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Coeliac disease gluten-sensitive enteropathy remains under-diagnosed and can have serious complications. [1] Gluten sensitivity has various manifestations such as enteropathy, dermatopathy and neuropathy. Furthermore, due to the disease overlap about 8% of patients with coeliac
disease develop neurological manifestations. [2] The most common manifestations are ataxia and peripheral neuropathy; and rapidly...
Coeliac disease gluten-sensitive enteropathy remains under-diagnosed and can have serious complications. [1] Gluten sensitivity has various manifestations such as enteropathy, dermatopathy and neuropathy. Furthermore, due to the disease overlap about 8% of patients with coeliac
disease develop neurological manifestations. [2] The most common manifestations are ataxia and peripheral neuropathy; and rapidly progressive neuropathy can be fatal in some cases. [3]
The mechanism for gluten neuropathy is likely to be immunological and through a low grade vasculitis. [3] Neurological features can be the presentation as well as complications of coeliac disese and can be successfully treated with a gluten free diet. [4]
Competing interest: None
References:
1. Goddard CJR, Gillett HR. Complications of celiac disease: are all patients are at risk? Postgrad Med J 2006; 82: 705-712
2. Holmes GKT. Neurological and psychiatric complications in celiac disease. In: Gobbi G, Anderman F, Naccarto S, eds. Epilepsy and other neurological disorders in celiac disease. London: john Libbey, 1997.
3. Hadjivassiliou M, Grunewald RA, Kandler RH, et al. Neuropathy associated with gluten sensitivity. J Nerol Neurosurg Psychiatry 2006;77:1262-66.
4. Hadjivassiliou M, Davies-Jones GAB, Sanders DS, et al. Dietary treatment of gluten ataxia. J Neurol Neurosurg and Psychiatry 2003;74:1221-6
The author rightly mentions that many people on expedition try to avoid prophylactic diamox.[1] It is not just because people want to experience the natural or the side effects of the medicine but in my experience in the Everest region, many western trekkers did not want to
take diamox because they believed it masks the symptoms of Acute Mountain Sickness. Diamox accelerates the natural process of acclimat...
The author rightly mentions that many people on expedition try to avoid prophylactic diamox.[1] It is not just because people want to experience the natural or the side effects of the medicine but in my experience in the Everest region, many western trekkers did not want to
take diamox because they believed it masks the symptoms of Acute Mountain Sickness. Diamox accelerates the natural process of acclimatization by increasing the ventilation but it does not mask the symptoms. Only dexamethasone masks the symptoms of AMS and symptoms can recur if people take dexamethasone for severe AMS then stop it when the symptoms improve and ascend up again. Hence people can take dexamethasone themselves for severe AMS only when they are descending. [2,3]
Diamox is a very useful medication in altitude illness. It has been used not only in prevention and treatment of Acute Mountain Sickness (125 mg twice a day for mild AMS and 250 mg twice a day for severe AMS) but
also as adjuvant treatment (to what is mentioned in the article) in High Altitude Pulmonary Edema (HAPE) and High Altitude Cerebral Edema (HACE). The use of diamox as adjuvant makes sense because the sole problem in these pathological processes is hypoxia and diamox improves oxygenation by causing hyperventilation.
When people get HAPE or HACE, they should descend immediately. It must be emphasized here that they must descend with a friend (or porters to carry them down to avoid exertion). We had few cases of both Nepali porters and foreign trekkers in the Everest region where HAPE patients were advised to go down alone by their team mates. However, they were not able to walk and were found by others in bad condition lying helpless on the way after several hours and had to be carried to the clinic (at
Pheriche).
The author has not mentioned the usefulness of Sildenafil(Viagra) and Salmeterol in the treatment and prevention of HAPE. [4] Sildenafil helps by
decreasing the pulmonary artery pressure and Salmeterol helps in reabsorption of the oedema fluid.
References:
1. Clarke C. Acute mountain sickness: medical problems associated with acute and subacute exposure to hypobaric hypoxia. Postgraduate Medical Journal 2006;82:748-753
2. Levine B, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med 1989;321:1707-13. [Abstract]
3. Ferrazzini Z, Maggiorini M, Kriemler S, Bartsch P, Oelz O. Successful treatment of acute mountain sickness with dexamethasone. BMJ 1987; 294:1380-83.
