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 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
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."
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...
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 academic excellence, sometimes at the expense of adequate sleep, a social life, or time to de-stress. I had friends openly state they would ‘sacrifice [their] mental health for a first class’ and spend all day with a textbook. However, during clinical school, pressure changed to be the pinnacle of professionalism as we are ‘held to a higher standard’. Suddenly family members would come to us with health questions and expect us to know the answers. The GMC was presented as a body to be feared, and stories circulated of doctors being struck off for admitting to mental illness – anecdotally, this seems to be one of the biggest barriers particularly for final year medical students to coming forward. However, this could be dispelled by blogs such as the Depressed Medical Student with people progressing through their careers despite struggles with mental health issues. Although I have yet to experience it, I imagine the pressure changes again for students after becoming FY1 doctors.
We are getting better at speaking up about mental illness, but there is a way to go before people can do so completely stigma-free. Furthermore, we have not successfully addressed the growing prevalence of mental health issues amongst medical students and doctors. To an extent, it is unavoidable, since medicine is inherently stressful, but maybe we could be doing more to support struggling doctors, particularly juniors who are most at risk.
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...
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, with a negative result, were carried out. In addition, seminal fluid-specific IgE levels were also determined, with a negative result [5].
In the present case, a relevant allergological study was not carried out at the time of the reaction in order to confirm the amoxicillin/clavulanic acid sensitization described by the patient, including in vivo and in vitro tests (skin tests, specific IgE levels or provocation tests to -lactam antibiotics). From the skin reaction after amoxicillin ingestion in childhood, it could be speculated that the patient is allergic to penicillins. However, this speculation has little experimental support. In the experience of most allergists, the cutaneous reactions produced in childhood, coinciding with the taking of penicillins, are usually infectious rashes. Neither skin tests nor determination of specific IgE to the semen have been carried out to rule out seminal plasma hypersensitivity (SPH) which, despite being a rare phenomenon, is more prevalent than the allergic reaction by drug transfer (amoxicillin), so it is necessary to rule out such a possibility [6]. It would also be necessary to rule out postcoital asthma or food allergy (it is not excluded that she has previously tolerated a food) through an in vivo and in vitro allergological study that includes the assessment of serum tryptase levels, other types of acute urticaria and even microorganisms, which in this case has not been investigated [7].
Although the prevalence of SPH is unknown, we believe that this pathology may be underdiagnosed. Currently, around 100 cases have been documented in the English literature, being more frequently between 20-30 years and occurring at first sexual intercourse in 40-50% of patients [8]. According to a survey conducted in 1997 to 1,073 US women, between 20,000-40,000 patients could suffer SPH (1/5,000) [9].
In Spain, the Allergy Unit of the General University Hospital of Elda published in 1993 the first case of immediate SPH, demonstrated by skin tests and determination of specific IgE positive to seminal plasma [10]. In December 2017, we published a second case of local SPH which, in turn, was the first case of local SPH with colposcopic and histopathological control after postcoital vulvovaginal exposure, as well as local manifestations (contact urticaria) after oral sex [11]. This work was the first case published in the literature of SPH demonstrated by genital biopsy and the first documented case of allergy to seminal fluid by oral sex. We also want to highlight the work carried out by Basagaña et al. describing the prostatic specific antigen (PSA) as one of the allergens that is sometimes responsible for SPH due to the cross-reactivity with Can f 5 allergen of dogs [12].
Therefore, it is desirable that scientific journals are keen to verify that published articles are supported by scientific evidence and solid experimental results, which make the "probable allergen" involved in the described allergic reaction very likely to be the "real allergen". This must always be taken into account, but even more so when the topic is very attractive for the general media to take the published information to look for eye-catching and sensational headlines. Of course, all the aforementioned information does not exclude that the allergic reaction was produced by amoxicillin transfer through the semen, but obviously it is necessary to have more experimental evidence to suggest it with certain guarantees of success. Articles should not be left in simple explanatory hypotheses without sufficient experimental evidence to support them.
REFERENCES
1. Gomez Caballero N, Almenara S, Tevar Terol A, Horga de la Parte JF. Anaphylaxis probably induced by transfer of amoxicillin via oral sex. BMJ Case Rep. 2019;12.
2. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981;30:239-45.
