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Displaying 11-20 letters out of 259 published in the last 9999 days

  1. Is cold only a biting bystander in this story?

    I have several points about this interesting case report.

    1/ The first point that surprised me is this: apparently, this patient has had neither at the end of the procedure nor after an intercostal infiltration with long-acting local anaesthetic drug

    2/ Then this could have helped in both diagnosis and treatment. The disappearing or alleviation of pain would have clearly identified the intercostal nerve injury and even broken the vicious circle of chronic pain if it had been done early after the onset. It would have also allowed an earlier onset of physiotherapy and potentially avoided such a risky and aleatory end for this chronic pain

    3/ About the mechanistic hypothesis Intercoastal nerve injury in thoracoscopy procedures is dependent on technique, size of the device and skill of the surgeon. It is a rather frequent complication of those procedures and prevention is key. It is mainly based on a surgical approach just at the upper edge of the rib in order to avoid any damage to the vessels which lead to a haematoma compressing the nerve or directly to the nerve

    4/ chronic pain is a neurobiological issue (https://www.ncbi.nlm.nih.gov/pubmed/12931188) which is the result of a persistent lesion of a peripheral nerve. Complex neurologic and epigenetic mechanisms are at the root of chronic pain and personal traits are associated to the development of chronic pain (https://www.ncbi.nlm.nih.gov/pubmed/16355225)(https://academic.oup.com/brain/article/137/3/724/389996). In my experience, one of the worst treatment for chronic pain in a thoracic surgical incision is systemic opioids (https://journals.lww.com/painrpts/Fulltext/2017/03000/Postoperative_pain_from_mechanisms_to_treatment.1.aspx). In this setting it is probable that strong and fast movements during the short swim can have released some local fibrous tissue in the wound and that a severe stress can have interrupted the vicious circle of chronic pain which is dependent on a central thalamic role (https://www.jscimedcentral.com/Neuroscience/neuroscience-5-1075.pdf)

    5/ Is cold a biting bystander in this case? We know on the contrary that cold could lead to neuropathy in case of chronic cold but non-freezing exposure(https://academic.oup.com/brain/article/140/10/2557/4100656). When cold is used for neurolysis it is with a cryoprobe and temperatures at the tip of the probe which is in contact with the nerve (CT guided procedure) is minus 50 Celsius. It is clear that the swimming episode did not reach this range of temperature.

    This case report is clearly mysterious and in absence of imagery and testing of the nerves, it is at odd to conclude of any direct action of cold water immersion on neuropathy.

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  2. Mitral stenosis - still a challange with a myriad of features,

    Rheumatic heart disease leading to mitral stenosis is seen more often in the developing countries than in the developed world. The patients are quite asymptomatic at rest until the 2nd or 3rd decade, when they may present with various signs and symptoms like dyspnoea on exertion, palpitations, easy fatigebility, dizziness, coughing up blood, chest pain or discomfort, and swelling in legs and upto 15% of patients may present with signs of systemic emboli as a first sign like transient ischemic attack, stroke, or suddden pain in abdomen due to gut ischemia or a renal infarct. Embolic phenomenon are seen in mitral stenosis patients with atrial fibrillation, but sometimes even patients in sinus rythm may present with clinical features of sytemic emboli.

    In the above case, a young women presented with a history of parasthesia and dysarthria, for the first time. Given that she was a young Mexican lady, a high level suspicion should have been on the cardiac origin of emboli and along with CT brain to rule out stroke , a 2-D cardiac echo study would have been very useful to rule out any emboli in the left heart. The echo would have given the appropriate diagnosis and guided the proper anticoagulation therapy and a further mitral valve replacement as the final treatment. In conclusion, a young patient presenting with a TIA/stroke/hemiparesis needs a thorough assessment of the source of the systemic emboli and thus a very high level of suspicion for cardiac origin.

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  3. Comment to "Fatal air embolism following local anaesthetisation: does needle size matter?

    I read with interest your case report (1), however I have to make the critical comment, that patient position in your case indeed was one essential factor of air embolism. You attempted to biopsy a lung nodule of the left lower lobe in dorso- lateral position with patient placed in prone oblique position on the right side. You should have placed patient in ipsilateral-dependent position, in other words on the side of the nodule, which is the left side! Only in this position the motion of the appropriate hemithorax is reduced and only in this position the biopsy can be performed below the level of the left atrium. Or, as we have stated in our paper (2), "lateral lesions can be biopsied in supine position or from the back in ipsilateral dependent position"

    Best regards, Gernot Rott

    1. Khalid F, Rehman S, AbdulRahman R, Gupta S: Fatal air embolism following local anaesthetisation: does needle size matter? BMJ Case Reports, February 2018, 2018:bcr-2017-222254 2. Rott G, Boecker F: Influenceable and avoidable risk factors for systemic air embolism due to percutaneous ct-guided lung biopsy: patient positioning and coaxial biopsy technique-case report, systematic literature review, and a technical note. Radiol Res Pract 2014;2014:1-8.

