Recent eLetters

Displaying 11-20 letters out of 276 published in the last 9999 days

  1. Case report should be withdrawn

    Dear Editor


    Case report should be withdrawn

    HealthWatch UK is a charity that promotes ‘science and integrity in medicine’, values we might all expect to be shared by the BMJ and all its subsidiary journals. Accordingly, we ask you to think again about the Publishing Executive’s response (1) to the e-letter submitted by our colleague Les Rose (2) regarding a report by Zaidi et al. (3) about curcumin as a treatment for myeloma.


    We regard the response as unsatisfactory because:


    1. Zaidi et al. had little regard for the extensive published research on the medicinal chemistry of curcumin. Their conclusion made a clear case for the clinical use of curcumin in myeloma, when it would have been far more appropriate to call for rigorous clinical trials. The BMJ was wrong to say the language they used was ‘cautious’.


    2. Zaidi et al. have not responded to Rose and their use of citations of research by an investigator whose related research has been retracted was not commented upon (1). This should have been detected both by reviewers and editors and should have been put right.


    3. It is poor judgment for BMJ Case Reports to deny responsibility for claims in other media – especially when our complaints to the BBC were rebutted by the justification that this was a peer-reviewed publication. Journal executives must know that such claims will be amplified by the lay media, especially when they are unusual and thus newsworthy. Indeed, journals often issue press releases for this purpose. Editors therefore have an obligation to ensure that peer review is rigorous and claims in published papers are made responsibly.


    4. While case reports have a role in medicine, they are no more than a suggestion of where proper research should next be carried out. It is not appropriate even to suggest that a treatment should be prescribed on the basis of anecdote.

    For all these reasons, HealthWatch UK considers that this report should be withdrawn and an editorial should be published explaining the reasons.


    Susan Bewley, Professor of Women’s Health, Kings College London, Chair of HealthWatch UK Nick Ross, writer, campaigner and broadcaster Roger Fisken, consultant physician (retired)


    On behalf of the Board of Trustees of HealthWatch UK.




    (1) Thomas J. Association is not Causation.

    (2) Rose L. Association is not Causation

    (3) Zaidi A, Lai M, Cavenagh J. Long-term stabilisation of myeloma with curcumin. BMJ Case Reports 2017: published online 16 April 2017, doi:10.1136/bcr-2016-218148

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  2. The importance of proper hygiene in self-monitoring of blood glucose

    Authors: Sami Wardat, PhD, MBA(1), Oliver Hauss, PhD(2), and Rolf Hinzmann, MD, PhD(1)

    Dear Editor,

    Partha Pratim Chakraborty and Shinjan Patra recently reported on a potential risk for patients welfare from maltose interference with glucose measurements in their case report 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.

    The authors are concerned that patients on maltose-containing therapies may receive an excessive dose of insulin due to falsely elevated blood glucose readings, leading to a hypoglycemic episode, and that, likewise, cases of hypoglycemia might not be treated if patients hypoglycemic states are masked by false blood glucose measurements.

    Our review of this case reports circumstances indicates that the situation described is highly unusual and based on violation of proper protocol on multiple levels.

    As for the course of events, the patient removed a maltose-containing infusion tube from the intravenous cannula himself. This is clearly not in line with the standards of medical practice and carries itself a significant risk to the patients safety. The removal of intravenous (i.v.) tubes should be left to properly trained medical personnel to avoid injuries. The infusion solution subsequently contaminated the patients left hand and a glucose measurement was taken from that very hand, without it being cleaned first. Our instructions for performing a blood glucose test for consumers clearly instruct patients to wash and dry their hands prior to using the lancing device (See Accu-Chek Performa manual page 10 available for India at ). We instruct healthcare practitioners to follow their institutional policies and assume these would suggest comparable standards of contamination prevention.

    As a result of violating proper medical procedures on two levels, the glucose measurement device was exposed to 10% maltose solution, which contains 100 mg/mL maltose, i.e. 10 000 mg/dL = 100 g/L or 320 mmol/L. This is around 30 times higher than the maltose concentrations tested in the clinical evaluation report on Accu-Chek Performa (400 mg/dL or 11.7 mmol/L). Thus, the interference should not come as a surprise and is to be expected.

