In a recently published paper entitled ‘Status and situation of postgraduate medical students in China under the influence of COVID-19” (1) is inappropriate, as the authors have hardly described the plights of the postgraduate (PG) students during this pandemic. They have broadly discussed the impact of it on the medical students in general (including both under and postgraduate students). The PG has much different education and training than the undergraduate (UG) students. And, also the responsibilities of these two groups of students are quite different. The PG courses are designed to create experts, who would be able to deliver specialized healthcare to the community. Hence, generalizing the impact of the pandemic on these two dissimilar groups is unfair.
COVID-19 pandemic has indeed disrupted the medical PG education and training globally, mainly in the following ways:
1. Due to a substantial decrease in the number of patients attending the hospitals, the requisite clinical experience of history taking, clinical examination, and attending their surgical interventions have been cut down significantly, leading to inadequate specialist training.
2. The PG teaching is also badly affected by the pandemic, with the abolition of conventional teaching like lectures, ward rounds, inter-departmental meetings, seminars, case presentations, and other academic activities (2).
3. The PGs are finding it challenging to complete their required d...
In a recently published paper entitled ‘Status and situation of postgraduate medical students in China under the influence of COVID-19” (1) is inappropriate, as the authors have hardly described the plights of the postgraduate (PG) students during this pandemic. They have broadly discussed the impact of it on the medical students in general (including both under and postgraduate students). The PG has much different education and training than the undergraduate (UG) students. And, also the responsibilities of these two groups of students are quite different. The PG courses are designed to create experts, who would be able to deliver specialized healthcare to the community. Hence, generalizing the impact of the pandemic on these two dissimilar groups is unfair.
COVID-19 pandemic has indeed disrupted the medical PG education and training globally, mainly in the following ways:
1. Due to a substantial decrease in the number of patients attending the hospitals, the requisite clinical experience of history taking, clinical examination, and attending their surgical interventions have been cut down significantly, leading to inadequate specialist training.
2. The PG teaching is also badly affected by the pandemic, with the abolition of conventional teaching like lectures, ward rounds, inter-departmental meetings, seminars, case presentations, and other academic activities (2).
3. The PGs are finding it challenging to complete their required dissertations and are deprived of attending any conferences or workshops for widening the horizon.
4. This pandemic has been extended for a long time; in the majority countries and no one known when would it end. Hence, many PG trainees would lose a significant amount of their PG course time, leading to inadequate training, and practical experience. Therefore, these COVID affected PGs are likely to be inadequately trained and shall not be able to provide skillful and sound treatment confidently, even after clearing the exit exams (3).
5. Due to the fear of acquiring COVID-19, the PGs to devoid of ‘face to face’ interactions with the patients leading to severe impact on their clinical teaching (4).
6. Although, virtual teaching and learning has become popular in these difficult times, still the experience of clinical examination and attending the surgical procedures physically cannot be replaced by any virtual means (5).
7. There has also been undue mental stress of the PGs for the reasons mentioned above, and also for their redeployment duties in the non-specialty areas.
2. Lal H, Sharma DK, Patralekh MK, Jain VK, Maini L. Outpatient Department practices in orthopaedics amidst COVID-19: The evolving model [published online ahead of print, 2020 May 18]. J ClinOrthop Trauma. 2020; 10.1016/j.jcot.2020.05.009.
3. Dougherty PJ , Jain AK. Orthopaedic Surgery Education in India. Clin Orthop Relat Res 2014; 472:410–414.
4. Kumar S, Tuli SM. Orthopedic education: Indian perspective. Indian J Orthop. 2008;42 (3): 245-246.
5. Palan J, Roberts V, Bloch B, Kulkarni A, Bhowal B, Dias J: The use of a virtual learning environment in promoting virtual journal clubs and case-based discussions in trauma and orthopaedic postgraduate medical education: The sleicester experience. J Bone Joint Surg Br 2012; 94:1170-1175.
Predicated improvement on steroids
Philip D Welsby Philipwelsby@aol.com
Assistant Editor, Postgraduate Medical Journal
1, Burnbrae,
Edinburgh EH12 8UB
0131 339 8141
John Launer’s recent On Reflexion details his heart block and lessons therefrom1. Might I be permitted to offer a similar lesson?
