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Thanks for reporting this interesting case of VAD.
The clinical versatility of this pathology calls for careful history
taking and examination to avoid the pitfall of inappropriate imaging
requests for patients who present with craniocervical pain with or without
headache.
The presence of new neurological deficits such as those described in
the case report would certainly warrant urgent imaging.
In the absence of...
Thanks for reporting this interesting case of VAD.
The clinical versatility of this pathology calls for careful history
taking and examination to avoid the pitfall of inappropriate imaging
requests for patients who present with craniocervical pain with or without
headache.
The presence of new neurological deficits such as those described in
the case report would certainly warrant urgent imaging.
In the absence of these,strong clinical concern by itself may not be
enough but should be supported by significant risk factors to justify
imaging,this would protect patients from undue radiation exposure and its
inherent risks,as some institutions tend to conduct a CT-brain prior to
MRA.
Thank you
I thank Drs. Onder and Jahanroshan for their interest in this report.
They raise excellent points. A video would have added a great deal,
however I was unable to locate proxies to consent for such a recording
during the time of what was a short lived tremor. An EEG done prior to
the appearance of the tremor showed global slowing with no epileptiform
activity. I can't exclude self limited hypoxia prior to being found bu...
I thank Drs. Onder and Jahanroshan for their interest in this report.
They raise excellent points. A video would have added a great deal,
however I was unable to locate proxies to consent for such a recording
during the time of what was a short lived tremor. An EEG done prior to
the appearance of the tremor showed global slowing with no epileptiform
activity. I can't exclude self limited hypoxia prior to being found but
his oxygenation was monitored and adequate at least from when he was found
breathing until after resolution of the tremor. Priopriospinal myoclonus
is certainly a consideration, though the explanation is not parsimonious.
Phenotypically, the tremor was nearly identical to the cited report of the
rest tremor in brain death which did include a video. Specifically, it
involved rhythmic finger flexion/extension with a pill rolling quality
which would have been unremarkable in a person with idiopathic Parkinson
disease.
Regards,
Laura S. Boylan, MD
I am always happy to see treatments that avoid medicines.
On the other hand, I am always sad to see that "cured" is not
defined, and as a result it is not possible to claim a cure for diabetes -
not even possible to know if a specific case, or a specific treatment, is
moving closer to cured, or farther away from cured.
When cured is defined, independent of treatment, we will be able to
find cures. Unt...
I am always happy to see treatments that avoid medicines.
On the other hand, I am always sad to see that "cured" is not
defined, and as a result it is not possible to claim a cure for diabetes -
not even possible to know if a specific case, or a specific treatment, is
moving closer to cured, or farther away from cured.
When cured is defined, independent of treatment, we will be able to
find cures. Until then, all research is questionable.
Conflict of Interest:
Author of: A Calculus of Curing
I blog about healthicine.
Dear Sir,
Though the authors claim that there was heterotopic pregnancy ideally they
should have done a curettage to prove chorionic villi from the
intrauterine pregnancy. The sac demonstrated in the uterus could be pseudo
sac. Without a clear evidence of villi in both sites, this will be wrong
message. The drop in the beta hCG can be a lab error or rupture of the
ovarian ectopic
Dear Sir,
Though the authors claim that there was heterotopic pregnancy ideally they
should have done a curettage to prove chorionic villi from the
intrauterine pregnancy. The sac demonstrated in the uterus could be pseudo
sac. Without a clear evidence of villi in both sites, this will be wrong
message. The drop in the beta hCG can be a lab error or rupture of the
ovarian ectopic
An excellent paper!
I think it would be useful if the authors explained if the patient was exposed to sclerogenic dusts, both in occupational and non-occupational scenarios.
Was this supplement a turmeric powder, simple water extract, or the
highly concentrated standardized turmeric extract with 95% curcuminoids
made using a hexane or organic solvent? This can be an important
determinant for causing liver toxicity.
