The article titled ‘Cardiovascular risk in South Asians’ by Ramaraj
et al initiates a healthy debate on the prevalence of cardiovascular
disease in the South Asian countries(1). The authors are to be
congratulated for a meticulous survey of the literature to find all
relevant papers in cardiovascular diseases.
The authors wrote about the ‘thrifty gene hypothesis’ which definitely
suggests an interaction between genetic p...
The article titled ‘Cardiovascular risk in South Asians’ by Ramaraj
et al initiates a healthy debate on the prevalence of cardiovascular
disease in the South Asian countries(1). The authors are to be
congratulated for a meticulous survey of the literature to find all
relevant papers in cardiovascular diseases.
The authors wrote about the ‘thrifty gene hypothesis’ which definitely
suggests an interaction between genetic predisposition and environmental
factors(1). In this context, it is very pertinent to mention any climatic
factors that could also be taken into account. A past study in China had
reported a strong association of climate and incidence of type 1 diabetes
and it was found that the incidence of type 1 diabetes was much higher in
the colder areas(2).
A recent study had studied the variation in the apolipoprotein A5 (APOA5)
and glucokinase regulatory protein (GCKR) genes in relation to fasting
glucose level in eight populations spread over the American, European and
Asian continent(3). Ethnicity could play an important role in the
incidence of the cardiovascular disease.
Research studies have shown that low intake of MUFA, n-3 PUFA and fibre,
and high intake of fats, saturated fats, carbohydrates and trans-fatty
acids could account for the high incidence of insulin resistance and
cardiovascular diseases in South Asian population(4).The socio-economic
status could also play an important role in the incidence and severity of
the cardiovascular disease.
The article is very interesting with an in depth analysis of all factors
responsible for the increase in incidence of cardiovascular disease in the
South Asian community and the author deserves special applause for
highlighting a burning problem.
References:
1.Ramaraj R,Chellapa P.Cardiovascular risk in South Asians.Postgrad Med J
2008; 84:518-23.
2.Yang Z,Long X,Shen J,Liu D,Dorman JS,Laporte RE,Chang YF.Epidemics of
type 1 diabetes in China.Pediatr Diabetes 2005 Sep;6(3):122-8.
3.Perez-Martinez P,Corella D,Shen J,Arnett DK, Yiannakouris N,Tai ES et
al. Association between glucokinase regulatory protein (GCKR) and
apolipoprotein A5 (APOA5) gene polymorphisms and triacylglycerol
concentrations in fasting, postprandial, and fenofibrate-treated states.
Am J Clin Nutr 2008 Dec 3.[Epub ahead of print].
4.Misra A,Khurana L,Isharwal S,Bhardwaj S.South Asian diets and insulin
resistance.Br J Nutr 2008 Oct 9:1-9.[Epub ahead of print].
The authors thank Henke Giele for his contribution to this
discussion. We are pleased to see that he allows for some delaying of a
curative operation in isolated cases when the inconvenience of the
procedure and its recovery are untimely. He goes on to state that there
is a correlation between severity of post-operative complaints and
chronicity of symptoms and cites three papers that come to that
conclusion. However...
The authors thank Henke Giele for his contribution to this
discussion. We are pleased to see that he allows for some delaying of a
curative operation in isolated cases when the inconvenience of the
procedure and its recovery are untimely. He goes on to state that there
is a correlation between severity of post-operative complaints and
chronicity of symptoms and cites three papers that come to that
conclusion. However this is not a situation where the literature offers
an unambiguous view. There are other publications, which have come to the
contrary opinion (Yu et al and Choi and Ahn). We have also looked at the
relationship between the duration and severity of symptoms and outcome
after carpal tunnel decompression (using the same patients that were
studied in the Primary Care Management paper)(Burke et al). Symptom
duration corrected for gender was not associated with Levine-Katz symptom
severity, Levine-Katz functional status or changes in these scores from
the pre-treatment to six months follow-up evaluations.
