Physicians Of Edinburgh Research Articles

Documenting the evidence: the case of scurvy.

Iain Milne & Iain Chalmers look at how James Lind's 1753 ground-breaking paper entitled "A treatise of the scurvy" helped to change the public health policy of his day and, in turn, improve public health. The authors describe how the Scottish naval surgeon recognized that there was widespread confusion over the diagnosis, prevention and cure of scurvy in the eighteenth century and how he sought to fill the knowledge gap with his paper. They review Lind's clinical experiments, methodology and conclusions as well as the effect of his work: within two years of ordering more generous provision of lemon juice scurvy had virtually disappeared from the ranks of the Royal Navy. In 1753, James Lind, a Scottish naval surgeon and medical graduate of Edinburgh University, published a 450-page, three-part Treatise of the scurvy (1). At that time, scurvy was killing thousands of people every year and was responsible for many more deaths of sailors in the Royal Navy than enemy action. Believing that one of the reasons there was so much confusion about the diagnosis, prevention and cure of scurvy was that "no physician conversant with this disease at sea had undertaken to throw light upon the subject", Lind set about filling this gap, with a clearly stated commitment to base his work on "observable facts" rather than on the theories that dominated medical decision-making at that time. Lind's Treatise is a classic for two main reasons: it is one of the earliest accounts so far identified of a prospectively organized controlled clinical trial, comparing six commonly used treatments for scurvy, and it is a systematic review of what had previously been published on the diagnosis, prognosis, prevention and treatment of scurvy. While serving in the Channel Fleet aboard HMS Salisbury in 1747, Lind reports having selected 12 sailors who were all at a clinically similar stage of scurvy, had the same basic diet, and were accommodated in the same part of the ship. He allocated two each to six of the many different treatments for scurvy then in use: a quart of cider daily; 25 gutts of elixir vitriol three times a day; two spoonfuls of vinegar three times a day; half a pint of seawater daily; a concoction of nutmeg, mustard and garlic three times a day; and two oranges and a lemon daily. "The most sudden and visible good effects", Lind reported, "were perceived from the use of oranges and lemons; one of those who had taken them being at the end of six days fit for duty ... The other was the best recovered of any in his condition; and being now deemed pretty well, was appointed nurse to the rest of the sick." Although Lind does not provide any information on how he allocated the sailors to the six treatments he compared, he is rightly celebrated for having taken care to compare like with like: his report shows his awareness of the need to guard against selection bias, noting that potential confounding factors--clinical condition, basic diet and environment--had been held constant. Although Lind is remembered for his controlled trial, his account of it fills only four pages in the book: the rest of it reports what had been published on the diagnosis, prognosis, prevention and treatment of scurvy. Lind's systematic review of the literature deserves greater recognition, particularly now that there is wide acceptance of the principle that decisions in health care and health policy should be informed by up-to-date, systematic reviews of reliable, relevant research. The year after Lind conducted his clinical experiment at sea, he left the Navy and returned to Enlightenment Edinburgh, where he graduated in medicine at the University, obtained a licence to practise, and became a fellow (and subsequently treasurer) of the Royal College of Physicians of Edinburgh. It was during this time, when his home was most probably an apartment in Paterson's Court off Edinburgh's Royal Mile (2), that Lind did the research that he reported in his Treatise. …

Thyroid feeding: a forgotten treatment for psoriasis.