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  4. No Incision No Drainage

    It has been known for years that kerion celsi can be misdiagnosed as bacterial infection and that incision and drainage is not only unnecessary but inappropriate treatment. (See these: Journal of Pediatric Surgery Volume 42, Issue 8, August 2007, Pages e33-e36; Feetham JE, Sargant N Kerion celsi: a misdiagnosed scalp infection Archives of Disease in Childhood 2016;101:503; and finally British Association of Dermatologists' guidelines for the management of tinea capitis 2014)

    Unfortunately this case report leaves the impression that I&D of "scalp abscesses" was necessary and appropriate treatment. It is so widely recognized that surgical treatment of these cases is not necessary, it is not always mentioned in guidelines.

    It would be wise to include an editors comments along these lines or perhaps suggested further reading?

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  5. Letter to the Author: response to "Multidisciplinary approach to the management of a case of classical respiratory diphtheria requiring percutaneous endoscopic gastrostomy feeding"

    Dear Editor,

    We read with interest the work by Haywood et al.[1] dealing with the treatment of a 67 years old Caucasian woman with a 4-day history of sore throat, dysphagia, fever and nasal blockage. During the examination it was revealed a swollen neck and pharyngeal pseudomembranes, positive on culture for Corynebacterium ulcerans after a throat swab, with toxin expression confirmed on PCR and Elek testing. The patient was diagnosed of classical respiratory diphtheria, and the diagnosis was later confirmed on the patient's domesticated dog, which was thought to be the source of infection. The dog had recently been attacked by a wild badger and was being treated for an ear infection. The patient made a good recovery with intravenous antimicrobial and supportive therapy; however, she subsequently developed a diphtheritic polyneuropathy in the form of a severe bulbar palsy with frank aspiration necessitating percutaneous endoscopic gastrostomy feeding. A mild sensorimotor peripheral neuropathy was also diagnosed. The patient eventually made an almost complete recovery.

    Zoonotic infections are defined, in general, as infections transmitted from animal to man (and, less frequently, vice versa), either directly (through direct contact or contact with animal products) or indirectly (through an intermediate vector, such as an arthropod)[2]. Zoonotic disease may affect ENT districts. Unfortunately, literature is often limited to single case reports from different countries and does not allow adequate appreciation of the problem.

    Otorhinolaryngologists often lack in-depth knowledge of zoonotic diseases, which complicates etiological identification and treatment and control strategies.

    In our study we already considered, examining a total of 164 articles, that larynx was the most commonly involved ENT organ. Otherwise, bacteria were the most representative microorganisms involved[2]. As read on another study examined by us, a Corynebacterium ulcerans infection can be responsible for a more aggressive involvement of the ENT district, being capable of involving the total upper airway[3], with the subsequent need to ensure a proper nutrition via a percutaneous endoscopic gastrostomy feeding, as Haywood at al. did facing their case[1].

    Another interesting thing to point out is that the ENT manifestations in most of the zoonoses are often produced in immunosuppressed patients, being responsible of disseminated forms which can lead to death rapidly if misdiagnosed[1]. Albeit this, We want to point out, thanks to the work of Vlachogianni et al., a case in which a zoonotic infection caused by Mycobacterium avium was diagnosed in an immunocompetent 78 years-old woman. She presented with a 6-month reddish, oedematous and painless lesion with fine scaling in the right ear. Histology showed numerous granulomas, composed of epithelioid histio-cytes without central necrosis. Cultures grew Mycobacterium avium. An unusual accidental ear injury was the portal of microbial entry. The patient's lesion fully regressed after a 9-month course of antibiotics[4].

    This two cases brought to Our attention the fact that the kind of diseases are still of difficult diagnosis for most of the ENT specialists, and need to be more pointed out by the Scientific Community, paying particular attention during the anamnesis.

