Journal of the Royal College of Physicians of Edinburgh

Lwin, AA; Lohani, S

doi: 10.4997/jrcpe.2010.405pmid: 21132136

We present a case of a young man with Lemierre’s syndrome characterised by suppurative thrombophlebitis of the internal jugular vein and multiple septic embolic lesions with cavitations in both lungs resulting from an infected branchial cyst which was previously undiagnosed. Lemierre’s syndrome is a rare presentation, especially with pulmonary cavitations, but remains a serious illness with a high mortality rate. Early recognition and prompt treatment have significant impact on prognosis. We believe this to be the first case of Lemierre’s syndrome complicated by a previously undiagnosed, infected branchial cyst.

Abbas, A; Raju, J; Milles, J; Ramachandran, S

doi: 10.4997/jrcpe.2010.406pmid: 21132137

Circadian rhythm sleep disorders are poorly understood and often misdiagnosed. They are all related to the timing of sleep within the 24-hour day. This paper describes a patient with a long history of sleep disturbance whom we diagnosed as having delayed sleep phase syndrome by history and measurement of urinary melatonin metabolite excretion. Literature on the characteristics, diagnosis and management of this syndrome are briefly reviewed. In addition, the relation of the neurohormone melatonin to circadian rhythm and its other physiological roles are described.

Ghosh, S; Jones, M; Swaminathan, K

doi: 10.4997/jrcpe.2010.407pmid: 21132138

Incidentally discovered adrenal masses (adrenal incidentalomas) found during radiological procedures are a by-product of modern-day medicine. Incidental findings of such adrenal masses pose uncertainties and dilemmas in evaluation and management. There is a paucity of comprehensive guidelines from professional societies, and current recommendations (based on expert opinions and the US National Institutes of Health statement, 2002) are open to debate with regards to cost and clinical benefit. We report two patients with ‘adrenal incidentalomas’ with different outcomes during the course of evaluation. We conclude with a simple guide to the evaluation and management of such masses based on the available literature.

Toms, AP

doi: 10.4997/jrcpe.2010.414pmid: 21132139

Bhatnagar, D

doi: 10.4997/jrcpe.2010.424pmid: 21132140

Lane, M

doi: 10.4997/jrcpe.2010.425pmid: 21132141

Jahangiri, M; Kappetein, AP; van Geldorp, M; Bogers, AJ

doi: 10.4997/jrcpe.2010.412pmid: 21132142

The shifting age demographic of the adult population has affected every area of contemporary medical and surgical practice. Many more people are living well, not just into their 70s but into their 80s and beyond. Their expectations of treatment for every illness have shifted markedly upwards at the same time. Despite the decline in cases of rheumatic fever in Westernised populations in recent times, the ageing population has led to no decline in the prevalence of valvular aortic stenosis. This is now realised to be an active pro-inflammatory disease, rather than a degenerative process. Thus the condition has remained in the mainstream and continues to be responsible for considerable morbidity, hospitalisation and mortality among the elderly and very elderly.Management has always been based on the triage of cases for direct intervention to the valve by surgery. Just as expectations have risen from patients, the techniques, application and monitoring of cardiac surgery have also made huge strides forward to meet this aspiration. More and more, surgeons are routinely asked to consider procedures in frailer, more elderly patients with more severe disease and co-morbidity. Managing the stenosis is rarely the only issue confronting the operating surgeon. Attempts to provide alternatives to open valve replacement surgery on cardiopulmonary bypass have now emerged. These are based around the transcutaneous placement of a valve prosthesis. While these technologies were initially highly selective in their application, they have now reached a stage to be compared with contemporary standards of cardiac surgical practice. In this debate we have invited two international experts from the fields of cardiac surgery (Professor Jahangiri) and interventional cardiology (Professor Kappetein and colleagues) to take deliberately opposing positions on the evolving management of valvular aortic stenosis in the very elderly. We have asked them to try to consider the strengths of each route. Both approaches provide options for patients who only a few years ago might have been regarded as essentially untreatable.

Reid, PT; Macleod, J; Robertson, JR

doi: 10.4997/jrcpe.2010.417pmid: 21132143

The use of cannabis is embedded within many societies, mostly used by the young and widely perceived to be safe. Increasing concern regarding the potential for cannabis to cause mental health effects has dominated cannabis research and the potential adverse respiratory effects have received relatively little attention. Studies on cannabis are challenging and subject to confounding by concomitant use of tobacco and other social factors, and while many of the studies referred to in this review are beset by the difficulties inherent in undertaking epidemiological research of the effects of cannabis, there is an emerging concern among many chest physicians who would suggest that habitual smoking of cannabis may contribute to the development of chronic obstructive pulmonary disease, pneumothorax and respiratory infections, including tuberculosis. Special attention should be given to the risk of lung cancer, particularly as biological plausibility may precede epidemiology.

Barrett, SV

doi: 10.4997/jrcpe.2010.418pmid: 21132144

Breast cancer is now the most common cancer of women in the UK and incidence is increasing. Because of major treatment advances and earlier diagnosis over the past 40 years, survival rates have been improving gradually and women diagnosed with breast cancer today are almost twice as likely to survive for 10 years or longer as women 40 years ago. However, breast cancer remains a major contributor to cancer morbidity and mortality in the UK. The majority of patients present with potentially curative disease and surgery is the mainstay of treatment. Many patients receive adjuvant (post-operative) therapy, which reduces the risk of loco-regional and distant disease recurrence. Treatment options include radiotherapy, chemotherapy, endocrine therapy and biological agents, with treatment increasingly tailored to the individual tumour and patient, aiming to provide maximum survival benefit with minimum toxicity. Many patients participate in clinical trials of radiotherapy, new agents, drug combinations or novel dosing regimens. Patients with metastatic disease can rarely be offered curative treatment, but improved quality of life and prolonged survival may be achieved with palliative treatment, including hormones, chemotherapy, radiotherapy, trastuzumab and bisphosphonates. This overview aims to summarise current knowledge and recent developments in the management of breast cancer.

Law, AB; McLaren, DB

doi: 10.4997/jrcpe.2010.419pmid: 21132145

Prostate cancer incidence is rising due to the ageing population and increased public and doctor awareness. The role of screening is still not clear due to the large number of asymptomatic men who would need to be screened and treated to prevent one death. Discussion of all treatment options should be undertaken, with the patient having the opportunity to meet a clinical oncologist and urological surgeon. Treatment options include active surveillance, external beam radiotherapy, brachytherapy and surgery. Low-dose rate brachytherapy involves the permanent insertion of radioactive seeds (half-life 60 days) under ultrasound guidance. It is a good option for many men as impotence and incontinence rates are lower than for surgery and it has reduced hospital costs and time off work and high rates of relapse-free survival (90–95% in low-risk disease). External beam radiotherapy offers a good treatment for men with more locally advanced disease and men who do not want to undergo an anaesthetic. New developments allow higher doses of radiotherapy to be given with reduced relapse rates and reduced toxicity to neighbouring structures such as bowel and bladder. High-dose rate brachytherapy involves the temporary insertion of applicators into the prostate so that a high energy source can temporarily be fed into different positions in the prostate, ensuring a high dose to the prostate gland but minimising dose to the bladder and bowel. It can be used as monotherapy or in combination with external beam radiotherapy.