eLetters

29 e-Letters

published between 2016 and 2019

  • Have guidelines lost their way?

    With all due respect to Dr Philip Welsby 1I think he has misunderstood my paper on the 5*3*5 rule for examining the upper limb. The 5*3*5 rule is not a guideline, it represents a paradigm shift in the way we should examine the upper limbs.

    In my experience guidelines are written by experts using what little evidence we have liberally laced with "expert opinion" to help guide clinicians to manage patients. I would agree with Dr Welsby that guidelines are often complex, impossible to memorise and difficult to use.

    The 5*3*5 rule does not require any knowledge of neuroanatomy nor does it need to be memorised. The idea is that the clinician has the pictures and the tables readily available in their clinic. All they have to do is examine the muscles, establish which muscles are weak and then consult the relevant table(s). A previous rule that I have published, the rule of four of the brainstem2 is used in this way. I have been informed by colleagues that they've seen this rule on computers in Accident and Emergency Departments.

    The 5*3*5 rule is not intended only for neurologists, it empowers non-neurologist's to accurately diagnose the cause of weakness in the upper limb. I have taught the rule to medical students in Australia, Rwanda and Fiji, to postgraduate physician trainees and osteopaths who have all found it useful.

    References
    1. Welsby PD. Have guidelines lost their way? Postgrad Med J 2019; 95(1127): 469.
    2....

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  • Breathe in, Hold on and breathe out, effective exercise for COPD

    Letter response to the article “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD

    Abstract
    Following the publication of the manuscript “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD” in Postgraduate Medical Journal written by Lin Q. et al., we describe the rationale and origin of the respiratory technique derived from yoga practice and adapted as breathing exercise for a pulmonary rehabilitation programme strategy for COPD patients. The discussed technique consist of breathing with an expiratory resistive load, is a modified Pranayama yogic breathing practices tailored with focus on the specific need of patient with COPD, that allow the patient to breathe simultaneously through both the nostrils and with exhalation to be completed against a resistance to the free flow of exhaled gases. The described method has also been proven very useful in reopening non-ventilating lung areas for both chronic and acute patients.
    I have read with great interest the manuscript “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD” published in Postgraduate Medical Journal written by Lin Q. and collaborators 1. As reported by the authors in the acknowledgment of the paper, I was instrumental to inspire the study while working with the Respiratory and Critical Care Medicine and RICU in the...

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  • Re: [How good are doctors at introducing themselves? #hellomynameis]

    Dear Editor,

    It was a pleasure reading the explorative study by Gillen et al, which focused on the effects of introductions and handshakes on patient satisfaction by the end of a consultation. The study concludes that the majority of patients expected such gestures; which was received positively. The results reinforced how powerful the #hellomynameis campaign was; given it was a lucrative collective effort which ultimately made patients feel comfortable. The paper demonstrates how these simple, yet overlooked, consultation techniques are pivotal in building a positive rapport with patients, translating into a successful patient-doctor experience.

    On reflection of our own experiences as medical students, introducing oneself is one of the first communication skills we are trained to do. Nailing your introduction is taught to be the basis of forming a courteous and lasting first impression. As students, we spend excessive amounts of time trying to formulate a focused history, sifting through our medical knowledge in search for the next question to ask in order to rule in and out conditions. It’s fair to say that the first few attempts at history taking are longer than an average consultation with a senior clinician. Therefore, we agree with Gillen et al that clinicians and by extension, medical students- should introduce themselves by their full name and state their objectives so that the patient feels at ease knowing who they are speaking to. Furthermore, impl...

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  • Lost in translation

    Fortuitously, the re-evaluation of the medical consultation(1) has coincided with the advent of intrusion of the computer into the doctor-patient interaction, typified by the comment "Clinicians [now] find themselves interacting more with their computers than with their patients...."(2). What that intrusion has meant is that the component of symptomatology emanating from body language is now being actively deleted from both the narrative and the normative versions of the patient's medical history. Discerning patients are probably aware of this shift in the dynamics of the consultation, the predictable consequence that "If patients do not have the impression we are listening and watching attentively, they may not tell us what we need to know, or ..............follow our advice" (1).
    In the Ying and Yang of the medical consultation a medically qualified patient might or might not be at an advantage, depending on what version of the patient's own story one might wish to read. The author of his personal experience of post-traumatic benign paroxysmal positional vertigo was in the fortunate position of submitting, to his own doctor, a narrative which coincided with the normative version of that disorder. The consequence was a well thought out therapeutic strategy, culminating in complete cure(3). However, notwithstanding the fact that benign paroxysmal positional vertigo(BPPV) is by far the most common type of vertigo, with a r...

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  • Neuropathy by overachieved rapid glycemic oral control

    Letter response to the article "Under-recognised paradox of neuropathy from rapid glycaemic control."

    I am a data point of what the author says is elusive example of neuropathy (albeit in initial stages) by rapid glycemic control using only oral medication.
    My A1c reduced by about 1 point ( 7.7 to 6.8) in 3 months and further down to 6.1 in 3 more subsequent months.

    From the initial 7.7 A1c date, I was started on a higher oral dosage, as well as serious diet modification.

    Two months later, I had a rapid onset of feet burning symptoms. The symptoms came on and off. With subsequent tighter diet control that included episodes of low glucose levels, feet burning was still present and became more frequent. After reading up on this subject and its counter intuitive conclusions, I loosened diet control and also had my doctor reverse the last medication increase to previous levels. This seems to have helped and my left foot has been free of burning for a few days now, and the right foot also improving. Continuing monitoring and hoping for the best. Thanks to your and similar articles for highlighting this controversial and elusive phenomenon.

