Journal of the Royal College of Physicians of Edinburgh

Blood safety is a high priority. As a result of many additional safety measures the risks of transmitting known infective agents is remarkably low. However, some blood safety measures are quite remarkably expensive by any conventional health economic standards. It is therefore surprising that much of our current blood prescribing is not founded on any reliable evidence. We question the logic of spending even more on safety measures that offer marginal benefits unless we also invest more to understand rather better when, and for who, transfusion is really beneficial. On 1 March 2005, the Royal College of Physicians of Edinburgh is holding a one-day meeting to investigate this balance of priorities. See www.rcpe.ac.uk/events/transfusion.html

Recent controversies have focused on whether shaking can injure the infant brain and if a diagnosis of SBS can be confidently made and distinguished from accidents (short falls) and non-traumatic conditions.

This article reviews documented cases, animal, biomechanical, and computer-modelling evidence to support the contention that shaking alone without additional impact results in a rotational brain injury with tearing of cortical emissary veins, parenchymal shearing, cervico-medullary, and hypoxic-ischaemic injury.

While the terminology SBS is best avoided because it implies a mechanism in what is usually an unwitnessed injury, a more secure diagnosis of NAHI can be offered, with varying degrees of certainty, based on clinical, imaging, and ophthalmological findings after excluding conditions simulating these features.

The type of brain injury (inertial, contact, hypoxic-ischaemic) and the context in which it is sustained, may enable an opinion about whether the mechanism is consistent with either a purely rotational or rotational impact-deceleration injury, compressive, penetrative or other combined mechanism.

The Respiratory Medicine symposium considered many topics including the difficulties of managing functional breathlessness and breathlessness in pregnancy, pigeon fancier's lung, interventional bronchoscopy, inhalation therapy for COPD, pulmonary rehabilitation, and terminal care in non-malignant respiratory disease. The Robert W Philip Memorial Lecture focused on advances in the acute respiratory distress syndrome.

On 22 December, Lord Warner, the Health Minister, announced a number of new measures to regulate complimentary medicine in response to report of a House of Lords Select Committee and a DoH Consultation Document published in 2003. Although the final paper, describing the way in which the government proposes to regulate herbal medicines and complementary healthcare professionals, has yet to be published, the DoH has announced that it will make £900,000 available to The Prince of Wales's Foundation for Integrated Health over the next three years to develop robust systems for the regulation of the main complementary healthcare professionals. A new Herbal Medicines Advisory Committee will be set up to advise the Medicines and Healthcare Products Agency on the safety and quality of herbal medicines. The present Advisory Board on the Registration of Homeopathic Products will retain its status as a free-standing committee, able to advise the government directly. This paper reflects on current attitudes and legislation in the herbal arena.

Traveller’s diarrhoea is a common problem. This article features the daignosis and management of dirrahoea in returned travellers to the UK. Treatment is essentially fluid replacement, bed rest if there is much colic, exclusion from work in certain infections, and antibiotics in certain situations.

Helicobacter pylori is strongly associated with chronic active gastritis, peptic ulcer disease, and gastric carcinoma. Understanding the mode of transmission of H. pylori is essential to limit its spread and serious associated diseases. Most infections are acquired in childhood and some risk factors associated with childhood infection include poor sanitation, overcrowding, bed sharing, and lower socio-economic status. The theory of direct person-to-person spread is now generally accepted, but the route of transmission remains open to conjecture. The evidence linking H. pylori with peptic ulcer disease and low-grade MALToma is extremely strong. However, the association with gastro-oesophageal reflux disease, non-ulcer dyspepsia and its synergism with NSAIDs in the causation of ulcers remains controversial. The infection can be diagnosed by invasive (endoscopic) and non-invasive testing. Current therapy is highly effective in eradicating the organism.