4. West JB. The Physiologic Basis of High-Altitude Illness. Ann Intern Med. 2004;141:789-800.
It was interesting to go through the informative article on mountain sickness by C Clarke. [1] There are some points we wish to make.
The author mentions that the preventive dose of acetazolamide for Acute Mountain Sickness(AMS) is 125mg but does not mention its role in the treatment of AMS. Acetazolamide is used widely in the Himalayas at a dose of 250 mg twice daily until the symptoms resolv...
It was interesting to go through the informative article on mountain sickness by C Clarke. [1] There are some points we wish to make.
The author mentions that the preventive dose of acetazolamide for Acute Mountain Sickness(AMS) is 125mg but does not mention its role in the treatment of AMS. Acetazolamide is used widely in the Himalayas at a dose of 250 mg twice daily until the symptoms resolve. A placebo controlled trail showed the drug decreased the severity of
symptoms by 74 percent within 24 hours. [2]
From my experience as a research doctor in the Everest region this autumn (October - November 2006) the side effects of acetazolamide, although quite annoying, were not that serious to anyone and they showed good compliance. This is in contrast to the author’s experience of the side effects of acetazolamide.
The author mentions that High Altitude Pulmonary Oedema(HAPE) is usually followed by AMS, but around as many as 50% HAPE patients do not have symptoms of AMS. [3] In addition, my experience in the Himalayas has shown a large number of patients who were diagnosed to have HAPE did not have the preceding symptoms of AMS.
Regarding the correlation between the age and AMS, studies show that age is reported to have no effect for individuals less than 60 years old, but has been reported to be protective for older individuals which is not
mentioned in the discussion of old and young. [4,5,6,7]
We were surprised that the author did not mention sleep disorders at high altitude which is very common. The problems are with initiating sleep and numerous awakenings due to apnoenic episodes and having vivid dreams. For these problems acetazolamide 125 mg or some even suggest as low as 62.5 mg just before bed time improves the quality of
sleep.
Laxmi Vilas Ghimire, MBBS
Research doctor
HAPE prevention Trial, Everest region.
Tribhuvan University Teaching Hospital
Kathmandu, Nepal
Matiram Pun
Junior Intern
Institude Of Medicine
Kathmandu, Nepal
References:
1. Clarke C. Acute mountain sickness: medical problems associated
with acute and subacute exposure to hypobaric hypoxia. Postgraduate
Medical Journal 2006;82:748-753;
2. Hackett P H. Roach R C. High–Altitude Illness. N Engl J Med,
2001;345: 107-114
3. Hultgren HN, Honigman B, Theis K, Nicholas D. High-altitude
pulmonary edema at a ski resort. West J Med 1996;164:222-7.
4. Bartsch P., and Roach R. (2001). Acute mountain sickness and high-
altitude cerebral edema. In High Altitude: An Exploration of Human
Adaptation. T. Hornbein and R.
Schoene, eds. Marcel Dekker, New York; pp. 731–775.
5.Hackett P.H., Rennie D., and Levine H.D.. The incidence,
importance, and prophylaxis of acute mountain sickness. Lancet, 1976;
2:1149–1155
6.Honigman B., Theis M.K., Koziol-McLain J., Roach R., Yip R.,
Houston C., Moore L.G., and Pearce P. Acute mountain sickness in a
general tourist population at
moderate altitudes. Ann. Intern. Med. 1993; 118:587–592.
7. Serrano-Duenas M.. Acute mountain sickness: the clinical
characteristics of a cohort of 615 patients.Med.Clin. 2000;115:441–445.
Low Molecular Weight Heparin (LMWH) has been shown to be effective in
the management of venous thrombosis. However, there is currently insufficient data of its safety at therapeutic dose in patients with renal failure. There is an increased potential of accumulation of antifactor Xa activity depending on the extent of renal impairment and the type of
LMWHs(1). Hence, the risk of haemorrhage may be greater...
Low Molecular Weight Heparin (LMWH) has been shown to be effective in
the management of venous thrombosis. However, there is currently insufficient data of its safety at therapeutic dose in patients with renal failure. There is an increased potential of accumulation of antifactor Xa activity depending on the extent of renal impairment and the type of
LMWHs(1). Hence, the risk of haemorrhage may be greater compared to unfractionated heparin especially in patients who are also on anti-platelet agents.