    Conflict of Interest
    None declared

  • The effect of sleep deprivation on surgical skill can be measured

    A study performed in the United States lends support to the recommendations made by the European Working Time Directive regarding "ring fencing" of rest times for surgical trainees. In that study the effect of daytime sleepiness(measured on the Epworth Sleepiness Scale(ESS) was measured in 19 surgical trainees in otolaryngology-head and neck surgery programmes in 2 academic institution. ESS was documented, and surgical skill(in performig septoplasty) was evaluated by attending physicians using a global assessment tool and a skill-based visual analog scale. The attending physicians were unaware of the trainees' report on the ESS. Trainees, themselves, were also required to rate their own performance. The outcome was that , in regression analysis, there was a statistically significant inverse association between ESS scores and attending physician-rated technical skill both for the global assessment tool(p < 0.001), and for the visual analog scale(p=0.03)(1). Using both parameters the self-rated scores obtained by the trainees did not reach statistical significance(1). In other words, the trainees did not recognise the effect that daytime sleepiness was having on their surgical performance.
    The wider inference that can be drawn is as follows:-
    Daytime sleepiness impairs performance even though the trainee may be unaware of this adverse effect
    These observations are generalisable both to trainees and to consultant staff
    Consultan...

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  • The tension between "gestalt" and the checklist

    The tension between head, heart and checklist is strikingly exemplified by the clinical decision process involved in the diagnosis of pulmonary embolism(PE). Currently, this process is characterised by a proliferation of clinical decision rules which involve mind numbingly long lists of items, and their associated calculations, the latter intended to generate numerical scores(1)(2) which confer a semblance of scientific credibility to the process. By contrast, a school of thought has emerged which posits that clinical acumen, defined as unstructured clinical impression or "gestalt" is, at the very least, as reliable a sole reliance on clinical prediction rules for discriminating among patients who have a low, moderate, or high pretest probability of PE(1). Over time, gestalt, itself, appears progressively to confer increasing diagnostic accuracy, judging by the diagnostic performance of senior physicians(postgraduate year 4 plus) vs interns(postgraduate year 1) working in the emergency department of a large teaching hospital(3). Concurrently, we have seen the emergence of gestalt-based clinical decision strategies such as the PERC rule(4) and the YEARS algorithm(5). as an attempt to resolve the tension between underdiagnosis and overdiagnosis of PE.
    Clinical acumen, itself, performs best when it is informed, not only by the numerical score of years since obtaining one's medical qualification, but also by interaction(through the medium of case co...

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  • S1Q3T3R3 left arm – V2 ECG lead misplacement

    Dear Editor,
    We read with interest Thomson et al’s article “ECG in suspected pulmonary embolism” which was published in Postgraduate Medical Journal in January 2019. We would like to bring to your attention another important but little-known cause of S1Q3T3, namely left arm – V2 ECG lead misplacement. This occurs when the yellow ECG cables are misplaced and can easily be misdiagnosed as a pulmonary embolism. A characteristic appearance occurs which we believe is pathognomonic for LA – V2 misplacement. In addition to S1Q3T3, a tall R wave in lead III is seen (1). In a study of 62 patients in whom we recorded both a normal and an LA V2 ECG lead misplacement, we observed that the presence of S1Q3T3R3 is highly statistically significant for left arm -V2 lead misplacement (P=0) (1). It is important to exclude lead misplacement, or the patient may have incorrect treatment administered or the correct treatment withheld because of an error in recording an ECG. Of 230 unrecognised ECG lead misplacements in our hospital, 10.9% were left arm – V2 (2).
    After a thorough search of the literature we have identified only 2 brief reports on this topic (3,4). Therefore, it is highly likely that if it does occur then ECG features will inadvertently be attributed to pulmonary embolism and managed inappropriately.

    1. Lynch R, Ballesty L, Kuan SC, Ponnambolam Y. Left arm – V2 ECG Lead Misplacement by Colour: a largely unknown entity which can easily be Misdiagnosed as a Pulmo...

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  • Overuse of imaging might be attributable to suboptimal clinical decision rules

    The judgment that imaging studies were over-utilised (1) should not be based on the degree of compliance with the Wells clinical decision rule (CDR), given the fact that the Wells score is not necessarily the optimal one for PE. In a study which compared 7 CDRs, namely, the Wells score, simplified Wells score, original Geneva score, revised Geneva score, Charlotte score and the Pisa model, diagnostic accuracy amounted to 0.44, 0.61, and 0.76 for simplified Wells score, Wells score, and Pisa model, respectively (2). The Wells score was tested in 598 primary care patients presenting with symptoms including cough, unexpected or sudden dyspnoea, deterioration in existing dyspnoea, and pleuritic pain, singly or in combination. These patients were referred to secondary care with suspected PE, where they were subsequently rigorously evaluated and investigated according to hospital guidelines. The diagnosis of PE was subsequently confirmed in 73 cases. However, in as many as 44 of those cases where PE was ruled out, the presenting Wells score amounted to >4 points (3), a score that is taken to signify "PE likely" in the simplified Wells score. In the evaluation of PE diagnostic confusion is compounded by the fact that PE can be an incidental finding, for example, during CT imaging in the oncological context (4). In the latter study, 25% of 52 patients with incidental PE had no PE-related symptoms (4). In the entire group of 52 patients with incidental PE, eight had m...

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  • 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).
    Comment
    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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