Journal of the Royal College of Physicians of Edinburgh

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.

Objectives: Identify the risk factors and the clinical impact of ARF in patients with severe falciparum malaria.

Method: Intensive care unit cases of severe falciparum malaria of Sarawak General Hospital were analysed.

Results: Out of 40 cases of severe falciparum malaria, 19 developed ARF. Patients with ARF were older (p=0·030), had higher AST (p=0·014), higher unconjugated bilirubin (p=0·041), and lower globulin (p=0·015). Aspartate transaminase level positively correlated with creatinine and urea level (log AST and urea: r=0·464, p=0·004; log AST and log creatinine: r=0·430, p=0·008); while unconjugated bilirubin level positively correlated with creatinine level with geometric transformation (r=0·402, p=0·020). Patients with ARF have higher mortality (p=0·004),and more failing organs (p = 0·0003). Patients with ARF that died had a higher number of organs failing compared with those that survived (p=0·043). Among patients with total parasite count of >300,000/µL, those patients treated with dialysis, haemofiltration or exchange transfusion developed less organ failure (p=0·050). Logistic regression with adjustment for age and malarial complications identified ARF to be the major predictor of mortality.

Conclusions: 1) Patients with severe falciparum malaria who developed ARF have higher rate of haemolysis, more organs failing and higher mortality rate. 2) Dialysis, haemofiltration or exchange transfusion may reduced the rate of organ failure among patients with parasite count >300000/µL.

We describe a 71-year-old lady with end-stage renal failure on haemodialysis who developed vertebral discitis due to MRSA. She was intolerant of glycopeptide antibiotics and was treated successfully with oral linezolid for four weeks followed by oral combination therapy with doxycycline and fusidic acid for two weeks. Her antibiotic management and her clinical course is described, and we discuss the usefulness of the above antibiotics to treat MRSA infections affecting bone and vertebral discs in patients with renal failure.

An initially diagnosed actinomycotic brain abscess was reclassified to Campylobacter gracilis. Structural similarities between Gram-positive anaerobes highlight the diagnostic difficulties in identifying brain abscess-causing organisms. Advances in microbial identification have led to new species and genera recognition and reclassification of existing taxa. Awareness of these is necessary in order to understand the role of newly-described/reclassified organisms in disease processes.

The majority of the approximately 100,000 sudden cardiac deaths each year in the UK are associated with coronary heart disease, but most sudden deaths in those under 30 years of age are caused by inherited cardiomyopathies and arrhythmias. In those aged 16–64 years, a coroner's post mortem examination is unable to identify a structural cardiac abnormality in 4·0%. The cause of death is therefore uncertain. These deaths are termed ‘sudden arrhythmic death syndrome’ or ‘sudden unexpected death syndrome’.

Recently there has been a lot of interest in the medical and lay press concerning exposure to mercury and its potential toxic effects. Mercury is a naturally occurring metallic element, which can be found as Hg or inorganic and organic salts. In this article we will review the risks of exposure and toxicity of each of the forms of mercury, including some of the current guidance concerning the risks of mercury toxicity from eating fish, dental amalgam and vaccinations containing mercury (thiomersal) preservatives.

Within the last three years there has been considerable comment and discussion, especially in electronic online forums, regarding the appropriateness of including political commentary in medical journals. Given the mandates of representative journals, and the direct impact politics can have on the health of populations, it is appropriate that politically related commentaries be included in medical journals. However, these commentaries should adhere to five criteria: the issue should be discussed in terms of its impact on health; any challenges based in ethical principles should use the relevant ethics code; if challenging the actual ethics of a group, the standard should be one that is globally accepted; all defamatory comments should be excluded; and journals should not participate in academic boycotts. Given adherence to these criteria, medical journals can expand their continued impact on health-related topics, without moving beyond their mandates.

The term ‘acute coronary syndrome’ encompasses STEMI,NSTEMI, and UA. The electrocardiogram identifies those with STEMI. An elevated troponin level measured at least 12 hours after the onset of pain distinguishes NSTEMI from UA. However, the separation of NSTEMI and UA is somewhat artificial, as the management of individual patients is based on their risk score, with troponin being only a small part of the equation. Patients at moderate to high risk of death, MI, or subsequent admission to hospital should be offered early coronary arteriography with a view to revascularisation. The CLARITY and COMMIT studies, when added to the CURE study, support the early use of clopidogrel in all patients with ACS, irrespective of age.

‘Device therapy’ refers to the use of implantable electronic devices to improve cardiac rhythm and function. Permanent pacemakers, initially developed in the 1960s to prevent bradycardia in patients with sinus node disease and atrioventricular block, represented the first wave of implantable devices that transformed cardiology practice. These devices are now commonplace, and advances in microprocessor and battery cell technology mean that pacemakers are small and highly programmable to patients’ individual requirements. Since then, this same technological revolution has led to the development of other implantable devices used in the treatment of patients with life-threatening ventricular tachyarrhythmias and with heart failure. The main focus of this article will be on these new advances in device therapy

European and American guidelines were published in 2005 that comprehensively summarised the evidence supporting currently recommended diagnostic and therapeutic approaches in HF. The need for these updates reflects the continuing progress in the management of this condition. In this article we briefly overview the current evidence-based treatment of HF. We focus on patients with reduced left ventricular systolic function, as there is no firmly evidence-based treatment for HF with preserved systolic function. Our review discusses treatments shown to favourably modify the natural history of HF when added to diuretic treatment. Diuretics should be used, as needed, to prevent sodium and water retention that can lead to peripheral and pulmonary oedema. Although diuretic treatment is empirical rather than evidence-based, it is widely agreed that the minimum dose needed to maintain ‘dry weight’ should be used.