3. Bansal AS, Chee R, Nagendran V, Warner A, Hayman G. Dangerous liaison: sexually transmitted allergic reaction to Brazil nuts. J Investig Allergol Clin Immunol. 2007;17:189-91.
4. Paladine WJ, Cunningham TJ, Donavan MA, Dumper CW. Letter: Possible sensitivity to vinblastine in prostatic or seminal fluid. N Engl J Med. 1975;292:52.
5. Green RL, Green MA. Postcoital urticaria in a penicillin-sensitive patient. Possible seminal transfer of penicillin. JAMA. 1985;254:531.
6. Shah A, Panjabi C. Human seminal plasma allergy: a review of a rare phenomenon. Clin Exp Allergy. 2004;34:827-38.
7. Nusair B, Gallagher E, Purohit P, Chye Gooi JH, Hamoda H. Seminal fluid hypersensitivity: A case report and review of the literature. Current Women's Health Reviews. 2018;14:81-6.
8. Resnick DJ, Chen L, Low J, Lee-Wong MF. Seminal plasma hypersensitivity and successful intravaginal graded challenge. Internet J Asthma Allergy Immunol. 2014;10.
9. Bernstein JA, Sugumaran R, Bernstein DI, Bernstein IL. Prevalence of human seminal plasma hypersensitivity among symptomatic women. Ann Allergy Asthma Immunol. 1997;78:54-8.
10. Jover Cerdá V, Parera M, Valera AC. Hipersensibilidad al fluido seminal humano: Presentación de un caso. Rev Esp Alergol Inmunol Clin Supl. 1993;8:223-7.
11. Jover Cerdá V, Rodríguez Pacheco R, Doménech Witek J, Durán García R, Garcia Teruel MJ, Santes García J, et al. Seminal plasma hypersensitivity: Clinical and histopathologic features in a multipara woman. J Allergy Clin Immunol Pract. 2017;5:1768-70.
12. Basagaña M, Bartolomé B, Pastor-Vargas C, Mattsson L, Lidholm J, Labrador-Horrillo M. Involvement of Can f 5 in a case of human seminal plasma allergy. Int Arch Allergy Immunol. 2012;159:143-6.
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
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
Reference
1. Thomas PA , Di Stefano D , Couteau C , et al . Contraceptive implant embolism into the pulmonary artery: thoracoscopic retrieval. Ann Thorac Surg 2017;103:e271–2.doi:10.1016/j.athoracsur.2016.08.094
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...
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 cord blood Hg level at birth in their children was 34.5 ng/mL (n = 935; maximum 181.3 ng/mL) and no clinical manifestations in the children were reported at age 7 years. In New York State, the Department of Health reported on 3,078 adults with blood Hg levels ≥ 15 ng/mL (3). Among them, 611 reported eating fish or seafood daily and that cohort had a mean blood Hg level of 30.8 ng/mL with maximum levels as high as 161 ng/mL (3). Confirmed MeHg poisoning from fish consumption has only been report following 2 major industrial pollution episodes in Japan over 50 years ago (4). The fish consumed in that poisoning had Hg levels as high as 117 ppm while commercial fish with only naturally acquired MeHg levels seldom exceed 1 ppm. Typical characteristics of MeHg poisoning include a delay of several weeks between exposure and symptoms, and clinical symptoms are generally considered irreversible. Thinking outside the box should be encouraged, but should be evidence based.
References
1. Bhandare D, Ruchi R. Unusual complication of an Alaskan cruise: thinking outside the box. BMJ Case Rep 2019; 12: e227727
2. Wahlberg K, Love TM, Pineda D, et al. Maternal polymorphisms in glutathione-related genes are associated with maternal mercury concentrations and early child neurodevelopment in a population with a fish-rich diet. Environment International 2018; 115: 142-149
3. Fletcher AM, Gelberg KH. An Analysis of Mercury Exposures among the Adult Population in New York State. J Community Health 2013; 38: 529-537
4. Yokoyama H. Mercury Pollution in Minamata. Springer Briefs in Environmental Science. Open Access: Singapore. 2018 pp 1-74
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.
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?
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...
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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Show MoreI 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.
Show MoreThe 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...
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...
Show MoreDear 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
Reference
Show More1. Th...
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...
Show MoreDear 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.
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