    1. Haywood MJ, Vijendren A, Acharya V, Mulla R, Panesar MJ. Multidisciplinary approach to the management of a case of classical respiratory diphtheria requiring percutaneous endoscopic gastrostomy feeding. BMJ Case Rep. 2017 Mar 6;2017. pii: bcr2016218408. doi: 10.1136/bcr-2016-218408.

    2. Galletti B, Mannella VK, Santoro R, Rodriguez-Morales AJ, Freni F, Galletti C, Galletti F, Cascio A. Ear, nose and throat (ENT) involvement in zoonotic diseases: a systematic review. J Infect Dev Ctries. 2014 Jan 15;8(1):17-23. doi: 10.3855/jidc.4206.

    3. Aaron L, Heurtebise F, Bachelier MN, Guimard Y. Pseudomembranous diphtheria caused by Corynebacterium ulcerans. Rev Med Interne. 2006 Apr;27(4):333-5. Epub 2006 Jan 6.

    4. Vlachogianni P, Volosyraki M, Stefanidou M, Krueger-Krasagakis S, Evangelou G, Haniotis V, Kofteridis D, Maraki S, Krasagakis K. Mycobacterium avium Auricular Infection in an Apparent Immunocompetent Patient: A Case Report. Folia Med (Plovdiv). 2016 Apr-Jun;58(2):131-5. doi: 10.1515/folmed-2016-0012.

    Conflict of Interest:

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  6. Endoscopic assisted Small Incision corneal reinnervation reduces vascularisation when combined with Keratoplasty and Gold weight implant

    Cases with combined facial nerve and trigeminal nerve involvement do present with complex issues as elucidated by Allevi et al (1) . This article helped us immensely in managing our case and we are grateful to the authors and the journal.

    A male patient suffering from fifth nerve and seventh nerve palsy presented to us with similar issues with severely vascularised hypertrophic insensitive bulging cornea with zero corneal sensations on anaesthesiometer .

    Leyngold et al (2) (3) suggested endoscopic approach with scalp incision and Bains et al (4) suggested a microincision approach.We combined these approaches and did a corneal trasplant as well, as we had no option since the cornea would otherwise perforate

    The facial palsy was treated with gold weight implant and corneal insensitivity with reinnervation and opacity with keratoplasty. Corneal reinnervation was done with a different combined approach and we did a small microincision surgery with endoscopical help , but did not take the scalp incision and instead anastomoses was done on one side with the contralateral supraorbital and supratrochlear nerve and the other end of the sural nerve graft was tunnelled from contralateral side to the ipsilateral side ,along the line connecting the eyebrows on either side ,and then across the ipsilateral eyelid , between the gold weight implant and the medial horn of leavator palpebrea superioris and then tunnelled subconjunctival as well as subtenons and after being dissected into fascicles , the fascicles were inserted into four scleral tunnels and sutured intrascleral. We got good short term result at two months and corneal sensations have returned and we await long term results before publishing the case . But in the interim we realised that we did see some findings which could help others in the interim , like we were helped by this article .

    The corneal vascularisation reduced markedly as the corneal nerves started growing and sensations returned ad the patient started feeling the eyedrops and actual complained of pain !The palisades of Vogt thickened and pigmentation was seen migrating into the cornea and corneal vascularisation was seen reduced significantly in areas where the pigmentation advanced into the cornea . There was no ptosis which we had expected since we thought the levator would be damaged during the procedure.

    Corneal innervation is known to be necessary to maintain stemness of stem cells and in the cornea nerves and neovessels are hypothesised to inhibit each other (5) but we saw this clinically with areas of corneal vascularisation disappearing as the corneal nerves grew and sensations returned.

    We thank all authors for the techiniques and would want to point out that journals like British Journal of Case Report with its open access policy and speedy publication of recent advances , need to be applauded for such articles which help us in the developing countries help our poor patients with the latest advances as soon as they occur.

