bluuebunny/crossref_metadata_2025 huggingface dataset:
A Physician’s thoughts on malingering
Authors: Wood RA
Published: January 2025

A recent book compilation of papers from an international symposium on malingering and illness deception is reviewed. Now that medical education is moving away from the traditional model it is timely for students and doctors in training to become aware that patients regularly mislead doctors by minimising or exaggerating their symptoms. This book concentrates on the latter. There are helpful insights into common conditions when the history dominates the picture and in which there are seldom findings on examination or reliable tests. Of particular interest are contributions on the epidemiology of sickness absence from work and on the effect compensation processes have on the chronicity of problems. This book is essential reading for doctors writing Reports for the Courts and in general offers insight that will help all doctors with their clinical practice.
The Assisted Dying for the Terminally Ill Bill: an inappropriate response to the challenge of caring for the dying
Authors: Jeffrey D
Published: January 2025

The Assisted Dying for the Terminally Ill Bill concerns deliberate acts to end life, not assisting in the natural dying process. The Bill was the subject of a House of Lords Select Committee Report which will form the basis of debate in the House of Commons when the legislation is reintroduced in the current parliamentary session. Practical issues of patient assessment and implementation of physician-assisted suicide are not addressed in this legislation. There is a lack of reliable evidence as to how most dying patients feel about euthanasia and physician-assisted suicide. The interests of dying patients would be better served by increasing access to palliative care, making care of the dying a priority for our society.
Management of osteoarthritis
Authors: Steven MM , Finlayson D
Published: January 2025

Osteoarthritis is the most common arthropathy worldwide and the clinical and radiological prevalence increase with age. The aetiology is uncertain, but genetic and environmental factors are recognised. Symptoms predominantly occur in the spine, hips, knees, hands and feet, in isolation or combination, and may be relapsing – remitting or progressive. The signs may mimic inflammatory arthropathies or non-articular rheumatism, but clinical signs and appropriate investigations are discriminatory. Management is multi-modal with emphasis on diet, physiotherapy, and occupational therapy. Simple analgesics and occasionally systemic or topical anti-inflammatories are symptom-relieving, but unremitting pain and increasing disability from the hips or knees are indications for arthroplasty in suitable patients.
Maternal medicine symposium 2005
Authors: Akolekar R
Published: January 2025

A reflection of the recent trends in medicine is the development of the sub-specialty of obstetric medicine. Advances in healthcare have made it possible for patients with high-risk medical disorders to survive into adulthood. These women need highly specialised multidisciplinary care during pregnancy and labour. Recognising these recent trends in medical practice, a maternal medicine symposium was organised by the Royal College of Physicians of Edinburgh.
Illness in literature: an example in Middle Scots
Authors: Buchanan WW , Upton ARM
Published: January 2025

Few poets have written on medical topics, but one who did was William Dunbar, an eighteenth century Scots poet who wrote of his headache. His headache was severe enough to confine him to his house, and may have been migraine, but this remains uncertain. Scotland’s king at that time was James IV who was well-educated and interested in medicine. He awarded Dunbar a salary, probably as a secretary in his household, which may reflect his general support for education and the arts.
The potential role of statins in the treatment of rheumatoid arthritis
Authors: Kitas GD , Sattar N
Published: January 2025

Rheumatoid arthritis is characterised by uncontrolled chronic inflammation of the joints, which leads to their destruction and functional disability. It is also associated with increased and early cardiovascular mortality. This is thought to be linked to chronic systemic inflammation, which can lead to accelerated atherosclerosis, and thus earlier and more severe CHD. The beneficial effects of statins in the primary and secondary prevention of CHD are wellestablished. These are not only due to their lipid-lowering properties. Statins have several anti-inflammatory and immunomodulatory effects through which they may modify the inflammatory mechanisms involved in the generation and rupture of atherosclerotic plaques. These effects may also be useful for controlling rheumatoid inflammation. Thus statins may be an important adjunctive therapy in RA, aiming to both reduce joint inflammation and improve cardiovascular outcome. This needs to be tested in randomised controlled trials designed specifically for the purpose.
Meeting the needs of rural and remote Australians for specialist medical care: issues and options
Authors: Pegram RW , Humphreys JS , McLean R
Published: January 2025

Residents of Australia’s rural and remote communities face increasing problems in accessing specialist care. This paper provides a comprehensive review of the issues and options for the provision of specialist care to non-metripolitan Australians.
Coffee is good for the liver
Authors: McAvoy NC , Hayes PC
Published: January 2025

The intake of coffee and caffeine has been shown epidemiologically to be associated with improved liver function tests, mainly in the form of alanine transaminase and gamma glutamyl transferase, a reduction in the incidence of cirrhosis and hepatocellular carcinoma. These observations suggest that coffee drinking is protective to the liver. Hepatocellular carcinoma is a common tumour worldwide and amenable to both primary and secondary preventive strategies. Surveillance for hepatocellular carcinoma by six-monthly alpha fetoprotein and ultrasound scanning in patients with cirrhosis is essential.
Folic acid and breast cancer
Authors: Kunkler IH
Published: January 2025

