24 e-Letters

published between 2015 and 2018

  • Terminology can be life-threatening

    The terminology of the chest x-ray report can, indeed, impact on the timeliness of the eventual validation of the diagnosis of pulmonary tuberculosis, as shown by the case report of a 75 year old man who was originally admitted with fever and backache. Chest x-ray showed "fibronodular infiltration of the left apex of the lung" (1). On the basis of magnetic resonance imaging, backache was attributed to osteomyelitis, and he was treated with antibiotics, and there was no "work-up" of the fibronodular infiltration of the lung apex. Over a period of two weeks fever persisted, and he became pancytopenic. However, it was only after a further 3 weeks, when pancytopenia became more severe, that bone marrow aspiration and bone marrow biopsy was performed. The latter showed epitheloid granulomas and acid fast bacilli. Polymerase chain reaction analysis of the bone marrow specimens was positive for M tuberculosis DNA, and his sputum was culture positive for M tuberculosis. Although antituberculous chemotherapy was initiated immediately after the bone marrow results he died 3 days after commencing treatment (2).
    Arguably, if the term "tuberculosis" had been used to qualify the nodular infiltration seen on chest x-ray, that would have raised the index of suspicion for tuberculosis (TB), and computed tomography might have been utilised to characterise the nodularity as being TB-related (2). Two weeks later, in the light of that heightene...

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  • role of new oral anticoagulants in mitigating the risk of heparin-induced thrombocytopenia in cancer patients

    Given the fact that the risk of heparin-induced thrombocytopenia (HIT) is higher with prolonged therapy, the new oral anticoagulants (NOACs) might have a role in shortening the duration of low molecular weight heparin (LMWH) thromboprophylaxis in cancer patients from its currently recommended minimum of 3 months (1) to a much shorter duration by facilitating a transition to NOACSs( 2). That strategy might mitigate the risk of occurrence of HIT.
    Currently, international guidelines recommend LMWH instead of warfarin for management of cancer-related venous thromboembolism (1), but the duration of that management strategy puts patients at risk of HIT, with all its attendant consequences. In an open-label, noninferiority trial, patients with cancer-associated venous thromboembolism were randomly assigned to LMWH for at least 5 days followed by oral edoxaban (60 mg/day) (edoxaban group) or subcutaneous dalteparin at an appropriate dose. Treatment duration in both cases was at least 6 months. In that study, recurrent venous thromboembolism occurred in 7.9% of the edoxaban group vs. 11.3% of the dalteparin group (P=0.09). Major bleeding occurred in 6.9% of the edoxaban group vs. 4% of the dalteparin group (P=0.04). The increase in major bleeding was principally attributable to upper gastrointestinal bleeding in patients who had gastric cancer (2). A criticism of that study is that the 60 mg/day of edoxaban is inherently associated with significantly (P=0.03) greater risk of...

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  • The emerging role of new oral anticoagulants in HIT

    In their excellent review the authors drew attention to alternative oral anticoagulants to manage heparin-induced thrombocytopenia(HIT)(1). The American College of Chest Physicians guideline for HIT and HIT-associated thrombosis(HITT) cautions against premature transition to vitamin K antagonist therapy due to significant risk of warfarin-induced skin necrosis or development of venous limb gangrene(2). According to a recent review, the new oral anticoagulants(NOACs) are not burdened with that disadvantage, and their rapid onset of action generates a smooth transition to forward anticoagulation in patients with HIT/HITT. Furthermore, NOACs do not cross-react with HIT antibodies(3). That review encompassed data from 56 HIT/HITT patients subsequently treated with NOACs. Data were derived from 3 studies and 8 case reports. Mean age of the 56 patients was 70, twenty four had HIT, and thirty two had HITT. At the time of HIT/HITT diagnosis a nonheparin parenteral agent was initiated in 42, and the remaining 14 transitioned to NOACs straightaway. The NOACS used in the 56 patients were rivaroxaban, apixaban, and dabigatran in 54%, 29%, and 18% of cases, respectively. There were only 2 instances of recurrent thrombosis with NOAC therapy. Major bleeding occurred in 3 patients who did not appear to be on NOAC therapy at the time of the bleed.
    (1) Prince M., Wenham T
    Heparin-induced thrombocytopemia
    Postgrad Med J 2018;94:453-547
    (2)Linkins L-A....

