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
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?
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...
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 significantly limits the generalisability of the study results. I hope that patient weight can be included in the study in order to give the reader a better insight.
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 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 College London and other universities implement this change. Each student signed up for mental health support be assigned a mentor/buddy, as students need the emotional support now if they are to work in a busy NHS later on.
RE: Acute transient psychotic disorder precipitated by Brexit vote (1)
Authors: Dr Sally Maryosh and Dr Madhavan Seshadri
Author information
Primary Author: Dr Sally Maryosh, Foundation Year 2 Trainee in Psychiatry, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Additional Author: Dr Madhavan Seshadri, Consultant Psychiatrist, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Dear Editorial Team,
We read this article with great interest as Brexit has clearly created significant stress and impact on everyone’s life in the U.K. This article has also been widely quoted in major Newspapers including The Sun, The Guardian and The Independent creating an interesting debate by portraying a picture that Brexit could cause psychosis. Hence, we wanted to critically appraise this article using Sir Austin Bradford Hill’s Criteria (2).
In 1965, Sir Austin Bradford Hill proposed a set of 9 criteria to provide evidence of a causal relationship between a presumed cause and an observed effect (2). Using his criteria we are able to examine epidemiological studies and factors to understand better how environmental factors relate to health and the advancement of disease.
The development of psychotic disorders is multifactorial, the article itself identifies “that additional work and family related stresses may have contributed” to this patient’s ATPD (1). The...
RE: Acute transient psychotic disorder precipitated by Brexit vote (1)
Authors: Dr Sally Maryosh and Dr Madhavan Seshadri
Author information
Primary Author: Dr Sally Maryosh, Foundation Year 2 Trainee in Psychiatry, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Additional Author: Dr Madhavan Seshadri, Consultant Psychiatrist, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Dear Editorial Team,
We read this article with great interest as Brexit has clearly created significant stress and impact on everyone’s life in the U.K. This article has also been widely quoted in major Newspapers including The Sun, The Guardian and The Independent creating an interesting debate by portraying a picture that Brexit could cause psychosis. Hence, we wanted to critically appraise this article using Sir Austin Bradford Hill’s Criteria (2).
In 1965, Sir Austin Bradford Hill proposed a set of 9 criteria to provide evidence of a causal relationship between a presumed cause and an observed effect (2). Using his criteria we are able to examine epidemiological studies and factors to understand better how environmental factors relate to health and the advancement of disease.
The development of psychotic disorders is multifactorial, the article itself identifies “that additional work and family related stresses may have contributed” to this patient’s ATPD (1). The author themselves highlight multiple social stressors occurring around the time of presentation, these include losing a court case and family pressures1. If we apply Bradford Hill’s criteria of specificity (2) to this scenario, we cannot be certain that result of the Brexit referendum was the driving factor for this patient’s development of ATPD (1). This is further strengthened by the author stating a similar episode was experienced by the patient “following work related stress, 13 years previously” (1).
To support Bradford Hill’s criteria of reproducibility (2), we would expect that three years following the Brexit referendum, there would be multiple witnessed cases of ATPD precipitated by Brexit, especially in patients who are vulnerable to psychotic episodes. Try as we might to avoid it, Brexit is currently a topic dominating the media and general conversation. Therefore, if we were to apply Bradford Hill’s “biological gradient” criterion which stipulates that a greater exposure generally leads to a greater incidence of the effect, we should be witnessing more reported cases of Brexit-precipitated ATPD. Despite this, the article lists only one other transient psychotic episode precipitated by a political event - a case from the USA - unrelated to Brexit.
We feel that it is a bold statement to imply that Brexit can precipitate an acute and transient psychotic disorder (ATPD) without considering the rules comparing causation and correlation. Brexit might be associated with an acute psychotic episode, and could be an associated symptom of this patient’s psychosis however; conclusion that it might have a causative role may be an arbitrary inference.
References:
1. Katshu M. Acute transient psychotic disorder precipitated by Brexit vote. BMJ Case Reports. 2019;12(10):e232363.
2. Lucas R, McMichael A. Association or causation: evaluating links between "environment and disease". The Royal Society of Medicine. 2005;83(10):792-795.
