eLetters

300 e-Letters

  • comment

    I would like to thank the authors of the interesting case here presented. In some instances, BCC can be devastating. I have seen a case resulting in extenteration of the right eye because of invasion of extra-ocular muscles.

    This provides everyone with an opportunity to revise the British Association of Dermatologist (BAD) guidelines for the management of BCC. Lesions of the central face, including the ears, eyes lips and nose, are at a higher risk of recurrence and should be considered higher risk. GPs should have a low threshold for referral or vigilant follow up. As a plastic surgical trainee, I commonly excise these lesions and offer a 6 months review regardless of histological clearance, particularly if the lesion of recurrent.

  • Response to the article " Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique": Not a Novel Technique

    1. We read with interest the article “Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique in your journal [1]. The authors, Gupta et al, have described the use of islanded melolabial flap for reconstruction of neopharynx after total laryngectomy. In the article, the islanded melolabial flap is presented as a novel, christened as DK Gupta flap, that compares favorably to other loco-regional and free flaps for similar reconstructions.
    2. The authors need to be commended for a well written article with clear descriptive photographs and the good clinical results obtained. However, an islanded one-stage arterialized nasolabial flap was described in 1981 by Rose [2] for the repair of the floor of mouth defect. The elliptical skin flap over the nasolabial crease was elevated between the skin and the level of buccinator, completely islanded and isolated on skeletonised facial artery and vein, exactly in the same manner as described by Gupta et al [1] in their article. The same flap, the islanded facial artery flap, with the same description of elevation was again described by Piggot in 1987 [3] in which the flap was introduced deep to the mandible for the repair of floor of the mouth defect. Even full thickness through and through islanded arterialized flap based on facial vessels that incorporates the buccal mucosa was described by Sasaki et al in 1980s for reconstructi...

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  • Simultaneous bilateral RSA

    Dear Editor, dear Authors:

    We read the case report of Wendling et al [1] with interest. We thank the Authors for sharing their experience, and we would like to congratulate with them. Even if with low-energy trauma in elderly patients, these cases are of interest because of the frequently multiple injuries and medical comorbidities that make the case difficult to treat, for the orthopedic surgeons as well as for our colleagues the anesthesiologists. We had a similar experience with a bilateral four-part fracture of the proximal humerus in a female in her late 70s, and we were able to carry out a simultaneous bilateral reverse shoulder arthroplasty (RSA) thanks to stability of vital parameters during the first procedure. Our patient was barely younger than yours, had no major medical comorbidities, and had no concomitant hip fracture: that’s the reason why we could managed a simultaneous bilateral RSA, and we published it as the first case described, to our knowledge, in Literature [2], a few weeks before you did.

    Pathology was quite similar: bilateral four-part fracture over gleno-humeral eccentric osteoarthritis in our case and left four-part posterior fracture-dislocation and right three-part posterior fracture-dislocation associated to a glenoid fracture in your case. As for indication to RSA, the correct treatment of proximal humeral fractures is still not clear, with recent meta-analysis [3] confirming prior reviews [4] about no super...

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  • Papillary Cystadenocarcinoma is a Unique Salivary Gland Tumor

    The authors state in the discussion that papillary cystadenocarcinoma (PAC) is not a rare tumor in the thyroid, ovary, or prostate. However, PAC is a unique cystic salivary gland tumor, and is not typically described in these locations1. There are few reports of PAC in the prostate, and they are possibly related to prostatic cystadenoma; however, it is not described as a salivary gland tumor in this location2. While papillary thyroid carcinomas can be cystic, the term PAC is not typically used in this location. A reference to a paper is included in the discussion afterwards, and is incorrectly cited as "papillary cystadenocarcinoma of the thyroid", when the actual article title is "papillary adenocarcinoma of the thyroid"3. Cystadenocarcinoma is a pattern described in ovarian tumors, on the other hand it is not currently mentioned in WHO classification of tumors of female reproductive organs4. Although PAC of the salivary gland is currently lumped under the heading of adenocarcinoma, NOS, survival is unique for these cystic tumors. They show rare recurrences with satisfactory surgical resection1. It should be important to acknowledge that PAC is a unique salivary gland tumor, and is distinct from cystic adenocarcinomas occurring in other organ sites.

    References
    1. El-Naggar AK, Chan JK, Grandis JR, Takata T, Slootweg PJ. WHO classification of head and neck tumours. International Agency for Research on Cancer; 2017.
    2. Lee T...

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  • Further research to achieve generalisability

    Although interesting, is a case study of three patients genuinely myth busting? Has further research been conducted in this area? My searches have only revealed aligned treatments which reduce the need for medication largely owing to weight loss (e.g. bariatric bands, ketogenic diet) but no generalisable data for fasting. I am concerned that fasting, like other rigorous dietary restrictions, is rarely sustainable and that as soon as the regime ends patients will quickly return to their previous clinical status. Furthermore, what do we know about the long-term side-effects of severely restricted dietary treatments, especially in comparison to long term medication? Signposting to other T2D fasting studies would be appreciated.

