Congratulations for publishing this important clinical lesson as this
is unfortunately missed in post natal ward from time to time. I therefore
tell the 'busy' junior doctors to spare some time to clean the perineum at
1st day check if it is soiled with meconeum so that the anal opening can
be identified and documented as meconeum can be passed from a perineal
fistula too. If he does not wish to clean then he should come b...
Congratulations for publishing this important clinical lesson as this
is unfortunately missed in post natal ward from time to time. I therefore
tell the 'busy' junior doctors to spare some time to clean the perineum at
1st day check if it is soiled with meconeum so that the anal opening can
be identified and documented as meconeum can be passed from a perineal
fistula too. If he does not wish to clean then he should come back later
to complete the examination rather than ticking the box as normal after
seeing the meconeum . I had a 4 month old infant who was first brought to
the hospital at the age of 1 week with a history of painful defecation .
He was reviewed few times in the paediatric ward ( by the on call team) at
quite senior level and sent home on lactulose with a follow up clinic
appointment ( he used to open his bowels daily and stools were never hard
and were in fact very soft ) In the clinic the attending paediatrician
identified an imperforate anus with an ectopic anal opening anteriorly .
He was referred to surgical team and had a good outcome .
I agree with the concept of a pre-tracheostomy USG to visualize the
neck veins in case of a percutaneous tracheostomy.
But I have to 2 points against --
1) I believe percutaneous tracheostomy is still not a routine method
of choice in elective tracheostomy in difficult surgical scenario like -
short neck, restricted extension, double chin, big pad of neck fat and
especially if patient is sick, as the...
I agree with the concept of a pre-tracheostomy USG to visualize the
neck veins in case of a percutaneous tracheostomy.
But I have to 2 points against --
1) I believe percutaneous tracheostomy is still not a routine method
of choice in elective tracheostomy in difficult surgical scenario like -
short neck, restricted extension, double chin, big pad of neck fat and
especially if patient is sick, as the risk of loosing control of airway or
bleeding complications can be significant.
2) How far the USG will be able to show small abnormal midline neck
veins, on a regular basis, and that's the reason why about 50 % of
intensive care doctors do not use it as a routine screening before
tracheostomy.
I would still stress on the use of USG for screening of abnormal neck
veins in case of difficult surgical scenarios, as mentioned above
especially in sicker patients who are to undergo surgical or percutaneous
tracheostomy.
We read with interest the article by Illing et al which described the
management of a patient with life threatening ACE inhibitor-induced
angioedema (ACEiA).1 We would like to make some comments on the
investigation and management of this condition.
Complement C3, C4 and C1 inhibitor levels should be checked in all
patients presenting with isolated angioedema (i.e. without urticaria) to
rule out hereditary, and some forms...
We read with interest the article by Illing et al which described the
management of a patient with life threatening ACE inhibitor-induced
angioedema (ACEiA).1 We would like to make some comments on the
investigation and management of this condition.
Complement C3, C4 and C1 inhibitor levels should be checked in all
patients presenting with isolated angioedema (i.e. without urticaria) to
rule out hereditary, and some forms of acquired, angioedema.
Bradykinin accumulation and resultant increase in vascular permeability is
thought to be the underlying cause for symptoms in ACEiA, although other
factors may also be important.2 Unlike histamine-mediated (allergic)
angioedema, the use of steroids is not helpful in the management of these
patients.3 However, there are some data to suggest that the use of
antihistamines may improve outcome.4 There are also data to suggest that
when treatment is initiated early after symptom onset the outcomes tend to
be better and, in patients with hereditary angioedema, more than one dose
of icatibant may be necessary for complete symptom resolution.5
Icatibant is the only therapeutic agent that has shown benefit in the
management of patients with this condition.3 Indeed, one of our patients
who was intubated for severe ACEiA responded very well to Icatibant,
expediting her extubation.6 We feel that this drug should be readily
available in emergency departments for the management of this rare but
serious condition, and awareness of its potential benefits heightened
among physicians.