Sirs,
As a neuromodulator and instructor with extensive (30 year) experience
with both "wired " and "wireless " systems, I feel compelled to repond to
the conclusions of the cited case report.
While the authors mention lead migration as an known complication of
spinal cord stimulation, it is useful to consider that Cameron (1) cited
361 lead migration events in 2753 patients , a 13.2% incidence.
Anderson (2) , i...
Sirs,
As a neuromodulator and instructor with extensive (30 year) experience
with both "wired " and "wireless " systems, I feel compelled to repond to
the conclusions of the cited case report.
While the authors mention lead migration as an known complication of
spinal cord stimulation, it is useful to consider that Cameron (1) cited
361 lead migration events in 2753 patients , a 13.2% incidence.
Anderson (2) , in his report of spinal cord stimulation for angina
pectoris, found lead migration to be the most frequent complication
requiring reoperation (23%), an incidence verified by North.
This is not the first case report of cephalad lead migration, although
less common than caudal migration. McGreevy and colleagues (3) at Johns
Hopkins reported a case of cephalad lead migration from T9 vertebral
segment to T1 two weeks postoperatively. The Titan (Medtronic) anchor was
sutured to lumbosacral fascia with a strain relief loop (SRL). An
additional SRL was placed beneath the implanted IPG.
This issue is not confined to percutaneous cylindrical leads, as
significant cephalad paddle -lead migration has also been reported (4).
A multitude of published research has confirmed that spinal cord
stimulation is indeed a safe procedure (5).
The author performing the procedure (MF) states that "this was the
implanters first experience with this (wireless) device". I can personally
attest that implanting the StimWave system is distinctly different in many
respects, than competing "wired " systems.
When teaching physicians , I continually stress these differences.
The manufacturer recommends anchoring either with traditional sleeve
anchors, or their proprietary Sandshark anchor. In addition, a knot is to
be tied in the lead distal to the last mark . A separate subcutaneous
incision (0.5cm) is made to secure the distal lead tip to the subcutaneous
fascia. There is no indication that the author followed these recommended
techniques. The authors also relate " challenges with connectivity and
aberrant programming".
I was informed personally that the StimWave engineer was able to obtain
connectivity and paresthesia mapping at the non-migrated lead, hoever the
patient expressed a preference for the "wired " system rather than the
"wireless" external system.
I concur with the authors recommendations for locking anchors and silicone
elastomer adhesives. . I strongly disagree with the assertions made that
this case "demands more research into the safety of externally powered
devices". I have successfully implanted this system for three years
,without any lead migration, as have countless physicians worldwide.
]The proper conclusion of this report should be that this new wireless
spinal cord stimulator system is distinctly different than previous wired
systems, requiring proper triaining, strict adherence to recommended
operative techniques and implanter experience. It is unfortunate that the
authors first case utilizing this system was unsuccessful, however , their
contention that these systems are unsafe is completely unfounded.
Sincerely,
George J.Arcos D.O.,FAOCA
1) Safety and efficacy of spinal cord stimulation for the treatment
of chronic pain; A 20-year review.
Cameron,T J Neurosurg (Spine3) 100:254-267 2004
2) Anderson C Complications in spinal cord stimulation for the treatment
of angina pectoris. Acta Cardiologica 52:35-39 1995
3)McGreevy K, WilliamsKA,Christo PJ
Cephalad lead migration following spinal cord stimulator implantation
Pain Physician 2012 Jan-Feb; 15(1): E 79-87
4) DiSanto S, Ravera E
Significant cephalad laddle lead migration after lumbar spinal cord
stimulator implant.
Neuromodulation 2014 Jun ;17 (4): 385
5) Bendersky D, Yampolsky C
Is Spinal cord stimulation safe?
World Neurosurg 2014 Dec; 82(6): 1359-68.
Conflict of Interest:
No stock or investment ownership. Senior Consultant for BSC and StimWave.
Thankyou to Professor Bewley and colleagues for their comments.