Folic acid plays a key role in cell synthesis and repair. Dietary supplementation with folate before conception reduces the risk of neural tube defects such as anencephaly and spina bifida. Most of the published literature suggests that plasma folate levels are inversely associated with the risk of breast cancer. The mechanisms by which folate deficiency contributes to carcinogesis are unclear. On balance most of the scientific evidence suggest that folic acid has a protective role against the development of breast cancer.
Genetics in modern medicine
Authors: Porteous MEM
Published: January 2025

Over the past 20 years there has been a massive worldwide investment in genetic research. Many claims have been made about the power of genetic knowledge to transform the practice of medicine. This aim of this symposium was to explore the role of genetic knowledge in the medical management at the present time and to anticipate future advances in treatment.
Acclimatisation at high altitude: lessons from individuals prone to high altitude pulmonary oedema
Authors: Sartori C , Scherrer U
Published: January 2025

High altitude constitutes an exciting natural laboratory for medical research. Over the past decade, the scope of high altitude research has broadened considerably, since it has become clear that the results of this research may have important implications, not only for the understanding of diseases in the millions of people living permanently at high altitude, but also for the treatment of hypoxemia-related disease states in patients living at low altitude. Studies in subgroups of subjects who do not adapt well to high altitude have greatly advanced our knowledge regarding underlying mechanisms predisposing to these diseases. high altitude pulmonary oedema is the best studied example of such a maladaptation. Here we will review recent work of our group that has provided novel insight in the pathogenesis of HAPE.
Acute neurology in a twenty-first century district general hospital
Authors: Weatherall MW
Published: January 2025

A significant expansion of acute neurological services in the UK is planned, but there is little contemporary information on the burden of acute neurology in modern hospital practice. The objective of this study was to provide comprehensive information on the numbers of patients admitted with acute neurological problems, referral patterns to neurological services, and the utilisation of resources for investigation of neurological problems. The method used was a prospective survey of 1,197 acute medical admissions to a district general hospital in North-West England. It was found that neurological problems accounted for 181 (15·1%) of acute admissions. Of these, only 59 (32·6%) saw a neurologist or neurosurgeon, and only 28 (15·5%) were admitted under the neurological services. The most common presenting complaints were cerebrovascular disease (34·3%), seizures (26·5%), and headache (17·7%). One hundred and nine patients (9·1%) underwent cranial CT scanning, 68 within 48 hours of admission. It was concluded that acute neurological problems are common. In many centres, even those with embedded neurological services, they are still largely managed by general physicians. A restricted range of neurological conditions make up most of the acute case load. These facts should be taken into consideration when planning acute neurological services, and also in the delivery of undergraduate and postgraduate education in neurology.
Pandemic flu: facts, feathers and forecast
Authors: Meyer N , Hawkins G
Published: January 2025

The Royal College of Physicians of Edinburgh organises ‘hot topic’ meetings in response to medical matters attracting major public and media interest. This report of the implications of a future influenza pandemic complements a previous report in the Journal on Asian flu.1a
The past, present and future of heart failure therapies
Authors: Leslie SJ
Published: January 2025

The publication of a large number of randomised controlled trials in heart failure patients over the last 25 years has allowed the development of several excellent evidence-based guidelines.1–3 Revised SIGN guidelines for heart failure are due for publication this year.3 The major challenge facing us now is the implementation of these evidence-based therapies and the allocation of resources to allow the development and assessment of emerging technologies to ensure that patients receive the treatments they need.
Beethoven’s terminal illness and death
Authors: Mai FMM
Published: January 2025

There is dispute about the cause of Beethoven’s death; alcoholic cirrhosis, syphilis, infectious hepatitis, lead poisoning, sarcoidosis and Whipple’s disease have all been proposed. In this article all primary source documents related to Beethoven’s terminal illness and death are reviewed. The documents include his letters, the report of his physician Andreas Wawruch, his Conversation Books, the autopsy report, and a new toxicological report of his hair.

His terminal illness was characterised by jaundice, ascites, ankle oedema and abdominal pain. The autopsy data indicate that Beethoven had cirrhosis of the liver, and probably also renal papillary necrosis, pancreatitis and possibly diabetes mellitus. His lifestyle for at least the final decade of his life indicated that he overindulged in alcohol in the form of wine. Alcohol was by far the most common cause of cirrhosis at that period. Toxicological analysis of his hair showed that the level of lead was elevated. During the eighteenth and early nineteenth centuries, lead was added illegally to inexpensive wines to sweeten and refresh them. These findings strongly suggest that liver failure secondary to alcoholic cirrhosis, associated with terminal spontaneous bacterial peritonitis, was the cause of death. This was complicated in the end stages by renal failure. If the presence of endogenous lead was verified by analysis of Beethoven’s skeletal remains, it would suggest that the lead was derived from wine that he drank. Lead poisoning may account for some of his end-of-life symptoms. There is little clinical or autopsy evidence that Beethoven suffered from syphilis.
What became of Arthur Conan Doyle’s father? The last years of Charles Altamont Doyle
Authors: Beveridge A
Published: January 2025

