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Review: Should we screen for asymptomatic coronary artery disease in the community?

ND Gollop, The Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, United Kingdom
SF Smith, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0SP, United Kingdom

Abstract

Introduction: Coronary artery disease (CAD) is the accumulation of atherosclerotic plaque in the coronary arteries; resulting in limited myocardial perfusion. CAD has high levels of global morbidity and mortality and is well researched. Asymptomatic coronary artery disease (ACAD) is the precursor subclinical state and is inadequately detected and researched. The aim of this article was to cross-examine the current research on ACAD. Emphasis was placed on methods of assessment and screening of ACAD.

Materials and Methods: A review of the literature was completed following a structured protocol; search engines, inclusion and exclusion criteria were defined a priori.

Results: Forty-eight articles met all inclusion criteria and were retrieved for detailed analysis. Outcome-based evidence suggested that cardiovascular disease risk stratification followed by imaging based assessments in low-to-moderate risk candidates were shown to be of clinical value in ACAD. A ‘treat all’ primary preventative approach was shown to be of most benefit; however the social and financial implications of this remain unclear.

Conclusions: Effective management of ACAD is essential to lower the worldwide incidence, morbidity and mortality of CAD. Further outcome-based evidence highlighting the benefits of identification, screening and early primary prevention of ACAD is urgently needed.

Keywords: Asymptomatic coronary artery disease, asymptomatic coronary atherosclerosis, subclinical coronary artery disease, subclinical coronary atherosclerosis, asymptomatic coronary artery disease screening, asymptomatic coronary artery disease investigations, asymptomatic coronary artery disease management

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Abstracts from the ATRIUM 2014 conference

Richard Heywood, Editor, Cambridge Medicine Journal.
Organisers of the ATRIUM conference

We are pleased to be able to publish the abstracts from the 6th Annual National ATRIUM Conference, which took place on 22nd February 2014 at the Chancellor’s Building, New Royal Infirmary of Edinburgh. This annual conference is organised by ATRIUM, a student-run organisation at the University of Edinburgh which aims to encourage research amongst undergraduate medical students. Their website is http://www.atriumsoc.co.uk/

There were a mixture of oral and poster presentations, which are listed below. The name of the presenting student is in bold.

Oral presentations

Optogenetics: A Vision of the Future of Neurology?

Fraser Brown, 3rd year Medical Student, University of Edinburgh, UK.

In 1979, Nobel laureate Francis Crick published a paper discussing progress in neuroscience. Describing the subject as “profoundly mysterious”, he speculated on new methods of investigating the brain, including the ability to inactivate one type of neuron whilst leaving the others “more or less unaltered” [1]. Crick is not alone; for years the mammalian brain has dumbfounded researchers [1,2]. In the human, a hundred billion neuronal parts and myriad connections lead to an interconnected system of a level of unparalleled complexity [3].

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5. Williams S. C. P, Deisseroth K. Optogenetics. Proc. Natl. Acad. Sci. USA. 2013 110(41):16287 DOI:10.1073/pnas.1317033110

6. Harz H, Hegemann P. Rhodopsin-regulated calcium currents in Chlamydomonas. Nature 1991 351(6326):489–491. DOI:10.1038/351489a0

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9. Tye KM, Prakash R, Kim S, Fenno LE, Grosenick L, Zarabi H, Thompson KR, Gradinaru V, Ramakrishnan C, Deisseroth K. Amygdala circuitry mediating reversible and bidirectional control of anxiety. Nature. 2011 17; 471(7338): 358–363 DOI:10.1038/nature09820

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The Future of Neurology: Announcing the winning essay of the 2014 “Neuroscience to Neurology” essay competition

Faye Begeti, Editor-in-Chief, Cambridge Medicine Journal

The World Health Organization estimates that neurological disorders currently affect one billion people worldwide, a number which is predicted to increase considerably as a result of an ageing population. The need to further understand the brain and make progress in the field of neurology has therefore never been greater. However, with over 100 million neurons each making over 1000 synapses, the human brain is undoubtedly the most complex organ in the human body, and it is this complexity that has meant that advances in neuroscience have been comparatively slow.

CamSurg conference 2014 Abstracts

Richard Heywood, Editor, Cambridge Medicine Journal.