Ten months ago I was asked “How are you today” Mostly this is a meaningless question, almost rhetorical, used by people to acknowledge your existence in a caring way. I was able to give a quantitative rather than vague qualitative response. “I am now well thank you, on 15 (of prednisolone) having had an ESR in the 80s and a CRP similarly raised.
I was very fit (at age of 72) with a resting pulse of 60 attributed to daily gym attendance, but then developed a less that definite pain and a less than definite stiffness in my shoulder and pelvic girdle. I correctly suspected Polymyalgia rheumatic and was put on 15mg of prednisolone. Having read the books my girdle symptoms responded within 24 hours (and thank you for your interest). I tapered down to 3mg when I developed a headache, mostly occipital, and less than definite masseter claudication (I became aware that I had such muscles and noted discomfort when playing the clarinet) along with less than well localised temporal tenderness. You all know that this was Temporal Arteritis, another manifestation of Giant Cell Arteritis, and s...
Predicated improvement on steroids
Philip D Welsby Philipwelsby@aol.com
Assistant Editor, Postgraduate Medical Journal
1, Burnbrae,
Edinburgh EH12 8UB
0131 339 8141
John Launer’s recent On Reflexion details his heart block and lessons therefrom1. Might I be permitted to offer a similar lesson?
Ten months ago I was asked “How are you today” Mostly this is a meaningless question, almost rhetorical, used by people to acknowledge your existence in a caring way. I was able to give a quantitative rather than vague qualitative response. “I am now well thank you, on 15 (of prednisolone) having had an ESR in the 80s and a CRP similarly raised.
I was very fit (at age of 72) with a resting pulse of 60 attributed to daily gym attendance, but then developed a less that definite pain and a less than definite stiffness in my shoulder and pelvic girdle. I correctly suspected Polymyalgia rheumatic and was put on 15mg of prednisolone. Having read the books my girdle symptoms responded within 24 hours (and thank you for your interest). I tapered down to 3mg when I developed a headache, mostly occipital, and less than definite masseter claudication (I became aware that I had such muscles and noted discomfort when playing the clarinet) along with less than well localised temporal tenderness. You all know that this was Temporal Arteritis, another manifestation of Giant Cell Arteritis, and symptoms promptly responded, this time to 60mg prednisolone.
Some observations of interest.
I was able to advise my rheumatologist that if he ever felt significant but less than definite symptoms he would initially feel better on steroids. This is true - I felt better than I felt I should. Anyone would feel better initially even if he or she had a condition that would soon be made a lot worse by the steroids.
Whilst I was aware of steroid psychosis I was not prepared for the “spaced-out“ feeling of not being perfectly in touch with reality
As a clarinet player I observed that in retrospect both presentations were associated with subliminal impairment of facility in tonguing the reed and facility in finger movement (Welsby’s sign) when playing all but two “standard pieces.” Firstly, the opening ascending wail (glissando to musicians) of Gershwin’s Rhapsody in Blue does not require finger agility, rather the ability to slow the ascent using throat and lips whilst sliding the fingers off the note holes. So that was fine. Of interest George Gershwin did not write this wail: he arranged the Rhapsody for two pianos and it was Ross Gorman, a Klezmer clarinet player in Paul Whiteman’s jazz band, who as a joke on Gershwin, converted Gershwin’s chromatic run into a glissando. Secondly, playing the famous 4 minutes 33 seconds of John Cage’s famous piece 4” minutes 33 seconds” of total silence posed no problems. Of interest is the outrageous but hardly known joke in the name. How many seconds are there in 4 minutes 33 seconds? The answer is 273. Put a minus sign in front of the 273 and you have… absolute zero.
We thank Dr Ding and Dr Zhang for their article on the impact of cancelling foundation year rotations as a result of the COVID-19 pandemic (1). As two members of the future generation of doctors, we would like to present our thoughts on the difficulties and opportunities that medical students face.
There are 35 medical schools in the UK that can award a UK medical degree with another six new schools and programmes currently under review by the GMC for approval (2). The UK medical degree is typically 5 years long with the first two years consisting of lecture-based study and the final three years being placement-based clinical teaching. Under normal circumstances in the placement years, medical students, like in the foundation programme, rotate around different medical and surgical specialties.
