Scottish Medical Journal

Increased availability of routine investigations results in significant over-investigation, burdening patients with unnecessary tests as well as increasing cost. We aimed to identify the extent of monitoring of liver function tests in lung resections, and to ascertain whether any impact on clinical decision-making occurred.

Cases were identified using theatre records coded as “lobectomy/bilobectomy” in the three-month period 20 June 2017 to 20 September 2017. Electronic records were used to collect patient data.

A total of 91 cases were included; 77 (85%) patients had 1 set of pre-operative LFTs, 12 (13%) patients had 2 sets, and 2 (2%) patients had 0 sets; 69 (76%) had normal LFTs pre-operatively; 298 sets of LFTs were measured post-operatively, with a median of 3 sets per patient; 61 (67%) patients had either normal or static LFTs post-operatively, 13 (14%) had isolated rise in GGT, 16 (17%) had derangement of ALT and AST, and 1 patient (1%) had deranged ALP. Altered clinical decision-making due to LFTs derangement was recorded in two cases (2%).

Clinicians have an obligation to justify expense, and practise in a cost-effective manner. Our data suggest that the routine perioperative monitoring of LFTs in thoracic surgery does not give any clear benefit to patient care.

Much has been written about the use of the Mental Health Act in psychiatric settings. There is, however, little written on its use to detain patients with mental disorder in general hospitals.

We therefore carried out a survey of the use of the Mental Health Act in general hospital settings in Aberdeen, and also posted a questionnaire to Scottish Liaison Psychiatrists, asking about their experience of the use of the Mental Health Act in general hospitals. Over a six-month period in Aberdeen Royal Infirmary, we identified 39 detentions. Out of hours, the use of Emergency Detention Certificates was more common than use of Short Term Detention Certificates – the latter is recommended by the Mental Welfare Commission, as patients are afforded more rights. When psychiatric staff were not directly involved, procedural and administrative errors were more likely to occur. Liaison psychiatrists elsewhere in Scotland reported similar observations.

General hospital clinicians are unfamiliar with the Mental Health Act and its use. Errors in its application therefore arise, and are more common when psychiatric staff is not involved. Better education, including the provision of written information and consideration of an electronic system, may improve current practice.

Reduction of benzodiazepines and non-benzodiazepine hypnotics (BZDs and Z-drugs) prescribing is a priority. Dundee, Scotland, has a total of 25 general practices, split into four clusters. The cluster with the highest recorded prescribing of BZDs and Z-drugs adopted a prescribing protocol that aimed to reduce such prescribing. This paper evaluates the impact of this protocol.

Quarterly prescribing data were obtained from Information Service Division, NHS Scotland from Q1 2015/16 to Q4 2017/18. Data were split into four clusters and standardised to Defined Daily Dose (DDDs) per 1000 registered patients. Interrupted time series (ITS) analysis was performed to assess prescribing one year after this protocol was introduced.

There was a crude reduction in prescribing of BZDs and Z-drugs across all GP practice clusters, but this related to an ongoing downward trend in prescribing. Allowing for this, in the cluster that adopted the protocol, ITS revealed there was no significant reduction attributable to the intervention in prescribing of DDD equivalent doses (−0.4%, 95% CI: −7.2 to 7.6).

Introduction of a cluster-wide prescribing protocol did not provide significant reduction of prescribing. Although crude figures might suggest an improvement, ITS analysis revealed this not to be the case.

Duplication of gallbladder is a rare congenital condition. We describe a patient who underwent robotic cholecystectomy for duplicated gallbladder with symptomatic gallstones.

Surgeons performing cholecystectomies must be aware of duplicated gallbladders and robotic cholecystectomy is a feasible option for such patients.

Coeliac crisis is a life-threatening presentation of coeliac disease. Severe diarrhoea, weight loss, electrolyte imbalances and malnutrition are prominent features. Although mainly a disease of childhood, it can on the rare occasion be diagnosed in adults.

A 25-year-old female with severe generalised oedema, lower extremity weakness, hypokalemia and profound hypoalbuminemia was referred with an initial diagnosis of nephrotic syndrome. Three months previously she had given birth to a healthy child following an uneventful pregnancy. She did not have proteinuria. She had a history of diarrhoea with gluten-containing food since childhood but lacked a formal diagnosis of coeliac disease. A duodenal biopsy confirmed the suspected diagnosis. Coeliac crisis was diagnosed with life-threatening multisystem involvement. Introduction of a gluten-free diet abolished all disease symptoms and ameliorated laboratory parameters at six months’ follow-up.

Coeliac crisis is a rare, yet dangerous presentation of coeliac disease in adults. As this case suggests, it can present with generalised oedema and hypoalbuminemia mimicking nephrotic syndrome. Rapid diagnosis is the key to successful treatment.

Isolated acquired Factor VII deficiency is a rare coagulation disorder which is independent of vitamin K deficiency. The exact pathophysiological basis of this condition is unclear. We present a series of cases highlighting different clinical scenarios where this condition was encountered.

The first case presented with intra-abdominal sepsis. The second was a patient admitted with acute kidney injury and subsequently diagnosed with myeloma. The final case presented with microangiopathic haemolytic anaemia and was suspected of having atypical Haemolytic Uraemic Syndrome. In each case, there was no family or personal history of a bleeding disorder. Follow-up Factor VII levels after recovery from illness was normal in all three cases.

Acquired Factor VII deficiency is an uncommon but important finding which should be considered in the general medical setting when an isolated prolonged prothrombin time is detected.