We agree with many of the concerns raised and want to point out it is
essential to read and interpret this article for what it is - a case
report. As has been rightly pointed out, it is therefore only anecdotal
and is the lowest grade quality of evidence.
Our intention in writing this article is merely to point out a
temporal association...
Thankyou to Professor Bewley and colleagues for their comments.
We agree with many of the concerns raised and want to point out it is
essential to read and interpret this article for what it is - a case
report. As has been rightly pointed out, it is therefore only anecdotal
and is the lowest grade quality of evidence.
Our intention in writing this article is merely to point out a
temporal association between taking curcumin and the patient's disease
entering a quiescent and stable phase. But this is prone to many
confounding factors and like any case report, has severe limitations. The
only conclusion that can be drawn from this case is that further studies
are needed to establish whether curcumin is indeed beneficial for myeloma.
The media response has been disproportionate and regrettable. We
believe the article did use cautious language but for further clarity:
In no way do we endorse the use of curcumin in Myeloma, either in
addition to and especially not in place of established therapy. There is
insufficient evidence to support this, doing so can be potentially
dangerous and it can come at significant financial cost to patients.
The article should not be removed as we maintain there is still an
important observation to be noted - but this needs evaluation in the
context of a clinical trial.
I have seen now that a correction was asserted. It is not
satisfactory on its face for two reasons.
The first is that my criticism of the report was not acknowledged for
pointing out that the original claim was of swallowing a bleach tablet,
which meant that treatment could be understood as inappropriate or
inadequate.
The second is that a "correction" that ascribed the problem as that
the patient ing...
I have seen now that a correction was asserted. It is not
satisfactory on its face for two reasons.
The first is that my criticism of the report was not acknowledged for
pointing out that the original claim was of swallowing a bleach tablet,
which meant that treatment could be understood as inappropriate or
inadequate.
The second is that a "correction" that ascribed the problem as that
the patient ingested a 3.5g(!) tablet (!) of sodium hydroxide clarifies
little or nothing.
1. Sodium hydroxide does not appear as "tablets" in any pharmacopoeia
of which I am aware. I will withdraw my objection if there is such with
documented reference.
2. The article still refers to the treatment of bleach ingestion without
addressing the chlorine content thereof, thus misunderstanding the key
point I made in my previous email, and misses the value I brought to the
discussion.
3. "Prilled" sodium hydroxide, the only type of lye of which I am aware
might remotely be thought a "tablet" is typically 0.1 g in size, not 3.5g
(35 times a prilled version!). Nor would such a material be near the
counter of a random patient where it might be mistaken for a tablet (if I
may hone the point a bit).
I believe that there should be more explained about this unfortunate
event, that my email should be published for consideration by other
experts, and that the modality of treatment should be better addressed by
the physicians.
We sincerely thank the technical product manager of ACCU-CHEK
Performa (Roche) for going through our article entitled '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 with interest. We provide our response to the
issues raised by our learned colleague.
We sincerely thank the technical product manager of ACCU-CHEK
Performa (Roche) for going through our article entitled '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 with interest. We provide our response to the
issues raised by our learned colleague.
Regarding the removal of maltose-containing infusion tube from the
intravenous cannula by the patient himself; yes, it is unacceptable but
probably not that uncommon in real life. It is possible for an extremely
agitated patient experiencing respiratory distress to remove the IV line
himself if left unattended for fraction of a second without waiting for
medically trained staffs to do their jobs. They have also expressed their
concerns regarding measurement of capillary glucose from an uncleaned
hand. In an intensive care setting, it may not be possible to "wash the
hands in warm, soapy water. Rinse and dry completely" before checking
capillary blood glucose in a patient who is actively seizing or having
altered sensorium as instructed in the package insert of ACCU-CHEK
Performa.
