eLetters

333 e-Letters

  • Aza induced hyperglycemia

    The author proposes two possible mechanisms for Aza induced hyperglycemia 1. Impaired beta cell function in pancreas via epigenetic mechanism 2. Increased secretion of cortisol. I suggest another possibility. A recent paper by Strand et al reports that Aza, a DNMT1 inhibitor, is a potent inducer of PTEN (this work done in vascular smooth muscle cells). It is well known that PTEN is an inhibitor of downstream elements of the insulin pathway, specifically PI3K-AKT-mTOR pathway and this results in insulin resistance. I suggest that the hyperglycemic activity of Aza is by PTEN induction of insulin resistance.
    Strand KA, Lu S, Mutryn MF, et al. High Throughput Screen Identifies the DNMT1 (DNA Methyltransferase-1) Inhibitor, 5-Azacytidine, as a Potent Inducer of PTEN. Arterioscler Thromb Vasc Biol. 2020;40:1854–1869.

  • Consistent messaging in airway emergencies

    We thank Dr Yap and colleagues for describing clearly the successful management of an unexpectedly challenging airway.1 We agree that the index case highlights the need for vigilance in all patients requiring airway management, particularly where an atypical presentation of a respiratory condition may indicate occult airway pathology.2 However, the case raises a number of important issues for airway assessment, intubation-related laryngeal pathology and the management of ‘can’t intubate, can’t ventilate’ scenarios which warrant further discussion, considered below.

    Airway assessment can be encapsulated by the quote, “Hindsight is a wonderful thing but foresight is better, especially when it comes to saving life,” attributed the 19th Century English poet William Blake. Whilst subtle, there were a number of clues in the described case report that could, and perhaps should, have prompted a more thorough evaluation of the airway. It is surprising that the patient did not report their extreme prematurity at birth, or the fact that they spent the first year of their life in hospital. This would have almost certainly have involved prolonged ventilation and sequelae into childhood. Respiratory and airway complications are well recognised in premature neonates and may coexist.3 The authors highlight the Difficult Airway Society’s airway algorithms and the fact that any clinician managing an airway should prepare for failure.4-6 This should involve an examination of the front...

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  • A Ticking Time Bomb – incidental finding of a giant thoracoabdominal aneurysm

    Dear Editor,

    Giant aortic aneurysm is a rare clinical entity. They may present with typical features of chest pain or abdominal pain, or most feared complications with dissection and rupture. However, an asymptomatic and unruptured giant thoracic aneurysm is extremely rare with only two case reports in the literature.

    I had a similar case which an 80-year-old lady admitted to a local district general hospital with a 5 day history of productive cough with shivers, which she was tested positive for COVID-19 on admission.

    Diagnostic workup demonstrated an incidental finding of a giant TAAA. Her case was referred to a tertiary hospital for vascular Multidisciplinary Team (MDT) discussion and planning.

    It was decided that for her to have pre-operative assessment and MDT discussion after her recovery from infection to have a definitive management of the TAAA. The patient is currently being managed supportively in hospital.

    According to National Institute for Health and Care Excellence (NICE), asymptomatic and 5.5 cm or larger aneurysm should be considered for repair. The case should be discussed in terms of the overall balance of benefits and risks with repair and conservative management, based on the current status of health and the expected future health. In this case, it was deemed that the risk of proceeding with repair at present outweighed the benefits.

    Incidental finding of a giant AAA/TAAA is rare. It emphasises the importance...

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  • Utilization of the Brighton Collaboration consensus case definition for the standardized assessment of sensorineural hearing loss in COVID-19 related hearing loss