After a diagnoses of Lipid Pneumonia, there were no samples tested of the eliquid the patient inhaled. Glycerol, or glycerin is an alcohol and cannot cause lipid pneumonia. Although there 'likely' were other ingredients in her cartridge besides VG, without testing there is no way to make a definitive assumption as to the nature of the exogenous inhalant. We do not know the exact etiology without knowing where the EC cartridge was procured from, in what manner it was ingested, how it was processed, or exactly what was in it. With the patient's extensive pulmonary history, we do not know what, if any, other medical issues may have contributed to the final diagnosis. Do we know if the eliquid was accidentally aspirated, if there was a presence of Vitamin E, acetic acid, or even vegetable oil, which is not the same as vegetable glycerin.
In response to this article, I would advise amending these findings to include that "without testing, we cannot conclude a single variable that caused this patient's lipoid pneumonia. More importantly, glycerol is an alcohol therefore could not cause a lipoid pneumonia. Although EC was determined to be the causation of this type of pneumonia, we do not know the exact contents of the liquid. To be noted, the patient did also show bilateral ground-glass opacities that may have contributed to her respiratory failure."
After a diagnoses of Lipid Pneumonia, there were no samples tested of the eliquid the patient inhaled. Glycerol, or glycerin is an alcohol and cannot cause lipid pneumonia. Although there 'likely' were other ingredients in her cartridge besides VG, without testing there is no way to make a definitive assumption as to the nature of the exogenous inhalant. We do not know the exact etiology without knowing where the EC cartridge was procured from, in what manner it was ingested, how it was processed, or exactly what was in it. With the patient's extensive pulmonary history, we do not know what, if any, other medical issues may have contributed to the final diagnosis. Do we know if the eliquid was accidentally aspirated, if there was a presence of Vitamin E, acetic acid, or even vegetable oil, which is not the same as vegetable glycerin.
In response to this article, I would advise amending these findings to include that "without testing, we cannot conclude a single variable that caused this patient's lipoid pneumonia. More importantly, glycerol is an alcohol therefore could not cause a lipoid pneumonia. Although EC was determined to be the causation of this type of pneumonia, we do not know the exact contents of the liquid. To be noted, the patient did also show bilateral ground-glass opacities that may have contributed to her respiratory failure."
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...
Show MoreIn 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?
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...
Show MoreWe 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...
Show MoreRE: Acute transient psychotic disorder precipitated by Brexit vote (1)
Authors: Dr Sally Maryosh and Dr Madhavan Seshadri
Author information
Primary Author: Dr Sally Maryosh, Foundation Year 2 Trainee in Psychiatry, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Additional Author: Dr Madhavan Seshadri, Consultant Psychiatrist, Herefordshire Mental Health and Learning Disability Services, Stonebow Unit, Hereford.
Dear Editorial Team,
We read this article with great interest as Brexit has clearly created significant stress and impact on everyone’s life in the U.K. This article has also been widely quoted in major Newspapers including The Sun, The Guardian and The Independent creating an interesting debate by portraying a picture that Brexit could cause psychosis. Hence, we wanted to critically appraise this article using Sir Austin Bradford Hill’s Criteria (2).
In 1965, Sir Austin Bradford Hill proposed a set of 9 criteria to provide evidence of a causal relationship between a presumed cause and an observed effect (2). Using his criteria we are able to examine epidemiological studies and factors to understand better how environmental factors relate to health and the advancement of disease.
The development of psychotic disorders is multifactorial, the article itself identifies “that additional work and family related stresses may have contributed” to this patient’s ATPD (1). The...
Show MoreAfter a diagnoses of Lipid Pneumonia, there were no samples tested of the eliquid the patient inhaled. Glycerol, or glycerin is an alcohol and cannot cause lipid pneumonia. Although there 'likely' were other ingredients in her cartridge besides VG, without testing there is no way to make a definitive assumption as to the nature of the exogenous inhalant. We do not know the exact etiology without knowing where the EC cartridge was procured from, in what manner it was ingested, how it was processed, or exactly what was in it. With the patient's extensive pulmonary history, we do not know what, if any, other medical issues may have contributed to the final diagnosis. Do we know if the eliquid was accidentally aspirated, if there was a presence of Vitamin E, acetic acid, or even vegetable oil, which is not the same as vegetable glycerin.
In response to this article, I would advise amending these findings to include that "without testing, we cannot conclude a single variable that caused this patient's lipoid pneumonia. More importantly, glycerol is an alcohol therefore could not cause a lipoid pneumonia. Although EC was determined to be the causation of this type of pneumonia, we do not know the exact contents of the liquid. To be noted, the patient did also show bilateral ground-glass opacities that may have contributed to her respiratory failure."
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