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Recent eLetters

Displaying 11-20 letters out of 212 published

  1. BESS ( benign enlargement of subara chnoid spaces)

    The authors rightly mention in their case report that it is not an uncommon finding in normal infants who are referred to the paediatrician because of large head size or a rapid increase in OFC. My concern is that the patient 1 in the case report may send a wrong message to the trainees or other doctors that CT head is the primary mode of imaging in such cases because of high dose of radiation involved with a CT. Most of them can be confirmed /recognized by a cranial ultrasound which can be easily performed even in a district general hospital setting and followed up by a repeat U/S if necessary, as the anterior fonatenelle is open in a large number of cases at that age. A CT or MRI should be needed rarely unless we have a case like patient 2 in the case report with head injury or suspicion of non accidental injury etc.

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  2. Oscillicoccinum has no benefit for influenza - it's inactive

    The authors make a claim that the patient developed angioedema following ingestion of oscillococcinum, a homeopathic "remedy" used for treating influenza symptoms. The authors claim that evidence of benefit exists to claim that this preparation has proven clinical activity. Unfortunately, they omit to use up-to-date information to base this claim on. The most recent Cochrane review (1), published January 2015 and authored by two well-known homeopaths concluded "There is insufficient good evidence to enable robust conclusions to be made about oscillococcinum in the prevention or treatment of influenza and influenza -like illness. Our findings do not rule out the possibility that oscillococcinum could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to oscillococcinum." The second problem with this report is the constituents of the oscillococcinum remedy itself. It is based on a preparation of Barbary duck heart and liver, misinterpreted by French physician Joseph Roy of a preparation of blood samples from victims of Spanish Flu towards the end of World War 1 (2). The preparation is supplied in the form of lactose pills onto which the remedy has been dripped. The solution dripped onto the pills has been diluted to the homeopathic "potency" of 200C. This involves serial centessimal dilutions to a factor of 200. This means that it is not possible to find a single particle or molecule of the original starting material in the final diluted solution. Serial dilution beyond the 12C "potency" exceeds Avogadro's constant. Dilution to 200C means that you could search the entire known universe and still fail to find a single entity from the starting material! (3) Their patient would appear to have had an allergic response to something, but if it is the pills he took, then it could only be the lactose, which is possible but unlikely. This therefore begs the question as to what the patient actually had the allergic reaction to? He should undergo a formal allergy review by a specialist, possibly including formal testing to work out what the allergy really is.

    1. http://www.cochrane.org/CD001957/ARI_homeopathic-oscillococcinumr- for-preventing-and-treating-influenza-and-influenza-like-illness 2. http://www.homeowatch.org/history/oscillo.html 3. https://www.sciencebasedmedicine.org/homeopathy-as-nanoparticles/

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  3. Not all ST - T & QRS complex changes are myocardial injury.

    I completely agree with the authors in saying that all ST-T changes are not myocardial injury.

    In my experience, not all new widened QRS complex changes (LBBB) indicate myocardial infarction or injury.

    I would like to say this on the basis that quite a few times, a patient with new wide QRS complex and bradycardia is referred to cardiology to rule out myocardial infarction and after investigations patient is found to have severe hyperkalemia and with ARF or an undiagnosed and progressive CKD. After immediate correction of hyperkalemia with glucose -insuln infusion, and intravenous Normal saline, and inj. frussemide in non-oliguric patients, the ECG changes revert back to normal.

    It's important to take ST-T changes on ECG seriously, but also have to look at clinical signs and symptoms and investigations to ascertain myocardial injury especially in emergency situations.

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  4. NG tube insertion - to be taken seriously

    Insertion of the nasogastric tube is taken very casually at the medical graduate level.

    In my opinion , insertion of NG tubes should be done very judiciously and gently in an awake patient.

    Points to note --

    1) Insert the tube very gently in the backwards and downward direction in the nostril, to avoid inadvertent damage of the roof of the nasal cavity, and passage of the tube intracranial.

    2) The tube should pass in without any resistance, in case of any undue resistance, please take it out and insert again.

    3) The NG tube be confirmed by auscultation on the epigastrium by inflating air with a 20 cc syringe.

    4) The patient can have cough while insertion, but this has to subside after few minutes, if cough persists, then it is very important to confirm the proper positioning of NG tube with the 4 point test mentioned in the case report.

    5) Its also important to insert the tube gently as it can cause trauma and bleeding especially in patients on antiplatelets/anticoagulants.

    In conclusion, insertion of NG tube is a routine procedure done in the hospitals,but it needs due diligence and good practice.

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  5. Preprocedure/pre tracheostomy USG-- is it beneficial /conclusive.

    I agree with the concept of a pre-tracheostomy USG to visualize the neck veins in case of a percutaneous tracheostomy.

