Dear Editor:
We read with great interest the case report published by De Silva and Winship1 in the September 2020 issue of this journal. They reported the medical history of a 52-year-old male patient who fulfilled the revised Chompret clinical criteria for Li-Fraumeni syndrome (LFS) and carried a germline CHEK2 mutation (NM_007194.4:c.1100del, p.Thr367fs). The authors highlighted the possible link between CHEK2 germline mutations and a Li-Fraumeni like syndrome phenotype.
The term Li-Fraumeni like syndrome (LFL) was introduced by Birch et al. in 1994 to describe LFS families who did not fulfill the classical LFS criteria, but carried a TP53 germline mutation.2,3 Nevertheless, germline mutations in TP53 gene may not detected in some families with clinical diagnosis of the syndrome. In 1999, Bells et al. reported a family who fulfilled classical LFS criteria and carried a CHEK2 pathogenic mutation, c.1100delC.4 At that time, the authors hypothesized for the first time that heterozygous CHEK2 mutations could be related to LFS phenotype. BRCA2 germline mutations were also described in TP53-negative LFS families.5
Most cancer predisposition syndromes have an autosomal dominant pattern of inheritance with incomplete penetrance and variable clinical expressivity. Genetic and environmental modifiers play a role in intra and interfamilial heterogeneity.8 Environmental modifiers were not mentioned by De Silva and Winship, and should have been described in the c...
Dear Editor:
We read with great interest the case report published by De Silva and Winship1 in the September 2020 issue of this journal. They reported the medical history of a 52-year-old male patient who fulfilled the revised Chompret clinical criteria for Li-Fraumeni syndrome (LFS) and carried a germline CHEK2 mutation (NM_007194.4:c.1100del, p.Thr367fs). The authors highlighted the possible link between CHEK2 germline mutations and a Li-Fraumeni like syndrome phenotype.
The term Li-Fraumeni like syndrome (LFL) was introduced by Birch et al. in 1994 to describe LFS families who did not fulfill the classical LFS criteria, but carried a TP53 germline mutation.2,3 Nevertheless, germline mutations in TP53 gene may not detected in some families with clinical diagnosis of the syndrome. In 1999, Bells et al. reported a family who fulfilled classical LFS criteria and carried a CHEK2 pathogenic mutation, c.1100delC.4 At that time, the authors hypothesized for the first time that heterozygous CHEK2 mutations could be related to LFS phenotype. BRCA2 germline mutations were also described in TP53-negative LFS families.5
Most cancer predisposition syndromes have an autosomal dominant pattern of inheritance with incomplete penetrance and variable clinical expressivity. Genetic and environmental modifiers play a role in intra and interfamilial heterogeneity.8 Environmental modifiers were not mentioned by De Silva and Winship, and should have been described in the case report. Inclusion of environmental risk factors 9 such as tabacco exposure, obesity, sun exposure, alcohol consumption, hypertension could be associated with a higher risk for the multiple primary cancers (clear cell renal cancer, low-grade urothelial tumor, cutaneous basal cell cancer). Furthermore, co-segregation analysis was not performed in affected family members. Her mother, who was diagnosed with a Non-Hodgkin lymphoma at age 47, and her sister, diagnosed with a breast cancer at age 26, were deceased. Nevertheless, her maternal aunt, who developed a pheochromocytoma at age 56 and breast cancer at age 66 was not tested for CHEK2 c.1100delC variant, despite being tested for BRCA1, BRCA2, VHL, MAX, RET, TMEM 127 and SDHx genes.
Differences in CHEK2 penetrance and clinical expressivity may be also modified by polygenic risk and family history (Cybulski et al., 2011; Gallangher et al., 2020). We agree with the authors that more studies are required to translate genetic testing clinical validity to clinical utility, mainly for moderate penetrance genes. Nevertheless, patients who have been diagnosed with LFS and who carry a germline mutation in TP53 gene should undergo high risk surveillance with whole body MRI and genetic testing of minors.6,7 The authors should make clear recommendations that we still don´t have enough data to consider CHEK2 as a causing gene for LFS. There aren´t any indications in this report or any further published data of a higher risk of childhood cancer in CHEK2 carries. Therefore, this information should be evaluated with caution in order to avoid scientific data extrapolation, such as CHEK2 genetic testing for asymptomatic minors, and iatrogenic interventions, such as bilateral mastectomy that is suggested in TP53 mutation carriers and not in CHEK2 mutation carriers (unless strong family history of bilateral breast cancer).