    The 100 mL of i.v. human immunoglobulin (IVIG) solution provided would have been administered in a short time frame of 15 to 30 min (based on the dosage indication for PlasmaGlob, which is 1.2 mL/kg of bodyweight, and on the assumption that the patient weighs around 80-85 kg). This would mean that roughly 200 mg/dL of maltose could be expected in the blood circulation, which would normally not result in interference with the mutant GDH-PQQ enzyme in the test strips.

    Furthermore, the situation is also not specific to maltose and the sensitivity to maltose interference of the enzyme used: if we assumed that the solution contained glucose, then the reading of any device, even one without sensitivity to maltose interference, would still show a false high concentration due to the undiluted solution present on the hands, thus preventing accurate measurement of the concentration within the circulating blood.

    The 50% difference between the heavily contaminated left hand and the right hand, which was likely only cross-contaminated, indeed points to external contamination as the key factor in the observation.

    The failure to heed the instructions concerning basic hand washing can hardly be seen as a significant risk posed by the product itself. It should be clear that blood should only be drawn from clean hands to prevent cases of cross-contamination.

    Therefore, we do not mandate any further steps other than strongly appealing to both patients and medical personnel to abide by our instructions to wash their hands before obtaining capillary blood and by general protocol, which would have been sufficient to prevent this course of events.


    Roche Diabetes Care GmbH
    Global Medical & Scientific Affairs
    Sandhofer Strasse 116
    68305 Mannheim / Germany

    Dr. Hauss Training & Consulting
    Lorscher Str. 24
    67133 Maxdorf / Germany

    Conflict of Interest:

    Sami Wardat and Rolf Hinzmann are employees of Roche Diabetes Care GmbH. Oliver Hauss is an independent consultant contracted by Roche Diabetes Care GmbH

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  3. Response to eletter

    Vishal Gupta 1 , Aakash Pandita 2

    1. Neonatology, Max Hospital, New Delhi, India.

    2. SGPGI, Lucknow, U.P, India

    We thank the reader for appreciating our work. The said patient was worked up for ARC syndrome and mutational analysis was done from outside as the primary care center does not have these facilities. The patient got the genetic analysis done from outside laboratory and came with the final reports during the last follow up. The mutation was noted in the case sheet and patient was asked to be on regular follow up. However, the patient did not report after that and was lost to follow up. We would have liked to share further details of the mutation but the contact could not be established. Furthermore, the patient as per clinical does does qualify for the ARC syndrome with supportive laboratory evidence.

    Conflict of Interest:

    None declared

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  4. Arthrogryposis, renal dysfunction and cholestasis (ARC) syndrome: a rare association with high GGT level and absent kidney.

    Dear Sir/Madam This is a potentially interesting report suggesting unusual features such as high GGT and absent kidney present in a clinically diagnosed case of ARC syndrome. Whilst this finding might be of interest to Paediatricians and Neonatologists, the author do not provide any evidence that their diagnosis is factually correct. They write that the VPS33B sequencing was suggestive of a mutation but no report of the mutation is in evidence. It is disappointing that in 2018 BMJ can publish such case reports, which I would not expect of a reputable journal. Unfortunately, this is most unhelpful and probably a misleading way to report clinical cases and in my opinion a corrigendum should be provided with definitive mutation data if this report to remain published at all. WIth respect

    Paul Gissen

    Conflict of Interest:

    None declared

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  5. Bleach is not sodium hydroxide

    The article starts as a report of ingestion of sodium hydroxide tablet and all but one reference within it is to sodium hydroxide.

    The single reference to bleach is the reason for my letter. It is not clear to me that anyone would have large tablets of sodium hydroxide (usu prilled pellets are <<1g), and I confess that solid bleach tablets are not an item I have used. I presume such would be to sanitize a dishwasher.

    That said, sodium hypochlorite (bleach) has a pKa of ~7.5, so a reference to the pKa of sodium hydroxide may not be warranted.

    There is no doubt that solid bleach would do what was described, imo, but some of the complications (lung irritation eg)may have arisen from the release of chlorine (if it was indeed bleach the patient ingested), and the concomitant inhalation.

    I thought clarification would be useful, and that the potential for chlorine ingestion/inhalation might be discussed by the physicians to keep in mind should such a case arise again.