Hormonal treatments are widely used in medicine such as vitamin D analogues for psoriasis. The effects of thyroid dysfunction on the skin have been known for over a century. Researchers in the past 30 years have been pondering a possible link between thyroid function and psoriasis although, surprisingly, the first clinical trial was conducted in Scotland over 100 years ago. Sir Byrom Bramwell (1847–1931) was a physician1 who practiced in Scotland, ultimately becoming president of the Royal College of Physicians of Edinburgh. His Atlas of Clinical Medicine2 published in 1896 by Constable in Edinburgh contained a remarkable case series of patients with psoriasis. It had previously been observed that patients with cretinism had a startling improvement in the quality of their skin after being fed with thyroid glands. This led Bramwell to postulate that ‘thyroid feeding’ may also be beneficial to patients with psoriasis. He reported a case series of 20 patients to whom he fed thyroid glands to treat their psoriasis. There was no standardization as some patients had mild disease while others were more severely affected. The thyroid supplementation was varied for the patients, some receiving minced raw gland, some dried extract and some liquid extract. Dosing was variable with patients treated later in the series receiving a hundred‐fold increase in dose compared with earlier subjects.

Society for Acute Medicine Autumn Meeting

The autumn meeting of the Society for Acute Medicine took us to the spectacular city of Edinburgh. More than 150 delegates attended this, the tenth meeting of the Society, by far the largest attendance to-date, and a clear ref lection of the rapid expansion of this new sub-specialty. We were hosted by the Royal College of Physicians of Edinburgh, in their grand building on Queen Street, and were made to feel welcome by all the staff there. A special mention must go to the immaculately turned-out doorman who helped me find my way from the Royal College to my accommodation at a nearby hotel.

The James Lind Initiative

The James Lind Initiative

A consensus statement clarifying the use of HRT in clinical practice has been issued at a conference convened by the Royal College of Physicians of Edinburgh,

A consensus statement clarifying the use of HRT in clinical practice has been issued at a conference convened by the Royal College of Physicians of Edinburgh,

Review: 'To Improve the Evidence of Medicine': The 18th century British Origins of a Critical Approach

1University of Durham ‘To Improve the Evidence of Medicine’: The 18th century British Origins of a Critical Approach Ulrich Tröhler Edinburgh Royal College of Physicians of Edinburgh 2000 xii + 147 Paperback£10.00 0‐85405‐056‐6

Artificial oxygen‐carriers: a clinical future? 9 May 2002, Royal College of Physicians of Edinburgh

Transfusion MedicineVolume 12, Issue 2 p. 153-153 Artificial oxygen-carriers: a clinical future? 9 May 2002, Royal College of Physicians of Edinburgh First published: 29 April 2002 https://doi.org/10.1046/j.1365-3148.2002.00367.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume12, Issue2April 2002Pages 153-153 RelatedInformation

Clinical standards for diabetes care in Scotland

ing clinical standards in diabetes care. In 1999 the two physician colleges, the Royal College of Physicians and Surgeons of Glasgow (RCPSG) and the Royal College of Physicians of Edinburgh (RCPE) met with Specialist Societies in Scotland and formed a Bicollegiate Steering Committee for Clinical Standards (BSCCS). A Diabetes Specialty Group involving representatives from both Colleges and Diabetes UK produced five standards for diabetes and these have been published on College Websites (www.rcpe.ac.uk/esd/clinical_standards/diabetes_standards.html) and are shown in table 1. In 1999 the Clinical Standards Board for Scotland (CSBS) was established as a special Health Board with the task of running a national system of quality assurance and accreditation of clinical services. The aim was to promote public confidence in NHS Scotland. In the Scottish Health Plan – A Plan for Action, A Plan for Change – a commitment was made to the development of a national framework for diabetes services, including the development of clinical standards for diabetes. The CSBS had responsibility for the development of these standards and in 2001 the Board established a Diabetes Project Group. Membership included members of the public, people with diabetes and healthcare professionals who were tasked with developing a set of standards spanning the range of diabetes care which patients and professionals considered important. The standard setting process was accessible and inclusive with two open meetings that involved lively workshops discussing draft proposals. After reflecting feedback at the meetings and comments in written submissions Clinical Standards Diabetes was published on International Diabetes Day 2001. The next step involved the development of a self-assessment tool for NHS Boards in Scotland to use for their primary and specialist care services. In the summer of 2002 the standards are due to be piloted in three areas prior to finalisation. Following this, all existing diabetes services in Scotland shall be systematically examined using this self-assessment tool in association with peer review team visits. The exercise will culminate in the CSBS publishing a report of its findings. In the development of both sets of standards the BSCCS and CSBS groups only considered evidence-based diabetes standards. This was greatly helped by the simultaneous development of SIGN Guideline 55. There was impressive overlap in membership of these three groups as well as the associated Scottish Diabetes Framework Working Group such that ownership of guidelines and standards never became a contentious issue. The credibility of the CSBS Standards is enhanced by the basic principles that apply. The aim is to produce standards which: Clinical standards for diabetes care in Scotland