We feel it is overly simplistic to classify all patients with Carpal
Tunnel Syndrome as in need of operative intervention. Mr Giele is
undoubtedly aware of the extended spectrum of symptom severity in these
cases and not all patients will consider the symptoms they are
experiencing justify the need to consider surgery. Over and above that
there is the characteristic remitting nature of the condition where
patients not uncommonly go through periods of resolution or easing of
symptoms for several months. The issue from our point of view is that of
patient choice. There are conservative methods of treating Carpal Tunnel
Syndrome, which are known to be effective and are underused. We prefer
the strategy of giving the patients the facts about their condition and
all treatment modalities that might benefit them, and allow the patient to
decide if they wish to explore the non-operative interventions. No
operative procedure is without its risks and the complications arising
from the use of non-operative methods in cases of mild to moderate Carpal
Tunnel Syndrome are slight. We remain of the view that the correlation
between extended duration of symptoms and poor outcome is not proven and
Mr Giele’s view that virtually all patients with Carpal Tunnel Syndrome
require expeditious decompression is not justified.
Yours sincerely
Frank Burke & Shaw Wilgis
Yu GZ Firrell JC Tsai TM. Pre-operative factors and treatment
outcome following carpal tunnel release. J Hand Surg 1992:17B:646-650
Choi SJ Ahn DS. Correlation of clinical history and
electrodiagnostic abnormalities with outcome after surgery for Carpal
Tunnel Syndrome. Plast Reconstr Surg 1998;102:2374-2380
Burke FD Wilgis EFS Dubin NH Bradley MJ Sinha S: Relationship
between the duration and severity of symptoms and the outcome of carpal
tunnel surgery. J Hand Surg 2006: 31A:1478-1482
We read with interest the paper entitled “Evaluation of the need for
endoscopy to identify low-risk patients presenting with an acute upper GI
bleed suitable for early discharge” Postgraduate Medicine Journal December
2007; 83: 768-722. The aim of this paper was to audit the safety of two
similar protocols used to manage low-risk upper GI bleeding within one
trust in Leeds. Both protocols advised...
We read with interest the paper entitled “Evaluation of the need for
endoscopy to identify low-risk patients presenting with an acute upper GI
bleed suitable for early discharge” Postgraduate Medicine Journal December
2007; 83: 768-722. The aim of this paper was to audit the safety of two
similar protocols used to manage low-risk upper GI bleeding within one
trust in Leeds. Both protocols advised admission to a clinical decisions
unit (CDU) whilst one advocated endoscopy during the admission compared to
early discharge and outpatient endoscopy/follow up in the other group. The
rationale for the audit is seemingly sound due to the high incidence of
Upper GI bleed and the use of two slightly different protocols within the
same primary care trust. However, the primary objective of the study was
to assess safety of the two policies - although safety was not actually
assessed or discussed. Although the authors did imply that very few
patients actually required intervention at endoscopy and relevant
morbidity and mortality was zero, this end point was not proved. The study
only used small numbers of patients and although clear exclusion criteria
were set out, the authors failed to produce data regarding all patients
with the numbers that were included or excluded and the outcomes for each
group and still included data from the >60age group in the results,
without explanation. Similarly there is no mention of the failure to
adhere to the afore mentioned protocol in ‘Hospital A’ where all patients
should undergo Oesophagogastroduodenoscopy (OGD) before discharge. Only
74% of this cohort did in fact have an OGD and no exclusion criteria were
discussed with reference to the remaining 26%. We also feel the selection
of such an Ultra-low risk group aids the authors in demonstrating the fact
that immediate OGD’s are unnecessary, and feel that a cost analysis for
each protocol was necessary.
Yes, the poor use of non-operative interventions (as reported in this
article)
does indeed seem to be the effective use of these interventions that (the
authors themselves acknowledge) are not curative but merely delay the
curative operation.
On both economic and patient parameters it is more economic to
proceed
directly with the curative intervention than waste resources and time
attempting non-curative inter...
Yes, the poor use of non-operative interventions (as reported in this
article)
does indeed seem to be the effective use of these interventions that (the
authors themselves acknowledge) are not curative but merely delay the
curative operation.
