rss

Recent eLetters

Displaying 1-10 letters out of 138 published

  1. Dwindling clinical skills- an unforgettable lesson

    Hopkins et al have presented and interesting and important case highlighting the need to look for organic aetiology in new onset psychosis. Psychiatrists are medically trained doctors and GMC good medical practice requires them to keep up to date with the latest knowledge and evidence. Unfortunately very little attention is being paid in the NHS to this aspect and developing skills like leadership, management, innovations are overemphasised, which undoubtedly are important skills but should not be at the expense of forgetting or losing clinical skills. Losing clinical skills renders clinicians less confident and defensive which increase the rate of referrals to other specialities for minor problems.

    During my on call a 47 year old patient was referred for mental health act assessment with new onset behavioural change and psychotic symptoms. The patient was seen by A&E consultant and declared medically fit. Due to the unusual presentation and some catatonic signs I insisted on further medical investigations to rule out organic aetiology. Having read a recent article and being aware of the specific causes for such presentations like space occupying lesions, haemorrhages and encephalitis helped me persuade the medical team for further investigations. The patient was treated for viral encephalitis with intravenous acyclovir and his psychotic symptoms resolved. This was an unforgettable lesson and further strengthened my resolve to keep my clinical skills up to date to provide the best and safe care to my patients.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  2. Dabigatran does not dissolve the thrombus. Instead fibrinolytic system dissolved the thrombus.

    Dear Editor

    I was reading with interest the manuscript of Hidekazu Takeuchi's [1]. The author believed that dabigatran dissolved the thrombus. As a consultant hematologist, I have noticed that many people including patients and practicing physicians believe that anticoagulants dissolve the clot. In reality, this is not the case. Anticoagulants never dissolve the thrombus.

    The aims of the anticoagulant therapy in the treatment of acute venous thrombosis are; (a) to stabilize the thrombus, (b) to prevent thrombus extension thereby preventing pulmonary embolism, (c) to prevent recurrent thrombosis, and (d) to limit late complications such as post- thrombotic syndrome [2]. While anticoagulant therapy tries to achieve those aims, it allows the endogenous fibrinolytic system to dissolve the thrombus gradullay over time. Depending on the rate of fibrinolysis, some thrombus may dissolve within a few weeks or a few months. Some are left with residual chronic thrombus [3-4]. If rapid dissolution of the thrombus is desired to quickly restore vascular patency and improve hemodynamics, we use thrombolytics such as tissue plasminogen activator [5].

    In this case, I believed that dabigatran did not dissolve the thrombus. Dabigatran just stabilized the thrombus, prevented thrombus extension and thereby allowing the patient's endogenous fibrinolytic system to dissolve the thrombus over time. It is prime time that practicing physicians should disgard the idea that anticoagulants dissolve the thrombus and to realize that it is the fibrinolytic system which dissolves the thrombus eventually.

    Thein H Oo, MD Associate Professor of Medicine/Consultant Hematologist The University of Texas M.D. Anderson Cancer Center Houston, Texas USA

    References:

    1. Takeuchi H. Floating thrombus in the left upper pulmonary vein dissolved by dabigatran. BMJ Case Rep 2013. Doi:10.1136/bcr-2013-200836

    2. Landaw SA, Bauer KA. Approach to the diagnosis and therapy of lower extremity deep vein thrombosis. www.uptodate.com, accessed November 1, 2013

    3. Leung LLK. Overview of hemostasis. www.uptodate.com, accessed November 1, 2013

    4. Kearon C. Natural history of venous thromboembolism. Circulation 2003;107(23 Suppl 1):122-130

    5. Tapson VF. Fibrinolytic (thrombolytic) therapy in acute pulmonary embolism and lower extremity deep vein thrombosis. www.uptodate.com, accessed November 1, 2013

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  3. Response to "Confirmed viral meningitis with normal CSF findings"

    This is a very important case report as it feeds into our understanding of how to interpret test results. If the pre-test probability is high (eg. features of meningism in acute febrile illness) then negative results should be treated with an index of suspicion. No test is perfect, with both pathophysiological (eg. delayed movement of WBCs from inflamed meninges into CSF), statistical (occasional representatives from the end of the bell curve) and technical (operator dependency) limitations. The clinical team did well to exclude all other possibilities. This case also provides further support for efforts to expand the panel of CNS virus PCR tests to pick up currently underrepresented viral pathogens in the CSF.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  4. propranolol and infantile hemangiomas

    Propranolol has now become the main stay for treatment of infantile hemangiomas even in developed countries unless it fails or the drug could not be used because of complications.This has been a matter of great relief not only for the parents/patients but the practicing doctors as well everywhere .