    References :-

    1) Allevi F, Fogagnolo P, Rossetti L, Biglioli F. Eyelid reanimation, neurotisation, and transplantation of the cornea in a patient with facial palsy. BMJ Case Reports. 2014;2014:bcr2014205372. doi:10.1136/bcr-2014- 205372. 2) Leyngold I, Weller C, Leyngold M, Espana E, Black KD, Hall KL, Tabor M.Endoscopic Corneal Neurotization: Cadaver Feasibility Study. Ophthal Plast Reconstr Surg. 2017 May 2. doi: 10.1097/IOP.0000000000000913. 3) Leyngold I, Weller C, Leyngold M, Tabor M. Endoscopic Corneal Neurotization:Technique and Initial Experience. Ophthal Plast Reconstr Surg. 2017 Nov 27. doi: 10.1097/IOP.0000000000001023 4) Bains RD, Elbaz U, Zuker RM, Ali A, Borschel GH. Corneal neurotization from the supratrochlear nerve with sural nerve grafts: a minimally invasive approach. Plast Reconstr Surg. 2015 Feb;135(2):397e-400e. doi:10.1097/PRS.0000000000000994. 5) Ferrari G, Hajrasouliha AR, Sadrai Z, Ueno H, Chauhan SK, Dana R. Nerves and neovessels inhibit each other in the cornea. Invest Ophthalmol Vis Sci. 2013 Jan 28;54(1):813-20. doi: 10.1167/iovs.11-8379.

    Conflict of Interest:

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  7. Regarding Artery of Percheron Infarction

    Sir, Its with interest that I read the small and crisp description and medical images related to Artery of Percheron infarct.

    The diagnosis of this condition indeed is sometimes difficult and requires clinical suspicion accompanied by proper radiological imaging.

    What i would also like to highlight is the fact that its not only the imaging modality i.e MRI which is required,or the sequence DWI/ADC which is also important, the imaging machinery should also be optimal i.e a magnetic strength of at least 1.5 tesla or higher.

    I emphasize this point because many MRI machines in the Indian context are suboptimally designed to pick up these important but often small lesions and prescribing physicians often donot have the proper knowledge and thus fail to arrive at a proper diagnosis.

    Thanks and regards,

    Dr Deep Das Consultant Interventional Neurology Kolkata, West Bengal, India

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  8. Perforation of Umbilical artery during insertion of UAC

    I would like to congratulate and thank you for taking the courage in publishing this case report for the benefit of the neonatal trainees and all neonatologist in general. I am not surprised that there aren't more case reports published as such cases tend not be published because of general feeling of guilt for negligence and not exposing the hospital for fear of bad name as the outcome is very poor as you rightly pointed out. I am personally aware of few such incidents from different hospitals though not directly involved in the care .Also because of the poor outcome and distress which these incidents cause to the family there is reluctance to get consent . Health industry is a risky business and specially in the neonatal units due to our heroic efforts to save the tiny babies unavoidable complications can occur.There is also an incessant desire to succeed in performing procedures on the part of the junior doctors, so more than acceptable attempts are seen in general to be made with different procedures like intubations , long line insertions,umbilical catheterizations etc, which increase the chances of undesirable outcomes. This can be witnessed in all the units from time to time which increase the chances of undesirable outcomes and if the doctors share such experiences then the wider doctor's community can benefit from other people's experiences in reducing the incidences of undesirable outcomes and thus help the babies /patients ultimately with a more positive experience .

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  9. Comment on the paper "Transient global amnesia following a whole-body cryotherapy session"

    Dear Editor,

    We read with interest the case report concerning a transient global amnesia (TGA) in an individual who was previously submitted to a session of whole body cryotherapy (WBC).1

    The scientific literature is already sufficiently wide to realize that the WBC is a safe procedure, while it could seem apparently dangerous due to very low temperature of the air used in the chambers during treatment.2 Only burns owing to sweat or water traces are reported as adverse events, considering some pathological, universally accepted, conditions as exclusion criteria for the treatment.3-9

    It is possible that some rare adverse events are neither known nor described in literature, thus possible pathological modifications of metabolism or behaviour can be important. However, in the case report,1 in order to build on a robust hypothesis about WBC-induced TGA, we believe that additional findings are needed. The patient previously underwent to WBC, thus the direct cause-effect relationship is in doubt; we outline that a standard treatment is based on two or three weeks (10-15 sessions). Moreover, the type of treatment should be more deeply detailed: was that a classical cryochamber doing a whole-body treatment or, instead, a cryosauna which is used to treat the body but the head; in the latter case the nitrogen could partially escape possibly causing nervous symptoms.

    The anamnestic evaluation lacks of drugs eventually taken by the individual and of mental reactivity and cognition evaluation, in order to exclude early sign of cognitive impairment due to Alzheimer or similar diseases. Furthermore, since the speculative association between WBC and TGA, it should be also taken into account the possible side effects (i.e., amnesia) of the proton pump inhibitors (PPI, e.g., omeprazole), taken by the patient, which were previously reported by Fireman et al.10 More recently, Feng et al. also reported about the psychotic symptoms of dissociative disorder, including amnesia, in a patient treated with clarithromycin and the PPI rabeprazole.11 Hence, if cold could be a risk factor for TGA, as reported by the authors,1 also the PPI use cannot be excluded as a potential trigger.