As there is a lack of systematic studies in this population, monitoring of antifactor Xa activity is advisable. Unfractionated heparin could be used as an alternative in view of its short life.
Reference 1. Gouin-Thibault I,Pautas E,Siguret V. Safety profile of different low molecular weight heparins used at therapeutic dose. Drug Saf. 2005;28(4):333-49
In my capacity as Professional Ethics Pharmacist at the Royal
Pharmaceutical Society (the professional and regulatory body for
pharmacists), I have been asked to write to the Postgraduate Medical
Journal on behalf of the Royal Pharmaceutical Society’s Law and Ethics
Committee.
An article relating to the sale of paracetamol from registered retail
pharmacy premises and non-pharmacy premises...
In my capacity as Professional Ethics Pharmacist at the Royal
Pharmaceutical Society (the professional and regulatory body for
pharmacists), I have been asked to write to the Postgraduate Medical
Journal on behalf of the Royal Pharmaceutical Society’s Law and Ethics
Committee.
An article relating to the sale of paracetamol from registered retail
pharmacy premises and non-pharmacy premises was published in the
Postgraduate Medical Journal on 7th August 2006.
The article referred to a survey of 107 individual who were admitted
to hospital for acute paracetamol overdoses. It stated that one patient
had purchased an excessive amount from a pharmacy (the study quotes an
excessive amount as being more than 32 tablets). The study also attempted
to determine how many pharmacies would be prepared to sell more than an
alleged “restricted amount” of paracetamol (the study quoted the amount as
32 tablets) and stated that researchers were able to purchase more than
the “restricted amount” in 4 out of the 8 pharmacies visited.
The article claims that legislation limiting OTC availability of
paracetamol is not being followed in South London. However, it does not
appear that any of the pharmacies referred to in the study have acted
unlawfully. Specifically, the article stated ‘pharmacies are allowed to
sell a maximum of 32 tablets containing 500mg of paracetamol’. The study
also stated that they were able to purchase more than the restricted
amount of paracetamol (at least 40 or more tablets instead of the maximum
of 32)’.
The Prescription Only Medicines (Human Use) Order 1997, as amended,
classes one hundred non-effervescent paracetamol tablets or capsules, or
more, as a Prescription Only Medicine. A pharmacist may therefore lawfully
sell up to100 non-effervescent paracetamol tablets or capsules to a person
at any one time.
Legislation came into force on September 16 1998, regarding the pack
sizes of paracetamol that are available from both pharmacy and non-
pharmacy premises. The changes were designed to improve the safety of over
the counter painkillers following concern about the number of deaths and
serious morbidity connected with overdosing and evidence that many
patients who intentionally overdose, use products that are readily
available in the home. These measures included pack size restrictions and
additional safety warnings with instructions to the patient on what to do
in the event of an overdose.
The pack size of paracetamol tablets available as a General Sale List
(GSL) medicine is restricted to sixteen tablets. Pack sizes of thirty two
paracetamol are only available from registered retail pharmacy premises
A pharmacist may lawfully sell 3 x 32 non-effervescent paracetamol
tablets or capsule to a person at any one time. Similarly a non-pharmacy
retail outlet can lawfully sell 6 x16 paracetamol tablets or capsules.
However, the Code of Ethics, for pharmacists, currently states:
Pharmacists must not promote inappropriate or excessive consumption
or use of medicines or their misuse, injudicious or unsafe use which may
be injurious to health.
Pharmacists must therefore use their professional judgement when they
receive requests for large quantities for paracetamol.
While none of the pharmacies in the study appear to have contravened
current legislative requirements, the Royal Pharmaceutical Society is in
the process of producing guidance for pharmacists about the sale of
paracetamol to remind them of the legal and professional considerations of
selling multiple packs of paracetamol. However, it was considered
important to high-light to the Postgraduate Medical Journal, the
inaccuracies in the article in relation to the legal requirements
governing the sale of paracetamol.