    To the authors:
    We read with interest the article entitled “Sudden irreversible hearing loss post COVID-19”.1 In this article, the authors presented an unusual case of a 45 year-old gentleman with sudden-onset sensorineural hearing loss (SNHL) after COVID-19 infection and treatment. In their literature review, five other case reports were cited with hearing loss noted after COVID-19.2-6 The patient in the case report experienced a decrease in his left sided hearing 1 week after his intensive care unit stay for COVID-19 treatment. His initial hearing loss was evaluated at the bedside with a tuning fork examination showing negative Rinne’s test on the side of reported hearing loss, and Weber’s test lateralizing to the side opposite to his hearing loss, which is consistent with SNHL of the affected side. He then had a 7 day treatment course of 60mg oral Prednisone daily in addition to a series of intratympanic steroid injection. His hearing loss was documented with elevated hearing thresholds of 65, 75, 75, and 85 dB at 2, 3, 4, and 6 kHz.
    As multiple countries across all continents are facing the effects of the pandemic, our understanding of the various immediate and long-term complications of COVID-19 is evolving. SNHL is one of these complications. The Coalition for Epidemic Preparedness Innovations (CEPI) has developed a Brighton Collaboration case definition of SNHL to be utilized in the evaluation of adverse events following immunization, which can also be...

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  • More to investigate and more to treat

    We read the article published by Jaikaran O. et al on ‘Portomesenteric thrombosis after robotic sleeve gastrectomy’ with great interest. The reported about a morbid obese patient having porto-mesentric thrombosis after robotic sleeve gastrectomy due to obesity and mutation in methylenetetrahydrofolate reductase (MTHFR) mutation. However, we have few factors to report on this aspect.

    Firstly, MTHFR enzyme dysfunction leads to hyperhomocysteinemia which leads to hypercoagulation state. Yet, the magnitude of this state is affected via degree of enzyme deficiency/dysfunction which is dependent on presence of heterogeneous/ homogenous mutation in enzyme gene. So, the authors must assess for the presence of hyperhomocysteinemia along with assessment of mutation.[1,2] Also the genetic homogeneity of the mutation must be assessed as heterogeneous mutation will have less effect on blood homocysteine levels.[3]

    Next, the importance of folic acid for management of thrombotic state due to hyperhomocysteinemia must be considered. The patient has undergone sleeve gastrectomy which may further aggravate her vitamin and micronutrient deficiency. The administration of folic acid (instead of aspirin) will decrease the blood homocysteine levels and reduce the risk of hypercoagulation.[4]

    References:
    1. Friso S, Girelli D, Trabetti E, Stranieri C, Olivieri O, Tinazzi E, Martinelli N, Faccini G, Pignatti PF, Corrocher R. A1298C methylenetetrahydrofolate reductase mu...

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  • Diagnosis, Plausible but Difficult to Establish.

    Some more information will make the Case Presentation more Illuminating and Educative, such as:
    1) What was Central Venous Pressure,
    2) If patient was, presumably Conscious, Oriented, Able to take Food and Fluids by Mouth, could the Intravenous Administration of Fluids be avoided,
    3) How did the Elevated Blood Pressure evolved during Hospitalization, either with or without Medications,
    4) What was Patient's Diet and Fluid Intake Both Quantitative and Qualitative during the Hospitalization,
    5) Whether the Patient took any Formal or Alternative Medicines or Home Remedies for Coryza he had Two Weeks before Episode of Shortness of Breath, that could have caused Autoimmune Hemolysis.
    5) If the Patient's Blood Pressure before Present Illnesses was known and if he took any medications for it and any other conditions eg Bleeding per Rectum,
    6) What were the instructions including those regarding medications diet and follow-up given to the Patient at the time of Discharge.
    The Authors need to be complimented for seeing the patient through the crisis and The BMJ be thanked for bringing it up to the Readers.

  • Cheiro-oral syndrome secondary to thalamic infarction: a clinical syndrome a physician should know

    Dear editor,
    The case report of published in BMI Case Reports 2020 Oct 29;13(10):e236017 by Ong et al. further expanded the knowledge of cheiro-oral syndrome, an incomplete sensory disorder, in clinical practice. Regarding to the classification of cheiro-oral syndrome, authors cited for Satpute et al. (2013), who clearly described the vascular anatomy of thalamus relating to the clinical picture of sensory and other neurological deficits, including some incomplete sensory syndromes. Bogousslavsky et al. (1988) had reported similar results before. However, to my understanding, the four types of cheiro-oral syndrome was firstly suggested by Chen WH (2009).