    But I have to 2 points against --

    1) I believe percutaneous tracheostomy is still not a routine method of choice in elective tracheostomy in difficult surgical scenario like - short neck, restricted extension, double chin, big pad of neck fat and especially if patient is sick, as the risk of loosing control of airway or bleeding complications can be significant.

    2) How far the USG will be able to show small abnormal midline neck veins, on a regular basis, and that's the reason why about 50 % of intensive care doctors do not use it as a routine screening before tracheostomy.

    I would still stress on the use of USG for screening of abnormal neck veins in case of difficult surgical scenarios, as mentioned above especially in sicker patients who are to undergo surgical or percutaneous tracheostomy.

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  6. Chloroquine induced bilateral anterior shoulder dislocation: a unique etiology for a rare clinical problem

    It is an interesting hypothesis to put forward. The bilateral dislocation of shoulder simultaneously is not very common especially if there has been no episodes of tonic clonic convulsions. However it is very difficult to associate this with the administration of Chloroquine is far fletched and in fact could be incidental. The mechanism of action of Chloroquine in the management of the basic disease does not indicate any relationship fo the drug with the clinical picture and such hypothesis need not be put forward

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  7. concurrent cryptococcal meningitis and disseminated tuberculosis occuring in an immunocompetent male

    Cryptococcal meningitis used to be quite common in immunocompromised patients, like those with HIV, before the availability of effective HRT for the same. We have seen and managed quite a number of such patients in the last decade of the last century. The prognosis used to be universally poor for these patients. Similarly, we came across disseminated cryptococcosis in immunocompetent patients as well. Some of them had tuberculosis, which happens to be still quite common in developing and underdeveloped countries. A duel treatment for both conditions offers the best possible prognosis for such patients. The fungus is widely spread in nature and a person can get infected and develop the manifestations, especially if he or she has another disease like tuberculosis or diabetes. One needs to be thinking of the possibility of more than one infection even if the patient is otherwise immunocompetent.

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  8. Uncommon mycosis in a patient with diabetes

    Disseminated cryptococcal infection in immunocompromised patients, such as those with HIV, used to be quite common. We have seen and reported a series of patients with cryptococcal meningitis and HIV in the late nineties of the last century, before the availability of effective HRT. The prognosis used to be universally poor. Some of our patients were likely to be immunocompetant since they did not have HIV. These patients mostly had disseminated tuberculosis or diabetes. Some of them did recover from the cryptococcosis, until they returned for follow up. With the availability of effective HRT for HIV, now the main factor for disseminated mycosis will be diabetes, as in the case report. The authors need to be complemented for the effective management in this case.

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  9. Hypokalaemia and drinking green tea - animal study shows potential potassium sparing potential

    I read with great interest the thought provoking article by Chong et al.[1] about the potential association between hypokalaemia and excessive green tea intake with or without concomitant medications. I would like to highlight the findings from an Indian animal study on rats [2] which found that green tea extract (GTE) in both high and low doses has significant diuretic activity with increased urinary sodium (Na+) excretion but without causing significant urinary potassium (K+)loss. In fact when it was combined with hydrochlorothiazide (HCT), a thiazide diuretic, GTE significantly reduced urinary potassium loss compared to treatment with HCT alone. The authors argued that this might be due to the angiotensin converting enzyme (ACE) inhibition effect of GTE leading to a reduction in aldosterone activity and increased potassium retention.

    The findings from this animal study are relevant given that patient 1 in Chong et al.'s case report who was on bendroflumethiazide had asymptomatic mild hypokalaemia which was only picked up by routine screening despite taking similar excessive amounts of green tea to his wife (Patient 2) who was not on a diuretic. It is possible that the reason why his serum potassium level was not significantly different from his wife's was because of the reduced renal K+ loss due to a combination of bendroflumethiazide and green tea.

    The mechanism by which green tea might induce hypokalaemia is clearly complex. Chong et al. give a very important warning for patients who are prescribed medications that can lower serum potassium about this risk. I think doctors who prescribe potassium lowering medications also need to be aware of the potential potassium sparing effect of green tea from thiazide diuretic induced hypokalaemia demonstrated in the Indian animal study. Obviously larger controlled studies are required to further clarify whether there is a causal relationship between excessive green tea intake and hypokalaemia.

    References 1. Chong SJK, Howard KA, Knox C. Hypokalaemia and drinking green tea: a literature review and report of 2 cases, BMJ Case Reports 2016:published online 16 Feb 2016, doi:10.1136/bcr-2016-214425

    2.Chakraborty M, Kamath JV, Bhattacharjee A. Potential Interaction of Green Tea Extract with Hydrochlorothiazide on Diuretic Activity in Rats, International Scholarly Research Notices, vol. 2014, Article ID 273908, 5 pages, 2014. doi:10.1155/2014/273908

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  10. Is skeletal flourosis?

    Thank you for this interesting report. Please check for skeletal fluorosis also given amount of tea consumed per day over so many years.

    Thank you

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