CHEK2 is a moderate penetrance gene that is part of the breast cancer predisposition genes´ family and predisposes also to a higher risk for colorectal cancer. Although patients may carry a higher risk to other cancers, the phenotype is clearly different from high penetrance TP53 carriers, which is the underlying cause of LFS. Cancer predisposition syndromes may share cancer risks, but management clearly differs in carriers of germline mutations in TP53 and CHEK2.
I have read the recent publication in the Journal by Bhattacharyya PJ, et al. BMJ Case Rep 2020;13:e239104. doi:10.1136/bcr-2020-239104 with interest, however I would propose a different interpretation of their case.
The authors present a case of the Takotsubo cardiomyopathy (TC) in a 38 weeks pregnant patient with COVID 19 positive presentation.
They showed that the apical dyskinesis was reversible 2 weeks after her presentation which is one of the features of TC. Nevertheless, the invasive coronary angiography that coincided with the day of the repeat echocardiography (2 weeks after presentation) in my opinion could be in keeping with a revascularized spontaneous coronary artery dissection (SCAD) of the mid LAD, hence the improved flow and recovery of the previously stunned apical left ventricular myocardium. The limited coronary angiographic images show a typical appearance of re-canalising SCAD with the abrupt caliber change of the LAD and the long segments circular and smooth caliber difference indicated by the white arrows on the original image.
It is known that pregnancy predisposes ladies to SCAD and lately we learnt that the COVID-19 inflammatory milieu enhances endothelial vulnerability.
This is an interesting case and the cardiologists and general physicians should all be aware of this type of presentation during COVID 19.
We read the response to our case report published in BMJ case reports " Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique"[1]
We would like to clarify that there is a difference between a new flap and a new technique. A new flap is the one described for the first time in the literature. Contrary to that in a novel technique either a previously described flap or a new flap is used for an indication which has no mention in the literature. Pedicled islanded nasolabial flap have been used in a number of ways and the the cited references by Dr M Alam et al are about its use for floor of mouth reconstruction or for cervical oesophagus for stricture correction. We have also published one such series recently for its versatile use in head neck reconstruction. [2]
To the best of our knowledge it has not been used for a neopharyngeal reconstruction following total laryngectomy and partial pharyngectomy and hence titled as the Novel Technique of neopharyngeal reconstruction.
We refute the statement made by Alam et al in there comment " 5. It is submitted that the rightful credit and recognition belongs to the authors who described the islanded skin flap based on facial vessels in the 1980s. It is not a novel flap christened as DK Gupta flap." and reiterate again that " Use of the facial artery-based cutaneous island flap (mel...
We read the response to our case report published in BMJ case reports " Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique"[1]
We would like to clarify that there is a difference between a new flap and a new technique. A new flap is the one described for the first time in the literature. Contrary to that in a novel technique either a previously described flap or a new flap is used for an indication which has no mention in the literature. Pedicled islanded nasolabial flap have been used in a number of ways and the the cited references by Dr M Alam et al are about its use for floor of mouth reconstruction or for cervical oesophagus for stricture correction. We have also published one such series recently for its versatile use in head neck reconstruction. [2]
To the best of our knowledge it has not been used for a neopharyngeal reconstruction following total laryngectomy and partial pharyngectomy and hence titled as the Novel Technique of neopharyngeal reconstruction.
We refute the statement made by Alam et al in there comment " 5. It is submitted that the rightful credit and recognition belongs to the authors who described the islanded skin flap based on facial vessels in the 1980s. It is not a novel flap christened as DK Gupta flap." and reiterate again that " Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: is a novel technique"
References :
1. Gupta DK, Chugh R, Singh SK, Pati S. Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique. BMJ Case Rep. 2019;12(8):e230712.
2. Chakrabarti, S., Gupta, D.K., Gupta, M., Daga, D., Mishra, A., Sharma, S.S., Chugh, R. and Singh, S.K. (2020), Versatility and Reliability of Islanded Pedicled Nasolabial Flap in Head and Neck Cancer Reconstruction. The Laryngoscope, 130: 1967-1972. doi:10.1002/lary.28662
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.
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...
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 reconstruction of oesophageal strictures and limited defects of upper aerodigestive tract [4, 5].
3. An inadvertent oversight in the review of literature might have caused the authors to not include the references of these seminal papers in their article.
4. This option of using skin from face as islanded flap could never become a popular reconstructive option despite being there in the armamentarium for over four decades due to inherent reluctance to use facial skin as donor for non face areas, high risk of injury to marginal mandibular nerve, loss of lower buccal facial nerve branches and a possible compromise on obtaining nodal clearance to preserve facial vessels.
5. It is submitted that the rightful credit and recognition belongs to the authors who described the islanded skin flap based on facial vessels in the 1980s. It is not a novel flap christened as DK Gupta flap.
