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Recent eLetters

Displaying 1-10 letters out of 214 published

  1. Anisakidosis as an emerging problem

    A relevant warning, particularly in front of an Anisakis' wide diffusion outside its traditional environment as a consequence of global warming.

    Nowadays, Anisakis is frequently present in anchovies, sardines and mackerels in Northern Mediterranean too, causing infestations after consuming uncooked or half-cooked fish.

    It is very difficult to recognize Anisakidosis if the suspect doesn't arise and this paper is very useful for increasing awareness of the problem.

    Conflict of Interest:

    None declared

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  2. Mouthpiece intermittent positive pressure ventilation: An old yet underutilized technique for long-term management of respiratory muscle failure.

    Dear Authors,

    We applaud your recognition that daytime mouthpiece intermittent positive pressure ventilation (IPPV) can serve as a practical alternative in cases of end stage respiratory muscle failure in which tracheostomy is usually the eventual conventional intervention of choice among the majority of today's clinicians. Lack of familiarity indeed seems to be the reason open-circuit mouthpiece ventilation, among other interfaces for IPPV, remains infrequently used among physicians today, despite first being described as an alternative to tracheotomy decades ago. In 1953 Dr. John Affeldt reported his experience working with polio patients with little to no vital capacity--how a simple mouthpiece attached to a positive pressure ventilator was able to provide ventilatory support for patients both during the day and while asleep.1 The application of mouthpiece rather than invasive IPPV for patients with neuromuscular disease (NMD) respiratory failure was greatly facilitated by the advent of portable positive pressure ventilators in 1957, the Puritan Bennett lip seal in 1964, nasal and oral-nasal interfaces after 1985, and mechanical in-exsufflation (MIE) devices in 1993.2, 3 While the on-demand mouthpiece mode (2013) for the Trilogy ventilator may represent the latest technologic development in mouthpiece IPPV, its earliest, far more simplistic predecessors, such as the Zephyr positive pressure blower (early 1950s), Monaghan portable respirator (1953), Thompson Bantam (1956), and Bird Mark 7 (commercially available 1958) have all been used to the same effect, to free polio and other NMD patients from negative pressure ventilators and tracheostomy mechanical ventilation.4,5,6

    Regarding the superiority of volume and pressure targeted modes, we prefer volume cycling since only it permits active lung volume recruitment (air stacking) that serves to maintain or improve lung compliance, permits effective coughing without personal assistance, increasing voice volume, etc., for those with glottis function.7 We only resort to pressure cycling when patients experience significant discomfort from abdominal distension.

    As you mentioned in your review there is now extensive literature on the success of up to continuous long-term mouthpiece IPPV in regimens of noninvasive ventilatory support but it should certainly not be viewed as a novelty considering its description in 1953 and its use by 257 patients described in 1993. Rather, the challenge is to break the paradigm that tracheostomy is required for ventilatory support for people with NMD or spinal cord injury.8 Current obstacles to implementing this management strategy today include abundance of nuisance alarms on commercial ventilators without mouthpiece ventilation modes and reimbursement for this type of "novel" care.9,10 Most importantly, continued lack of physician familiarity directly contributes to candidates missing out on this potential option to their long-term care.

    References

    1. Affeldt J. Round Table Conference on Poliomyelitis Equipment; Roosevelt Hotel, New York City; May 28-29, 1953. Sponsored by the National Foundation for Infantile Paralysis, Inc.

    2. Bach JR, Tuccio MC. Respiratory physical medicine: Physiatry's neglected discipline. Am J Phys Med Rehabil 2011;90(2):169-174.

    3. Garuti G. et al. Open circuit mouthpiece ventilation: Concise clinical review. Rev Port Pneumol. 2014;20(4):211-18.

    4. Gilgoff IS. The Breath of Life: the Role of the Ventilator in Managing Life-Threatening Illnesses. Lanham, MD: Scarecrow Press; 2001.

    5. Copyright Office, The Library of Congress. Catalog of Copyright Entries, Third Series: 1953: July-December. Vol 7. Washington;1954.