On both economic and patient parameters it is more economic to
proceed
directly with the curative intervention than waste resources and time
attempting non-curative interventions that merely delay the procedure and
add to the overall cost of the event. Delaying a curative operation may
be of
benefit in some isolated cases when the inconvenience of the procedure and
its recovery are untimely. Non- curative symptom controlling interventions
can also be of use whilst waiting for the procedure. However, the symptom
controlling interventions can lead to delay in the performance of the
curative
operation possibly resulting in worse outcomes. There is a correlation
between severity and chronicity of symptoms with poorer outcome (Hobby et
al, Townshend et al, Bland et al.) As carpal tunnel syndrome progresses
the
annoying symptoms of pain and paraesthesia may actually dissipate leading
the sufferer to believe their condition is improving whilst unbeknown to
them
the severity of their condition is worsening, their obvious symptoms being
insidiously replaced by the less obvious loss of sensibility and motion.
Intervention at this later stage is less likely to result in complete
cure.
In carpal tunnel syndrome, as in most diseases the intervention
likely to cure
the condition should be implemented without unnecessary costly steps or
delay.
Hobby JL, Venkatesh R, Motkur P.
The effect of age and gender upon symptoms and surgical outcomes in
carpal tunnel
syndrome.
J Hand Surg [Br]. 2005 Dec;30(6):599-604. Epub 2005 Sep 6.
Townshend DN, Taylor PK, Gwynne-Jones DP.
The outcome of carpal tunnel decompression in elderly patients.
J Hand Surg [Am]. 2005 May;30(3):500-5.
Bland JD.
Do nerve conduction studies predict the outcome of carpal tunnel
decompression?
Muscle Nerve. 2001 Jul;24(7):935-40.
We read with much interest the article ‘Pathological fracture of the
talar neck associated with amyloid deposition’ by Christafi et al., which
was published in the 2007; 83; 749 issue (1). The case appears to be
interesting. Since, the case appears to be related to primary amyloidosis,
involvement of kidney, other viscera, carpal and tarsal bones is not
uncommon. One would be eager to know if there...
We read with much interest the article ‘Pathological fracture of the
talar neck associated with amyloid deposition’ by Christafi et al., which
was published in the 2007; 83; 749 issue (1). The case appears to be
interesting. Since, the case appears to be related to primary amyloidosis,
involvement of kidney, other viscera, carpal and tarsal bones is not
uncommon. One would be eager to know if there was any significant X-ray
finding of the chest. There are reports of unilateral and bilateral hilar
adenopathy in case of amylodosis (2). This study in 1980, had described
the involvement of the talus bone hence the authors are incorrect when
they say that involvement of talus is not reported in literature.
There are previous research reports pertaining to the deposition of
amyloid in the talocalcaneal joint due to chronic renal failure (3).It is
an accepted fact that long term haemodialysis would result in amyloid
deposits (4).. A clear haemodialysis history of the patient would have
been better The authors have not mentioned about stress fractures
involving the talus bone in athletes (5). These fractures are also common.
It is not an accepted fact that talus is infrequently involved in any
skeletal injury. The authors say that pathological fractures through
amyloid deposits occur mainly in the femoral neck but no reference has
been quoted for such. Overall, it is an interesting case which may
generate much arguments but the authors are to be congratulated for their
sincere effort in highlighting such a case.
Conflict of interest: None
References:
1.Christafi T, Gupta P, Kankate l, Kankate RK. Pathological fracture of
the talar neck associated with amyloid deposition. Postgrad Med J 2007;
83: 749.
2.Osnoss KL, Harrell DD. Isolated mediastinal mass in primary
amyloidosis. Chest 1980; 78 ;786-788.
3.Sekiya H, Arai Y, Sugimoto N, Sasanuma H, Hoshino Y. Tarsal
tunnel syndrome caused by a talocalcaneal joint amyloidoma in a long term
hemodislysis patient: a case report. J Orthop Surg 2006 ; 14: 350-3.
4.Jadoul M, Garbar C, Noel H, Sennesael J, Vanholder R, Bernaert P,
et al. Histological prevalence of beta 2-microglobulin amyloidosis in
hemodialysis: a prospective post-mortem study. Kidney Int 1997;51:1928–32.
5.Griffiths HJ. Trauma to the ankle and foot. Crit Rev Diagn Imaging.
1986; 26:45-105.