Inflammatory bowel disease comprising of ulcerative colitis and Crohn's disease can no longer be considered to be diseases confined to the West. Genetic susceptibility, mucosal immune dysregulation and intestinal bacterial flora contribute to the pathogenesis, but the exact causes remain uncertain. The identification of Nod2 gene mutations associated with Crohn's disease points to defects in innate immune system that alter interaction with microbial agents. Early recognition is important to prevent morbidity and complications. This poses special challenge in countries where the incidence is lower than that in the West and infective diseases involving the intestinal tract is common. Management requires a multidisciplinary medical-surgical team effort and is focussed on disease modifying therapy rather than simply management of acute relapses. Corticosteroid therapy, though valuable, is not disease modifying and is associated with considerable side effects and morbidity. Specific targeted therapy using monoclonal antibodies has been a most important advance in recent years, but the cost of such therapy continues to be prohibitive.

Cancers of the GI tract are the most common cancers in Europe and the US. Surveillance is recommended in Barrett's oesophagus, gastric atrophy, and inflammatory bowel disease. For Barrett's oesophagus, 3-5-yearly endoscopic surveillance is appropriate. The natural history of colorectal cancer justifies screening the general population or certain high-risk groups. The most widely accepted screening method is FOBT followed by colonoscopy if the FOBT is positive. In patients with excised adenomatous polyps, repeat colonoscopy is recommended in 3 years if high risk and 5 years if low risk. Surveillance is justifiable up to 75 years of age if there is no significant co-morbidity. Colonoscopic surveillance in inflammatory bowel disease starts 10 years from diagnosis for pancolitis and 15 years from diagnosis for left-sided colitis; thereafter every 3 years. Asymptomatic patients with strong family history of colorectal cancer should be referred to a clinical geneticist for risk assessment prior to colonoscopy screening.

Questions are not infrequently asked about the meaning of the motto displayed on the College Arms (see Figure 1). When a translation is offered –usually along the lines of “It is forbidden to be cruel” – there is often puzzlement about why a College of Physicians should have chosen such a phrase to embody its aims and aspirations. In this essay I discuss the motto’s relation to the couplet of Latin verse from which it derives and offer a possible explanation of how the misquotation – for such it is – that forms the motto may have come about. Then I say a little about the circumstances under which, some 2000 years ago, the Roman poet Ovid composed the poem which is its source. Finally, I show how consideration of an accurate text of Ovid’s whole original couplet offers an interpretation of the motto that was apposite at the time of the College’s foundation and is no less so more than three centuries later.

For the last nine years of his life Adolf Hitler, a lifelong hypochondriac had as his physician Dr Theodor Morell. Hitler's mood swings, Parkinson’s disease, gastro-intestinal symptoms, skin problems and steady decline until his suicide in 1945 are documented by reliable observers and historians, and in Morell’s diaries. The bizarre and unorthodox medications given to Hitler, often for undisclosed reasons, include topical cocaine, injected amphetamines, glucose, testosterone, estradiol, and corticosteriods. In addition, he was given a preparation made from a gun cleaner, a compound of strychnine and atropine, an extract of seminal vesicles, and numerous vitamins and ‘tonics’. It seems possible that some of Hitler’s behaviour, illnesses, and suffering can be attributed to his medical care. Whether he blindly accepted such unorthodox medications or demanded them is unclear.

The history of curare is both curious and convoluted. A product of South American culture it emerged in the sixteenth century from the mists of antiquity at the same time as quinine, coca, and chocolate. Like quinine, at first came the extract but no plant, and later the plant but no chemical compound. It took more than 300 years and the efforts of many explorers and scientists to resolve the problem. These included Condamine, Humboldt, Brodie,Waterton, Bernard, Dale,Walker, and King. Finally, the pure compound d-tubocurarine was isolated from the liana Chondrodendron and synthesised. Its specific physiological action was blockade of the effect of acetylcholine at the neuro-muscular junction. Such a paralytic poison could be used to kill oneself or others. The bizarre plot to kill the Prime Minister, Lloyd George, during the First World War is described. Fortunately this nefarious plan was thwarted by the Secret Service!