References
1. Gupta DK, Chugh R, Singh SK, Pati S. Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique. BMJ Case Rep. 2019;12(8):e230712.
2. Rose EH. One-stage arterialized nasolabial island flap for floor of mouth reconstruction. Ann Plast Surg. 1981;6(1):71-75.
3. Piggot TA, Logan AM, Knight SL, Milner RH. The facial artery island flap. Ann Plast Surg. 1987;19(3):260-265.
4. Sasaki TM, Taylor L, Martin L, Baker HW, McConnell DB, Vetto RM. Correction of cervical esophageal stricture using an axial island cheek flap. Head Neck Surg. 1983;6(1):596-599.
5. Sasaki TM, Standage BA, Baker HW, McConnell DB, Vetto RM. The island cheek flap: repair of cervical esophageal stricture and new extended indications. Am J Surg. 1984;147(5):650-653.
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...
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 superior results of operative versus nonoperative treatment, especially in the elderly. Given the choice for surgical treatment, pre-operative planning should take into account Hertel’s criteria [5] to predict the risk of humeral head avascular necrosis to reduce the risk for patient to undergo revision surgery. [6] Increasing evidence presently in the literature that RSA is a valid option for the treatment of displaced fractures of humeral head in the elderly. [7] In the rare case of simultaneous bilateral traumatic disease, the treatment of choice is more controversial. Simultaneous bilateral three-part or four-part fractures of the proximal humerus are even more rare, and in our opinion, their treatment should rely on the same principles as for monolateral injury, even if concerns about post-operative care and rehabilitation exist.
We believe the issue is not the simultaneous or the near-simultaneous procedure from the surgical point of view, because it is a matter of anesthesiologic feasibility (better: of patient’s medical condition) and not of orthopedic expertise. In our opinion the real challenge is physical rehabilitation and personal care because of the complete temporary disability. That’s the reason why major bilateral upper limb surgery is not proposed to patients in case of elective surgery, but it can be done “by necessity” in traumatic diseases.
Again, we congratulate with the Authors for the case, and we would appreciate more challenging cases like this.
References
[1] Wendling A, Vopat ML, Yang S-Y, Saunders B. Near-simultaneous bilateral reverse total shoulder arthroplasty for the treatment of bilateral fracture dislocations of the shoulder. BMJ Case Rep 2019;12:e230212. doi:10.1136/bcr-2019-230212
[2] Ceri L, Mondanelli N, Sangaletti R, Bottai V, Muratori F, Giannotti S. Simultaneous bilateral reverse shoulder arthroplasty for bilateral four-part fracture of the proximal humerus in an elderly patient: A case report. Trauma Case Rep. 2019;23:100242. Published 2019 Aug 19. doi:10.1016/j.tcr.2019.100242
[3] Beks R.B., Ochen Y., Frima H., Smeeing D.P.J., van der Meijden O., Timmers T.K. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J. Shoulder Elb. Surg. 2018;27:1526–1534.
[4] Handoll H.H., Gibson J.N., Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst. Rev. 2003;4:CD000434.
[5] Hertel R., Hempfing A., Stiehler M., Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J. Shoulder Elb. Surg. 2004;13:427–433.
[6] Jost B, Spross C, Grehn H, et al. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg 2013;22:542–9.
[7] Jawa A., Burnikel D. Treatment of proximal humeral fractures. JBJS Reviews. 2016;4:e31–e39.
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...
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 TK, Miller JS, Epstein JI. Rare histological patterns of prostatic ductal adenocarcinoma. Pathology. 2010;42(4):319-324.
3. Yousuf K, Archibald SD. Brain metastases from papillary adenocarcinoma of the thyroid. J Otolaryngol. 2006;35(6).
4. Carcangiu M, Kurman RJ, Carcangiu ML, Herrington CS. WHO classification of tumours of female reproductive organs. International Agency for Research on Cancer; 2014.
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.
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...
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 and 36%(n=4) a combination. 27%(n=3) had Botox® injection monotherapy. In 72%(n=8) the Botox was complementary to surgical intervention including neurolysis 54%(n=6), neurectomy 27%(n=3), completion amputation, excision calcinosis, first rib excision and sympathectomy, tenolysis, digital nerve repair and nerve graft reconstruction 9%(n=1).
All patients (100% (n=11)) reported improvement in quality of life, 82%(n=9)) reduced pain, 55% (n=6) less allodynia, 45% reported increased mobility, 36%(n=4) reduced their analgesia and 45%(n=5) were successfully discharged from the clinic.
