Scottish Medical Journal

Endogenous endophthalmitis is a sight-threatening condition caused by microorganisms crossing the blood–ocular barrier and inducing profound intraocular inflammation.

A 65-year-old female experienced bilateral loss of vision after developing infective endocarditis as a complication of combined Bentall procedure and coronary artery bypass grafting. She was diagnosed with bilateral endogenous endophthalmitis secondary to Serratia marcescens. Despite aggressive treatment with intravitreal injections of antibiotics and steroids, intensive topical and systemic antibiotic therapy, there was permanent loss of sight in both eyes.

The case highlights the importance of early recognition of the symptoms and signs of endogenous endophthalmitis in any patient with systemic infection by all clinicians and the necessity of prompt ophthalmological referral if a useful level of vision is to be preserved.

It is rare to see heart block as the first-and-only presentation of Lyme disease, the reported incidence being just 1% in untreated patients.

We report a patient who presented with syncope secondary to a fluctuating heart block. He had no previous manifestations of Lyme disease. Lyme carditis was suspected after the other usual etiologies of heart block were ruled out. Later, serologies came positive and patient’s heart block resolved on ceftriaxone therapy.

In at-risk individuals, clinicians should rule out this readily-treatable cause of heart block before proceeding with permanent pacemaker implantation due to enormous clinical and cost implications involved. Missing the diagnosis also exposes the patient to the risk of developing the late complications of Lyme disease. Diagnosis of isolated Lyme carditis is a challenge because the clinician does not have the diagnostic-clues that can usually be gleaned from the more common stigmata of Lyme disease.

To present an extremely rare case of sebaceous carcinoma arising in a mature cystic teratoma of the ovary.

A 66-year-old woman presented with abdominal discomfort and a pelvic mass. Abdominal and pelvic ultrasound, as well as CT scan, revealed a 27 cm complex right pelvic mass, which was diagnosed histologically as a sebaceous carcinoma arising in a mature cystic teratoma. The patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy, peritoneal washings, appendicectomy and infracolic omentectomy.

This case adds to the rare reports in the literature of sebaceous carcinoma occurring in a mature cystic teratoma. The clinical behaviour and optimal management of this entity are not well established. The patient has been well for 32 months following surgery with no evidence of recurrent disease clinically.

Prostate cancer is the commonest cancer in men and a major health issue worldwide. Screening for early disease has been available for many years, but there is still no national screening programme established in the United Kingdom.

To assess the latest evidence regarding prostate cancer screening and whether it meets the necessary requirements to be established as a national programme for all men.

Electronic databases and library catalogues were searched electronically and manual retrieval was performed. Only primary research results were used for the analysis.

In recent years, several important randomised controlled trials have produced varied outcomes. In Europe the largest study thus far concluded that screening reduced prostate cancer mortality by 20%. On the contrary, a large American trial found no reduction in mortality after 7–10 years follow-up. Most studies comment on the adverse effects of screening – principally those of overdiagnosis and subsequent overtreatment.

Further information about the natural history of prostate cancer and accuracy of screening is needed before a screening programme can be truly justified. In the interim, doctors and patients should discuss the risks, benefits and sequelae of taking part in voluntary screening for prostate cancer.

To determine whether angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) initiation in people with diabetes is monitored as recommended by recent guidelines and the incidence of associated adverse renal events.

Retrospective population database analysis of 4056 people in Tayside, Scotland with type 2 diabetes prescribed an ACEI/ARB between 1 January 2005 and 31 December 2009.

Measurement of urea and electrolytes (U&Es) before and after ACEI/ARB initiation and renal adverse events; defined as a ≥30% rise in serum creatinine and post-initiation potassium of ≥5.6 mmol/L. Associations of adverse events with patient demographics or co-prescription of drugs with known renal effects were examined.

Overall, 89% of initiations were with an ACE inhibitor. A total of 18.84% (CI 95% 18.82–18.86) of patients initiating ACE inhibitor or ARB had U&Es measured in the 90 days before initiation and within 5–14 days after initiation. Only 1.7% of patients had an adverse renal event. Patients prescribed with an ARB were less likely to be monitored than those prescribed with an ACE inhibitor, but no less likely to suffer harm.

Current clinical practice of biochemical monitoring of ACE inhibitor/ARB is poor, but adverse events are rare. Further studies with serial U&Es are needed to establish the critical time window for adverse renal events and evaluate whether intensive biochemical monitoring recommended is required in low-risk groups.

Implementation of an in-house polymerase chain reaction (PCR) multiplex assay by West of Scotland Specialist Virology Centre to improve sample processing means all viral eye swabs are now routinely tested for Adenovirus, Herpes simplex, Varicella and Chlamydia. Concern was raised regarding subsequent management and sexual health attendance for Chlamydia-positive patients identified in eye casualty.

