Scottish Medical Journal

Background: Secondary prevention of coronary artery disease is effective in reducing morbitiy and mortality. Our aim was to assess lipid management following non-attendance to a hospital based secondary prevention clinic Methods: Data were collected over 5 years on statin usage and total cholesterol levels for patients with coronary artery disease following attendance at a cardiac nurse led outpatient clinic. Lipid levels were taken from a central laboratory database, for both patients discharged from clinic and non-attenders. Results: From 935 inpatients discharged from hospital, 248 (29%) defaulted from outpatient follow up. Lipid lowering drug usage was similar (72% vs. 74% for non-attenders, p=NS). Attenders at the nurse led outpatient clinic were more likely to achieve a total cholesterol <5mmol/L at discharge than non-attenders (70% vs. 43%;p<0.001), with a lower mean total cholesterol (4.75 ± 0.06 mmol/L vs. 5.33±0.08 mmol/L; p<0.001). Non-attenders subsequently had a greater number of cholesterol measurements than those who were discharged from the hospital based clinic (range 0–12, c2 23.8 on 12df, p<0.05). Lipid profiles in hospital non-attenders remained inferior with fewer achieving a total cholesterol <5mmol/L (61% vs. 78%; p<0.001), and having greater mean total cholesterol levels (4.85 ± 0.06 mmol/L vs. 4.52 ± 0.05 mmol/L; p< 0.001). Conclusions: Patients defaulting from hospital follow up have higher total cholesterols with fewer at target level compared to attenders. Though non-attenders receive subsequent lipid measurement, inferior lipid profiles persist compared to patients who completed hospital follow up to be discharged. Further implementation strategies are needed with regard to lipid management in this patient group.

Background: The role of the ‘clicky hip’ symptom as a prognostic predictor of developmental dysplasia of hip (DDH) is controversial. We aim to study the role of isolated hip clicks as a prognostic predictor of DDH. Material and methods: 235 babits with persisting or referred with clicky hip beyond six weeks of age were prospectively followed up to note the incidence of DDH. Of these 176 babies were referred for a hip click without additional risk factors. Results: 7 out of 176 cases (4 - IIa, 2 - IIb, 1 - IIc) had initial abnormal ultrasound examination based on Graf classification. However, all babies with isolated hip clicks eventually had normal hips on clinical and radiographic examination. Discussion: While screening of babies with clicky hips does help in diagnosing the odd case of DDH this is not consistently reproducible. Modifying the targeted ultrasound screening by including clicky hip as a risk factor will not reduce the incidence of missed cases. Isolated clicks in the hip joint beyond six weeks age are rarely a predictor of DDH. However when in doubt such cases should be referred to be reviewed by an orthopaedic surgeon or a radiologist experienced in hip ultrasound.

Aims: This study assessed the patterns of weight change in response to surgical treatment for obesity. Methods: Vertical Banded Gastroplication (VBG) was performed during the period 1994–2000. Patients were required to follow a liquid diet (8oo kcals) for 12 weeks before surgery. The same diet plus a multivitamin capsule (Forceval) was followed for 12 weeks postoperatively, after which normal foods were introduced. Data from 23 patients, 16 women and 7 men, aged 33–63 years (mean, SD; 42±8yrs), with BMI from 38 to 69 kg/m2 (52.5 ± 8.1 kg/m2) at the time of the surgery were available for analysis. Follow up was 3 to 7 years (mean 4 years). Results: An initial weight loss of 44.4 ± 24.3 kg (min 11.5, max 110.5 kg) was reached during the first two years (mean BMI decrease 15.8 kg/m2). However a regain in weight (36% of the initial weight loss = 5.6 kg/m2) up to 3 to 7 years after surgery was usual. Average annual regain was 13.6 kg (n=17), 9.45 kg (n=11) and 0.8 kg (n=8) during the 3rd, 4th and 5th year after surgery). Five participants reached a BMI below 30 but only one, BMI<25, has maintained all the weight loss after 5 years. Conclusions: Weight loss following VBG ceased after two years with a subsequent substantial weight regain. Auxiliary therapies to counteract weight regain are necessary after VBG.

Background and Aims: The high prevalence of smoking in disadvantaged communities gives serious cause for concern in terms of adverse effects on health and social outcomes. In Scotland, smoking—related lung cancer rates are particularly high and compare less favourably with the rest of the UK and Europe. GPs are increasingly being recognised as having an important role in smoking cessation and are allowed to prescribe NRT to those on a low income. This study aimed to follow up a group patients from a disadvantaged area who had been prescribed nicotine patches by their GP. Methods: An initial self-complete questionnaire gathered details on age, sex, motivation, marital status, employment history, contact with other smokers, concern about weight gain, and nicotine dependence. (Nicotine dependence was assessed by using the Tagerstrom Test). Follow up was carried out at three months after commencing NRT prescription. Data was also gathered from patient case notes as to whether the participant had a smoking-related diagnosis, periods of depression, drug and/or alcohol problems. Outcome was measured in terms of “smoke the same”, “smoke less” and “stopped”. The statistical methods used for testing each factor against smoking were Spearman rank correlation, chi-squared test for trend and Kruskal-Wallis test. Basic descriptive statistics were used to report general outcomes of the study. Results: The study enrolled 120 patients but 19 were lost to follow up. Out of 101 who used their prescription, 35 were smoking the same, 46 were smoking less and 20 had stopped. The variables most strongly affecting outcome were age, with older smokers having more success (p<0.001), and those who had a diagnosis of depression having a worse outcome in terms of smoking cessation (p<0.05). Conclusion: This study's findings indicate that encouraging GPs to take a proactive approach in prescribing NRT is effective, even in an area of socio-economic deprivation, and particularly with older smokers.