This paper examines the fate of Arthur Conan Doyle’s father, Charles Altamont Doyle, a Victorian illustrator, who spent his last years as an asylum inmate. Based on new archival research, it looks at the reasons for his institutionalisation and what befell him during his stay. It will consider Doyle’s claim that he was wrongfully confined and also the suggestion that his family were responsible for having him committed. Finally, the paper will examine the nature of Doyle’s condition and the creative work he produced whilst an asylum inmate.
The Solanaceae II: The mandrake (Mandragora officinarum); in league with the Devil
Authors: Lee MR
Published: January 2025

In this second article on the plant family, the Solanaceae (the mandrake) is discussed. This plant (Mandragora officinarum) was well known to the ancients, including the Greeks, the Romans, the Arabs and Hebrews. Regarded by them all as having magical powers, it was thought to be possessed by a Satanic spirit. In order to gather it safely, a number of elaborate rituals were developed by these different ethnic groups. It was also thought to be propagated at scenes of execution where the body of the felon released urine and semen. In later medieval times, these superstitious beliefs were rejected but the mandrake was still highly valued as a powerful anaesthetic and had considerable use as one constituent of the soporific surgical sponge. Eventually, nitrous oxide, ether and chloroform consigned the mandrake to obscurity. Nevertheless, its story remains one of the most fascinating in the history of medicine.
Diabetes and pregnancy
Authors: Lindsay RS , Mackenzie F
Published: January 2025

The recent CEMACH report provides important information on outcomes and processes of care for pregnancy complicated by pre-gestational diabetes in England,Wales and Northern Ireland. Similar information for Scotland was published previously by the Scottish Diabetes in Pregnancy Study Group. The Confidential Enquiry into Maternal and Child Health found that maternal diabetes was associated with increased rates of stillbirth (4·7-fold), perinatal mortality (3·8-fold), and congenital anomaly (2-fold), compared to pregnancy not complicated by diabetes. Assessment of rates of pre-pregnancy counselling (documented in 34·5%), measurement of HbA1c in early pregnancy (38%) and pre-conception folic acid supplementation (39·2%), suggest areas where service development might be concentrated to improve outcomes. Finally, CEMACH provides the first largescale survey of an increasingly prevalent patient group – women with type 2 diabetes in pregnancy – who made up 27·2% of the survey and showed similar adverse outcomes to the women with type 1 diabetes.
Movement disorders: a brief practical approach to diagnosis and management
Authors: Burn DJ
Published: January 2025

The characteristic feature of all movement disorders is an abnormality of the form and velocity of movements of the body. The term ‘movement disorder’ has become synonymous with basal ganglia disease and extrapyramidal features. Although many movement disorders do arise from pathology within the basal ganglia, disorders such as myoclonus may also arise from other structures. Abnormality of movement may be the only manifestation of a disease process, or may be part of a more widespread neurological disorder. It is important not to divorce the disorder of movement from general medical problems, since these may be directly or indirectly related (for example, chorea in systemic lupus erythematosus; DIP caused by amiodarone). Basal ganglia disease is commonly associated with neuropsychiatric symptoms and these may have a greater impact upon the patient and their family than the movement disorder itself.

An essential first step in the approach to the patient with a movement disorder is to correctly determine the phenomenology of the problem (for example, is the dominant problem chorea or dystonia?). Once this first step has been made, appropriately targeted investigations may then be required to determine the diagnosis. Thereafter, consideration is given to treatment, based upon clinical and social factors, as well as patient preference. This overview will describe a practical approach to the patient with a movement disorder. It will also briefly consider some broad principles in the investigation and management of such cases.
A clinical approach to alcoholic hepatitis
Authors: Forrest EH
Published: January 2025

There has been a dramatic increase in alcoholic liver disease in Scotland over recent years. Alcoholic hepatitis is perhaps the most florid manifestation of this, however considerable controversy exists regarding its diagnosis and management. This review indicates that it is possible to confidently make a diagnosis of alcoholic hepatitis on clinical grounds using a minimum threshold of serum bilirubin as a diagnostic criterion. All patients with alcoholic hepatitis need nutritional assessment and support. The severity of alcoholic hepatitis can be ascertained using the Discriminant Function, however the Glasgow Alcoholic Hepatitis Score appears to be more specific and accurate predictor of outcome. Patients with severe disease should be considered for specific treatment. The evidence is in favour of corticosteroids which have the added benefit of allowing responsiveness to the treatment to be assessed after one week. Pentoxifylline may be a useful alternative to corticosteroids. The patients with alcoholic hepatitis and concomitant sepsis have a very poor prognosis. Previously regarded as a contraindication to specific treatment, it might be beneficial to broaden the indications for corticosteroids or pentoxifylline in these patients.
Challenges in ensuring drug safety
Authors: Beard K , Waller P
Published: January 2025