    6. Kacmarek RM. The Mechanical Ventilator: Past, Present, and Future. Respir Care 2011;56(8):1170-80.

    7. Bach JR, Mehta AD. Respiratory muscle aids to avert respiratory failure and tracheostomy: a new patient management paradigm. Journal of Neurorestoratology. 2014;2:25-35.

    8. Bach JR, Alba A. Intermittent positive pressure ventilation via the mouth as an alternative to tracheostomy for 257 ventilator users. Chest 1993;103:174-82.

    9. Khirani S, Ramirez A, Delord V, et al. Evaluation of ventilators for mouthpiece ventilation in neuromuscular disease. Respir Care 2014;59:1329-37

    10. Carlucci A, Mattei A, Rossi V, Gregoretti C. Ventilator settings to avoid nuisance alarms during mouthpiece ventilation. RespCare 2015;61(4):2-6.

    Conflict of Interest:

    None declared

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  3. Trousseau's sign at the emergency department

    The Trousseau's sign as described here is usually indicative of Hypocalcemia as was evident in this patient. However its sensitivity as well as specificity may not be that high as referred in the case report. It can be induced by hyperventilation leading to respiratory alkalosis even in so called normal healthy persons. This patient did have hypocalcemia as well as hypomagnesemia and hypokalemia in addition all probably partly because of acute kidney injury. She had gastric malignancy as well which could have contributed to development of the electrolyte and calcium imbalance. She could also be having paraneoplastic syndrome as well. It was unfortunate that the patient did not agree for further evaluation. The management in such patients should include treatment of the basic cause in addition to replacement of the deficient electrolytes and Vit D .

    Conflict of Interest:

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  4. Case of CML lymphoid blast crisis presenting as bilateral breast masses

    This is an interesting case. However the postulation proposed by the authors that a case of CML going into blast crisis of Lymphoid variety appears to be slightly far from reality. Knowing that haemopoetic stem cells can develop in any cell variety it is possible that the cells described could morphologically resemble Lymphoblasts but are in fact better labeled as Undifferentiated Blasts. The patient had many symptoms of underling rapidly progressive malignant process although her basic disease of CML may have gone unnoticed for quite some time as she might not be aware of the growing size of the Spleen since we do not pay attention to our tummy size in general as compared to size of the breasts in particular. Leukemic deposits an various tissues including skin and orbits are very well known to develop during blast crisis in case of AML and the blastic transformation of the CML. The prognosis for such patients is less favourable compared to usual CML patients.

    Conflict of Interest:

    None declared

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  5. Haemophilia A related haematoma. management in resourse constrained settings

    Haemophilia A is not so uncommon in India but perhaps remains unnoticed or non cared for because of the non availability of the replacement therapy or the cost factors for the therapy. This patient appears to have a milder form of the condition as no mention has been made about the frequency with which he requires the replacement of factor VIII, although it has been mentioned that at some stage the levels were less than 1%. There has been no reference as to how frequently during 24 hours the FFP was transfused. Perhaps the levels of factor VIII during the current episode was not very low and was sufficiently corrected by the volume of FFP by the care takers. It should be noted that if the hospital /clinic has the facility to prepare the FFP the blood bank can easily prepare Cryoprecipitate that can be used for replacement of the factor VIII. The methodology of preparation of the same is very simple and is now available at many centres. The use of a synthetic drug 8DDAVP can also be considered in the management of such patients, although the cost of this drug also will be a limiting factor. The frequency of spontaneous bleeding becomes less and less as these patients become older and of course they become self informed as to how to avoid the injuries.