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  5. Cause of pancytopenia in a Lyme serology patient

    Pancytopenia is a rare expression of Lyme Disease.My worry is that the patient may have been co-infected with a virus for which, at this time, there is no form of positive identification. Such a virus could be related to one of the other viral scourges the vector of which are hard ticks.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  6. Re:Response to Gluteal compartment syndrome with severe rhabdomyolysis

    Dear Mr. Latimer Thanks you for your response to my case report. Fasciotomy and debridement in the presence of crush syndrome is a controversial topic. As far as evidence is concerned there are proponents and opponents of fasciotomy in the presence of rhabdomyolysis. Although there is a theoretical risk of worsening the renal function and electrolyte imbalance, leaving the compartment closed in the presence of clinical evidence of compartment syndrome is not advisable. I have reference some recent evidence that suggest that the most appropriate treatment for crush syndrome is on going resuscitation to restore renal function and electrolyte balance but if there is an associated compartment syndrome, the compartments have to be surgically released. In our case if the compartment hadn't been released it could have led to permanent damage to the sciatic nerve. Secondly, leaving dead muscle in a patient who is already immunocompromised can lead to life threatening sepsis. Therefore, the management of crush syndrome with compartment syndrome should consist of continuous medical management along with surgical release of compartment, the decision is however clinical and should be tailored to the individual patient.

    References:

    1. Shaikh N. Complication of crush injury, but a rare compartment syndrome. J Emerg Trauma Shock 2010 Apr;3(2):177-81.

    2. Mrsi V1, Nesek Adam V, Grizelj Stojc E, Rasi Z, Smiljani A, Turci I. Acute rhabdomyolysis: a case report and literature review Acta Med Croatica 2008 Jul;62(3):317-22.

    3. Genthon A, Wilcox SR. Crush syndrome: a case report and review of the literature J Emerg Med 2014 Feb;46(2):313-9.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  7. An interesting article

    I wish to commend the efforts of the authors of this interesting article being the first of its kind in the literature. I would like them to share with us the duration of therapy in this case and follow up information. Thank you.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  8. Appropriate biochemical evaluation of phaeochromocytoma during pregnancy

    The occurrence of phaeochromocytoma in pregnancy is extraordinarily rare, with a frequency of 1 in 54, 000 (0.002%) (1-2). Due to the potentially devastating consequences to the mother and foetus it is essential to consider phaeochromocytoma in the differential diagnosis of uncontrollable hypertension.

    In order to do this the appropriate initial biochemical investigation(s) are vital. Memon et el (3) rightly highlighted that in healthy pregnant women, plasma and urinary catecholamine concentrations are not or only slightly increased. As a consequence it is not recommended that plasma or urinary catecholamines are measured in the evaluation of a pregnant patient under investigation for uncontrollable hypertension. Moreover it is not appropriate to measure urinary vanillylmandelic acid due to its poor diagnostic sensitivity (4). Recommendations for the initial evaluation of phaeochromocytoma include measurement of total fractionated urine metadrenalines and or plasma metadrenalines (5). The initial test used in the initial evaluation of phaeochromocytoma should have the strongest power to exclude the tumour as reliably as possible so that no tumour is missed. Metadrenalines have this power as they have the highest sensitivity and highest negative predictive value (4). It is therefore the authors recommendation that metadrenalines are measured in the initial biochemical evaluation of phaeochromocytoma during pregnancy.

    References:

    1. Harrington JL, Farley DR, van Heerden JA & Ramin KD. Adrenal tumours and pregnancy. World Journal of Surgery 1999 23 182-186.

    2. Harper MA, Murnaghan GA, Kennedy L, Hadden DR, Atkinson AB. Phaeochromocytoma in pregnancy. Five cases and a review of the literature. British Journal of Obstetrics and Gynaecology 1989 96 594-606.