Recent high profile cases have highlighted the importance of establishing the appropriate balance of benefits and risks regarding drug therapy. The regulatory authorities and the pharmaceutical industry are responsible for ensuring drug safety, but prescribers and patients also have responsibilities in this regard. Providing better education for professionals and developing better information for patients are amongst the most important challenges to be faced.
Eponymous doctors associated with Edinburgh, part 3 – Abraham Colles, Sir William Ferguson, John S Haldane, Argyll Robertson, Thomas Young
Authors: Doyle D
Published: January 2025

In the first papers in this series,1, 2 it was shown that eponyms were often bestowed on physicians and surgeons who were already famous, had made many discoveries never honoured with eponyms, and were often the leading doctors of their day. Only occasionally was the eponym suggested by a friend or colleague; more usually it was a doctor abroad who wanted to show respect to a great man but the choice of the particular syndrome or discovery was a random one. Eponyms may have had their uses. They were usually much shorter than a detailed description of a medical syndrome or anatomical feature and may sometimes have been used as euphemisms in much the same way as, until recently, bedside teachers protected the patients by speaking of ‘mitotic lesions’ or ‘neoplasms’, ‘Hansen’s Disease’ or ‘acid-fast bacilli’. The conferring and use of eponyms appears to be lessening but, as shown in this final paper, they are still used and possibly useful, and can tell us things of interest about the recipient and the proposer.
The opercular syndrome, or, the Foix-Chavany-Marie syndrome
Authors: Gordon N
Published: January 2025

The opercular syndrome is due to bilateral, and sometimes unilateral, lesions of this area of the cerebral cortex, or its connections with the brain stem. The symptoms and signs of the syndrome are described, especially the type of facial palsy. They differ slightly in childhood, and may be accompanied by developmental delay. They can be reversible when linked to epileptic activity in the opercular areas. The symptoms can be suggestive of two well-established syndromes in childhood. Firstly, the Landau–Kleffner syndrome (and there may well be shared pathophysiological mechanisms) and secondly, those first described by Worster–Drought.

The investigations needed to establish the location and the possible causes of the opercular syndrome are discussed. The most common causes are vascular lesions, but other possibilities such as infections and trauma have to be considered. Also malformations of prenatal origin can result in the suprabulbar palsy so typical of the syndrome. If the cause can be established there is always the possibility of treatment.
Current treatments for multiple sclerosis
Authors: Young CA
Published: January 2025

Multiple sclerosis is a complex lifelong condition, with the severity of symptoms varying greatly between patients. In this article, requested by visitors to the www.behindthemedicalheadlines.com site, Professor Carolyn Young provides an overview of the different sub-types of MS and the diverse treatments which are currently available for this disease.
Stranger’s fever in Charleston, South Carolina: a mistaken diagnosis?
Authors: Cohen J , Cohen J
Published: January 2025

George Augustus Clough was a young Englishman who died in Charleston, South Carolina, in 1843. The cause of death, which unusually was given on his gravestone, was Stranger’s fever, which is now known to be yellow fever. Stranger’s fever first appeared in North America in Florida in 1649, and continued to cause both sporadic cases as well as serious epidemics, mainly in the South and along the Eastern seaboard of the US until the beginning of the twentieth century. It gained its name from its propensity to mainly afflict recent arrivals, and Clough had only been in Charleston for two years before his death. However, a re-examination of the evidence suggests that he may not in fact have died of yellow fever.
Chronic obstructive pulmonary disease
Authors: Albert P , Calverley P
Published: January 2025

Chronic obstructive pulmonary disease is a disease state characterised by airflow obstruction that is not fully reversible. It is predominantly caused by smoking, although other factors such as occupational exposures also contribute to the development. The obstruction arises from chronic inflammation in the airways and lung parenchyma. Chronic obstructive pulmonary disease produces symptoms, disability and impaired quality of life but significant airflow obstruction may be present before the patient is aware of symptoms. Chronic obstructive pulmonary disease is the preferred term for patients who may have been labelled as having chronic bronchitis or emphysema in the past. Chronic obstructive pulmonary disease is generally a progressive disease. If the patient stops smoking, the disease may still progress due to the decline in lung function that occurs with the normal aging process. However, ongoing smoking accelerates the process.
Influenza and pneumococcal vaccination: an update
Authors: Roberts HJ , Lim WS
Published: January 2025

Influenza and Streptococcus pneumoniae cause considerable morbidity and mortality. Excess deaths in the UK per year from influenza have been between 2,000 and 4,000 in recent years. There are over 5,000 cases of invasive pneumococcal disease in the UK per annum. Vaccination was introduced to the UK in the eighteenth century. Since then, there have been major advances in the development and administration of vaccines. The use of hens’ eggs for viral growth meant that influenza vaccination became more widely available, and the recognition of different serotypes of pneumococcus led to increased effectiveness of immunisation. Recent developments have led to a conjugate pneumococcal vaccine which is effective in children and has had dramatic effects on the incidence of invasive disease in the US. It has recently been introduced into the childhood immunisation programme in the UK. This article gives a background to the development of influenza and pneumococcal vaccination, and an update on recent advances and recommendations.
Professor HT (Harry) Howat: prime leader in pancreatology development in the UK
Authors: Shreeve DR
Published: January 2025