The package insert of ACCU-CHEK Performa categorically mentions about
the elevated levels of galactose (>15mg/dl or >0.83 mmol/L),
triglycerides (>1,800mg/dl or >20.3 mmol/L) , ascorbic acid
(>3mg/dl or >0.17mmol/L), haematocrit (should be between 10-65%)
that may cause erroneous glucose values. It has pointed towards
"clinically relevant maltose interference" without mentioning the
concentration of maltose known to be associated with such interference.
This e-letter has discussed issues, which had already been focused in
our article. The probable reasons of erroneous capillary glucose values,
the difference of capillary glucose values between right and left hand
fingertips, the blood level of maltose which is unlikely to cause such
interference have already been highlighted in our article.
Sir, what we have discussed in our article is exactly what we had
experienced in our clinical ward rounds. We strongly believe proper
protocol has to be followed in each and every step and this article is
definitely a "reminder of important clinical lesson" of violating the
basic principles. We do not have the intention to spread false information
related to any manufacturing company & we do not endorse such ideas
ever. Having said that, we strongly believe that the package insert of
ACCU-CHEK Performa should specify the maltose concentration that may cause
overestimation of blood glucose.
Thanks for reporting this interesting case of VAD. The clinical versatility of this pathology calls for careful history taking and examination to avoid the pitfall of inappropriate imaging requests for patients who present with craniocervical pain with or without headache.
The presence of new neurological deficits such as those described in the case report would certainly warrant urgent imaging. In the absence of...
I thank Drs. Onder and Jahanroshan for their interest in this report. They raise excellent points. A video would have added a great deal, however I was unable to locate proxies to consent for such a recording during the time of what was a short lived tremor. An EEG done prior to the appearance of the tremor showed global slowing with no epileptiform activity. I can't exclude self limited hypoxia prior to being found bu...
I am always happy to see treatments that avoid medicines.
On the other hand, I am always sad to see that "cured" is not defined, and as a result it is not possible to claim a cure for diabetes - not even possible to know if a specific case, or a specific treatment, is moving closer to cured, or farther away from cured.
When cured is defined, independent of treatment, we will be able to find cures. Unt...
Dear Sir, Though the authors claim that there was heterotopic pregnancy ideally they should have done a curettage to prove chorionic villi from the intrauterine pregnancy. The sac demonstrated in the uterus could be pseudo sac. Without a clear evidence of villi in both sites, this will be wrong message. The drop in the beta hCG can be a lab error or rupture of the ovarian ectopic
Conflict of Interest:
...An excellent paper! I think it would be useful if the authors explained if the patient was exposed to sclerogenic dusts, both in occupational and non-occupational scenarios.
Conflict of Interest:
None declared
Was this supplement a turmeric powder, simple water extract, or the highly concentrated standardized turmeric extract with 95% curcuminoids made using a hexane or organic solvent? This can be an important determinant for causing liver toxicity.
Conflict of Interest:
Work for supplement industry
Sirs, As a neuromodulator and instructor with extensive (30 year) experience with both "wired " and "wireless " systems, I feel compelled to repond to the conclusions of the cited case report.
While the authors mention lead migration as an known complication of spinal cord stimulation, it is useful to consider that Cameron (1) cited 361 lead migration events in 2753 patients , a 13.2% incidence. Anderson (2) , i...
Thankyou to Professor Bewley and colleagues for their comments.
We agree with many of the concerns raised and want to point out it is essential to read and interpret this article for what it is - a case report. As has been rightly pointed out, it is therefore only anecdotal and is the lowest grade quality of evidence.
Our intention in writing this article is merely to point out a temporal association...
I have seen now that a correction was asserted. It is not satisfactory on its face for two reasons.
The first is that my criticism of the report was not acknowledged for pointing out that the original claim was of swallowing a bleach tablet, which meant that treatment could be understood as inappropriate or inadequate.
The second is that a "correction" that ascribed the problem as that the patient ing...
We sincerely thank the technical product manager of ACCU-CHEK Performa (Roche) for going through our article entitled '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 with interest. We provide our response to the issues raised by our learned colleague.
Regarding the removal of maltose-contai...
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