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  • A point of view: Diuretics and many dietary components significantly increase the risk of uric acid stone formation--Our major concern

    A point of view:
    Diuretics and many dietary components significantly increase the risk of uric acid stone formation--Our major concern.
    We read with interest and applauded the authors of the review article that mentions adjustment of potential pathophysiologic defects by pharmacotherapy and strongly recommends dietary modification for the prevention of uric stone recurrence (1).
    Two thirds of urate excretion occurs at the kidney, the remainder being excreted by the gut. Earlier studies have suggested that the urate is almost fully reabsorbed and that the urate excreted by the kidney is the result of tubular secretion. But more recent data suggests that secretion plays little part, and that excreted urate largely represents the filtered urate which escapes reabsorption. (2)
    Different diuretics are likely to have different effects on the renal handling of urate, but this has not been critically ascertained; patients receiving more powerful loop diuretics have a higher risk of developing gout than those receiving the weaker thiazides (3)
    Conceptually, a visit to a beer garden is dangerous for two reasons, the intake of purine rich food and drinks (beer) and the intake of fructose-rich soft drinks that blocks certain urate transporters that facilitate urate excretion (4).
    These are also associated with a number of common situations, such as the metabolic syndrome, which is correctable by changing to a low caloric diet, essential hypertensio...

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  • Secondary syphilis in the context of HIV-related immunosuppression

    The secondary syphilis we see today is potentially different from the secondary syphilis which belongs to the era antedating the presently high incidence and prevalence of human immunodeficiency virus (HIV) infection. Sexually active subjects who harbour the coexistence of HIV infection (with attendant immune suppression) and syphilis are also at risk of opportunistic infections such as tuberculosis and cryptococcosis (1)(2)(3). In one HIV-positive patient aged 43, neurosyphilis coexisted with both cryptococcal meningitis and tuberculous meningitis. The cerebrospinal fluid (CSF) was characterised by lymphocyte predominance low glucose and high protein. Furthermore, in the CSF, cryptococcal antigen amounted to 1;640, and the VDRL from the CSF was also reactive. CSF culture grew M. tuberculosis, and this was confirmed by the polymerase chain reaction (1). In another instance, a 37 year old man with past medical history of HIV infection had neurosyphilis coexisting with cryptococcal meningitis. The CSF was characterised by lymphocyte predominance, positive fluorescent treponemal antibody test and cryptococcal antigen titre of 1:640 (2). Another report involved a 40 year old man with coexisting neurosyphilis and cryptococcal meningitis. The CSF showed lymphocyte predominance and high protein concentration. Cryptococcus was cultured from the CSF and both serum serology and CSF were positive for syphilis (3). These anecdotal reports might underestimate the true prevalence of coe...

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  • Exercise training does reverse left ventricular diastolic dysfunction in high risk subjects

    While it is true, as the authors assert, that there is limited data on exercise-induced reversal of cardiac remodeling, a recent study suggests that the cardiac effects of sedentary aging(in middle age) can be reversed by exercise training(1). In that study sixty one(48% male) healthy sedentary participants of mean age 53 were randomly assigned to either 2 years of exercise training(n=34) or attention control(control=27). In each subject measurements were taken to evaluate left ventricular stiffness. Maximal oxygen uptake was measured to quantify changes in fitness. Fifty three participants completed the study. Adherence to prescribed exercise sessions was 88% on average. As a result of exercise training left ventricular stiffness was significantly(p=0.0018)reduced(right/ downward shift in the end-diastolic pressure-volume relationships) in comparison with its pre-exercise value. This parameter did not change in the control group. Exercise significantly(p<0.001)increased the left ventricular end diastolic volume , whereas pulmonary capillary wedge pressure was unchanged, thereby generating significantly(p=0.007) greater stroke volume for any given filling pressure. The authors concluded that regular exercise training could provide protection against the future risk of heart failure with preserved ejection fraction by mitigating the risk of increase in cardiac stiffness attributable to a sedentary lifestyle(1). Accordingly, although we cannot influence the natu...

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  • Choice of words is crucial in effective communication

    Improving communication in decision-making is a worthy goal and the choice of words is crucial. Sayma and colleagues (1) have not considered the implications of some of their choices.