Positioned in the posterior abdomen, the pancreas remained little observed until nineteenth century advances in physiology, followed later in the century by abdominal surgery, brought the organ into the clinical domain. The discovery of pancreatic stimulating hormones during the twentieth century culminated in the description of pancreozymin by Harper and Raper in Manchester in 1943. After World War II, Henry T Howat was appointed physician in that city and was able to analyse the results of hormonal stimulation in pancreatic disorders. He became the first doctor in Britain to specialise in pancreatology. His collaboration with colleagues in Britain and in Europe, through the evolution of specialist societies, encouraged the coordination of basic science, medicine, pathology, radiology and surgery, to further research in, and management of, pancreatic disease. Academic recognition by Manchester University resulted in his being appointed its first Professor of Gastroenterology and originator of a gastrointestinal research unit. As he pointed out, continuing scientific and technological advances influenced the concepts of disease, and moved the management of pancreatic disease from the general physician and surgeon to gastroenterologists. Howat’s career illustrates the continuing specialisation witnessed in the latter half of the twentieth century.
Pulmonary thromboembolism presenting as a cavitating lesion on chest X-ray
Authors: Khalid S , Bailey S , Houghton C
Published: January 2025

Pulmonary embolism presenting as a cavitating lesion on a chest X-ray is described in a patient with a six-week history of worsening dyspnoea. A chest X-ray performed 27 days earlier did not show the cavitating lesion. On the day of presentation, the patient had developed streak haemoptysis. Due to the progressive nature of dyspnoea, hypoxia and the rapid development of the cavitating lesion on the X-ray, pulmonary infarction leading to cavitation secondary to pulmonary thromboembolism was considered to be among the list of differential diagnoses. The modified Wells criteria for this patient were 2·5 (Heart rate > 100, haemoptysis). This diagnosis was confirmed on CTPA, which showed the presence of large pulmonary emboli in the pulmonary vasculature supplying the affected lobe. Subsequent Doppler ultrasound revealed the presence of a below right knee thrombosis. Although rare, cavitation has previously been observed in patients with pulmonary thromboembolism.1–3
Galen, Gaia and global climate change: Harvey and the history of air
Authors: Seaton A
Published: January 2025

Harvey’s scientific method was taken up by his pupils and successors and led to the discovery of carbon dioxide and oxygen and their role in animal metabolism. The carbon cycle was discovered in the 19th century and by the end of that century the role of carbon dioxide in the greenhouse effect had been demonstrated. The late 20th century saw the gradual appreciation that industrialisation and combustion of fossil fuels were making an important contribution to rising carbon dioxide levels in the amosphere and that the earth's capacity to absorb the excess was limited. We are now at a point where it would be seriously imprudent not to take global action to reduce emissions, in view of the likely consequences of further global climate change. All individuals in the prosperous world need to take action to reduce their carbon footprint; paying it lip service is no longer sufficient.
Neurology symposium report
Authors: Taylor K
Published: January 2025

The Royal College of Physicians of Edinburgh held its latest Neurology Symposium on 9 November 2006.The topics, summarised in this report, included useful clinical approaches to some common neurological problems (blackouts, dizziness, headache, and functional symptoms), original basic and clinical research on subarachnoid haemorrhage, a discussion of exciting new advances made in multiple sclerosis over the last 10 years, and current thinking on the management of Parkinson’s disease. Finally, a debate on the controversial issue of the role of NICE in neurology concluded that NICE had not enhanced the care of neurological patients in the UK. However, there was a general consensus that there is an important role for an organisation to appraise neurological healthcare interventions.
Mastocytosis: an uncommon cause of collapse
Authors: Pearce S , Talapatra I
Published: January 2025

A 59-year-old man was referred to the authors’ medical clinic with a history of four episodes of collapse over five years. The patient had a history of urticaria pigmentosa diagnosed 12 months previously. The recognition of his skin condition and the history of recurrent, albeit infrequent, collapses accompanied by hypotension and pruritis led to the suspicion of mastocytosis. He had persistent elevation of serum tryptase consistent with mast cell disease, but the analysis of a bone marrow biopsy failed to confirm systemic disease. Mastocytosis can lead to numerous symptoms directly related to the degranulation of mast cells by certain physical and pharmacological stimuli, and can present with recurrent anaphylactic attacks. Provision of an EpiPen can be life-saving in affected individuals. The association of urticaria pigmentosa and mastocytosis is of vital importance to physicians who are frequently faced by patients presenting with collapse without cause.
Non solum… sed etiam: added cardiac benefits of TNFa blockade in rheumatoid arthritis
Authors: GM Raftery  , DJ Armstrong
Published: January 2025

Tumour necrosis factor alpha (TNFa) has emerged as one of the key cytokines in the fields of infection and inflammation, and has been linked with disease activity and joint damage in rheumatoid arthritis. Acute myocardial infarction remains the leading cause of death in rheumatoid arthritis, and there is now a large body of evidence placing TNFa and other inflammatory cytokines at the centre of the development of atherosclerotic plaques and their subsequent rupture, which is in keeping with the observation of accelerated atherosclerosis in rheumatoid arthritis patients. TNFa might also have a role to play in the increased incidence of congestive cardiac failure seen in rheumatoid arthritis.