References
1. Illing EJ, Kelly S, Hobson JC, Charters S. Icatibant and ACE inhibitor
angioedema. BMJ Case Rep;2012.
2. Vleeming W, van Amsterdam JGC, Stricker BHC, de Wildt DJ. ACE Inhibitor
Induced Angioedema: Incidence, Prevention and Management. Drug Safety
1998;18(3):171.
3. Bas M, Greve J, Stelter K, Bier H, Stark T, Hoffmann TK, Kojda G.
Therapeutic Efficacy of Icatibant in Angioedema Induced by Angiotensin-
Converting Enzyme Inhibitors: A Case Series. Annals of Emergency
Medicine;56(3):278.
4. Grant NN, Deeb ZE, Chia SH. Clinical experience with angiotensin-
converting enzyme inhibitor-induced angioedema. Otolaryngol Head Neck Surg
2007;137(6):931-5.
5. Cicardi M, Banerji A, Bracho F, Malbr??n A, Rosenkranz B, Riedl M, Bork
K, Lumry W, Aberer W, Bier H, et al. Icatibant, a New Bradykinin-Receptor
Antagonist, in Hereditary Angioedema. New England Journal of
Medicine;363(6):532-541.
6. Icatibant: A Novel Treatment for Angiotensin Converting Enzyme
Inhibitor induced Angioedema: A Case Report. Poster Abstracts. Anaesthesia
2012;67(s1):6-46.
Insertion of the nasogastric tube is taken very casually at the
medical graduate level.
In my opinion , insertion of NG tubes should be done very judiciously
and gently in an awake patient.
Points to note --
1) Insert the tube very gently in the backwards and downward
direction in the nostril, to avoid inadvertent damage of the roof of the
nasal cavity, and passage of the tube intracranial....
Insertion of the nasogastric tube is taken very casually at the
medical graduate level.
In my opinion , insertion of NG tubes should be done very judiciously
and gently in an awake patient.
Points to note --
1) Insert the tube very gently in the backwards and downward
direction in the nostril, to avoid inadvertent damage of the roof of the
nasal cavity, and passage of the tube intracranial.
2) The tube should pass in without any resistance, in case of any
undue resistance, please take it out and insert again.
3) The NG tube be confirmed by auscultation on the epigastrium by
inflating air with a 20 cc syringe.
4) The patient can have cough while insertion, but this has to
subside after few minutes, if cough persists, then it is very important to
confirm the proper positioning of NG tube with the 4 point test mentioned
in the case report.
5) Its also important to insert the tube gently as it can cause
trauma and bleeding especially in patients on
antiplatelets/anticoagulants.
In conclusion, insertion of NG tube is a routine procedure done in
the hospitals,but it needs due diligence and good practice.
A 13 yr old adolescent girl could be a fussy eater. Her ht/ wt is not
mentioned; if she is underweight. she may not be eating citrus fruits. Her
gingivitis could also be due to scurvy due to dietary vitamin C
deficiency that should have been excluded or treated. Suggested
investigations are vitamin C levels and x-rays of knee and wrist joints.
Examination for bone aches.
A 13 yr old adolescent girl could be a fussy eater. Her ht/ wt is not
mentioned; if she is underweight. she may not be eating citrus fruits. Her
gingivitis could also be due to scurvy due to dietary vitamin C
deficiency that should have been excluded or treated. Suggested
investigations are vitamin C levels and x-rays of knee and wrist joints.
Examination for bone aches.
Vitamin C deficiency can lead to bleeding and swollen gums in an
adolescent girl if she is a fussy eater. Diet history, x-ray and blood
levels can exclude/ confirm Vitamin C deficiency.
I completely agree with the authors in saying that all ST-T changes
are not myocardial injury.
In my experience, not all new widened QRS complex changes (LBBB)
indicate myocardial infarction or injury.