    Conflict of Interest:

    None declared

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  6. Successful treatment of recurrent rectal prolapse using three Thiersch sutures in children

    We read with interest the article from Chauhan Kashif et al, entitled "Successful treatment of recurrent rectal prolapse using 3 Thiersch sutures in an 8-year-old boy" [1] and would like to add some comments. The authors proposed a novel technique of Thiersch procedure using three sutures that included one non absorbable polypropylene suture to successfully treat a re-recurrent full-thickness rectal prolapse in an 8- year-old boy. It is important to specify in the title and background that the various options proposed by the authors to treat rectal prolapse and recurrent rectal prolapse are described in children, as other procedures are available in adults, namely the Delorme procedure and the Altemeier procedure. Moreover, injection sclerotherapy and Thiersch wire are no longer used for total rectal prolapse treatment in adults. The authors should explain the aetiology of the full-thickness rectal prolapse; they mention some kind of constipation and a Rassmussen syndrome. Do they think the chronic constipation and dyschezia were responsible for the anatomical abnormality? If yes, how do they explain that the treatment of the prolapse improved the transit time? If not, what was the cause of the prolapse? Is it part of the syndrome? The original description of the anal encirclement by Thiersch and following authors [2] involved a non absorbable material (silver wire, fascia strips, nylon strips, etc). The first and second surgical treatment of the patient in this paper included injection of 5% phenol almond oil and insertion of 1/0 PDS suture around the anal canal. As this single circumferential suture is made of absorbable material, it is not surprising that a recurrence occurred 3 months later, which is about the delay for PDS absorption in both operations. Moreover, successful outcome following the third operation may have happened because of the use of one non absorbable, polypropylene suture. One could argue that only one non absorbable suture might have been sufficient to successfully treat the patient, and that the 2 absorbable PDS sutures were unnecessary. Therefore, the procedure described in the paper is not really a novel technique, but the true Thiersch procedure. We also miss some details from the hospital stay. Did the young patient suffer from the operation? Did he experience some bleeding? Was he given some kind of regimen? Painkillers? Antibiotics? How long did he stay in hospital? Lastly, 6 months follow-up to ensure absence of recurrence is probably too short. Dealing with functional disorders such as rectal prolapse, one should wait at least 5 years to consider the surgical treatment is efficient and stable with time [3]. References 1. Chauhan K, Gan R, Singh S. Successful treatment of recurrent rectal prolapse using 3 Thiersch sutures in children. BMJ Case Rep. 2015 Nov 25;2015. pii: bcr2015211947. doi: 10.1136/bcr-2015-211947. 2. Devesa JM, Hervas PL, Vicente R, Rey A, Die J, Moreno I, et al. Anal encirclement with a simple prosthetic sling for faecal incontinence. Tech Coloproctol 2011;15:17-22. 3. Faucheron JL, Trilling B, Girard E, Sage PY, Barbois S, Reche F. Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results. World J Gastroenterol 2015;21:5049-55

    Conflict of Interest:

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  7. Opportunity for a "one health" approach overlooked?

    To Whom It May Concern

    "Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly"1 describes an excellent outcome thanks to an elegant diagnostic work up and excellent treatment. However, I believe the headline "Lick of death" is unnecessarily fear-mongering and unwarranted (the patient, after all, did not die). Additionally, while the authors should be congratulated for educating practitioners about C. canimorsus, I feel there is scope for discussion with veterinarians to reduce further risk to this and other patients.

    The authors conclude that the source of the patient's infection was the owner's own dog, via a lick, on the grounds that Capnocytophaga canimorsus was isolated from that patient, that it is a zoonotic organism and that the patient admitted to being licked by the dog. My understanding is that this conclusion is based on findings that C canimorsus colonises the mouths of dogs and cats. This seems reasonable though for the sake of completeness and illuminating our understanding of this condition I feel it would have been helpful to examine and test the dog, and here there is scope for veterinary input2.

    As the authors note, the elderly rely on companion animals. Could C canimorsus be isolated from the oral cavity of the patient's Italian greyhound? Was the dental and periodontal health of the dog assessed? What measures could be taken to reduce the risk of exposure, apart from avoiding being licked by the dog? A recent UK study found that 9.3 per cent of dogs suffered from periodontal disease3. What we don't know is whether regular dental scaling may reduce carriage of C canimorsus.

