298 e-Letters

  • Pancoast Tumor

    The terms Pancoast tumors, superior sulcus tumors, and superior pulmonary sulcus tumors are applied to neoplasms located at the apical pleuro pulmonary groove. In 1924, Henry K. Pancoast, described a patient afflicted with a lung carcinoma occupying the apical thoracic cavity that was associated with a constellation of symptoms that included shoulder pain radiating down the arm, atrophy of the hand muscles, and Horner’s syndrome.[ 1] Since then, it has become widely accepted that the term Pancoast syndrome can be applied to any clinical condition in which a neoplasm in the apex of a lung is accompanied by shoulder or arm pain. Anatomically, the definition includes any tumor invading through the parietal pleura at the level of the first rib and above. The pulmonary sulcus refers to the costo vertebral gutter extending from the first rib to the diaphragm. The superior pulmonary sulcus is therefore analogous to the superior most portion of this recess. The first rib is at the base of the thoracic inlet. The thoracic inlet contains the subclavian vein anteriorly, the subclavian artery, phrenic nerve and trunks of the brachial plexus medially, and the nerve roots of the brachial plexus and the stellate ganglion posteriorly. The bony thorax in the superior sulcus includes the upper ribs and the associated vertebral bodies. It is invasion of this complex anatomical area that accounts for the classic symptoms of the Pancoast tumor. Superior sulcus carcinomas have the same biologic...

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  • Replay to “Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS”

    Dear Editor,
    We read with interest the report in the present Journal of Edington M. et al [1] titled “Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS”.
    Erectile disfunction drugs play a role increasing levels of cyclic guanosine monophosphate (cGMP) with subsequent effects on nitric-oxide release. This condition can lead to acute angle-closure glaucoma (AACG) in case of anatomical predisposition. AACG is an ophthalmic emergency, it can lead to irreversible blindness if not identified and treated immediately and precipitating factors include certain drugs as nitrates, bronchodilators, cough mixtures, cold and flu medication, antidepressants, antihistamines and anticonvulsants [2]. Furthermore, a precedent case of AACG following sildenafil citrated therapy is also described [3].
    We would like underline that this situation could lead to more serious effects, that only the mild chemical ocular injury, in presence of ophthalmic structural diseases.

    1. Edington M, Connolly J, Lockington D. Prescribing lessons from an ocular chemical injury: Vitaros inadvertently dispensed instead of VitA-POS. BMJ Case Rep. 2018 Dec 3;11(1). doi: 10.1136/bcr-2018-227468.
    2. Murray D. Emergency management: angle-closure glaucoma. Community Eye Health. 2018;31(103):64.
    3. Ramasamy B, Rowe F, Nayak H, Peckar C, Noonan C. Acute angle-closure glaucoma following sildenafil citrate-aided sexua...

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  • Using all capital may not be safer

    This prescribing-dispensing error is unusual in that no-one spotted the obvious mistake. Superficially it would seem that recommending that handwritten prescriptions are in capital letters would improve safety, but this could introduce a different type of error, that is more common. Calligraphers know from experience that attempting to use an unfamiliar upper-case style is harder and distracting. Concentrating on forming the letters takes attention away from the content and before you know it you’ve just written a perfectly formed but incorrect letter. There is no research to transfer knowledge from this craft to prescribing, but the danger is that by asking prescribers to focus on an unfamiliar style of writing diverts attention from getting the correct drug name. One of the commonest and most dangerous errors is simply prescribing the wrong drug. This is easy to do when two very different drugs have similar names, as in the case report. So common is this potentially serious error, that previously the RCGP Quality Unit in collaboration with ten other organisations, including universities, indemnity providers, and colleges, issued a pamphlet “In Safer Hands” and sent it to every GP in the country pointing out this danger. Despite the huge collaboration, of the eighteen drugs given as examples of high-risk similar names, three were misspelt. All capitals might improve legibility of a drug name, the receiving end of the communication, but at the cost of damaging the transmis...

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  • Imaging In Vertebral Artery Dissection
    Nosakhare I Idehen

    Thanks for reporting this interesting case of VAD. The clinical versatility of this pathology calls for careful history taking and examination to avoid the pitfall of inappropriate imaging requests for patients who present with craniocervical pain with or without headache.

    The presence of new neurological deficits such as those described in the case report would certainly warrant urgent imaging. In the absence of...

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  • Author Reply
    Laura Boylan

    I thank Drs. Onder and Jahanroshan for their interest in this report. They raise excellent points. A video would have added a great deal, however I was unable to locate proxies to consent for such a recording during the time of what was a short lived tremor. An EEG done prior to the appearance of the tremor showed global slowing with no epileptiform activity. I can't exclude self limited hypoxia prior to being found bu...

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  • Cure?
    Tracy Kolenchuk

    I am always happy to see treatments that avoid medicines.

    On the other hand, I am always sad to see that "cured" is not defined, and as a result it is not possible to claim a cure for diabetes - not even possible to know if a specific case, or a specific treatment, is moving closer to cured, or farther away from cured.

    When cured is defined, independent of treatment, we will be able to find cures. Unt...

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  • dr
    vaidyanathan Gowri

    Dear Sir, Though the authors claim that there was heterotopic pregnancy ideally they should have done a curettage to prove chorionic villi from the intrauterine pregnancy. The sac demonstrated in the uterus could be pseudo sac. Without a clear evidence of villi in both sites, this will be wrong message. The drop in the beta hCG can be a lab error or rupture of the ovarian ectopic

    Conflict of Interest:

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  • An excellent paper, but some further details would be useful
    Roberto Calisti

    An excellent paper! I think it would be useful if the authors explained if the patient was exposed to sclerogenic dusts, both in occupational and non-occupational scenarios.

    Conflict of Interest:

    None declared

  • Abstract should indicate the type of turmeric supplement
    Brien Quirk

    Was this supplement a turmeric powder, simple water extract, or the highly concentrated standardized turmeric extract with 95% curcuminoids made using a hexane or organic solvent? This can be an important determinant for causing liver toxicity.

    Conflict of Interest:

    Work for supplement industry

  • Response to case report; cephalad migration of externally powered spinal cord stimulator.

    Sirs, As a neuromodulator and instructor with extensive (30 year) experience with both "wired " and "wireless " systems, I feel compelled to repond to the conclusions of the cited case report.

    While the authors mention lead migration as an known complication of spinal cord stimulation, it is useful to consider that Cameron (1) cited 361 lead migration events in 2753 patients , a 13.2% incidence. Anderson (2) , i...

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