Therefore, Botox® should be considered as an adjunct in the treatment of neuropathic pain.
References:
1. H.M. Oh, M.E. Chung, Botulinum Toxin for Neuropathic Pain: a review of the literature. Toxins 2015, 7, 3127-3154; doi:10.3390/toxins7083127.
2. N. Attal, D.C de Andrade, F. Adam, D. Ranoux, M.J. Teixeira, R. Galhardoni, I. Raicher, N. Uceyler, C. Sommer, D. Bouhassira. Safety and efficacy of repeated injections of botulinum toxin in peripheral neuropathic pain: a randomised, double blind, placebo controlled trial. The Lancet. Neurology. 2016:15(6);555–565.
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...
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 significantly limits the generalizability of the study results. I hope that patient weight can be included in the study in order to give readers a better insight.
* I would like my email (amrmetwa@gmail.com) to be included in the reply
Dear Editor:
Show MoreWe read with great interest the case report published by De Silva and Winship1 in the September 2020 issue of this journal. They reported the medical history of a 52-year-old male patient who fulfilled the revised Chompret clinical criteria for Li-Fraumeni syndrome (LFS) and carried a germline CHEK2 mutation (NM_007194.4:c.1100del, p.Thr367fs). The authors highlighted the possible link between CHEK2 germline mutations and a Li-Fraumeni like syndrome phenotype.
The term Li-Fraumeni like syndrome (LFL) was introduced by Birch et al. in 1994 to describe LFS families who did not fulfill the classical LFS criteria, but carried a TP53 germline mutation.2,3 Nevertheless, germline mutations in TP53 gene may not detected in some families with clinical diagnosis of the syndrome. In 1999, Bells et al. reported a family who fulfilled classical LFS criteria and carried a CHEK2 pathogenic mutation, c.1100delC.4 At that time, the authors hypothesized for the first time that heterozygous CHEK2 mutations could be related to LFS phenotype. BRCA2 germline mutations were also described in TP53-negative LFS families.5
Most cancer predisposition syndromes have an autosomal dominant pattern of inheritance with incomplete penetrance and variable clinical expressivity. Genetic and environmental modifiers play a role in intra and interfamilial heterogeneity.8 Environmental modifiers were not mentioned by De Silva and Winship, and should have been described in the c...
To the Editor,
I have read the recent publication in the Journal by Bhattacharyya PJ, et al. BMJ Case Rep 2020;13:e239104. doi:10.1136/bcr-2020-239104 with interest, however I would propose a different interpretation of their case.
The authors present a case of the Takotsubo cardiomyopathy (TC) in a 38 weeks pregnant patient with COVID 19 positive presentation.
They showed that the apical dyskinesis was reversible 2 weeks after her presentation which is one of the features of TC. Nevertheless, the invasive coronary angiography that coincided with the day of the repeat echocardiography (2 weeks after presentation) in my opinion could be in keeping with a revascularized spontaneous coronary artery dissection (SCAD) of the mid LAD, hence the improved flow and recovery of the previously stunned apical left ventricular myocardium. The limited coronary angiographic images show a typical appearance of re-canalising SCAD with the abrupt caliber change of the LAD and the long segments circular and smooth caliber difference indicated by the white arrows on the original image.
It is known that pregnancy predisposes ladies to SCAD and lately we learnt that the COVID-19 inflammatory milieu enhances endothelial vulnerability.
This is an interesting case and the cardiologists and general physicians should all be aware of this type of presentation during COVID 19.
We read the response to our case report published in BMJ case reports " Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique"[1]
We would like to clarify that there is a difference between a new flap and a new technique. A new flap is the one described for the first time in the literature. Contrary to that in a novel technique either a previously described flap or a new flap is used for an indication which has no mention in the literature. Pedicled islanded nasolabial flap have been used in a number of ways and the the cited references by Dr M Alam et al are about its use for floor of mouth reconstruction or for cervical oesophagus for stricture correction. We have also published one such series recently for its versatile use in head neck reconstruction. [2]
To the best of our knowledge it has not been used for a neopharyngeal reconstruction following total laryngectomy and partial pharyngectomy and hence titled as the Novel Technique of neopharyngeal reconstruction.
We refute the statement made by Alam et al in there comment " 5. It is submitted that the rightful credit and recognition belongs to the authors who described the islanded skin flap based on facial vessels in the 1980s. It is not a novel flap christened as DK Gupta flap." and reiterate again that " Use of the facial artery-based cutaneous island flap (mel...
Show MoreI 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.
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.
Show More2. 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...
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...
Show MoreThe 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
Show More1. 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...
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.
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...
Show MoreDear 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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