A retrospective review of virology results identified 76 Chlamydia-positive patients from 1914 eye swabs (4%) from May 2007 to April 2008. Of these results, 12 originated from Glasgow eye casualty and available clinical notes were cross-referenced with the sexual health network (Sandyford).

Identified issues included no documentation of implications of testing, poor communication of positive results and poor referral pathways to sexual health for assessment; all leading to inadequate management. A shared care network was created to address these issues. A designated sexual health advisor was identified to improve sexual health referral, specialist assessment, standardised management and contact tracing. Re-audit showed more consistent follow-up.

New PCR technology has resulted in a shared care approach to address corresponding implications of testing. Effective communication with a structured protocol and a central point of contact has improved follow-up and ensures appropriate best practice management of chlamydial conjunctivitis.

Osteoid osteoma is a classically described benign bone tumour. Traditionally, the surgical treatment of choice was excision, but this can have significant morbidity. Percutaneous radiofrequency ablation (RFA) has grown in popularity as an alternative treatment. This study reports the outcomes using this technique in our regional bone tumour unit.

Between May 2003 and October 2007, 14 patients underwent CT-guided RFA. All patients were subsequently offered follow-up in the out-patient clinic. Outcomes were taken from the Scottish Bone Tumour Registry database.

Eleven patients (78.6%) had complete resolution of symptoms after one RFA. Three (21.4%) cases were unsuccessful but one of these was due to technical failure. All three of the above patients had complete relief of symptoms after one further RFA. One (7.1%) patient initially had complete relief of symptoms, but suffered recurrence after 9 months. This patient also had a second curative treatment.

Percutaneous RFA for osteoid osteoma is an attractive treatment due to its efficacy and low morbidity. Our results showed a primary success rate of 78.6%, a secondary success rate of 100% (after one additional procedure). Our results add to the growing literature supporting RFA as the preferred treatment for osteoid osteoma.

The incidence of uterine carcinosarcoma and factors associated with its survival are little known and this study helps to address this question for women residing in north-east Scotland.

Data were collected from women diagnosed with carcinosarcoma of the uterus residing in north-east of Scotland from 1991 to 2009. Kaplan–Meier plots and Cox regression analysis were used for analysis. A total of 43 women were analysed during this period. The median survival was 25 months. The estimated five-year survival for stage I/II disease was 52.5% (95% CI: 30.5–74.5%). The 2-year survival rate for stage III/IV disease was 46% (95% CI: 16–75%). There was an increase in the incidence during this period. Improved survival was seen in early-stage disease (FIGO stages I and II) and in the absence of lymphovascular space invasion (LVSI; p = 0.015). A total of 26% of the women had a history of tamoxifen usage with no effect seen on survival. Multivariate analysis showed that when treatment modality and LVSI were adjusted for FIGO staging, there was no statistical significance in the survival outcomes.

The incidence of uterine carcinosarcomas is increasing parallel with endometrial carcinomas with no significant effect of tamoxifen on survival.

The Scottish Bowel Screening Programme aims to detect cancer in asymptomatic individuals. We aimed to measure the prevalence of lower gastrointestinal symptoms in faecal occult blood (FOB) screen-positive patients, to correlate the symptoms with neoplasia and to compare the predictive value of FOB screening with urgent symptomatic referrals in Ayrshire and Arran.

Data were collected prospectively on FOB screen-positive patients undergoing colonoscopy. Patients completed a symptom questionnaire. Positive predictive values (PPVs) for detecting neoplasia were calculated and a chi-square test was performed to determine any influence of symptoms in diagnosing neoplasia. Symptomatic patients undergoing colonoscopy via a general practice fast-track system were compared.

A total of 378 FOB screen-positive patients were included. In all, 198 (52%) had colorectal symptoms. Overall, 32 were diagnosed with colorectal cancer and 93 had polyps . FOB positivity and symptoms gave a PPV of 34% for neoplasia. FOB positivity without symptoms gave a PPV of 32% for neoplasia. Urgent referral of symptomatic patients had a lower PPV of 21% for neoplasia (p < 0.001).

Half the FOB screen-positive patients had bowel symptoms. Symptoms in these patients had no correlation with an increased rate of neoplasia. The PPV for neoplasia is superior in symptomatic and asymptomatic screen-positive patients when compared to conventional urgent symptom-based referral.

The abuse of illicit substances is very common amongst forensic psychiatry populations and is known to be one of the most potent risk factors for interpersonal violence. Forensic psychiatry units hence strive to keep themselves as free as possible from illicit substances and in Scotland drugs of abuse have traditionally been screened for by means of urine testing. The aim of this study is to examine patients’ preferences for drug testing methods and to compare the acceptability of urine testing versus oral fluid testing (OFT) within a secure hospital setting.

Patients in three continuing care wards at the State Hospital, Carstairs were offered the choice of either urine or oral fluid testing. We developed protocols and recording forms and trained staff in the administration of the OFT. We recorded the sampling time for OFT and urine, and the views of patients and staff on the testing procedures over a six month period.

