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Recent eLetters

Displaying 1-10 letters out of 276 published

  1. Imaging In Vertebral Artery Dissection

    Thanks for reporting this interesting case of VAD. The clinical versatility of this pathology calls for careful history taking and examination to avoid the pitfall of inappropriate imaging requests for patients who present with craniocervical pain with or without headache.

    The presence of new neurological deficits such as those described in the case report would certainly warrant urgent imaging. In the absence of these,strong clinical concern by itself may not be enough but should be supported by significant risk factors to justify imaging,this would protect patients from undue radiation exposure and its inherent risks,as some institutions tend to conduct a CT-brain prior to MRA. Thank you

    Conflict of Interest:

    None declared

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  2. Author Reply

    I thank Drs. Onder and Jahanroshan for their interest in this report. They raise excellent points. A video would have added a great deal, however I was unable to locate proxies to consent for such a recording during the time of what was a short lived tremor. An EEG done prior to the appearance of the tremor showed global slowing with no epileptiform activity. I can't exclude self limited hypoxia prior to being found but his oxygenation was monitored and adequate at least from when he was found breathing until after resolution of the tremor. Priopriospinal myoclonus is certainly a consideration, though the explanation is not parsimonious. Phenotypically, the tremor was nearly identical to the cited report of the rest tremor in brain death which did include a video. Specifically, it involved rhythmic finger flexion/extension with a pill rolling quality which would have been unremarkable in a person with idiopathic Parkinson disease. Regards, Laura S. Boylan, MD

    Conflict of Interest:

    None declared

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  3. Cure?

    I am always happy to see treatments that avoid medicines.

    On the other hand, I am always sad to see that "cured" is not defined, and as a result it is not possible to claim a cure for diabetes - not even possible to know if a specific case, or a specific treatment, is moving closer to cured, or farther away from cured.

    When cured is defined, independent of treatment, we will be able to find cures. Until then, all research is questionable.

    Conflict of Interest:

    Author of: A Calculus of Curing I blog about healthicine.

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  4. dr

    Dear Sir, Though the authors claim that there was heterotopic pregnancy ideally they should have done a curettage to prove chorionic villi from the intrauterine pregnancy. The sac demonstrated in the uterus could be pseudo sac. Without a clear evidence of villi in both sites, this will be wrong message. The drop in the beta hCG can be a lab error or rupture of the ovarian ectopic

    Conflict of Interest:

    None declared

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  5. An excellent paper, but some further details would be useful

    An excellent paper! I think it would be useful if the authors explained if the patient was exposed to sclerogenic dusts, both in occupational and non-occupational scenarios.

    Conflict of Interest:

    None declared

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  6. Abstract should indicate the type of turmeric supplement

    Was this supplement a turmeric powder, simple water extract, or the highly concentrated standardized turmeric extract with 95% curcuminoids made using a hexane or organic solvent? This can be an important determinant for causing liver toxicity.

    Conflict of Interest:

    Work for supplement industry

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  7. Response to case report; cephalad migration of externally powered spinal cord stimulator.

    Sirs, As a neuromodulator and instructor with extensive (30 year) experience with both "wired " and "wireless " systems, I feel compelled to repond to the conclusions of the cited case report.

    While the authors mention lead migration as an known complication of spinal cord stimulation, it is useful to consider that Cameron (1) cited 361 lead migration events in 2753 patients , a 13.2% incidence. Anderson (2) , in his report of spinal cord stimulation for angina pectoris, found lead migration to be the most frequent complication requiring reoperation (23%), an incidence verified by North. This is not the first case report of cephalad lead migration, although less common than caudal migration. McGreevy and colleagues (3) at Johns Hopkins reported a case of cephalad lead migration from T9 vertebral segment to T1 two weeks postoperatively. The Titan (Medtronic) anchor was sutured to lumbosacral fascia with a strain relief loop (SRL). An additional SRL was placed beneath the implanted IPG. This issue is not confined to percutaneous cylindrical leads, as significant cephalad paddle -lead migration has also been reported (4).

    A multitude of published research has confirmed that spinal cord stimulation is indeed a safe procedure (5). The author performing the procedure (MF) states that "this was the implanters first experience with this (wireless) device". I can personally attest that implanting the StimWave system is distinctly different in many respects, than competing "wired " systems. When teaching physicians , I continually stress these differences. The manufacturer recommends anchoring either with traditional sleeve anchors, or their proprietary Sandshark anchor. In addition, a knot is to be tied in the lead distal to the last mark . A separate subcutaneous incision (0.5cm) is made to secure the distal lead tip to the subcutaneous fascia. There is no indication that the author followed these recommended techniques. The authors also relate " challenges with connectivity and aberrant programming". I was informed personally that the StimWave engineer was able to obtain connectivity and paresthesia mapping at the non-migrated lead, hoever the patient expressed a preference for the "wired " system rather than the "wireless" external system. I concur with the authors recommendations for locking anchors and silicone elastomer adhesives. . I strongly disagree with the assertions made that this case "demands more research into the safety of externally powered devices". I have successfully implanted this system for three years ,without any lead migration, as have countless physicians worldwide. ]The proper conclusion of this report should be that this new wireless spinal cord stimulator system is distinctly different than previous wired systems, requiring proper triaining, strict adherence to recommended operative techniques and implanter experience. It is unfortunate that the authors first case utilizing this system was unsuccessful, however , their contention that these systems are unsafe is completely unfounded.