  • Botox® in the Treatment of Chronic Neuropathic Pain 


    Dear Editor,
                    in their interesting case report the authors highlight the desperation often felt by patients with intractable chronic neuropathic pain.  
    We present the findings of a single centre case review of 11 patients who lived with chronic neuropathic pain refractory to pain relief regimens for a mean of 11.8 years (range 3-16 years), 100% (n=11) of whom reported benefit following Botox® therapy. 

    Onabotulimum toxin A (Botox®) is a neurotoxin. Botox® causes muscle relaxation or paralysis via inhibition of the presynaptic acetylcholine neuromuscular junction synapse and has analgesic effects via substance P and glutamate neuroinflammatory inhibition. Botox® was first used in the treatment of strabismus in 1980 and it was licensed for use in chronic migraine in the UK in 2010.(1) Attal et al. (2016) conducted a double blind randomised control trial utilising 2 subcutaneous Botox® injections (up to 300U) vs placebo in 152 patients over a 24 week period and demonstrated a significant improvement in peripheral neuropathic pain (p=<0.0001).(2)


    The majority of our patient’s had pain secondary to trauma (55% (n=6)), 36% (n=4) secondary to systemic sclerosis and 9% (n=1) had Raynaud's disease; 90% (n=10) affecting the upper limb and 10% (n=1) the ankle. All of the patients (100% (n=11)) had Botox® therapy intraoperatively, dose range 30-100U (mean 70U) with 45%(n=5) injections administered intradermally, 18%(n=2) intraneurally...

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  • Absence of patient weight (possible major confounder)

    Dear Editor,

    Pursuant to the study methodology, I would like to comment on the use of a reduced dose of apixaban. As per literature, and according to the authors, a reduced dose of apixaban is recommended if the patient has two of three conditions (Serum creatinine ≥1.5 mg/dL, age ≥80 years of age, or body weight ≤60 kg). The authors mentioned that the patient was eligible to a full dose (5 mg twice daily) based on his age (85 years old) and serum creatinine level (1.38 mg/dl); nevertheless, they decided to use a reduced dose (2.5 mg twice daily) due to impaired renal function despite serum creatinine level did not reach the required threshold for reduction. Until this point, reader may imply that patients with old age (≥80 years of age) can use the reduced dose with similar efficacy for reducing thrombus size even if serum creatinine does not reach the set threshold that is necessary for a reduced dose. However; a major confounder was not mentioned in patient baseline characteristics which is the patient weight. If the patient weight was equal to or less than 60 KG, the patient would have been eligible to a reduced dose, which means that the result of this study would be limited to the use of the recommended dose based on age, weight, and serum creatinine rather than the treating physician discretion. Moreover, there were no referenced studies to support the non-inferiority of the reduced dose of apixaban compared to the standard dose in eligible patients, which si...

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  • What about the sugar?

    In milk, there is more sugar than fat. With 5 litres of milk, the patient would have ingested about 250g sugar. So could it be that the increase of triglycerides was due to excess sugar intake in a diabetic patient off hid medication?

  • Absence of patient weight (possible major confounder)

    Dear Editor,

    Pursuant to the study methodology, I would like to comment on the use of a reduced dose of apixaban. As per literature, and according to the authors, a reduced dose of apixaban is recommended if the patient has two of three conditions (Serum creatinine ≥1.5 mg/dL, age ≥80 years of age, or body weight ≤60 kg). The authors mentioned that the patient was eligible to a full dose (5 mg twice daily) based on his age (85 years old) and serum creatinine level (1.38 mg/dl); nevertheless, they decided to use a reduced dose (2.5 mg twice daily) due to impaired renal function despite serum creatinine level did not reach the required threshold for reduction. Until this point, reader may imply that patients with old age (≥80 years of age) can use the reduced dose with similar efficacy for reducing thrombus size even if serum creatinine does not reach the set threshold that is necessary for a reduced dose. However; a major confounder was not mentioned in patient baseline characteristics which is patient weight. If the patient weight was equal to or less than 60 KG, the patient would have been eligible to a reduced dose, which means that the result of this study would be limited to the use of the recommended dose based on age, weight, and serum creatinine rather than the treating physician discretion. Moreover, there were no referenced studies to support the non-inferiority of the reduced dose of apixaban compared to the standard dose in eligible patients, which signif...

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  • Changing perspectives on Campus; KCL

    We have read this paper; Ahmed Khaldoon Hankir et al. (2014) with great enthusiasm. We are medical students from Kings College London. We are aware that mental health disorders are a serious and widespread problem across medical schools.
    Recently, there has been a greater emphasis on mental health in medical students and is currently highest compared to previous years.

    Awareness on our campus has been mainstreamed by staff at the university, and events by societies. However, turn out at these events are discernably low, despite being publicised on the same platforms that cater to similar-sized social events. Our experience is that in a setting that is thought to be free from judgement by peers and seniors, students are still reluctant to seek help.

    One way to counter this difficulty for Kings College London, and other universities, other courses, would be to introduce a questionnaire to medical students, across the U.K, to find out what they believe are the reasons that they or their peers with mental health problems are reluctant to seek help. We think a practical way of managing this would be to implement a PALS type scheme but catered for students with mental health concerns. This one-on-one type talks can discuss aspects of stress, sleep deprivation, academic struggles that may contribute to their state. This type of help was incredibly helpful for students who had difficulty adjusting to the change in academic pace.

    We recommend Kings Colleg...

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