    Another question, perhaps to be answered by veterinarians, is whether the patient's comorbidities contributed to the licking by the dog? Companion animals may alter behaviour in response to owners, and may engage in licking or biting as an attempt to rouse owners with a reduced state of consciousness4. In fact, licking behaviour was performed by 50 per cent of seizure response dogs when owners suffered seizures5. (It is important to note that while licking may be detrimental, seizure response dogs can save lives - in the previous study, one dog brought the cordless phone, another rolled the owner, who had a history of aspiration pneumonia, onto their side, and yet another turned off the electric wheelchair as several accidents had occurred during seizures).

    Human animal interactions are complex, involving mutual benefit as well as potential risks to both parties. This complexity demands a genuine 'one health' approach. Discussion of the role of the dog in this case with a veterinarian may help illuminate and reduce animal-based risk factors.

    Sincerely,

    Anne Fawcett

    References

    1. Wilson JP, Kafetz K, Fink D. Lick of death: Capnocytophaga canimorsus is an important cause of sepsis in the elderly. BMJ Case Reports 2016;2016. 2. Speare R, Mendez D, Judd J, et al. Willingness to Consult a Veterinarian on Physician's Advice for Zoonotic Diseases: A Formal Role for Veterinarians in Medicine? Plos One 2015;10(8):8. 3. O'Neill DG, Church DB, McGreevy PD, et al. Prevalence of Disorders Recorded in Dogs Attending Primary-Care Veterinary Practices in England. Plos One 2014;9(3):16. 4. Seligman WH, Manuel A. The cat and the nap. Medical Journal of Australia 2014;200(4):229-29. 5. Kirton A, Winter A, Wirrell E, et al. Seizure response dogs: Evaluation of a formal training program. Epilepsy Behav 2008;13(3):499-504.

    Conflict of Interest:

    I am a companion animal veterinarian and co-habit with companion animals.

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  8. 7q11.23-q21.2 microdeletion: 2 years follow-up

    As reported in the original article, the developmental assessment at 13.5 months (adjusted for prematurity) showed a global developmental delay.

    Bayley III assessment at 24.8 months (adjusted for prematurity) confirmed the global developmental delay affecting cognitive, communication and motor domains (percentile ranks: 0.4, 4, 0.4, respectively). The passive tone of his upper extremities was symmetrical bilaterally, but with mild hypotonia.

    His mother also reported two major episodes of generalised tonic-clonic seizures requiring attendance to hospital and referral to epilepsy clinics.

    Conflict of Interest:

    None declared

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  9. Gastrointestinal bleeding secondary to trimethoprim-sulfamethoxol induced vitamin K deficiency

    The combination of trimethoprim and sulafamethoxole has been used for the prophylaxis of malaria for over several decades. While the development of vitamin K deficiency due to this drug combination is theoretically possible, it is not very common. There are many risk factors for vitamin K deficiency, such as diet, interactions with other drugs and basic liver function. To state that this drug combination caused vitamin K deficiency in the patient is presumptive. Other factors may have lead to reduced levels of vitamin K in this patient. Furthermore, to state that the patient developed GI bleeding secondary to vitamin K deficiency is speculative. The use of this drug combination for the prevention of malaria is important for those residing in these endemic areas and for those intending to travel to these areas.

    Conflict of Interest:

    Nil

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  10. Spleen and gone? An interesting case of fever in a young man

    The spleen can become infected as a result of septicemia, especially in immunodeficient patients. On some occasions, it can also get infected in immunologically competent patients. The spleen is known to undergo infarction in situ and may subsequently become infected. In addition, it could undergo sequestration and get infected under a variety of situations, without producing any significant symptoms and clinical findings. It is therefore not surprising to note that there was no palpable splenic mass before the radiological investigations revealed an abscess in the splenic region. The repeat admission and drainage of the collection of pus occurred because the patient may have been discharged too early and could have been avoided. Most of these patients require treatment with high doses of broad spectrum antibiotics for a sufficient duration. A possibility of accessory spleen also needs to be considered. A primary source of infection needs to be established. The prognosis is good for most immunologically competent patients as long as the usual precautions are taken after splenectomy.

    Conflict of Interest:

    None declared

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