Although anti-TNFa therapies were originally developed with a view to controlling joint disease in rheumatoid arthritis, evidence is emerging of a positive benefit in reducing heart disease as well. A range of mechanisms has been suggested by which anti-TNFa treatment might achieve a reduction in incidence of myocardial infarction and cardiac failure, some of which will have implications for the treatment of cardiovascular disease in general.
Newly diagnosed type-2 diabetes presenting with hemichorea-hemiballismus
Authors: Demssie YN , Kaushal K
Published: January 2025

Hemichorea-hemiballismus (HC-HB) is a unilateral, involuntary, random movement disorder that can involve both proximal and distal groups of muscles. It is caused by lesions in the contralateral corpus striatum. The most common aetiology is an acute cerebrovascular event, but infections, drugs, tumours and neurodegenerative disorders can all be implicated. Non-ketotic hyperglycaemia has been identified as a metabolic cause of HC-HB, particularly in elderly female patients with newly diagnosed or poorly controlled diabetes. These patients tend to have a characteristic hyperintense signal in the putamen on T1-weighted MR imaging. Often the movement disorder resolves within days to weeks after correction of the hyperglycaemia, but complete resolution of the radiological signs commonly takes months. An 86-year-old woman with newly diagnosed type-2 diabetes presented with hyperglycaemia-induced right-sided HC-HB and typical contralateral high signal change in the putamen on T1-weighted MR scanning. Her symptoms completely resolved within five days of achieving euglycaemia.
Is there a link between problem-based learning and emotional intelligence?
Authors: Evans P
Published: January 2025

A brief description of problem-based learning is given and reference is made to the difficulties in demonstrating its value in terms of ‘accumulated knowledge’ with respect to the literature. The author suggests that problembased learning may be a suitable curriculum component for developing a student’s emotional intelligence.
Guests, ghosts and trust
Authors: Finlayson N
Published: January 2025

Correspondence to N Finlayson, Communications &Publishing, Royal College of Physicians, 9 Queen Street, Edinburgh EH2 1JQ, UK tel. +44 (0)131 247 3652 e-mail niall.finlayson@brightgrey.com
Haematology symposium report: an update for the general physician and the specialist
Authors: Mathai S
Published: January 2025

This symposium covered a wide range of topics of interest to both general physicians and specialists in haematology. Problems commonly encountered by acute physicians were explored, including the management of over-anticoagulation, thrombocytopenia associated with thrombosis and dealing with current and emerging risks of blood transfusion. Updates on the management of chronic lymphocytic leukaemia, multiple myeloma and Hodgkin’s lymphoma were presented. The discovery of the JAK2V617F mutation and the use of tyrosine kinase inhibitors in chronic myeloid leukaemia have changed the way we diagnose and treat myeloproliferative disorders. New approaches to monitoring and treating transfusional iron overload were discussed. In the field of stem cell transplantation, the vogue for reduced intensity allogeneic transplants has allowed older patients to benefit from this treatment approach.
Treating patients with cancer: individualising therapy, improving outcome
Authors: Michie CO
Published: January 2025

This is an exciting time in the treatment of patients with cancer, as new therapies and technologies begin to impact on patient care. The concept of individualisation of therapy has come to the fore in both clinical practice and in cancer research; this excellent symposium introduced several ways in which new molecular techniques can improve patient selection and aid clinical decisionmaking. Methodical, evidence-based approaches to common clinical problems in oncology were also presented. It is clear that the challenges now are to investigate and validate which potential new therapeutic targets are important in vivo, and to identify which subgroups of patients benefit most from specific therapies and which patients can be spared treatment and its inherent risk of potential morbidity. In addition to this, by working together to enhance supportive care and reduce toxicity, the ultimate goal of improved outcome for patients can be realised.
The St Kilda boat cough under the microscope
Authors: Stride P
Published: January 2025

The inhabitants of St Kilda, a remote archipelago in the Outer Hebrides, suffered from outbreaks of a respiratory tract infection known as the boat cough every time strangers visited their isolated community between the seventeenth and nineteenth centuries. This condition has always been labelled influenza, but a review of contemporary records and modern microbiological evidence strongly suggests the illness was due to rhinovirus.
Norovirus: an established viral plague
Authors: Dancer SJ
Published: January 2025

Norovirus, or the winter vomiting virus as it has become more commonly referred to, is responsible for acute epidemics of gastroenteritis and diarrhoea throughout the year and has gained much public notoriety due to its impact on semi-closed communities such as schools, hospitals, offices and cruise liners. In this article Dr Stephanie Dancer provides an expert overview of norovirus and what can be done to stop it spreading.
Probable catastrophic antiphospholipidsyndrome (CAPS)
Authors: Das AK , Higgins A , Lok A , Kalidindi RS
Published: January 2025