    Conflict of Interest:

    None declared

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  6. Analysis of Synthetic Cannabinoids

    Was the substance that this patient was found with sent to an analytic organic chemist to identify the specific chemical moeties present? Synthesis of cannabinoids can result in a product that has radically different pharmacologic properties than the desired compound. The classic example is Ecstacy. Distillation at the wrong temperature, just a few degrees off, results in a total body paralysis drug. In the presented case it may be anything from an impure drug to co-synthesis of the Dextro and Levo forms of the active agent. For instance Levo-methadone is an opiate effective against nociceptive pain while Dextro-methadone is an NMDA antagonist effective against neuropathic pain.

    We really need to identify the specific agent that causes the cardiovascular effects. If street chemists are manufacturing synthetic cannabinoids we need to identify the specifics in order to identify the product (urine drug screen?), look for the specific pathologic effects in patients presenting with atypical symptoms, and hopefully develope a treatment protocol to minimize any damage.

    Conflict of Interest:

    None declared

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  7. Re-Shoulder pain in smokers

    Intersting case with missed clinical data. The available photos of the patient showed abnormal craniofacial contour. The head seems long and narrow with a possibility of a compensatory growth might occured in the antero-posterior direction resulted in a scaphocephalic like skull. The bi - temporal narrowing with narrow frontal area, deep-seated eyes, widow peak with dense eye browes and abnormal length of the nose are features of a possible craniosynostosis? This patient needs a comprehensive clinical and radiological phenotype study. Tumours are not uncommon outcome in patients with syndromic entities.

    Conflict of Interest:

    None declared

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  8. Optic nerve involvement in Acute Lymbhobastic Leukaemia , more than what meets the eye

    Acute Lymphoblastic Leukaemia can affect the eye in various ways . It may present with an ischaemic optic nerve involvement (1) or optic nerve swelling due to direct involvement . But sometimes it may also present as an optic nerve involvement as an effect of a drug like Linezolid which has been used for treatment of infections which coexist (2) or it may present as an infiltration of the nerve in combination with herpes virus (3)

    Though papillodema is the most frequent sign of optic nerve involvement it can be absent in direct infiltration of the nerve by leukemic cells, or present just due to increased intracranial pressure , or swelling because of retrolaminar leukemic invasion.

    The involvement in invasion of the optic nerve usually occurs during the evolution of acute lymphoblastic leukemia, but that , when as is elucidated in the present case and also by Mess et al earlier in 2003, is the first sign of acute lymphoblastic leukemia or of extramedullary relapse after remission , it usually means a poor prognosis for the patient, especially if it happens when the patient is still receiving treatment, rather than after it. And so earlier it is picked up, the better .Hence the value of a routine check even in absence of symptoms .

    Optic nerve swelling may mean many things and one needs to differentiate the causes of the optic nerve swelling clinically and with non invasive tests like Ocular coherence tomography ( OCT ) so as to institute proper therapy . Optic nerve involvement, as one needs to emphasise again , is not always a result of leukaemia infiltration as a surprise in remission . Sometimes Peripapillary retinal leukemic infiltration may be associated with papilledema in a patient without cranial or optic nerve involvement.(4) . Optic nerve swelling may be seen due to optic neuritis (5) which can be seen sometimes in cases of leukaemia without leukaemic infiltration .Sometimes the peri neuritis may be transient (6) Papillodema due to central nervous system involvement may be seen .Medications used for treatment may sometimes cause secondary optic nerve affectation and may include but be not limited to toxicity of chemotherapy, antibiotics or radiotherapy, ischemia after anaemia or hyperviscosity, and opportunistic infections in immunocompromised patients. In such cases to figure out whether the optic nerve involvement is indeed direct infiltration one may look for other layers of eye being involved . (7) So if there are other layers involved there is a clue and an eye surgeon will pick it up because conjunctival , scleral and trabecular involvement is characteristic

    But in a case where optic nerve alone is involved one can use OCT to figure out what's hapenning at the optic nerve level. The swelling begins not at superior or inferior edge of the optic nerve as in papillodema due to raised intra cranial pressure and "doesn't follow ISNT rule " ( that's a rule in glaucoma where loss occurs in that order but sometimes swellings occur in similar way ) and also one doesn't see a typical swelling of optic neuritis then it's obvious that a lot of clues are waiting to be picked up

    The present case report helped us manage a case locally and so we are thankful to the authors and the journal for the same

    The optic nerve is relatively unaffected by systemic chemotherapy and serves as a sanctuary of ALL.(8) So it is probably essential that an eye surgeon opinion is sought regularly since there's a lot they can tell , lots more than meets the non ophthalmologist's eye .

