342 e-Letters

  • What about the sugar?

    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?

  • Absence of patient weight (possible major confounder)

    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 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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  • Rapid Response: Critical appraisal of the article - acute transient psychotic disorder precipitated by Brexit vote

    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...

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  • Changing perspectives on Campus; KCL

    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 Colleg...

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  • "Likely cause', How A Respiratory Therapist sees it.

    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."


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  • The importance of adequate allergological studies in order to confirm the penicillin sensitization through seminal fluid

    The publication of a clinical case in the BMJ Case Report on March 8 [1], entitled "Anaphylaxis probably induced by transfer of amoxicillin via oral sex", has resulted in interest in social networks, local and national press, radio, and television, reporting with big headlines of such allergic reaction, but without contrasting the work assessing the scientific content and experimental support.

    The article reports the case of a woman with a history of allergy to penicillin in childhood who, after having sexual intercourse (vaginal and oral) with her partner, who was being treated for otitis media with amoxicillin/clavulanic acid and ibuprofen, presents dyspnea, vomiting, and urticaria. The patient had not ingested any unusual food. She was diagnosed with anaphylaxis probably induced by amoxicillin/clavulanic acid transfer in the seminal fluid of the couple through oral sex. This diagnosis was based solely on a skin reaction suffered in her childhood after taking amoxicillin (no description of how that diagnosis was made) and a probability algorithm [2]. No allergological investigation was conducted at the time of the reaction.

    Previous studies have shown that seminal fluid can serve as a route of transmission of ingested allergens, such as nut proteins [3], and drugs such as vinblastine [4], and penicillin [5]. The latter study was the only one in which intradermal tests with penicillin, with a positive result, and intra-epidermal tests with semen, w...

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  • Changes in the Last Five Years

    I read this article with interest and, as a final year medical student, I am writing to add my thoughts to this growing area of discussion and describe how, in my experience, the situation has changed since 2014, when I started medical school and this article was published.
    The authors of this article noted that talking openly about challenges people with mental health issues face could relieve negative effects of stigma and help change general attitudes. I believe we have made progress towards this over the past five years. During the first part of university, mental health awareness campaigns came from student unions, not the MedSoc or clinical school, and there was little specific emphasis on medical student welfare. Now, my clinical school consistently encourages its students to speak out if they are struggling and signposts professionals and services we can access if needed. Additionally, students and doctors are talking publicly about their struggles, such as the rise of blogs including the Depressed Medical Student, and research by the British Medical Association (BMA).
    The article does not explore how the institutionalised pressure of medicine contributes to or exacerbates mental health problems. A BMA report showed that 90% survey respondents attributed their condition to the working or studying environment (“BMA - Supporting the mental health of doctors and medical students,” n.d.). In my pre-clinical years at medical school, we were pushed for academ...

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  • Interesting Queries

    Dear Editors

    While I have not doubt there are incidents involving vascular migration of Implanon NXT, the presentation of this case study raises some interesting questions verging to concerns about the details:

    1. As stated by the authors, the device measures 4 cm long and 2 mm diameters. The suggested radioopaque foreign body shown in Figure 1 and 2 appears to be disproportionately long. These images suggest the skeletal frame involving torso of the woman is no wider than 25-30 cm (bone-wise) which meant this is an extra-ordinarily small woman.

    2. CT Chest reported ‘hyperdense image with 40 mm, compatible with Implanon in the anterior basal segment of the lower left lobe in intravascular topography'. Interestingly the authors stated that "Implanon was removed by video assisted thoracoscopic surgery without pulmonary resection. Surgical procedure and postoperative course had no complications. " As reader may be aware, video assisted thoracoscopic surgery (VATS) primarily involved the insertion of thoracoscopes into pleural cavities via small incision on the chest. It would have been helpful to know if the implanon device had been found in the pulmonary vasculature, lung tissue or actually in the pleural space itself. As reflected in the article's own reference (1) on an example of VATS retrieval, it is no simple matter.

    The lack of such details in the article raises more questions than answers

    1. Th...

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  • Thinking outside the box is important, but carries some risk

    We read with interest the article by Bhandare and Ruchi (1). They diagnosed severe organic mercury (Hg) poisoning in a 69 year old man with known hypertension and diabetes who presented with a transient altered mental status. The diagnosis was based on a history of increased fish consumption and a blood Hg level of 35 ng/mL. Methylmercury (MeHg) is the form present in seafood, but there are multiple chemical forms of Hg and each has different health consequences. Everyone who consumes seafood is exposed to MeHg, but it is the dosage that is critical. The US EPA determined the MeHg reference dose (defined as “…a daily oral exposure …that is likely to be without an appreciable risk of deleterious effects during a lifetime”) to be 5.8 ng/mL in blood. That value was based on dividing the lowest observed adverse effect level of 58 ng/mL (a value reported from a large, controversial epidemiological study) by a safety factor of 10. Blood MeHg exposures of 35 ng/mL and higher are common, with no evidence of clinical symptoms. For example, residents of the Seychelles islands consume large amounts of marine fish, have documented blood MeHg exposures at or above 35 ng/mL, and are asymptomatic. A recent Seychelles study of 1,266 mothers reported that they ate fish with meals 8.5 ± 4.5 times per week while pregnant and had a mean blood Hg level of 18.2 ng/mL (2). The maximum blood Hg level in that study was 84.2 ng/mL and no mother reported clinical manifestations. The mean...

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  • Karl Otto Geier, MD, MSc, Acupuncturist.

    Dear authors. The location of the needle was interscapular, but it does not mention the exact site since the interscapular would be the spine. Anyway, I think pneumothorax must have been arrived from puncturing a pleural bubble. More, was "bounce" maneuver stimulation performed with the needle? This maneuver entails numerous punctures of the bubble, facilitating the pneumothorax.