Medical schools have responded to the COVID-19 pandemic as they deemed appropriate – this has largely been the suspension of clinical placement, face-to-face teaching, and examinations. In making these difficult decisions medical schools will have had to take into account a number of factors: not only considering student, staff, and patient safety but also the repercussions this will have for the future generation of doctors. The enormity of these decisions is not lost on medical students, as many are left wondering what the implications will be for them.
One of the decisions of most concern is the cancellation of placements. Similar to the foundation doctors, the r...
We thank Dr Ding and Dr Zhang for their article on the impact of cancelling foundation year rotations as a result of the COVID-19 pandemic (1). As two members of the future generation of doctors, we would like to present our thoughts on the difficulties and opportunities that medical students face.
There are 35 medical schools in the UK that can award a UK medical degree with another six new schools and programmes currently under review by the GMC for approval (2). The UK medical degree is typically 5 years long with the first two years consisting of lecture-based study and the final three years being placement-based clinical teaching. Under normal circumstances in the placement years, medical students, like in the foundation programme, rotate around different medical and surgical specialties.
Medical schools have responded to the COVID-19 pandemic as they deemed appropriate – this has largely been the suspension of clinical placement, face-to-face teaching, and examinations. In making these difficult decisions medical schools will have had to take into account a number of factors: not only considering student, staff, and patient safety but also the repercussions this will have for the future generation of doctors. The enormity of these decisions is not lost on medical students, as many are left wondering what the implications will be for them.
One of the decisions of most concern is the cancellation of placements. Similar to the foundation doctors, the rotations around different specialties on clinical placements gives a unique learning experience, exploring the core knowledge of the specialty and enabling students to refine their communication skills. These rotations are designed to help prepare them for their examinations as well as equip them with the skills needed to be good junior doctors. Some students may miss the opportunity to gain experience in a particular specialty that they are considering pursuing as a career, and some may miss specialties they had not previously considered. Many students will also be disappointed to be missing out on their medical elective. This is a unique challenge and opportunity to discover global medicine that many clinicians have fond memories of several years later.
Going forward, there are multiple unanswered questions which are creating a lot of uncertainty for medical students. Will they get the opportunity to experience the placements that have been missed? With the disruption to exams, how will the Foundation Programme application be affected, and how will this differ between medical schools? What will the NHS look like, and how will it be operating on their return to placement? Will they be fully prepared for being a junior doctor when the time comes?
Whilst the COVID-19 outbreak has created a lot of uncertainty, it has also provided medical students a unique opportunity to gain skills in other areas of healthcare. A prime example of this is at Aalborg University and Aalborg University Hospital in Denmark, where medical students were enrolled in fast-track courses to work as ventilator therapy assistants, nursing assistants, and those in their final year employed as temporary residents. Teaching became digitally based and new portfolios were developed for students to complete to showcase what learning activities had been achieved during the pandemic (3). With approximately two thirds of students working in one of those three roles within two weeks, the mobilisation demonstrated by Aalborg University is impressive and shows medical students can be valuable assets.
Similar initiatives have taken place in the UK with final year medical students given the option to ‘opt in’ to their medical careers slightly earlier than planned in the newly created Interim F1 (FiY1) posts. It is anticipated that FiY1 doctors will join the clinical teams and perform tasks including note-taking, ordering investigations and basic procedures whilst under supervision (4). Although it is no doubt daunting for the new FiY1s, their commitment to taking up this role should allow for a smooth transition into commencing formal F1 training come August.
Medical students in lower years who would like to have an active role during the pandemic have been encouraged to take up positions as health care assistants (HCAs). In doing so they will continue to get exposure to a hospital-based environment and develop a greater understanding of the individual roles within the wider healthcare team. The work is team based and has frequent patient contact, mainly orientating around personal care, which contributes to improving communication with patients as well as colleagues. Research completed by Norwich Medical School has shown that medical students who have worked as HCAs found the experience promoted empathy, built confidence and helped them become more ‘ward smart’ (5). Working on the NHS front line, exposed to new and unfamiliar challenges, should help to establish key skills of resilience and determination at an early stage in their careers.