    Firstly, throughout the article they have used the word ‘advanced’ when describing decisions and care plans. This is a common misspelling but such issues are not superior formats but are care plans and decisions made in advance. Secondly, the authors mention ‘ceilings of care’ but do not explain that there are no ethical or legal permissions that allow care to be limited. This term is often misused when what is meant is a limit to treatment options. Finally the use of ‘escalation’ in care plans has been shown to be threatening to patients.(2) The term is too often used by clinicians without considering how this might be considered by patients.

    None of this should not detract from the value of the information provided during the study, but perhaps the authors will think carefully in future about their choice of words.

    Claud Regnard

    1. Sayma M et al. Improving the use of treatment escalation plans: a quality improvement study. Postgrad Med J, 2018; doi: 10.1136/postgradmedj-2018-135699.
    2. Fritz Z, Fudd JP. Development of the Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a cross disciplinary approach. J Evaluation in Clinical Practice 2014; 21: 109-117.

  • The role of the dedicated nurse practitioner and other issues

    I agree with the authors of this excellent review that blood pressure(BP) measurement is often performed carelessly, and this is true both in primary and in secondary care. Although both doctors and nurses are responsible for this state of affairs, appropriately trained and dedicated(in terms of their job description) nurse practitioners are the ones who would be best placed to comply with the requirements for correct blood pressure measurement within "real world" time constraints(1). My proposal is to allocate a 10-15 minute slot for the nurse practitioner to measure the blood pressure in the relaxed environment of her own consulting room. Thereafter she can hand the patient over to the doctor to fulfil his own 10 minute or so time slot.
    Choice of diuretic medication for management of hypertension is the other issue specially relevant to the elderly. Although diuretics of first choice for antihypertensive treatment are typically either thiazides or indapamide, what needs to be recognised is that susceptibility to diuretic-related hyponatraemia involving those two drug subclasses is uniquely age-related, patients aged 60 or more being the ones most vulnerable to this complication(2)(3)(4)(5)(6). It is even conceivable that symptoms of drug-related hyponatraemia such as falls(2)(3) , might, on occasion, be misattributed to attainment of goal blood pressure, even if that target blood pressure is a modest one, with the consequence that antihypertensive...

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  • Response to: "Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys". A medical student perspective.

    Dear authors,

    Your recent report titled “Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys”(1) provided a thought-provoking read.

    As highlighted in your report, the uptake in training for specialties such as general practice continues to remain low. I strongly agree that in order to address this it is necessary to identify the factors that determine career choice in junior doctors. Furthermore, to encourage doctors to peruse undersubscribed specialties, it may be useful to identify the stage in training that the foundations of career choice are made. This may provide an opportunity to spark interest about these low uptake specialties in doctors who are still open minded about their future career.

    Your report demonstrates that even very early on in training, many doctors have a definite choice about their future specialty (1). Data collected from students at Brighton and Sussex medical school demonstrated that specialty choice is highly influenced by student’s experiences at medical school (2). I am a fourth year medical student, currently rotating through these various specialty placements and beginning to realistically consider my own personal career options. I too believe that the clinical phase of medical school may hold a unique window to motivate students to become interested in those undersubscribed specialties.

    Earlier this year a cohort study at the University of Dundee showed t...

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  • Promoting resilience among physicians is not an effective way to tackle burnout.

    In recent times, a lot has been spoken about the concept of ‘promoting physician resilience’ to tackle burnout.(1)(2) However, since the definitions and the strategies of resilience revolve around intrinsic factors, there is skepticism about this concept.(3) Now that the focus is being shifted towards the external factors influencing the burnout, this systematic review by Fox et al redefines ‘resilience’ in order to incorporate these external determinants into the domain of resilience.(4) While this letter agrees with the views portrayed by the authors of the review, it additionally discusses certain drawbacks of stressing the promotion of physician resilience.
    Though the resiliency training program, focusing on personal and psychological empowerment of physicians, temporarily improved the resiliency rates, it did not reduce the reported levels of fatigue among the participants.(2) Such resiliency methods in isolation do not seem to have a long-term benefits on the day-to-day practice in medicine. However, they may be handy even as a standalone strategy, in recharging the professionals in certain temporary situations like epidemic breakout, disaster scenario, warfare etc. Another drawback of repeated usage of resilience strategies is that it may render them ineffective with time, even in the same individual in whom the same strategies would work wonders earlier. In addition, repeated resiliency sessions could dilute the strive for perfection in medicine be...

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