Authors:
DR. SRIJIT DAS,
Lecturer, Department of Anatomy, Faculty of Medicine
Universiti Kebangsaan Malaysia
Jalan Raja Muda Abdul Aziz
50300 Kuala Lumpur , Malaysia
DR.NILESH KUMAR MITRA
Senior Lecturer, Human Biology
International Medical University,
No 126, Jalan 19/155B, Bukit Jalil,
57000 Kuala Lumpur, Malaysia
Adrenal crisis is a medical emergency. If suspected treatment should
be started as soon as possible. Every emergency physician should be
familiar with adrenocortical insufficiency—a potentially life-threatening
entity. The initial diagnosis and decision to treat are presumptive and
are based on history, physical examination, and, occasionally, laboratory
findings. Delay in treatment while attempting to confirm this diag...
Adrenal crisis is a medical emergency. If suspected treatment should
be started as soon as possible. Every emergency physician should be
familiar with adrenocortical insufficiency—a potentially life-threatening
entity. The initial diagnosis and decision to treat are presumptive and
are based on history, physical examination, and, occasionally, laboratory
findings. Delay in treatment while attempting to confirm this diagnosis
can result in poor patient outcomes.
The predominant manifestation of adrenal crisis is shock, but the
patients often have nonspecific symptoms such as anorexia, nausea,
vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion or
coma and hyperpigmentation [3]. Hypoglycemia is a rare presenting
manifestation of acute adrenal insufficiency; it is more common in
secondary adrenal insufficiency caused by isolated corticotropin (ACTH)
deficiency [1,2].
Treatment consists of starting an intravenous line, taking the
blood samples for plasma cortisol levels, acth, serum electrolytes and
glucose. Fluid deficit should be corrected with 5 percent DNS or normal
saline. Initially 2-3 litres may be required. Thereafter give IV fluids
according to the central venous pressure. Patients with addisons disease
have low cardiac reserve, so watch for fluid overload.
Give hydrocortisone 100-300 mg IV, there after 50-100mg every six hourly
for the first day. On the second day give the same amount of dose eight
hourly. Then according to the clinical response. Then switch to oral
hydocortisone 10-20 mg every six hours. Most patients settle with a BD
dose of 10-20mg of hydrocortisone daily. A few may need mineralocorticoid
therapy in the form of fludrocortisone. Instead of hydrocortisone,
dexamethasome can also be used. Hydrocortisone should not be given for
atleast eight hours before ACTH stimulation test. Correct the electrolyte
abnormalities as per the lab reports. Broad spectrum antibiotics should
be given at this time.
2. Stacpoole, PW, Interlandi, JW, Nicholson, WE, Rabin, D. Isolated
ACTH deficiency: a heterogeneous disorder. Critical review and report of
four new cases. Medicine 1982; 61:13.
3. Barnett, AH, Espiner, EA, Donald, RA. Patients presenting with
Addison's disease need not be pigmented. Postgrad Med J 1982; 58:690.
In reply to Dr Koprowski's letter, we would like to point out that
the absence of rigorous evidence supporting the efficacy of
individualised herbal medicine shown by our systematic review remains
fact - regardless of how the various types of individualised herbal
medicine are categorised. If we had examined only individualised
traditional oriental herbal medicine, we would have found even less
evidence. If there is "act...
In reply to Dr Koprowski's letter, we would like to point out that
the absence of rigorous evidence supporting the efficacy of
individualised herbal medicine shown by our systematic review remains
fact - regardless of how the various types of individualised herbal
medicine are categorised. If we had examined only individualised
traditional oriental herbal medicine, we would have found even less
evidence. If there is "actual knowledge of the efficacy of traditional
oriental medicine" in U.S. states this has certainly not been translated
into rigorous clinical trials with a positive result.
Response to:
R Guo, PH Canter, E Ernst. A systematic review of randomised clinical
trials of individualised herbal medicine in any indication. Postgrad Med J
2007;83:633-637
From:
Ally Broughton Bsc (Hons) MNIMH
Director of Research for, and Member of, the National Institute of Medical
Herbalists (NIMH)
Contact: ally.broughton@blueyonder.co.uk
I am a trained herbal practitioner of 12 years and teach resea...
Response to:
R Guo, PH Canter, E Ernst. A systematic review of randomised clinical
trials of individualised herbal medicine in any indication. Postgrad Med J
2007;83:633-637
From:
Ally Broughton Bsc (Hons) MNIMH
Director of Research for, and Member of, the National Institute of Medical
Herbalists (NIMH)
Contact: ally.broughton@blueyonder.co.uk
I am a trained herbal practitioner of 12 years and teach research
methodology on BSc and MSc courses in herbal medicine.