Obituary Professor Jim Petrie

Obituary Professor Jim Petrie

Platelet transfusion trigger in difficult patients

There is general consensus that a prophylactic pre-transfusion trigger at 10.000 platelets/μL in stable oncohematological patients is as safe as the traditional trigger of 20.000/μL, and that perioperative triggers at 50.000 and 100.000/μL are adequate in most surgical and neurosurgical conditions respectively. Guidelines on the trigger and other issues related to platelet transfusion can be found in nine documents published during 1987–2001 by the National Institutes of Health (NIH), the British Committee on Standardization in Hematology, the Royal College of Physicians of Edinburgh, the College of American Pathologists, the American Society of Anesthesiology and the American Society of Clinical Oncology (ASCO). Although consensus may be less evident on specific triggers for ‘difficult’ patients, the following triggers, listed by progressively increasing levels, have been proposed in the literature and have found general agreement: a stable oncohematological recipient: 10.000; lumbar puncture in a stable pediatric leukemic patient: 10.000; heparin-induced thrombocytopenia: 10.000; bone marrow aspiration and biopsy: 20.000; gastrointestinal endoscopy in cancer: 20.000–40.000; disseminated intravascular coagulation: 20.000–50.000; fiber-optic bronchoscopy in a bone marrow transplant recipient: 20.000–50.000; neonatal alloimmune thrombocytopenia: 30.000; major surgery in leukemia: 50.000; thrombocytopenia secondary to massive transfusion: 50.000; invasive procedures in cirrhosis: 50.000; cardiopulmonary bypass: 50.000–60.000; liver biopsy: 50.000–100.000; a nonbleeding premature infant: 60.000; neurosurgery: 100.000. The proposed values must be considered within the context of careful clinical evaluation of each individual patient, and attention should be given to the power of discrimination of platelet counters at low counts and to the prompt availability of good quality platelet products in the case of emergency.

Book Review: To Improve the Evidence of Medicine: The 18th Century British Origins of a Critical Approach