    1.Bogousslavsky J, Regli F, Uske A. Thalamic Infarcts: clinical syndromes, etiology, and prognosis. Neurology. 1988;38:837–848.
    2.Chen WH. Cheiro-Oral Syndrome: A Clinical Analysis and Review of Literature. Yonsei Med J. 2009;50(6):777–783.
    3.Satpute S, Bergquist J, Cole JW. Cheiro-Oral syndrome secondary to thalamic infarction: a case report and literature review. Neurologist 2013;19:22–5.

  • Lets call EVALI what it is: THC VALI

    To the editor,
    The authors of this article appear to be unaware that the cause of "EVALI" was identified almost a year ago. To quote Dr Ann Schuchat, Principal Deputy Director of CDC in December, 2019: "we can conclude that what I call the explosive outbreak of cases of EVALI can be attributed to exposure to THC-containing vaping products that also contained Vitamin E acetate." (1). This followed publication in NEJM of a study which noted that "Vitamin E acetate was identified in BAL fluid obtained from 48 of 51 case patients (94%) in 16 states but not in such fluid obtained from the healthy comparator group." It also noted that "47 of 50 (94%) had detectable tetrahydrocannabinol (THC) or its metabolites in BAL fluid or had reported vaping THC products." It is widely known that people who have become ill due to use of illicit products, such as THC vapes, do not always tell the truth about the illegal products they used. The NEJM study also reported that "9 of 11 patients who reported no use of THC-containing e-cigarette products in the 90 days before the onset of illness had detectable THC or its metabolites in their BAL fluid." These and numerous other studies have clarified that EVALI is caused by vaping THC products contaminated by vitamin E Acetate. Since the cause became clear in December 2019, identification of new cases of this disease dropped markedly, and in February 2020 CDC stopped reporting new cases. We...

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  • Selumetinib should be preferred to a surgical approach in case of extensive plexiform neurofibromas

    Dear Editor,
    we found the case report of Banthia et al. extremely interesting. First of all, penile plexiform neurofibromas are quite infrequent. Secondly, the subject described did not have a former clinical diagnosis of neurofibromatosis type I prior to the identification of this tumor, which is even rarer. However, we take exception to the therapeutic approach chosen by the authors. In fact, the surgical treatment of deep and extended plexiform neurofibromas is generally unsatisfactory, since their complete resection is frequently unattainable, allowing the masses to grow back (1-2). A partial tumor debulking should be considered only in case of high-risk conditions, such as a urethral or ureteral compression or a bowel obstruction. Apart from these scenarios, a medical approach should always be preferred, at least as a first attempt.
    Selumetinib, an inhibitor of MEK 1 and 2 kinase, has demonstrated to be effective in reducing the size of plexiform neurofibromas in pediatric patients (3-4). The drug is generally well tolerated and safe in the pediatric population. Only few patients failed to show a clinical response to the treatment and even fewer had to stop it due to the appearance of severe adverse events.
    In a recent study, we reported a cohort of nine patients with inoperable plexiform neurofibromas treated with selumetinib (5). Eight of them showed a partial response to the drug, i.e. a reduction of the tumor size by more than 20%. Remarkably, on...

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  • Association or coincidence?

    The authors describe a single patient who tested positive for SARS-Cov-2 and had sensorineural hearing loss.
    In their article they mention that the annual incidence of sudden sensorineural hearing loss (SSNHL) is between 5 and 160 patients per 100,000.
    The current population of the UK is 67.866.011 according to the latest data (https://www.worldometers.info/demographics/uk-demographics/, accessed 18th October 2020).
    This therefore suggests that there will be between 3,393 and 108,585 patients presenting with SSNHL in the UK this year. Accepting that we have not completed the year we can expect around 80% of the above figures to represent the expected incidence so far i.e. somewhere between 2,714 and 86,868 patients experiencing SSNHL.
    The estimated incidence of Covid in the UK population is 0.62%, or 1 in 160 people have so far had Covid.
    Therefore, purely by statistics alone, the number of patients with both Covid and SSNHL should lie somewhere between 17 and 543.
    Whilst the authors make no claim that in their presented case the Covid was directly responsible for the SSNHL it seems surprising that this article was published by the BMJ as it stands without the authors making any attempt to discern the true incidence of SSNHL in patients with Covid.

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