We describe the case of a 53-year-old man who presented with a cerebellar stroke. He developed a thrombus in his left ileo-femoral vein, and his IgG anticardiolipin antibody turned out to be positive. He then developed thrombosis of the right ileo-femoral vein while well anticoagulated with warfarin. Despite aggressive anticoagulation he developed livedo reticularis, pulmonary embolism, adult respiratory distress syndrome and renal failure over a few weeks and eventually died from a large gastrointestinal bleeding. He probably had catastrophic antiphospholipid syndrome (CAPS) or Asherson’s syndrome, which has a high mortality. We discuss the current treatment options available for such a patient.
Prevention of venous thrombosis in hospitalised medical patients
Authors: Dolan G
Published: January 2025

Venous thromboembolism (VTE), mainly deep vein thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality in the Western world. It has been estimated that there are 300,000 new cases of first lifetime VTE in the US each year, and there are 60,000 deaths annually from VTE in the UK. Parallels have been drawn with other clinical conditions that have received more attention, and it has been estimated that the mortality rate for VTE in the UK is five times greater than the combined total number of deaths from breast cancer, AIDS and road traffic accidents and more than ten times greater than from methicillin-resistant Staphylococcus aureus infection.
Organising an MRCP course in Pakistan
Authors: Hafeez H , Yusuf A
Published: January 2025

The MRCP(UK) examination enjoys a tremendous reputation internationally. Recent changes to the immigration system have made it difficult for international graduates to come to the UK for training, which has resulted in many doctors taking the MRCP examination without having worked in UK. Understandably, these doctors face difficulty in tackling the exam, especially the talking stations (2 and 4) of the Practical Assessment of Clinical Examination Skills examination (PACES). Our answer to the problem was to set up preparatory courses for the MRCP examination in our hospital. Although faced with logistical difficulties we have managed, with support from our consultant colleagues, to set up and run courses both for Part 1 and the PACES examination of Part 2. In holding the courses we have identified a huge deficiency in the training of our doctors in communication skills. We hope that similar courses will be set up across the country, and that communication skills will gain more recognition in the medical curricula at all levels.
Risks from, and appropriate use of, blood products
Authors: Manson LM , Preston GC
Published: January 2025

Transfusion medicine has come a long way since the discovery of ABO blood groups by the Austrian scientist Karl Landsteiner in 1900. There has been continual improvement in the quality and safety of blood products available for clinical use, but, as with any treatment, there are associated risks. However, the UK national haemovigilance scheme has shown that most of those related to blood products are due to human error and could be prevented. Indeed, the most frequently reported category of transfusion reaction is ‘incorrect blood component tranfused’, which is nearly always due to an error of patient identification or prescribing, and can be fatal. Junior doctors are most often implicated, as they are delegated responsibility for blood-product prescribing and many mistakes arise due to lack of knowledge. While a lot of media emphasis has been put on the risk of viral and, more recently, prion transmission, transfusion-transmitted infections are very rare. In the UK there have only been four cases of confirmed variant Creutzfeldt-Jakob disease due to blood transfusion, and the risk of HIV transmission is approximately one per four million units transfused. Other problems, such as febrile, allergic and haemolytic reactions, are much more common. The use of red cells, platelets, fresh frozen plasma and cryoprecipitate requires understanding both of their content and of the clinical situations in which they are used. Doctors need to be aware of these issues in order to use blood products appropriately.
Scientific knowledge and clinical authority in dentistry: James Sim Wallace and dental caries
Authors: Nicolson M , Taylor GS
Published: January 2025

Once the germ theory had become generally accepted within medicine, the importance of experimental science to the improvement of medical practice could no longer be reasonably doubted. However, clinicians still sought to retain control of how knowledge that had originated in the laboratory was interpreted and applied within practical diagnostics and therapeutics. Thus how practitioners incorporated new scientific knowledge into their medical discourse and practice is a matter for careful empirical inquiry. James Sim Wallace, born in Renfrewshire in 1869 and a graduate in medicine from the University of Glasgow, was a leading figure in British dentistry throughout the first half of the twentieth century. Through an examination of his voluminous writings, we explore how the new ‘chemico-parasitical’ theory of dental caries was accommodated within dentists’ understanding of oral hygiene. The paper also looks at the controversies that surrounded the application of the vitamin theory to the problems of rickets and dental caries, focusing on the contentious interaction between Sim Wallace and his colleagues, on the one hand, and the eminent physiologists May and Edward Mellanby, on the other.
Umbilical cord-derived stem cell transplants– what’s changed in three years?
Authors: Davies JM
Published: January 2025