Inborn errors of metabolism are genetically determined interruptions of one (or several related) metabolic pathway(s). Clinical symptoms are caused by deficiency of the pathway product and/or toxicity resulting from the accumulation of an intermediary compound. Inborn errors of metabolism are mostly recessive disorders, with clinical symptoms rare in heterozygous individuals. The genetic defects involve homozygous (autosomal) or hemizygous (X-linked) mutations in genes encoding proteins with a single enzymatic function. However, interruptions in biochemical pathways may also result from mutations affecting the bioavailability of an enzymatic co-factor or disordered transport of the enzyme across intracellular membranes. In the latter two circumstances it is likely that more than one enzymatic process will be affected.

The five main modes of presentation of IEM in the neonatal period are acute intoxication, energy deficiency, organomegaly, profound central hypotonia, and malformations. The common diagnoses in each of these groups will be presented, with brief descriptions of the currently available options for diagnosis and therapy.

The timing of carotid endarterectomy in patients with symptomatic carotid stenosis is vital if it is to provide maximum benefit to patients. Throughout Scotland there are delays in referring patients to neurovascular clinics and on to surgery, where indicated. Evidence suggests that in those patients with symptomatic carotid stenosis, greater than 70%, surgery should ideally be performed within two weeks. In order to reduce delays to surgery (where appropriate) there needs to be an improvement in the organisation of services so that rapid assessment of high-risk patients can be made.

It is agreed that all patients with insulin-treated diabetes should regularly self-monitor their blood glucose to guide insulin doses and detect and avoid hypoglycaemia, but there remains little consensus as to the value of SBGM in patients with type 2 diabetes treated with diet and/or tablets. This Royal College of Physicians of Edinburgh mini-symposium brought together a panel of experts to examine the current evidence surrounding SBGM in this context. The aim of this document is to provide an overview of the points raised and where consensus was achieved. The document summarises the general situations where SBGM may or may not be useful, and it is hoped that this will be a platform for production of specific guidelines for healthcare professionals to use to advise a monitoring programme for an individual patient. These recommendations include results of evidence published since November 2004.

There is increasing public awareness of the rising incidence of obesity in childhood and adolescence, and its consequences for long-term health – type 2 diabetes, cardiovascular disease and cancer. This year’s symposium meeting focused on epidemiology, management and mechanisms of obesity. The trends in obesity in children and adolescence, at both a global and national level were reviewed. The UK House of Commons Select Committee’s report on obesity suggests that obesity ‘will soon surpass smoking as the greatest cause of premature loss of life’. If we can understand the cause we can potentially make an impact on future healthcare. The review covered primary prevention, early intervention and management of the significantly obese. People want to understand why they are overweight and what impact obesity will have on their health. Rare monogenic causes of severe obesity give insight into central mechanisms underlying weight control. Hormones are intrinsically linked with obesity, but do not provide the easy solution hoped for by many. A discussion around three case studies concluded the symposium.

The plant family Solanaceae contains important foodstuffs such as the potato, tomato and aubergine, together with powerful poisons including mandrake, henbane and deadly nightshade. In the first article in this short series on the family, the history and importance of the potato are described. It was first cultivated by the Inca people in the altiplano of the Andes in prehistoric times. Then it was translocated to Europe by the Spanish invaders. Originally reviled as ‘peasant food’, it was regarded with great suspicion as an evil plant and a potential cause of leprosy. Over several centuries it gradually became established throughout Britain, France and the continent, and in particular in Ireland, where its growth allowed the population to expand very rapidly between 1750 and 1850. In the late 1840s, nemesis arrived in the form of the potato blight and the Irish famine. The ‘tatties’ went black, a great hunger ensued and thousands died. Later, the causative fungus was isolated and steps were taken to avoid further similar disasters.

It is not generally appreciated that potatoes can be poisonous if they are turning green or sprouting (chitting). The tuber is then producing toxic quantities of the alkaloid a-solanine. The clinical syndrome of potato poisoning is described briefly.

William Henderson was appointed professor of general pathology at Edinburgh University and physician-in-ordinary to the ERI. He produced several papers on clinical and pathological aspects of aortic and heart disease and contributed to the differentiation of typhus and typhoid fevers. He became a homeopathist and was at the centre of a controversy surrounding the introduction of homeopathy to Edinburgh in the 1840s. This involved the Faculty of Medicine, the RCPE and medical societies as well as medical personalities, prominent among whom were Professor Sir James Y Simpson, Professor Sir Robert Christison and Professor James Syme. Many Scottish medical graduates were involved in the introduction of homeopathy to the British Isles. Glasgow is one of only four UK cities still to have a homeopathic hospital.

Scottish physician Dugald Christie commenced practice in the city of Mukden (Shenyang) in Manchuria in 1883. In 1911, he founded the Mukden Medical College, the first Western medical school in Manchuria. Edinburghtrained physicians and surgeons largely staffed the college and in 1934 it became the first foreign university to have its medical degree recognised by the University of Edinburgh. It was merged into the China Medical University (Zhongguo yi ke da xue) in 1949. During its separate existence the Mukden Medical College brought modern medicine and medical education to northeastern China, and its legacy continues to influence both medical practice and medical education in China.

Although one group of drugs (including amyl nitrite and glyceryl tinitrate) has been used in the treatment of angina for over 100 years, the mode of action became clear only after the endothelium-derived relaxing factor had been identified as nitric oxide in 1987. Originally sodium nitrite was included in this group of drugs but it rapidly fell out of favour. Recently, however, interest in its therapeutic use has been revived. The medical uses of saltpetre (potassium nitrate) may be due to the presence of nitrite as an impurity.