At the time of writing, the UK is still “mid-pandemic”. While the world is left to speculate about how to best navigate the new normal left in the wake of COVID-19, medical students are no different. Universities have been working hard to keep in regular contact with their students and have been proactive in making extra support available to students who may be struggling to cope during these uncertain times. Resuming teaching at medical schools to its previous normality may be extremely difficult, maybe even impossible, but medical schools still have a duty to patients to produce doctors that have sufficient training. The COVID-19 pandemic has created a testing time for us all and is likely to have lasting effects on healthcare globally. Healthcare professionals have embraced the challenges presented to them, and now medical students must do the same.
References:
1. Ding A, Zhang Y. Impact of cancelling foundation year rotations due to the covid-19 outbreak in the UK. Postgraduate Medical Journal Published Online First: 20 April 2020. doi: 10.1136/postgradmedj-2020-137775.
2. Bodies awarding UK medical degrees - GMC. Available from: https://www.gmc-uk.org/education/how-we-quality-assure/medical-schools/b...
3. Rasmussen S, Sperling P, Poulsen MS, Emmersen J, Andersen S. Medical students for health-care staff shortages during the COVID-19 pandemic. Lancet. 2020 May;395(10234):e79–80.
4. UK Foundation Programme 2020: Allocations to Interim F1 Posts. Available from: https://healtheducationengland.sharepoint.com/UKFPO/Website Documentation/Forms/AllItems.aspx?id=%2FUKFPO%2FWebsite Documentation%2FCOVID-19%2FEarly Allocation of Qualified Medical Students_April 2020.pdf&parent=%2FUKFPO%2FWebsite Documentation%2FCOVID-19&p=true&originalPath=aHR0cHM6Ly9oZWFsdGhlZHVjYXRpb25lbmdsYW5kLnNoYXJlcG9pbnQuY29tLzpiOi9nL1VLRlBPL0VSb1dUNUNCYmtoQXBPbjlfOEtHN3QwQk15dTV1RVlWQ05JQmRPVWl0M0NHeUE_cnRpbWU9MDVUaEpPancxMGc
5. Davison E, Lindqvist S. Medical students working as health care assistants: an evaluation. Clin Teach. 2019 Nov 7;16:1–7. doi: 10.1111/tct.13108.
The communication from Pal and colleagues is timely. (1) However, a few more points might have been included.
At present, Non-communicable diseases (NCDs) are responsible for 55.4% Disability Adjusted Life Years (DALY) in India. (2) The major risk factors for NCDs are tobacco, alcohol abuse, physical inactivity, and unhealthy diet. Therefore, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) focuses on the prevention of risk factors and awareness generation. (3)
As the ongoing pandemic of Coronavirus disease (COVID 19) is ravaging most of the countries, India has imposed a lockdown for 21 days since 25 March 2020, in an attempt to avoid the catastrophe. While it is being considered as a masterstroke for putting the spread of the epidemic on hold, it would also restrict access to tobacco or alcohol for many, in favor of NCD prevention. However, some routine activities like physical activity would need to be re-planned for this duration, as parks and gyms are not accessible. As public transport is being operated at the minimal frequency, many patients of NCD might find it difficult to reach the nearest hospital for collecting their medicines. For NCD patients purchasing medicines (out-of-pocket expenditure) from a pharmacy, access to medicine may be restricted. Migrants working as daily wager may be the worst hit as the possibility of being laid off looms large, even if the government is asking the...
The communication from Pal and colleagues is timely. (1) However, a few more points might have been included.
At present, Non-communicable diseases (NCDs) are responsible for 55.4% Disability Adjusted Life Years (DALY) in India. (2) The major risk factors for NCDs are tobacco, alcohol abuse, physical inactivity, and unhealthy diet. Therefore, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) focuses on the prevention of risk factors and awareness generation. (3)
As the ongoing pandemic of Coronavirus disease (COVID 19) is ravaging most of the countries, India has imposed a lockdown for 21 days since 25 March 2020, in an attempt to avoid the catastrophe. While it is being considered as a masterstroke for putting the spread of the epidemic on hold, it would also restrict access to tobacco or alcohol for many, in favor of NCD prevention. However, some routine activities like physical activity would need to be re-planned for this duration, as parks and gyms are not accessible. As public transport is being operated at the minimal frequency, many patients of NCD might find it difficult to reach the nearest hospital for collecting their medicines. For NCD patients purchasing medicines (out-of-pocket expenditure) from a pharmacy, access to medicine may be restricted. Migrants working as daily wager may be the worst hit as the possibility of being laid off looms large, even if the government is asking the organizations not to treat their employees so harshly. (4) The same difficulty in the conveyance is applicable for the clients in need of counseling for de-addiction. The movement of health care workers may also suffer in the same way. Besides, access to regular dietary variety may also be restricted due to several reasons such as the disruption of the supply chain resulting from lockdown, unavailability of daily wagers owing to limited movements, and limited visits allowed to grocery stores. At times, the operating time for grocery stores is also shorter.