Dear Editor,
This artice from A Shenkin [1] is timely and very informative on micronutients in health and their role in preventing disease. As mentioned in the article, pre-existing nutritional deprivation has consistently been shown in studies as a very good indication for
micronutrient replacement. [2] Detsky's subjective global assessment tool is well validated and to be used when nutritional intervention...
Dear Editor,
This artice from A Shenkin [1] is timely and very informative on micronutients in health and their role in preventing disease. As mentioned in the article, pre-existing nutritional deprivation has consistently been shown in studies as a very good indication for
micronutrient replacement. [2] Detsky's subjective global assessment tool is well validated and to be used when nutritional intervention in adults in indicated. For clinicians, the better marker for nutritional
intervention in adults is unintentional weight loss. There have been various meta-analyses evaluating protein energy supplementations in adults, though results are inconsistent. The review by the American
Gastroenterology Association [3]supports the use of
these supplements, especially in patients with short bowel syndrome. There is evidence to suggest benefit of micronutrient supplementation in patients with alcoholic liver disease [4], coeliac disease, and some evidence in non-alcoholic steatohepatitis. [5] However, this benefit might be due to associated malnutrition, overtly seen in alcoholics and symtomatic coeliacs. There is evidence to show that selenium deficiency is seen in alcoholics and has effect on mood changes.[6] Also, the use of micronutrients in critically ill patients is established and multivitamin and trace element preparations suitable for most patients
requiring parenteral nutrition are widely available, but concerns regarding individual patients requiring additional supplements or smaller amounts of certain micronutrients have to be kept in mind. [7] Hence, in clinical practice, especially in alcoholics, stress for prevention of
malnutrition is crucial to health rather than disease.
References 1. A Shenkin, Micronutrients in health and disease
Postgrad Med J 2006; 82: 559-567
2. Souba, WW. Nutritional support. N Engl J Med 1997; 336:41.
3. Koretz, RL, Lipman, TO, Klein, S. AGA Technical Review on Parenteral Nutrition. Gastroenterology 2001; 121:970.
5. Miele L, Gabrieli ML, Forgione A, et al. Oxidative stress in metabolic syndrome and nonalcoholic steatohepatitis. Is it possible a role
for vitamins in clinical practice? Recenti Prog Med. 2006
Jan;97(1):1-5.
6. Role of selenium depletion in the etiopathogenesis of depression in patients with alcoholism [corrected].
Med Hypotheses. 2002 Sep;59(3):330-3. Review. Erratum in: Med Hypotheses. 2003 Sep;61(3):416.
7. Nutrition and alcoholic liver disease.Semin Liver Dis. 2004 Aug;24(3):289-304.
The article from Myint et al [1] is interesting, simple and easy to understand for clinical practitioners like me. Post-stroke seizure is a neurological emergency associated with significant morbidity and mortality. Understanding the factors will help practitioners give patients and their families adequate information about the possibility of post-stroke seizure and post-stroke epilepsy. The question is "Should we give prophy...
The article from Myint et al [1] is interesting, simple and easy to understand for clinical practitioners like me. Post-stroke seizure is a neurological emergency associated with significant morbidity and mortality. Understanding the factors will help practitioners give patients and their families adequate information about the possibility of post-stroke seizure and post-stroke epilepsy. The question is "Should we give prophylatic medication to patients with clear risk factors?"
References
1. Myint PK, Staufenberg EFA, Sabanathan K. Post-stroke seizure and post-stroke epilepsy. Postgrad Med J 2006; 82: 568-572.
We read with interest the review of Bourke and colleagues.(1)
Interstitial lung disease (ILD) and especially idiopathic pulmonary
fibrosis (IPF) epidemiology in the United States has not yet been well
characterized.(2) The review of Bourke et al. has not addressed this
issue. The data of ILD registries confirmed that epidemiological
registries can be useful tools to investigate rare or relatively rare
disorders, (e.g....
We read with interest the review of Bourke and colleagues.(1)
Interstitial lung disease (ILD) and especially idiopathic pulmonary
fibrosis (IPF) epidemiology in the United States has not yet been well
characterized.(2) The review of Bourke et al. has not addressed this
issue. The data of ILD registries confirmed that epidemiological
registries can be useful tools to investigate rare or relatively rare
disorders, (e.g. sarcoidosis and IPF), in order to design multicentric
clinical studies of adequate sample size, especially cohort and
prospective studies aimed at providing standardized diagnostic,
management and follow up criteria with a particular regard to outcome
measures such as survival and quality of life. This consideration is a
consequence of the fact that death certificates and state mortality data
are neither sensitive nor accurate for describing the occurrence of ILD.