Ulrich Trohler's thesis is that a quantitative and critical approach to medicine did not originate in Paris in the first half of the nineteenth century, as is generally believed, but was first fostered in Britain in the second half of the eighteenth century. At this time several British doctors perceived the need for adequate empirical evaluation of existing and proposed treatments. They understood that the way forward was a rejection of the traditional dependence on dogma and complex pathophysiological theories of disease and instead a reliance on comparative trials with the results expressed as numbers—something they referred to as `medical arithmetic'. With its roots in a PhD written over twenty years ago the book finally brings Trohler's valuable and fascinating research to a wide audience. It is broadly divided into three parts. In the first there is an overview of the state of British medicine in the eighteenth century and an explanation of the intellectual and structural elements which allowed the new arithmetic approach to be applied. The intellectual basis was essentially the emergence of a climate of `rational empiricism', a general emphasis on observation rather than theory, and also the profusion of medical societies allowing these views to be propagated. The structural change was the increased dependence on institutionalized medical treatment in hospitals and dispensaries and in the armed forces which permitted adequate numbers of cases to be collected together to use the new methods. The second and largest part is the exploration of contemporary health issues to illustrate Trohler's theory. Trohler states that this presentation is for a general readership and undoubtedly it provides both a vivid insight into the medical practice of the period and a cogent argument for a British origin for quantitative evaluation. The subjects addressed are the management of fever (the `cancer' of the eighteenth century), surgery for bladder stones, the treatment and prevention of scurvy, digitalis in dropsy, the use of spa waters for rheumatic disorders, amputation for limb injuries in war and the control of syphilis and ophthalmia in the army. Even the very familiar, such as Lind's work in scurvy and Withering's in dropsy, are reinvigorated by Trohler's exhaustive research. In the third and final part the major findings are summarized. There is discussion of the type of men who invented this new medicine—often outside the mainstream, `dissenting' in nature, and from a military or provincial background with Scottish connections. The immediate impact of `medical arithmetic' on day-to-day practice and the ethical issues it raised about experimenting on patients are addressed. Most significantly, Trohler draws striking parallels between the eighteenth and early nineteenth century work of the `arithmetic observationists and experimentalists' and ongoing developments in the second half of the twentieth and early twenty-first centuries. One is repeatedly impressed by the apparent modernity of the methods used by these pioneers of evidence-based medicine. I have no serious criticisms. The title is a direct quote from the eighteenth century but perhaps the book deserved something more inspiring. On occasion Trohler's `rocky Swiss English' (his own words) has evaded the editors. This is a scholarly and entertaining work. The author argues his case lucidly with a profusion of historical detail which is thoroughly referenced. The Royal College of Physicians of Edinburgh have produced it very nicely in softback format with pleasing illustrations and at a surprisingly reasonable price. I strongly recommend it to all those with an interest in the history or future of British medicine.

A National Panel for Research Integrity: a proposed blueprint for the prevention and investigation of misconduct in biomedical research*

Biomedical researchers in the UK have made major contributions to disease prevention and patient care through the publication of a large quantity of research evidence in peer-reviewed journals. Isolated (but well publicized) instances of deliberate misconduct (fraud) in clinical research by doctors in the UK have been reported to, and dealt with by, the General Medical Council (GMC) as part of its procedures for professional misconduct [1]. The UK has not yet developed systematic procedures for identification and investigation of suspected deliberate misconduct in biomedical research, unlike other countries such as the US and Denmark [2]. Whilst increasingly publicized and requiring joint attention by the medical profession, and by its colleagues in the biomedical sciences (over whom the GMC has no jurisdiction), such isolated instances of deliberate misconduct probably have little lasting effect on the scientific basis of medical practice [3]. In contrast, it has been suggested that ‘almost certainly far more direct harm to patients results from the inept efforts of poorly trained researchers than ever results from deliberate deception’ [3]. Hence there is a need to address not only deliberate research misconduct, but also to address non-intentional behaviour by researchers which falls short of good ethical and scientific standards. In a recent international survey of biostatisticians, who routinely work closely with physicians and scientists in many branches of medical research and therefore have an unique insight into data, 51% of the 37% who responded knew about fraudulent projects (e.g. fabrication and falsification of data, deceptive reporting of results, suppression of data and deceptive design or analysis) [4]. A recent consensus statement developed at a UK Consensus Conference on Misconduct in Biomedical Research organized by the Royal College of Physicians of Edinburgh defined research misconduct as ‘behaviour by a researcher, intentional or not, that falls short of good ethical and scientific standards’ [2]. It proposed that representatives of both of the Royal Colleges of Physicians of Edinburgh and London, the Royal College of Physicians and Surgeons of Glasgow and their joint Faculty of Pharmaceutical Medicine meet to consider the establishment and remit of a national panel for good research practice. We therefore established our joint working group to address these issues. At a series of meetings we have developed a blueprint for such a panel, which we now publish to inform people of developments and to invite public debate. We have also had discussions with the UK government (Departments of

Dr H C Bastian, scientific Jekyll and Hyde

The neurological library of S A Kinnier Wilson, now in the Royal College of Physicians of Edinburgh, contains two books by Henry Charlton Bastian. Various forms of hysterical or functional paralysis (1893) is inscribed "To Dr Wilson by the Author, July 1906". Wilson was Bastian's house-physician at the time. The second book, given to Wilson's son by Bastian's daughter in 1940, is a lavishly illustrated tome, Studies in heterogenesis (1903). The two books testify to a scientific Jekyll and Hyde--one of the founders of neurology and a wildly unorthodox biologist.