    3. Memon MA, Aziz W, Abbas F. Surgical management of pheochromocytoma in a 13-week pregnant woman. British Medical Journal Case Report 2014. doi:10.1136/bcr-2013-202838.

    4. Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P et al. Biochemical diagnosis of phaeochromocytoma: which test is best? Journal of American Medical Association 2002;287:1427-1434.

    5. Pacak K, Eisenhofer G, Ahlman H, Bornstein SR, Gimenez-Roqueplo AP, Grossman AB et al. Pheochromocytoma: recommendations for clinical practice from the First International Symposium, October 2005. Nature Clinical Practice Endocrinology Metabolism 2007;3:92-102.

    Conflict of Interest:

    None

    Read all letters published for this article

    Submit response
  9. RE: McConnell's sign is not specific to PE nor should this finding alone prompt use of thrombolytics

    I am glad to receive comments on my previous publication on McConnell sign in which we had stressed upon the clinical relevance of this echocardiographic sign of pulmonary embolism. These comments are well taken and are acceptable to me. I wish to clarify my point which I wished to stress upon by means of this image publication.

    McConnell sign although is not a definitive evidence of massive embolism but is truly an indicator of haemodynamically significant embolus which is affecting the function of the right ventricle. After having gone through the reference given in the query, I agree that this sign has lesser specificity in the diagnosis of embolism but we wish to stress upon in usage for predicting an embolism to be haemodynamically significant which could help in guiding therapy.

    The indication of thrombolytic therapy in embolism is controversial and is often used even in intermediate risk group especially if the bleeding risk is low and essentially is a matter of decision of the treating physician.

    Although we do not suggest using McConnell sign alone as a marker to thrombolyse but it sure is a marker of significance of embolism which can be used along with other parameters.

    Your point is valid and is acceptable for us but I think our point is clear in this regard and I feel that the above sentences would make our perspective clear.

    I will be happy to discuss the issue further if need be.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response
  10. McConnell's sign is not specific to PE nor should this finding alone prompt use of thrombolytics

    To the Authors,

    I enjoyed reading your case report. It is indeed a classic example of what appears to be massive PE with echocardiographic findings of RV dysfunction. However, I have some concerns about the learning points in your conclusion.

    1) You state that McConnell's sign is "a distinct echocardiographic feature of acute massive PE". This conclusion is misleading since McConnell's sign has been shown in case series to lack specificity. In fact, it is no better than a "coin toss" in differentiating PE from other causes of RV dysfunction (e.g. RV infarct): Casazza et al. showed a sensitivity and specificity of 70% and 30%, respectively (Eur J Echocardiography (2005) 6, 11e14). What's more, McConnell's sign does not differentiate "submassive" or "intermediate risk" PE from "massive" PE. This clinical distinction is based on the presence of hypotension/shock (Journal of Intensive Care Medicine 26(5) 275-294)

    2) You state that thrombolytics should be given in acute PE when this sign is found. What is the evidence for this firm recommendation? McConnell's sign can also be seen in "sub-massive" or "intermediate risk" PE, which is not associated with shock or hypotension. In fact, 90% of the normotensive patients in the series you cite by Grifoni et al. did well in the short term with conventional therapy. Furthermore, we know from the recent PEITHO trial that thrombolysis for this category of patients might have a benefit but with significant risk of major bleeding (N Engl J Med 2014; 370:1402-1411). The decision to use thrombolytics should be a careful, individualized decision. On the contrary, in cases of massive PE (defined by shock, hypotension), thrombolysis is indicated and not based at all on echocardiographic findings.

    The learning points in your case report overly simplify 2 important steps in a nuanced clinical algorithm: the interpretation of McConnell's sign and the decision to use thrombolytics in VTE.

    Conflict of Interest:

    None declared

    Read all letters published for this article

    Submit response

Register for free content

The full text of all Editor's Choice articles and summaries of every article are free without registration

The full text of Images in ... articles are free to registered users

Only fellows can access the full text of case reports (apart from Editor's Choice) - become a fellow today, or encourage your institution to, so that together we can grow and develop this resource

Don't forget to sign up for content alerts so you keep up to date with all the case reports as they are published, and let us know what you think by commenting on the Editor's blog