I would like to say this on the basis that quite a few times, a
patient with new wide QRS complex and bradycardia is referred to
cardiology to rule out myocardial infarction and after investigations
pa...
I completely agree with the authors in saying that all ST-T changes
are not myocardial injury.
In my experience, not all new widened QRS complex changes (LBBB)
indicate myocardial infarction or injury.
I would like to say this on the basis that quite a few times, a
patient with new wide QRS complex and bradycardia is referred to
cardiology to rule out myocardial infarction and after investigations
patient is found to have severe hyperkalemia and with ARF or an
undiagnosed and progressive CKD.
After immediate correction of hyperkalemia with glucose -insuln infusion,
and intravenous Normal saline, and inj. frussemide in non-oliguric
patients, the ECG changes revert back to normal.
It's important to take ST-T changes on ECG seriously, but also have to
look at clinical signs and symptoms and investigations to ascertain
myocardial injury especially in emergency situations.
This is a prime example of a situation where it would be easy for
someone to say "this isn't possible" but when you offer irrefutable proof,
all one can say is "WOW!!"
The authors make a claim that the patient developed angioedema
following ingestion of oscillococcinum, a homeopathic "remedy" used for
treating influenza symptoms. The authors claim that evidence of benefit
exists to claim that this preparation has proven clinical activity.
Unfortunately, they omit to use up-to-date information to base this claim
on. The most recent Cochrane review (1), published January 2015 and
author...
The authors make a claim that the patient developed angioedema
following ingestion of oscillococcinum, a homeopathic "remedy" used for
treating influenza symptoms. The authors claim that evidence of benefit
exists to claim that this preparation has proven clinical activity.
Unfortunately, they omit to use up-to-date information to base this claim
on. The most recent Cochrane review (1), published January 2015 and
authored by two well-known homeopaths concluded "There is insufficient
good evidence to enable robust conclusions to be made about
oscillococcinum in the prevention or treatment of influenza and influenza
-like illness. Our findings do not rule out the possibility that
oscillococcinum could have a clinically useful treatment effect but,
given the low quality of the eligible studies, the evidence is not
compelling. There was no evidence of clinically important harms due to
oscillococcinum."
The second problem with this report is the constituents of the
oscillococcinum remedy itself. It is based on a preparation of Barbary
duck heart and liver, misinterpreted by French physician Joseph Roy of a
preparation of blood samples from victims of Spanish Flu towards the end
of World War 1 (2). The preparation is supplied in the form of lactose
pills onto which the remedy has been dripped. The solution dripped onto
the pills has been diluted to the homeopathic "potency" of 200C. This
involves serial centessimal dilutions to a factor of 200. This means that
it is not possible to find a single particle or molecule of the original
starting material in the final diluted solution. Serial dilution beyond
the 12C "potency" exceeds Avogadro's constant. Dilution to 200C means that
you could search the entire known universe and still fail to find a single
entity from the starting material! (3)
Their patient would appear to have had an allergic response to something,
but if it is the pills he took, then it could only be the lactose, which
is possible but unlikely. This therefore begs the question as to what the
patient actually had the allergic reaction to? He should undergo a formal
allergy review by a specialist, possibly including formal testing to work
out what the allergy really is.
Gluten intolerance is an autoimmune enteropathy cased by
heterogeneous mixture of wheat storage proteins. Malabsorption symptoms
imply diarrhoea, abdominal pain/bloating, and weight loss. This case
describes a 22 years old female subject, who suffered chronic headache,
joint pain, urticaria, and long period of amenorrhea. Skin prick tests
revealed a sensitization to ?-gliadin, while neurological, gynaecological,
endocrin...