Background: We aimed to study the timing of aspirin prescription in ischaemic stroke comparing patients admitted to an acute stroke unit (ASU) directly or via a general medical ward. We also analysed prescription of secondary preventive therapies in stroke patients in an ASU. Methods: Retrospective analysis was made of medical notes and prescription records of 69 patients admitted to an ASU over a three month period to establish timing of aspirin prescription with respect to onset of stroke symptoms, CT brain scan and route of admission to the ASU. Results: CT brain scans were obtained at a median of 2.1 days post stroke (IQ range 1.3–4.3). Patients directly admitted to the ASU received aspirin earlier post admission compared to those admitted via a medical ward (0.7 vs 2.2 days, p<0.01) and were also more likely to receive aspirin prior to CT scan being performed (57% vs 19%, p=0.02). 86% of stroke patients were discharged on an antiplatelet therapy, 79% on a statin, 37% on a thiazide diuretic and 32% on an ACE inhibitor or angiotensin II antagonist. Conclusion: Aspirin was given more promptly in acute stroke and more commonly prior to CT scanning in an ASU compared to a medical ward. Statin therapy is used extensively in stroke but there is a much lower rate of initiation of other secondary preventive therapies (e.g. anti-hypertensive therapy) in hospital. These findings demonstrate a hesitancy in early use of aspirin amongst general physicians and lends support for the use of stroke units.

Background: The World Health Organisation cites a sedentary lifestyle as one of the top ten causes of morbidity and mortality worldwide.4 A recent, large-scale clinical study showed that brisk walking and vigorous exercise are associated with substantial (and similar) reductions in the incidence of coronary heart disease,6 Current guidelines suggest 10,000 steps per day as an appropriate activity target for healthy adults.7 Aims: This study aims to assess whether doctors are meeting this daily walking target during working-hours, and whether additional out-of-hours exercise is required. Methods: 16 doctors from St. John's Hospital in Livingston (comprising 4 Medical Consultants, 4 Surgical Consultants, 4 Medical PRHOs and 4 Surgical PRHOs) each used a belt-worn pedometer to record all steps made during 5 consecutive day shifts. Stride length and total daily steps were recorded. Steps made out-with working hours were not counted. Total steps and hours worked were recorded at the end of each day. Results: Average daily steps recorded were 7907 (Medical PRHOs), 5068 (Surgical PRHOs), 4822 (Surgical Consultants) and 4647 (Medical Consultants). P values of <0.1 were obtained for the variation in steps between the Medical PRHOs and both the Consultant Surgeons and Consultant Physicians. Distance walked per shift varied from 3.84 (Consultant Physicians) to 6.85 kilometres (Medical PRHOs). Conclusion: Walking at work does provide a substantial proportion of a doctor's recommended daily activity quota. However, it is still necessary to engage in additional, out-of-hours exercise in order to consistently meet the current recommendations for physical exercise.

Background and aims: Patients attending Accident and Emergency (A&E) on a frequent basis consume a large amount of NHS resources and often frustrate health workers employed in the service. This audit aimed to identify the personal and psychiatric characteristics of these patients and highlight areas where intervention may be helpful. Method and results: Patients presenting to A&E more than 20 times in four years were comparison to non-frequent attenders using case register information. The study demonstrates that frequent attenders are well known to psychiatric services, but are not engaged in ongoing contact. This is not due to a difference in attendance rate between frequent attenders and controls but may represent reluctance for follow up either on the part of the patient or the psychiatrist. Conclusions: These patients have a combination of physical, psychiatric and social pathologies and the services to address these needs does not seem to currently exist but should be considered.

Aim: To assess the extent to which prescribing of cardiovascular medications in a busy medical unit deviates from the local joint primary and secondary care drug formulary guidelines. Method: A retro spective audit of the case notes, prescription charts and discharge summaries oj 150 randomly selected emergency medical admissions overa 4 month period. Results: No patient receiving a non-formulary cardiovascular drug on admission had the choice reviewed in line with formulary recommendations. One third of new cardiovascular medications commenced in hospital were not compliant with formulary recommendations. Decisions about drug therapy were rarely justified in the written hospital record. Conclusions: Our results demonstrate that in a busy acute medical admissions' unit there is a clear jailure to amendor query non formulary prescribing at the time of admission and a tendency to exacerbate it during theinpatient period. This potentially undermines the purpose of a joint drug formulary as a guideline for safe, evidence-based and cost-effective prescribing.

A five year old girl with Neimann-Pick disease type C subsequently developed Crohn's Disease. This association has only been presented once previously in the literature. This report discusses the options for managing one chronic disease in the presence of another life limiting condition.