Royal College of Physicians of Edinburgh. Autologous transfusion, 3 years on: what is new? What has happened?

Royal College of Physicians of Edinburgh. Autologous transfusion, 3 years on: what is new? What has happened?

Update statement from the conference 'Autologous transfusion', 3 years on--what is new? what has happened?" held at the Royal College of Physicians of Edinburgh, 10-11 November 1998.

Update statement from the conference 'Autologous transfusion', 3 years on--what is new? what has happened?" held at the Royal College of Physicians of Edinburgh, 10-11 November 1998.

EDITORIAL INTRODUCTION

It is 20 years since the last international gathering of experts to discuss anti-D prophylaxis (McMaster Conference 1977)1 and since then relatively little has changed with respect to the incidence of failures of anti-D prophylaxis which remain constant in the region of 1-2%. On the other hand, major advances have occurred in the monitoring and management of affected fetuses in uteru, and in neonatal intensive care. This has resulted in a very significant reduction in reported mortality associated with RhD haemolytic disease to the extent that it is not perceived as a problem any more. However, it has long been advocated that there is significant under reporting of mortality, and there is greater appreciation of the impact of morbidity, and the resources consumed by monitoring and caring for alloimmunised women and their babies. In the UK, routine antenatal prophylaxis has been resisted on the grounds of lack of demonstrable cost-effectiveness in the UK healthcare setting, and concerns about meeting the demands for the additional anti-D required. The latter is a concern worldwide as anti-D plasma supply from donors is a finite resource, and there have been concerns about the ethics and safety of deliberate immunisation of RhD-negative volunteers. The possible early introduction of monoclonal anti-D proved to be a false dawn, and some countries have difficulties in maintaining self-sufficiency in anti-D plasma because of premature closure or reduction of anti-D immunisation programmes. It therefore seemed timely to have a conference of interested parties to debate these issues, and to attempt to come to a consensus. The consensus framework used by the Royal College of Physicians of Edinburgh was chosen as the vehicle for a 2-day conference (held jointly with the Royal College of Obstetricians and Gynaecologists) addressing a number of specific issues. The details of the questions to be addressed, and the consensus methodology are given in a paper in this supplement, and the evidence presented to the panel is also published. This consists of the three background papers prepared in advance and the abstracts of the oral and poster presentations. The final consensus statement is published in full, together with a personal view from a panel member. One specific objective of the Conference was to obtain a definitive statement on the position of antenatal anti-D prophylaxis in the UK, either for, or against. The session in the programme dealing with this topic was therefore chosen to be addressed with speakers chosen to speak for and against, with the opportunity for each to cross-examine the other in public, and for the panel and audience to judge the weight of evidence. This proved to be a successful format for summarising the issues for and against. Finally, and importantly, the conference presentation and statement produced by the panel provided the UK Committee of experts charged with revising and updating the 1991 UK Guidelines on Anti-D Prophylaxis with essential information to complete their task. These revised recommendations are awaited shortly.

Fellowship and Membership Survey: The Royal College of Physicians of Edinburgh

Fellowship and Membership Survey: The Royal College of Physicians of Edinburgh

Royal College of Physicians of Edinburgh

Royal College of Physicians of Edinburgh

Fellowship and Membership Survey: The Royal College of Physicians of Edinburgh

Fellowship and Membership Survey: The Royal College of Physicians of Edinburgh

Consensus Conference 27-28 November Physicians of Edinburgh, on Platelet Transfusion 1997, Royal College of Scotland, UK

Consensus Conference 27-28 November Physicians of Edinburgh, on Platelet Transfusion 1997, Royal College of Scotland, UK