It is our pleasure to once again be able to publish the abstracts for posters presented at the recent CamSurg conference, which took place on Saturday 22nd February, 2014, at Addenbrooke's Hospital in Cambridge. Following on from the successful 2013 conference, CamSurg organised an interesting mix of keynote speakers, workshops and oral and poster presentations. The full programme can be found on the CamSurg website http://www.camsurg.co.uk/CamSurg/#

The following abstracts were put forward for presentation at the conference:

Obstetric ultrasound: A guide for medical students

Stephanie F. Smith, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 0SP
Nicholas D. Gollop, The Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY
Christoph Lees, Fetal Medicine, Rosie Maternity, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge. CB2 2QQ

At some point within your medical training, whether it’s during your first Obstetrics attachment or if you venture to the Radiology department, you are likely to encounter the use of Obstetric ultrasound scanning. However, it can be a complex subject to master and is not covered extensively in the undergraduate core curriculum or textbooks. This article discusses the key essentials that will help you make the most of your learning experience in these situations.

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References: 

1. Department of Health. Managing high value capital equipment in the NHS in England. National Audit Office. March 2011. Available online at http://www.official-documents.gov.uk/document/hc1011/hc08/0822/0822.pdf [Accessed 15 May 2013]
2. Collins S, Arulkumaran S, Hayes K, Jackson S, Impey L. Oxford Handbook of Obstetrics and gynaecology, 2nd Ed. Oxford University Press, 2008. pp114.
3. ter Haar G. The new British Medical Ultrasound Society Guidelines for the safe use of diagnostic ultrasound equipment. Ultrasound May 2010 vol. 18 no. 2 50-51 doi: 10.1258/ult.2010.100007

Detection of Coeliac Patients at Risk of an Osteoporotic Fracture: A Two-Cycle Clinical Audit

Adam Charles Nunn, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, United Kingdom
Damian David Patterson, Abbey View Medical Centre, Salisbury Road, Shaftesbury, Dorset SP7 8DH, United Kingdom

Abstract

Patients diagnosed with Coeliac disease are known to be at higher risk of suffering a low-impact fracture, and even as children it is important to detect and correct malabsorption due to Coeliac since this may have a lasting impact on their lifelong fracture risk. The British Society of Gastroenterologists recommends that those Coeliac patients with two or more additional risk factors for osteoporotic fracture undergo a dual X-ray absorptiometry (DEXA) scan to determine their bone density. This audit addressed the question of whether this standard was being adhered to in a general practice setting in the south-east of England. The capture of cases represented a prevalence of 1:275 (similar to previously reported figures for the prevalence of this condition). The rate of DEXA scanning in this population was disappointingly low (only 37%), and since many of those Coeliac patients who should have been scanned, and were not, possessed ‘minor’ risk factors such as smoking or female gender, the low pick-up rate may be attributable to a lack of awareness of the small but significant risk that these factors pose. Of those DEXA scans performed, the bone mineral densities of the patients concerned was inversely proportional to the number of risk factors they possessed, supporting the stance of the BSG. Practitioner education alone was not sufficient to improve the rate of scanning, which actually declined following a period of raising awareness of the need for such scans.

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Figure 4
References: 

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7. Davie MW, Gaywood I, George E, Jones PW, Masud T, Price T, Summers GD. Excess non-spine fractures in women over 50 years with celiac disease: a cross-sectional, questionnaire-based study. Osteoporos Int 2005 Sep;16(9):1150-5. DOI: 10.1007/s00198-004-1822-z
8. Fickling WE, McFarlane XA, Bhalla AK, Robertson DA. The clinical impact of metabolic bone disease in coeliac disease. Postgrad Med J 2001 Jan;77(903):33-6. DOI: 10.1136/pmj.77.903.33
9. Ludvigsson JF, Michaelsson K, Ekbom A, Montgomery SM. Coeliac disease and the risk of fractures - a general population-based cohort study. Aliment Pharmacol Ther 2007 Feb 1;25(3):273-85. DOI: 10.1111/j.1365-2036.2006.03203.x
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The Medicalisation of Criminal Behaviour: A Unifying Approach

Jonathan Rogers, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0SP, England, UK

Introduction

Quand tu sauras mon crime et le sort qui m’accable,
Je n’en mourrai pas moins, j’en mourrai plus coupable.