Proof of that could be the apparently low mortality rates from IPF in the USA
when compared with other countries.(3)
A limitation in the data of ILD
registries was the limited use of biopsies since open lung biopsy should
be the gold standard. As reported above,(3) only low percentages of cases
had histology confirmed diagnosis, while most diagnoses are based upon
clinical observation and radiological and high-resolution computed
tomography (HRCT) scan. Unfortunately, accuracy of HRCT scan is limited,
as only about 50% of diagnosis obtained in that way could be confirmed.(4)
Comparability of histological pattern between registries is limited, as
RIPID (Italian Registry) included only 167 cases out of 4169 and Flanders
only 71 out of 362. Aosta Valley (126,000 inhabitants) regional hospital
had all its 128 cases diagnosed with ILD of unknown aetiology in the
period 1995-2004 histologically confirmed and this series was not included
in the RIPID. In this context, we suggest that more epidemiological
studies of good quality could be relevant to improve clinical practice of
ILD.
References
1. Bourke SJ. Interstitial lung disease: progress and problems. Postgrad Med J 2006; 82 (970):494-9.
2. Raghu G, Weycker D, Edelsberg J, et al. Incidence and Prevalence of Idiopathic Pulmonary Fibrosis. Am J Respir Crit Care Med. 2006 Jun 29; [Epub ahead of print]
3. Coultas DB, Hughes MP. Accuracy of mortality data for interstitial lung diseases in New Mexico, USA. Thorax. 1996 Jul; 51(7): 717-20.
4. Gross TJ, Hunninghake GW. Idiopathic pulmonary fibrosis. N Eng J Med 2001; 345: 517-525
In his article on aphthous ulceration Scully(1) mentions several systemic rheumatic diseases including Behcet's syndrome, Reiter's syndrome and Sweet’s syndrome, that may result in aphthous-like ulcers. I am somewhat surprised that Scully omitted the association of such
lesions with systemic lupus erythematosus and Wegener's granulomatosis.
I would like to emphasize that painful or painless oral ulcers observ...
In his article on aphthous ulceration Scully(1) mentions several systemic rheumatic diseases including Behcet's syndrome, Reiter's syndrome and Sweet’s syndrome, that may result in aphthous-like ulcers. I am somewhat surprised that Scully omitted the association of such
lesions with systemic lupus erythematosus and Wegener's granulomatosis.
I would like to emphasize that painful or painless oral ulcers observed by a physician are so relevant that they are included in the standard classification ("diagnostic") criteria for systemic lupus
erythematosus (2). Oral ulceration is also one of the diagnostic criteria for Wegener's granulomatosis (3), although they are the presenting feature in only five percent of patients (4). In lupus, however, a history
of mouth ulceration is reported in about one third of patients and in 15 percent of them, ulcers are the first manifestation of their disease (5).
1. Scully C. Clinical practice. Aphthous ulceration. N Engl J Med 2006;355:165-72.
2. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1997;40:1725.
3. Leavitt RY, Fauci AS, Bloch DA, et al. The American College of Rheumatology 1990 criteria for the classification of Wegener's granulomatosis. Arthritis Rheum 1990;33:1101-7.
4. Patten SF, Tomecki KJ. Wegener's granulomatosis: cutaneous and oral mucosal disease. J Am Acad Dermatol 1993;28:710-8.
5. Yell JA, Mbuagbaw J, Burge SM. Cutaneous manifestations of systemic lupus erythematosus. Br J Dermatol 1996;135:355-62.
I am studying the relation of Parkinson's Disease to
tranquilizers. In particular...Diazepam. Which is a
dopamine antagonist and, if properly addressed, may
offer a 'cure' of a large number of patients. This is
a 'team' effort toward the elimination of PD. If,
you would care to collaborate with me, I would very
much like to hear from you as soon as possible to
determine how this may be addressed. I hav...