Umbilical cord-derived haemopoietic stem cells (UCDSCs) were first shown to be capable of supporting sustained engraftment approximately 30 years ago, but their role as a transplant source has been slow to develop. Recent work, however, suggests an increasing future use of UCDSCs in both children and adults. The transplantation of UCDSCs is feasible, and concerns around cell dose and poor engraftment have been partly addressed with the use of double-cord donation. Other developments in this area include the potential for ex vivo expansion of UCDSCs and, intriguingly, the direct transplantation of UCDSCs into the marrow cavity. Clinical studies have confirmed the utility of UCDSCs and suggest that they have a particular role in patients who do not have an available sibling or fully matched unrelated donor. Given the potential availability of UCDSCs and the less stringent requirements for human leukocyte antigen matching to the recipient, the use of UCDSCs is likely to increase. This could, in theory, allow near-universal access to allogeneic transplantation for those patients who may benefit from the procedure.
Nodular thyroid disease
Authors: Toft AD
Published: January 2025

Nodular thyroid disease is common. Ultrasound examination of the neck for a variety of reasons has revealed a linear increase in the prevalence of thyroid nodules from negligible at 15 years to 50% by the age of 60. Only 10% of these nodules are palpable by experienced examiners. Conversely, 50% of patients referred to a thyroid clinic with an apparently solitary thyroid nodule will be found to have a multinodular goitre. In the absence of marked asymmetry, rapid growth or an obvious ‘cold’ area on isotope imaging, multinodular goitre is, for practical purposes, a benign condition that may be associated with hyperthyroidism at presentation or in future years. On the other hand, a solitary palpable nodule may be malignant and the issue for the clinician is to identify the 5% that are malignant (usually papillary or follicular carcinomas) by using a combination of clinical assessment, imaging, thyroid function tests and cytology. Ultrasound-guided fine needle aspiration of impalpable thyroid nodules identified by imaging has demonstrated that malignancy is as common as in palpable solitary nodules. Although the natural history of these thyroid incidentalomas in an ageing population is not known, growth is likely to be slow and, in the UK at least, it is not common practice to adopt an aggressive policy of investigation and treatment.
Palliative care in your hospital
Authors: Buchanan D
Published: January 2025

This thought-provoking symposium explored some of the issues related to the provision of palliative care within hospital settings. Session one focused on difficult symptoms – neuropathic pain, dyspnoea and malignant bone pain – and the new techniques and science that inform their management. The theme of delivering targeted, individual care was developed through the sessions, and the challenges of providing equitable, effective care were repeatedly highlighted. Importantly, there is a need to combine current, developing research and clinical knowledge to provide high-quality, individual symptom management.
Venous thromboembolism: the role of the clinician
Authors: Curry N , Keeling D
Published: January 2025

Deep venous thrombosis is a diagnosis that should be considered in any patient who presents with a swollen or painful leg. Clinical examination alone has low sensitivity and specificity for detecting patients with clots, and in recent years a diagnostic pathway has been devised that is more effective. This involves integration of three modalities: clinical assessment, D-dimer analysis and ultrasound. The management of a patient found to have a deep venous thrombosis includes immediate treatment but also the consideration of risk factors, family history, need for thrombophilia testing, duration of treatment and the prevention of postthrombotic syndrome.
A prospective survey of acute hospital admissions with atrial fibrillation in Karachi, Pakistan
Authors: Haq U , Lip GYH
Published: January 2025

Background: There are established differences in cardiovascular disease in different racial groups. Worldwide, the literature regarding the clinical epidemiology of atrial fibrillation (AF) in non-white populations is scarce.

Objectives: To document the clinical epidemiology of AF among hospital admissions to two teaching hospitals in Karachi, Pakistan, over a two-month period and to describe the clinical features and management of these patients.

Subjects: 3,766 acute medical admissions, of whom 245 (6.5%) had AF.

Results: Of 245 patients with AF, clinical notes of 24 were lost in the system. Of the remaining 221 patients with AF (107 males; mean age 66 years), 22% were Afghani Muslims, 3% Indians, 1% white and the rest were Pakistani with unknown country of origin. The most common associated medical conditions were hypertension (54%), valvular heart disease (54%) and ischaemic heart disease (IHD, 47%). The most common presenting complaints in female patients were palpitations (51%) and anxiety (35%). In males, the most common symptoms were palpitations (46%), chest pain (35%) and anxiety (27%). Among male patients, 100% had an electrocardiogram (ECG), 93% an X-ray, 89% echocardiography and 49% thyroid function testing. Direct current (DC) cardioversion was attempted in 8%. Of the male admissions with AF, 64% were taking aspirin, while 75% were anticoagulated in hospital and 40% of patients were discharged on anticoagulants with cessation documented in 14%. Beta blockers and amiodarone were prescribed in 74% and 19% of male cases respectively. In females, 100% had an ECG, 76% chest X-rays and 81% had echocardiography proposed. Thyroid function tests were done in 46% of cases, and DC cardioversion was attempted in 11%. Of the female AF patients, 70% were anticoagulated in hospital and 48% went home on anticoagulants. Cessation of warfarin was documented in 27% of female patients, and beta blockers and amiodarone were prescribed in 80% and 26% respectively.

Conclusion: Among acute medical admissions to hospital in Pakistan the prevalence of AF was 6.5%. Consistent with previous similar surveys in mainly Western (Caucasian) populations, standard investigations in this cohort were inadequate and there was underuse of anticoagulation (with a high cessation rate).