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Recent eLetters

Displaying 11-19 letters out of 268 published in the last 9999 days

  1. 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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  2. 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 Several papers from this author were withdrawn in or about 2012 as possibly fraudulent (3), casting doubt on his authority.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?

    References

    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. http://bit.ly/2AHTN20 (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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  3. Re:excellent%20paper%2C%20something%20useful%20to%20add%20towards%20a%20full%20comprehension%20of%20this%20case

    Thank you for your suggestion to add other risk factors the patient could have had which may have lead to his diagnosis. According to the records, the patient did have exposures to both radiation and petroleum.

    Conflict of Interest:

    None declared

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  4. LA clot in Severe Mitral stenosis

    Varying sizes and quality of clots are seen in severe rheaumatic mitral valve stenosis, especially in Asian subcontinent. LA clots are also found in patients with non-valvular atrial fibrillation, but to a lesser extent as compared to rheumatic valvular disesase and are seen more in the advanced world. The clots can be fresh ones or multilayered organised clots or a mixture of the two. In severe mitral stenosis, because of the obvious stasis of blood in LA, there are high possibilities of clot formation, and this is seen more so in the Indian subcontinent due to poor patinet compliance with anticoagulation therapy and this is a major issue in the management of patients with rheumatic mitral stenosis.This leads to various complications such as Stroke, TIA, and embolisation to various other systemic organs and lower limbs ausing ischemia. It is important to treat these patients as an urgent case for LA clot removal and Mitral valve repalcement along with surgical management of lower limb ischemia.

    Conflict of Interest:

    None declared

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  5. excellent paper, something useful to add towards a full comprehension of this case

    I deeply appreciated the excellent description and discussion of the case in this paper. I would suggest one more piece of information to be given to the readers; not only genetic factors play a relevant role in the male breast cancers' web of causation but some, mainly occupational, exposures do too. I would therefore find it useful to know which work the patient practised, and if this occupation involved exposure to high levels of heat (e.g. in consequence of being assigned to an industrial oven). Yours sincerely Roberto

    Conflict of Interest:

    None declared

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  6. Nerf gun eye injuries

    We read with interest this case series having seen several nerf gun eye injuries in our own department. A search of the electronic patient records revealed 17 such cases since 2014. Of these 12 were male and 5 female with 9 under the age of 18. Analysis of the primary injury revealed 5 hyphemas, 5 cases of traumatic iritis, 2 corneal abrasions, 1 case of commotio retinae and 1 case of angle recession with the risk of glaucoma.

    In addition this placed an additional strain on an already stretched eye casualty as many of the patients required treatment with an average of 3 visits with 1 patient requiring 8 visits.

    We therefore support the authors call for patients and parents to be aware of the types of 'bullets' used and to use eye protection to prevent significant eye injuries.

    Conflict of Interest:

    None declared

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

    I greatly appreciate the well-advised comments from the reader on my case report, ''Fatal air embolism following local anaesthetisation: does needle size matter?''. (1) They discuss the significance of proper positioning prior to performing the biopsy. While having the appropriate hemithorax in ipsilateral-dependent position certainly minimizes the motion and reduces the risk of air embolism as the core biopsy needle traverses the lung parenchyma; our case report was meant to emphasize the risk of air embolism during the administration of local anesthetic where the needle typically does not penetrate any significant portion of lung parenchyma. Since 25-gauge needle is very small and usually not linked to air embolisms, we discussed that all the risk factors (including improper positioning) that are associated with air embolism during core biopsy are applicable to smaller Lidocaine needle as well. In our patient, it is likely that positioning in addition to negative intra-thoracic pressure generated by patient's cough resulted in air embolism.

    1. Khalid F, Rehman S, AbdulRahman R, Gupta S. Fatal air embolism following local anaesthetisation: does needle size matter? BMJ Case Rep. 2018;2018.

    Conflict of Interest:

    None declared

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  8. Kite surfing: epidemiology of trauma: literature review methods

    I read with interest Dunne et al's paper kite surfing: epidemiology of trauma. They state that 'a comprehensive review of EMBASE, PubMed and Google Scholar was conducted' and that 'the search strategy included medical subject headings (MeSH) kitesurf/kitesurfing/kitesurfing hip/kitesurfing pelvis/kitesurfing fracture/kitesurfing injury'. At the time of writing, (3 April 2018) none of these terms may be found in the MeSH thesaurus (https://meshb.nlm.nih.gov/search), and MeSH terms would not, in any case, have helped in a search of EMBASE or of Google Scholar. Existing papers in MEDLINE on kite surfing injuries have been indexed with the term Athletic Injuries, and no subordinate terms yet exist. A more productive strategy might have been to search titles and abstracts using the strings kite* ADJ3 surf* OR kitesurf*. A search using these strings on the HDAS interface finds 29 results in MEDLINE and 33 in EMBASE. A more elaborate strategy for the other concept in the search, that of pelvic and acetabular fractures is certainly possible using a combination of controlled vocabulary and natural language terms.

    Conflict of Interest:

    None declared

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  9. 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.

    Conflict of Interest:

    None declared

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