    Reference :-

    1) Chaudhuri T, Roy S, Roy P. Ischaemic optic neuropathy induced sudden blindness as an initial presentation of acute lymphoblastic leukemia. Indian J Med Paediatr Oncol 2013;34:335-6

    2) Joshi L, Taylor SRJ, Large O, Yacoub S, Lightman S (2009). A case of optic neuropathy after short-term linezolid use in a patient with acute lymphocytic leukemia. Clin Infect Dis 48:73-74. ISSN 1537-6591.

    3) Bhatt UK, Gregory ME, Madi MS, Fraser M, Woodruff HA (2008). Sequential leukemic infiltration and human herpervirus optic neuropathy in acute lymphoblastic leukemia. Journal of AAPOS 12:200-202. ISSN 1528-3933.

    4) ?eki? O, Biberoglu E, Esen F. Peripapillary retinal leukemic infiltration associated with papilledema in a T-ALL patient without cranial or optic nerve involvement. Tumori. 2016 Nov 11;102(Suppl. 2). doi: 10.5301/tj.5000490

    5) Yo Han Ra, Sun Young Park, Soo Ah Im, Jee Young Kim, Nak Gyun Chung, Bin Cho. Enhancement of Optic Nerve in Leukemic Patients: Leukemic Infiltration of Optic Nerve versus Optic Neuritis.iMRI 2016;20:167-174.

    6) Townsend JH, Dubovy SR, Pasol J, Lam BL. Transient optic perineuritis as the initial presentation of central nervous system involvement by pre-B cell lymphocytic leukemia. J Neuroophthalmol 2013;33:162-164

    7) Rosenthal AR. Ocular manifestations of leukemia. A review. Ophthalmology 1983;90:899-905

    8) Ninane J, Taylor D, Day S. The eye as a sanctuary in acute lymphoblastic leukemia. Lancet. 1980;1:452-3.

    Conflict of Interest:

    None declared

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  9. Re:Association is not causation

    BMJ approached the authors for their comments, but did not receive a response. This case was reviewed by two external peer reviewers prior to publication. It uses cautious language throughout and correctly offers no definitive conclusions. BMJ Case Reports is not responsible for claims made in other media.

    Conflict of Interest:

    I am the Publishing Executive for BMJ Case Reports

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  10. Association is not causation

    Zaidi et al conclude that "Dietary supplements, such as curcumin, may be beneficial for some myeloma patients". This is on the basis of their single case report; in other words it is an anecdote. In contrast, the medicinal chemistry of curcumin has been studied in depth for many years. Nelson et al conclude that, despite over 120 clinical trials, no beneficial effect has been observed (1).

    I am wondering about how rigorous was the peer review of this case report. Did the reviewers evaluate what was the more likely explanation, in the light of the published literature?

    I note that Zaidi et al cite a review by Aggarwal et al in 2009 (2). Several papers from this author were withdrawn in or about 2012 as possibly fraudulent (3), casting doubt on his authority. I do not think this oversight reflects well on the authors of the present case report, or on its reviewers.

    This case report has recently attracted substantial attention from the lay media. Exaggerated claims have been made on national radio. Yet there is good evidence that cancer patients who rely on alternative treatments such as plant extracts have worse outcomes (4). Was it really responsible of the BMJ to publish this report in its present form?


    1. Nelson KM, Dahlin J, Bisson J et al. The Essential Medicinal Chemistry of Curcumin. J Med Chem. 2017 Mar 9; 60(5): 1620-1637.

    2. Aggarwal BB, Harikumar KB. Potential therapeutic effects of curcumin, the anti-inflammatory agent, against neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases. Int J Biochem Cell Biol 2009;41:40-59.

    3. Ackerman T. M.D. Anderson scientist, accused of manipulating data, retires. Houston Chronicle, March 2, 2016 Updated: March 4, 2016. (accessed 8th Jan 2018)

    4. Johnson SB, Park HS, Gross CP et al. Use of Alternative Medicine for Cancer and Its Impact on Survival. Journal of the National Cancer Institute, Volume 110, Issue 1, 1 January 2018

    Conflict of Interest:

    I have had smouldering myeloma for nine years but have not required treatment.

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