    The description of the case is important to outline the impact of WBC on nervous system, since this procedure is now indicated for the symptomatic treatment of nervous and psychiatric disorders, after the successful symptomatic treatment of chronic inflammatory ones.12,13 However, care should be taken in associating this universally considered safe procedure with possibly spurious, and not surely associated, adverse events.

    References

    1. Carrad J, Lambert AC, Genn? D. Transient global amnesia following a whole-body cryotherapy session. BMJ Case Rep. Epub Aehad of Print. doi: 10.1136/bcr-2017-221431

    2. Lombardi G, Ziemann E, Banfi G. Whole-Body Cryotherapy in Athletes: From Therapy to Stimulation. An Updated Review of the Literature. Front Physiol 2017;8:258. doi:10.3389/fphys.2017.00258

    3. Cholewka A, Stanek A, Sieron A, Drzazga Z. Thermography study of skin response due to whole-body cryotherapy. Skin Res Technol 2012;18(2):180-7. doi:10.1111/j.1600-0846.2011.00550.x

    4. Hausswirth C, Schaal K, Le Meur Y, et al. Parasympathetic activity and blood catecholamine responses following a single partial-body cryostimulation and a whole-body cryostimulation. PloS One 2013;8(8):e72658. doi:10.1371/journal.pone.0072658

    5. Demoulin C, Vanderthommen M. Cryotherapy in rheumatic diseases. Joint Bone Spine 2012;79(2):117-8. doi:10.1016/j.jbspin.2011.09.016

    6. Louis J, Schaal K, Bieuzen F, et al. Head Exposure to Cold during Whole-Body Cryostimulation: Influence on Thermal Response and Autonomic Modulation. PloS One 2015;10(4):e0124776. doi:10.1371/journal.pone.0124776

    7. Pournot H, Bieuzen F, Louis J, et al. Time-course of changes in inflammatory response after whole-body cryotherapy multi exposures following severe exercise. PloS One 2011;6(7):e22748. doi:10.1371/journal.pone.0022748

    8. Kruger M, de Marees M, Dittmar KH, et al. Whole-body cryotherapy's enhancement of acute recovery of running performance in well-trained athletes. Int J Sport Physiol Perform 2015;10(5):605-12. doi:10.1123/ijspp.2014-0392

    9. Schaal K, Le Meur Y, Louis J, et al. Whole-Body Cryostimulation Limits Overreaching in Elite Synchronized Swimmers. Med Sci Sports Exerc 2015;47(7):1416-25. doi:10.1249/MSS.0000000000000546

    10. Fireman Z, Kopelman Y, Sternberg A. Central nervous system side effects after proton pump inhibitor treatment. J Clin Gastroenterol 1997;25(4):718.

    11. Feng Z, Huang J, Xu Y, et al. Dissociative disorder induced by clarithromycin combined with rabeprazole in a patient with gastritis. J Int Med Res 2013;41(1):239-43. doi: 10.1177/0300060513475384.

    12. Bettoni L, Bonomi FG, Zani V, et al. Effects of 15 consecutive cryotherapy sessions on the clinical output of fibromyalgic patients. Clin Rheumatol 2013;32(9):1337-45. doi: 10.1007/s10067-013-2280-9.

    13. Bouzigon R, Grappe F, Ravier G, Dugue B. Whole- and partial-body cryostimulation/cryotherapy: Current technologies and practical applications. J Therm Biol. 2016;61:67-81. doi: 10.1016/j.jtherbio.2016.08.009.

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  10. Deaths are rare in neurocysticercosis

    I read with interest the case report about a fatal case of neurocysticercosis. I want to emphasize that deaths are rare in neurocysticercosis and in neurocysticercosis there is no malignant course. Lesion load seems to be quite low. In fact the patient not fully worked up for more likely diagnosis. For example miliary tuberculosis and miliary secondary malignancy. The CSF should have examined for malignant cells and Mycobacterium tuberculosis. X-ray chest would have revealed miliary lesions in lungs as well. Multiple tiny parenchymal rim-enhancing lesions are characteristically not seen in neurocysticercosis.

    Another point I want to mention is that neurocysticercosis can not occur via direct consumption of infected pork because a human is a definitive host and pork consumption will produce adult worms in human intestine. It will not lead to larval spread to brain.

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