Jean Racine (1639–1699), Phèdre1

Phèdre is a tragedy which explores the relationship between moral culpability and responsibility for one’s actions by examining the incestuous love of a queen for her step-son, a passion that is apparently imputed to her by a vengeful deity. What is fascinating for the purposes of our discussion is the dynamic interplay between the portrayals of Phèdre’s infatuation both as an illness and simultaneously as a crime, for this is essentially the same question we must consider in deciding to what extent a malady excuses behaviour that contravenes society’s judicial expectations. While this was doubtless an intriguing consideration for a seventeenth century French dramatist, it is all the more pertinent for us today given the extent of medicalisation that has occurred in recent decades across many spheres of society. In terms of psychiatry, this may be illustrated merely with reference to the DSM, which between its first edition in 1952 and the fourth revision fifty-two years later has more than tripled the number of conditions it identifies, taking the total from 112 to more than 370 today [1]. This inexorable rise has led certain commentators to question the extent to which this phenomenon is justified, particularly where it impinges on the realm of moral accountability. This is exemplified in an article by the sociologist Frank Furedi entitled The seven deadly personality disorders, in which he describes how all of those vices that the Catholic Church once taught to be mortal sins are now considered by Western culture to be addictive illnesses, with the sole exception of pride, which is thought to be a virtue, the helpful antidote to low self-esteem [2]. This issue is one of eminent importance to the forensic psychiatrist, who may be obliged to stand as an expert witness and give evidence on a defendant’s mental state, potentially obviating the accusation that they had the mens rea for a crime. This is particularly the case in homicide, where mental illness can reduce a verdict from murder to manslaughter, but it is of more general significance in the verdict of ‘not guilty by reason of insanity’. Thus, this essay shall concern itself with a consideration of the current theories on which medico-legal practice seems to be predicated, before examining a possible alternative to this model and the congruence of this with a broader philosophical perspective, concluding with some speculation as to the implications of this concept for clinical practice and for society.

References: 

1. Peter W. Halligan, Christopher Bass, David A. Oakley. Malingering and Illness Deception. s.l. : OUP, 2003.
2. Furedi, Frank. The seven deadly personality disorders. Spiked Online. [Online] 12 March 2008. [Cited: 26 11 2011.] http://www.spiked-online.com/index.php?/site/article/4862/.
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Case Report: Left knee pain in a young female athlete

Jonathan Packer, University of Birmingham, Birmingham, UK

Clinical History

A 14 year old girl was seen in clinic after an injury whilst playing rugby. Although her description was vague, she intimated that a valgus stress had been put on her left leg and described being tackled in rugby practice. She fell on her left knee and heard an audible cracking or ‘pop’ sound, experiencing immediate pain and swelling of the joint. She had no significant past medical history and was taking no regular medication.

References: 

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2. Moore. K.L, Dalley. A.F, Agur. A.M.R – Clinically Orientated Anatomy 6th Edition – Lippincott Williams & Wilkins. 2010.

3. Clifford R. Wheeless III, James A. Nunley, II, MD and James R. Urbaniak, MD - Wheeless Textbook of Orthopaedics available at : http://wheelessonline.com/

4. Solomon. L, Warwick. D.J, Nayagam. S - Appley’s Concise System of Orthopaedics and Fractures - Third Edition, Published by Hodder Arnold, 2005.

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7. Molander ML, Wallin G, Wikstad I. ‘Fracture of the intercondylar eminence of the tibia: a review of 35 patients’. 1981, Journal of Bone and Joint Surgery Br. 63-B(1):89-91. http://www.bjj.boneandjoint.org.uk/content/63-B/1/89.long

The need for a Liaison and Mediation Service to assist doctors and their young patients who refuse treatment

Zenon Stavrinides, Tutor in Medical Ethics, University of Leeds, UK

Abstract

This paper attempts four things:
(1) to identify uncertainties and ambiguities in English law and medical guidance concerning the circumstances in which a competent adolescent patient who refuses a clinically indicated treatment can be overruled by a court of law in their own best interests;
(2) to clarify the nature and sources of two opposing attitudes towards the matter of the extent and limits of an adolescent patient’s right to refuse clinically indicated treatment;
(3) to argue for the need to set up in hospitals a Liaison and Mediation Service to facilitate communication between an adolescent who refuses treatment and their doctors with a view to developing, if possible, an agreed decision; and
(4) to outline a widened conception of an adolescent’s best interests which includes, besides the restoration of their health, respect for their personality and autonomy, acknowledgement of their right to be informed about the treatment proposed to them, recognition of their capacity to gain considerable understanding of the nature and consequences of the treatment and any alternatives, and also acceptance by doctors and judges of their ability to make their own decisions which is commensurate to the degree of intellectual and emotional maturity they have attained.

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