    Sincerely, George J.Arcos D.O.,FAOCA

    1) Safety and efficacy of spinal cord stimulation for the treatment of chronic pain; A 20-year review. Cameron,T J Neurosurg (Spine3) 100:254-267 2004 2) Anderson C Complications in spinal cord stimulation for the treatment of angina pectoris. Acta Cardiologica 52:35-39 1995 3)McGreevy K, WilliamsKA,Christo PJ Cephalad lead migration following spinal cord stimulator implantation Pain Physician 2012 Jan-Feb; 15(1): E 79-87 4) DiSanto S, Ravera E Significant cephalad laddle lead migration after lumbar spinal cord stimulator implant. Neuromodulation 2014 Jun ;17 (4): 385 5) Bendersky D, Yampolsky C Is Spinal cord stimulation safe? World Neurosurg 2014 Dec; 82(6): 1359-68.

    Conflict of Interest:

    No stock or investment ownership. Senior Consultant for BSC and StimWave.

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  8. Re:Case report should be withdrawn

    Thankyou to Professor Bewley and colleagues for their comments.

    We agree with many of the concerns raised and want to point out it is essential to read and interpret this article for what it is - a case report. As has been rightly pointed out, it is therefore only anecdotal and is the lowest grade quality of evidence.

    Our intention in writing this article is merely to point out a temporal association between taking curcumin and the patient's disease entering a quiescent and stable phase. But this is prone to many confounding factors and like any case report, has severe limitations. The only conclusion that can be drawn from this case is that further studies are needed to establish whether curcumin is indeed beneficial for myeloma.

    The media response has been disproportionate and regrettable. We believe the article did use cautious language but for further clarity: In no way do we endorse the use of curcumin in Myeloma, either in addition to and especially not in place of established therapy. There is insufficient evidence to support this, doing so can be potentially dangerous and it can come at significant financial cost to patients.

    The article should not be removed as we maintain there is still an important observation to be noted - but this needs evaluation in the context of a clinical trial.

    Conflict of Interest:

    None declared

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  9. Bleach is not sodium hydroxide

    I have seen now that a correction was asserted. It is not satisfactory on its face for two reasons.

    The first is that my criticism of the report was not acknowledged for pointing out that the original claim was of swallowing a bleach tablet, which meant that treatment could be understood as inappropriate or inadequate.

    The second is that a "correction" that ascribed the problem as that the patient ingested a 3.5g(!) tablet (!) of sodium hydroxide clarifies little or nothing.

    1. Sodium hydroxide does not appear as "tablets" in any pharmacopoeia of which I am aware. I will withdraw my objection if there is such with documented reference. 2. The article still refers to the treatment of bleach ingestion without addressing the chlorine content thereof, thus misunderstanding the key point I made in my previous email, and misses the value I brought to the discussion. 3. "Prilled" sodium hydroxide, the only type of lye of which I am aware might remotely be thought a "tablet" is typically 0.1 g in size, not 3.5g (35 times a prilled version!). Nor would such a material be near the counter of a random patient where it might be mistaken for a tablet (if I may hone the point a bit).

    I believe that there should be more explained about this unfortunate event, that my email should be published for consideration by other experts, and that the modality of treatment should be better addressed by the physicians.

    Conflict of Interest:

    None declared

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  10. Response to e-letter

    We sincerely thank the technical product manager of ACCU-CHEK Performa (Roche) for going through our article entitled 'Erroneously elevated glucose values due to maltose interference in mutant GDH-PQQ based glucometer, Chakraborty PP, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-219928 with interest. We provide our response to the issues raised by our learned colleague.

    Regarding the removal of maltose-containing infusion tube from the intravenous cannula by the patient himself; yes, it is unacceptable but probably not that uncommon in real life. It is possible for an extremely agitated patient experiencing respiratory distress to remove the IV line himself if left unattended for fraction of a second without waiting for medically trained staffs to do their jobs. They have also expressed their concerns regarding measurement of capillary glucose from an uncleaned hand. In an intensive care setting, it may not be possible to "wash the hands in warm, soapy water. Rinse and dry completely" before checking capillary blood glucose in a patient who is actively seizing or having altered sensorium as instructed in the package insert of ACCU-CHEK Performa.

    The package insert of ACCU-CHEK Performa categorically mentions about the elevated levels of galactose (>15mg/dl or >0.83 mmol/L), triglycerides (>1,800mg/dl or >20.3 mmol/L) , ascorbic acid (>3mg/dl or >0.17mmol/L), haematocrit (should be between 10-65%) that may cause erroneous glucose values. It has pointed towards "clinically relevant maltose interference" without mentioning the concentration of maltose known to be associated with such interference.

    This e-letter has discussed issues, which had already been focused in our article. The probable reasons of erroneous capillary glucose values, the difference of capillary glucose values between right and left hand fingertips, the blood level of maltose which is unlikely to cause such interference have already been highlighted in our article.

    Sir, what we have discussed in our article is exactly what we had experienced in our clinical ward rounds. We strongly believe proper protocol has to be followed in each and every step and this article is definitely a "reminder of important clinical lesson" of violating the basic principles. We do not have the intention to spread false information related to any manufacturing company & we do not endorse such ideas ever. Having said that, we strongly believe that the package insert of ACCU-CHEK Performa should specify the maltose concentration that may cause overestimation of blood glucose.

    Conflict of Interest:

    None declared

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