Sixty-two samples were taken, with 53 (85%) opting for OFT and nine (15%) opting for urine sampling. The average time taken for OFT was 13 minutes, while the average time taken for urine sampling was 33 minutes. The majority of patients and staff rated oral fluid and urine testing as comfortable and easy. Patients recorded comments on 46 (87%) of OFT samples, only two of which were negative. In general they preferred the OFT because it was quicker and easier and they commented on it being more dignified and private. Patients recorded comments on five (55%) of urine samples, with one of the primary reasons for opting for urine sampling appearing to be a reluctance to try new things, though a few said they did not want to have anything in their mouths. Staff returned comments on 24 (45%) of OFT samples and one (11%) of urine samples. Comments on the OFT were overwhelmingly positive and pointed out the relative speed and ease of this sampling method.

We concluded that the pilot study was successful. OFT was found to be generally preferred by patients and staff. Although there was an additional financial cost, this was considered to be outweighed by the significant benefits arising from offering patients choice, the preservation of patient dignity and staff time savings. The option of OFT has now been extended to all patients within the State Hospital. Practitioners will wish to consider the value of OFT in forensic psychiatry inpatient settings given the benefits identified within this study.

Rates of re-operation, which may be related to an unsatisfactory surgical outcome, can provide a long-term index of the quality of strabismus surgery. This study aims to evaluate the utility of the Scottish Morbidity Records (SMR1) in determining nature and rates of re-operation for strabismus at the Royal Hospital for Sick Children (RHSC), Glasgow.

SMR1 data on strabismus surgery performed on children aged between 0 and 17 years at the RHSC, Glasgow, between January 2000 and March 2009 were analysed.

In total, 1376 strabismus procedures were carried out on 1274 individuals. The median time between first and subsequent procedures was 19 months; the commonest reasons being under-correction or recurrence. The Kaplan–Meier rate of undergoing re-operation was 7.4% after 9 years with a 95% confidence interval of 5.4–9.9%.

The SMR1 is a useful source of hospital-based and population data. With supplementation from parallel databases, routine administrative databases like the SMR1 can provide better quality data to inform practice.

Coding of patients' diagnosis and surgical procedures is subject to error levels of up to 40% with consequences on distribution of resources and financial recompense. Our aim was to explore and address reasons behind coding errors of shoulder diagnosis and surgical procedures and to evaluate a potential solution.

A retrospective review of 100 patients who had undergone surgery was carried out. Coding errors were identified and the reasons explored. A coding proforma was designed to address these errors and was prospectively evaluated for 100 patients. The financial implications were also considered.

Retrospective analysis revealed the correct primary diagnosis was assigned in 54 patients (54%) had an entirely correct diagnosis, and only 7 (7%) patients had a correct procedure code assigned. Coders identified indistinct clinical notes and poor clarity of procedure codes as reasons for errors. The proforma was significantly more likely to assign the correct diagnosis (odds ratio 18.2, p < 0.0001) and the correct procedure code (odds ratio 310.0, p < 0.0001). Using the proforma resulted in a £28,562 increase in revenue for the 100 patients evaluated relative to the income generated from the coding department.

High error levels for coding are due to misinterpretation of notes and ambiguity of procedure codes. This can be addressed by allowing surgeons to assign the diagnosis and procedure using a simplified list that is passed directly to coding.

CT coronary angiography (CTCA) is an emerging diagnostic tool in the assessment of patients with suspected coronary artery disease. It has several advantages over conventional coronary angiography (CCA); however, its use is not yet widespread in large teaching centres.

To determine what proportion of patients who have CTCA, do not require subsequent CCA.

A prospective analysis of all patients referred for CTCA from the start of the service in January 2008 to April 2010.

CTCA provided definitive diagnostic images in 85% of patients. Overall only 12% (n = 33) of patients had subsequent CCA. The proportion of patients who subsequently had CCA reduced with time reflecting increasing confidence with the clinical service.

A CTCA service can be successfully established out with a large teaching centre hospital. Close working between cardiologists and radiologists leads to increased confidence in the service and obviates the need for CCA in a large proportion of patients.

A systematic review of the literature is presented with regard to urological complications resulting from inguinal hernia surgery. Considering the amount of inguinal hernia operations performed, the resulting complications, which may be urological in presentation, have potential late irreversible and medico-legal implications.

A Pubmed search of ‘urological’ ‘complications’ and ‘inguinal hernia surgery’ was carried out and clinical practice was also taken into consideration.

Approximately 75% of hernias occur in the groin; two-third of these are indirect and about one-third direct. Most of these repairs are carried out by the general surgeons and any complication, including urological, are often initially managed by the operating general surgeon. Often a urological opinion is sought late for conditions which may be reversible. We present potential urological complications, their presenting features and management.

Recognition, timely referral and appropriate treatment of urological complications after hernia surgery are necessary to avoid potential consequences and long-term morbidity.