I am studying the relation of Parkinson's Disease to
tranquilizers. In particular...Diazepam. Which is a
dopamine antagonist and, if properly addressed, may
offer a 'cure' of a large number of patients. This is
a 'team' effort toward the elimination of PD. If,
you would care to collaborate with me, I would very
much like to hear from you as soon as possible to
determine how this may be addressed. I have been having
Parkinson's symptoms...it seems from what I observe.
Although, it has been thought to be caused by genetic
factors, I am more apt to believe that the cause is
often likely to be from chemical toxic conditions.
Either 'external', or more likely 'internal'. If you
are interested please contact me. Thank you very much.
Regards,
Dr. David M. Adams
PO BOX 221133
St. Louis, MO 63122
U.S.A.
Dear Editor,
Coeliac disease gluten-sensitive enteropathy remains under-diagnosed and can have serious complications. [1] Gluten sensitivity has various manifestations such as enteropathy, dermatopathy and neuropathy. Furthermore, due to the disease overlap about 8% of patients with coeliac disease develop neurological manifestations. [2] The most common manifestations are ataxia and peripheral neuropathy; and rapidly...
Dear Editor,
The author rightly mentions that many people on expedition try to avoid prophylactic diamox.[1] It is not just because people want to experience the natural or the side effects of the medicine but in my experience in the Everest region, many western trekkers did not want to take diamox because they believed it masks the symptoms of Acute Mountain Sickness. Diamox accelerates the natural process of acclimat...
Dear Editor
It was interesting to go through the informative article on mountain sickness by C Clarke. [1] There are some points we wish to make.
The author mentions that the preventive dose of acetazolamide for Acute Mountain Sickness(AMS) is 125mg but does not mention its role in the treatment of AMS. Acetazolamide is used widely in the Himalayas at a dose of 250 mg twice daily until the symptoms resolv...
Dear Editor
Low Molecular Weight Heparin (LMWH) has been shown to be effective in the management of venous thrombosis. However, there is currently insufficient data of its safety at therapeutic dose in patients with renal failure. There is an increased potential of accumulation of antifactor Xa activity depending on the extent of renal impairment and the type of LMWHs(1). Hence, the risk of haemorrhage may be greater...
Dear Editor
In my capacity as Professional Ethics Pharmacist at the Royal Pharmaceutical Society (the professional and regulatory body for pharmacists), I have been asked to write to the Postgraduate Medical Journal on behalf of the Royal Pharmaceutical Society’s Law and Ethics Committee.
An article relating to the sale of paracetamol from registered retail pharmacy premises and non-pharmacy premises...
Dear Editor,
This artice from A Shenkin [1] is timely and very informative on micronutients in health and their role in preventing disease. As mentioned in the article, pre-existing nutritional deprivation has consistently been shown in studies as a very good indication for micronutrient replacement. [2] Detsky's subjective global assessment tool is well validated and to be used when nutritional intervention...
The article from Myint et al [1] is interesting, simple and easy to understand for clinical practitioners like me. Post-stroke seizure is a neurological emergency associated with significant morbidity and mortality. Understanding the factors will help practitioners give patients and their families adequate information about the possibility of post-stroke seizure and post-stroke epilepsy. The question is "Should we give prophy...
We read with interest the review of Bourke and colleagues.(1) Interstitial lung disease (ILD) and especially idiopathic pulmonary fibrosis (IPF) epidemiology in the United States has not yet been well characterized.(2) The review of Bourke et al. has not addressed this issue. The data of ILD registries confirmed that epidemiological registries can be useful tools to investigate rare or relatively rare disorders, (e.g....
In his article on aphthous ulceration Scully(1) mentions several systemic rheumatic diseases including Behcet's syndrome, Reiter's syndrome and Sweet’s syndrome, that may result in aphthous-like ulcers. I am somewhat surprised that Scully omitted the association of such lesions with systemic lupus erythematosus and Wegener's granulomatosis.
I would like to emphasize that painful or painless oral ulcers observ...
Dear Editor,
I am studying the relation of Parkinson's Disease to tranquilizers. In particular...Diazepam. Which is a dopamine antagonist and, if properly addressed, may offer a 'cure' of a large number of patients. This is a 'team' effort toward the elimination of PD. If, you would care to collaborate with me, I would very much like to hear from you as soon as possible to determine how this may be addressed. I hav...
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