A herbal practitioner undergoes a 3-4 year degree level accredited
training course which includes clinical skills and differential diagnosis,
materia medica (plant medicine), and clinical experience in accredited
training clinics. Professional bodies are currently self regulating and
exist to ensure professional and best clinical practice.
In teaching, I use critical appraisal tools developed by the Critical
Appraisal Skills Programme (CASP)(i) , I used a tool to evaluate this
review to minimise bias.
Study validity
Only 3 small scale clinical studies are included for review, one of which
is a pilot study. The review can have no statistical significance.
The studies have very different outcome measures and investigate
entirely different conditions, making comparison difficult.
Selection criteria
From the 1345 references identified, 3 studies were selected. There was
no clear pre-determined strategy used to determine which studies were
included.
The reviewers recognise this limitation saying they had ‘difficulties
designing a search strategy to locate RCTs of individualised herbal
medicine because of the large number of potential descriptors for such
studies’. This is a strong limitation in the review methodology.
Statistical Analysis
The results for each of the studies are assessed by statistical
significance, however there is no clear indication given of p values or
confidence intervals used by any of the studies.
Critical Analysis
The analysis focus is on statistical data. Some potentially valid points
are not reviewed. For example in the Bensoussan trial(ii) there was no
significant difference between the individualised and standard treatments
at 16 weeks were reported, however, on follow-up 14 weeks after treatment,
only the individualised treatment group maintained improvement. The
reviewers entirely dismissed this as statistically non significant. It is
an important point considering that individualised, holistic treatment
addresses underlying causes of illness which takes longer to resolve but
often with longer lasting benefit compared to symptomatic treatments.
Discussion Analysis
In the discussion analysis there is consistently inadequate links made
between the review evidence and the conclusions made by the authors.
Discussion on herbal practice and safety issues are not substantiated or
referenced, in fact there are only 7 references for the entire review.
Conclusions
There is a lack of scientific rigour in the review methodology. Based on
the evidence presented in the review the conclusions made by the authors
appear arbitrary and insufficiently based on the evidence presented.
Designing a randomised controlled trial to investigate individual
treatment is highly complex and not without limitations. Within the field
of complementary medicine current research is looking for new or adapted
research paradigms appropriate to holistic medicine (iii,iv) .
(i)Oxman AD, Cook DJ, Guyatt GH, Users’ guides to medical literature.
VI. How to use an overview. JAMA 1994; 272(17): 1367-1371
(ii) Bensoussan A et al. Treatment of irritable bowel syndrome with
Chinese herbal medicine. JAMA 1998;280:1585-9
(iii)Boon H et al. Evaluating complex healthcare systems: A critique
of four approaches. eCAM Advance Access 2006; doi:10.1093/ecam/nel079
(iv) Fonnebo V et al. Researching complementary and alternative
treatments – the gatekeepers are not at home. BMC Medical Research
Methodology 2007;7:7
Thank you, Peter Canter, for your e-letter in the Postgraduate
Medical Journal.
We find it somewhat shocking that you think herbal medicines are no
better than a "placebo." This belies the facts.
In America, in states like Florida, acupuncturists are licensed as
"acupuncture physicians" and are considered by medical regulatory
authorities to be primary care practitioners, who can also dispense
herbs, a...
Thank you, Peter Canter, for your e-letter in the Postgraduate
Medical Journal.
We find it somewhat shocking that you think herbal medicines are no
better than a "placebo." This belies the facts.
In America, in states like Florida, acupuncturists are licensed as
"acupuncture physicians" and are considered by medical regulatory
authorities to be primary care practitioners, who can also dispense
herbs, and provide other therapies. This is not the case now in the U.K.
One certainly hopes that U.K. regulators, however, make contact
with American regulators in Florida and other U.S. states where there is
actual knowledge of the efficacy of traditional oriental medicine when
making their decisions on new policies.
Your claim that "we therefore reject the notion that different
schools of individualised herbal medicine cannot be included in a single
review," is as we say in Latin, ipse dixit. Just because you say it,
does not make it so.
Chinese medicine differs distinctly from European herbalism and
Ayurveda.