Gluten intolerance is an autoimmune enteropathy cased by
heterogeneous mixture of wheat storage proteins. Malabsorption symptoms
imply diarrhoea, abdominal pain/bloating, and weight loss. This case
describes a 22 years old female subject, who suffered chronic headache,
joint pain, urticaria, and long period of amenorrhea. Skin prick tests
revealed a sensitization to ?-gliadin, while neurological, gynaecological,
endocrine and clinical-laboratory examinations did not justify the above-
mentioned symptoms. Gluten-free diet resolved chronic symptoms and re-
established the menstrual cycle, whereas a temporary gliadin daily diet re
-exacerbated all clinical symptoms. Urticaria occurred 20 minutes and the
chronic headache the next day after exposure to the gliadin-rich diet. In
addition, it was observed the missing of the expected menstrual bleeding.
This case demonstrates that gliadin intake can induce not only
malabsorption but also "idiopathic" neuronal or gynaecological symptoms.
Congratulations for publishing this important clinical lesson as this is unfortunately missed in post natal ward from time to time. I therefore tell the 'busy' junior doctors to spare some time to clean the perineum at 1st day check if it is soiled with meconeum so that the anal opening can be identified and documented as meconeum can be passed from a perineal fistula too. If he does not wish to clean then he should come b...
I agree with the concept of a pre-tracheostomy USG to visualize the neck veins in case of a percutaneous tracheostomy.
But I have to 2 points against --
1) I believe percutaneous tracheostomy is still not a routine method of choice in elective tracheostomy in difficult surgical scenario like - short neck, restricted extension, double chin, big pad of neck fat and especially if patient is sick, as the...
We read with interest the article by Illing et al which described the management of a patient with life threatening ACE inhibitor-induced angioedema (ACEiA).1 We would like to make some comments on the investigation and management of this condition. Complement C3, C4 and C1 inhibitor levels should be checked in all patients presenting with isolated angioedema (i.e. without urticaria) to rule out hereditary, and some forms...
Insertion of the nasogastric tube is taken very casually at the medical graduate level.
In my opinion , insertion of NG tubes should be done very judiciously and gently in an awake patient.
Points to note --
1) Insert the tube very gently in the backwards and downward direction in the nostril, to avoid inadvertent damage of the roof of the nasal cavity, and passage of the tube intracranial....
A 13 yr old adolescent girl could be a fussy eater. Her ht/ wt is not mentioned; if she is underweight. she may not be eating citrus fruits. Her gingivitis could also be due to scurvy due to dietary vitamin C deficiency that should have been excluded or treated. Suggested investigations are vitamin C levels and x-rays of knee and wrist joints. Examination for bone aches.
Conflict of Interest:
...Vitamin C deficiency can lead to bleeding and swollen gums in an adolescent girl if she is a fussy eater. Diet history, x-ray and blood levels can exclude/ confirm Vitamin C deficiency.
Conflict of Interest:
None declared
I completely agree with the authors in saying that all ST-T changes are not myocardial injury.
In my experience, not all new widened QRS complex changes (LBBB) indicate myocardial infarction or injury.
I would like to say this on the basis that quite a few times, a patient with new wide QRS complex and bradycardia is referred to cardiology to rule out myocardial infarction and after investigations pa...
This is a prime example of a situation where it would be easy for someone to say "this isn't possible" but when you offer irrefutable proof, all one can say is "WOW!!"
It's never too late to learn something new!
Conflict of Interest:
None declared
The authors make a claim that the patient developed angioedema following ingestion of oscillococcinum, a homeopathic "remedy" used for treating influenza symptoms. The authors claim that evidence of benefit exists to claim that this preparation has proven clinical activity. Unfortunately, they omit to use up-to-date information to base this claim on. The most recent Cochrane review (1), published January 2015 and author...
Gluten intolerance is an autoimmune enteropathy cased by heterogeneous mixture of wheat storage proteins. Malabsorption symptoms imply diarrhoea, abdominal pain/bloating, and weight loss. This case describes a 22 years old female subject, who suffered chronic headache, joint pain, urticaria, and long period of amenorrhea. Skin prick tests revealed a sensitization to ?-gliadin, while neurological, gynaecological, endocrin...
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