women are affected. The disorder can be acute or chronic and when severe, it can threaten one's life and limbs. Acute attacks may bring spontaneous recovery in months, but the chronic state can last for a life-time. Death will overtake some before it runs its inevitable course.

Upper gastrointestinal haemorrhage (UGIH) is a common medical emergency. Recent publications have emphasised the need for early risk assessment of patients with this condition to help direct management. Several risk scores have been developed for UGIH and are variably used in clinical practice. In this article, we discuss the various risk scoring systems for this condition and summarise the available evidence for their use.

The use of herbs as cures for human ailments is as old as modern man, but has now been replaced by synthetic drugs. However, the mixture of bioactive substances found in many traditional herbal remedies has similarities with modern combination therapies, like those developed by Sir John Crofton in Edinburgh for the treatment of tuberculosis. It is suggested that, in the development of these therapies, it might be possible to learn from the drug ‘cocktails’ found in plants.