I enjoyed reading the article on 'testis cancer' by Khan et al.I
agree with the authors that the survival rate has increased over the past
few years.The authors have rightly pointed out the role of chromosome in
causing such anomalies while the primordial germ cells are undergoing cell
division.While going through the risk factors,I would certainly like to
highlight the exposure of dyes and paints.The dyeing agents are kn...
I enjoyed reading the article on 'testis cancer' by Khan et al.I
agree with the authors that the survival rate has increased over the past
few years.The authors have rightly pointed out the role of chromosome in
causing such anomalies while the primordial germ cells are undergoing cell
division.While going through the risk factors,I would certainly like to
highlight the exposure of dyes and paints.The dyeing agents are known to
cause such cancers.The website addresses mentioned in the text are
beneficial for clinicians.Overall, the article is informative and the
authors need to be praised for their lucid style of presentation.
The article titled ‘Cardiovascular risk in South Asians’ by Ramaraj et al initiates a healthy debate on the prevalence of cardiovascular disease in the South Asian countries(1). The authors are to be congratulated for a meticulous survey of the literature to find all relevant papers in cardiovascular diseases. The authors wrote about the ‘thrifty gene hypothesis’ which definitely suggests an interaction between genetic p...
The authors thank Henke Giele for his contribution to this discussion. We are pleased to see that he allows for some delaying of a curative operation in isolated cases when the inconvenience of the procedure and its recovery are untimely. He goes on to state that there is a correlation between severity of post-operative complaints and chronicity of symptoms and cites three papers that come to that conclusion. However...
To the Editor,
We read with interest the paper entitled “Evaluation of the need for endoscopy to identify low-risk patients presenting with an acute upper GI bleed suitable for early discharge” Postgraduate Medicine Journal December 2007; 83: 768-722. The aim of this paper was to audit the safety of two similar protocols used to manage low-risk upper GI bleeding within one trust in Leeds. Both protocols advised...
Yes, the poor use of non-operative interventions (as reported in this article) does indeed seem to be the effective use of these interventions that (the authors themselves acknowledge) are not curative but merely delay the curative operation.
On both economic and patient parameters it is more economic to proceed directly with the curative intervention than waste resources and time attempting non-curative inter...
Dear Editor,
We read with much interest the article ‘Pathological fracture of the talar neck associated with amyloid deposition’ by Christafi et al., which was published in the 2007; 83; 749 issue (1). The case appears to be interesting. Since, the case appears to be related to primary amyloidosis, involvement of kidney, other viscera, carpal and tarsal bones is not uncommon. One would be eager to know if there...
Adrenal crisis is a medical emergency. If suspected treatment should be started as soon as possible. Every emergency physician should be familiar with adrenocortical insufficiency—a potentially life-threatening entity. The initial diagnosis and decision to treat are presumptive and are based on history, physical examination, and, occasionally, laboratory findings. Delay in treatment while attempting to confirm this diag...
In reply to Dr Koprowski's letter, we would like to point out that the absence of rigorous evidence supporting the efficacy of individualised herbal medicine shown by our systematic review remains fact - regardless of how the various types of individualised herbal medicine are categorised. If we had examined only individualised traditional oriental herbal medicine, we would have found even less evidence. If there is "act...
Response to: R Guo, PH Canter, E Ernst. A systematic review of randomised clinical trials of individualised herbal medicine in any indication. Postgrad Med J 2007;83:633-637
From: Ally Broughton Bsc (Hons) MNIMH Director of Research for, and Member of, the National Institute of Medical Herbalists (NIMH) Contact: ally.broughton@blueyonder.co.uk
I am a trained herbal practitioner of 12 years and teach resea...
Thank you, Peter Canter, for your e-letter in the Postgraduate Medical Journal.
We find it somewhat shocking that you think herbal medicines are no better than a "placebo." This belies the facts.
In America, in states like Florida, acupuncturists are licensed as "acupuncture physicians" and are considered by medical regulatory authorities to be primary care practitioners, who can also dispense herbs, a...
I enjoyed reading the article on 'testis cancer' by Khan et al.I agree with the authors that the survival rate has increased over the past few years.The authors have rightly pointed out the role of chromosome in causing such anomalies while the primordial germ cells are undergoing cell division.While going through the risk factors,I would certainly like to highlight the exposure of dyes and paints.The dyeing agents are kn...
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