With older patients being the common victims for both NCD and COVID 19, there is a need like never before to ensure optimum management for NCDs. (5) More so, because most of the countries are occupied with the pandemic and routine care for chronic diseases is on the verge of impending compromise. We need to take care of that in a delicate manner.
References
1. Pal R, Bhadada SK. COVID-19 and non-communicable diseases. Postgrad Med J. Published Online First: 30 March 2020. doi: 10.1136/postgradmedj-2020-137742
2. Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation. India: Health of the Nation's States - The India State-level Disease Burden Initiative. New Delhi, India: ICMR, PHFI, and IHME; 2017.
3. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke. (Available at https://dghs.gov.in/content/1363_3_%20NationalProgrammePreventionControl..., last accessed on 7th April, 2020).
4. Covid-19: Public, pvt cos told not to cut salaries, lay off staff. Available at https://economictimes.indiatimes.com/jobs/covid-19-public-pvt-cos-told-n..., last accessed on 7th April, 2020)
5. Chen T, Wu D, Chen H, et al. Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ 2020;368. doi:10.1136/bmj.m1091
Conflict of Interest
None declared
Malhotra, et al [1] correctly defines a concern regarding the treatment of patients and the selection of appropriate interventions. However, to provide this “right care and high-value” cardiac care requires the shedding of incorrect beliefs and opinions – including diagnostic, etiologic and treatment - and the quantification of CAD itself.
Quantification [2] makes it possible to diagnostically define the true extent and severity of CAD present in an individual and to accurately measure CAD treatment outcomes. Only by using true quantification can we remove the errors (sensitivity and specificity) in imaging [2] and treatment studies [3] and provide patients with “right care and high-value cardiology” free of physician bias and misperceptions. To provide this type of care we must focus our full attention on evidence-based medicine; avoiding the errors of the past.
The very foundation of evidence-based medicine is the ability to accurately, consistently and reproducibley measure quantifiable outcomes [2] as shown in Figure 1, and to avoid the use of qualitative or semi-quantitative methods, which misdiagnose the presence (sensitivity) or absence (specificity) of disease [2]. This is now possible using “The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) Using Same State Single or Sequential Quantification Comparisons” [2].
FMTVDM is able to accurately, consistently and reproducibly define the extent and severity of CAD by fir...
Malhotra, et al [1] correctly defines a concern regarding the treatment of patients and the selection of appropriate interventions. However, to provide this “right care and high-value” cardiac care requires the shedding of incorrect beliefs and opinions – including diagnostic, etiologic and treatment - and the quantification of CAD itself.
Quantification [2] makes it possible to diagnostically define the true extent and severity of CAD present in an individual and to accurately measure CAD treatment outcomes. Only by using true quantification can we remove the errors (sensitivity and specificity) in imaging [2] and treatment studies [3] and provide patients with “right care and high-value cardiology” free of physician bias and misperceptions. To provide this type of care we must focus our full attention on evidence-based medicine; avoiding the errors of the past.
The very foundation of evidence-based medicine is the ability to accurately, consistently and reproducibley measure quantifiable outcomes [2] as shown in Figure 1, and to avoid the use of qualitative or semi-quantitative methods, which misdiagnose the presence (sensitivity) or absence (specificity) of disease [2]. This is now possible using “The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) Using Same State Single or Sequential Quantification Comparisons” [2].
FMTVDM is able to accurately, consistently and reproducibly define the extent and severity of CAD by first quantitatively calibrating the camera (SPECT, PET) utilizing the isotope being employeed for measurement, followed by measurements of isotope both in the baseline and enhanced regional blood flow differences states. From these measured changes in isotope emissions, percent diameter stenosis and regional changes in coronary blood flow can be obtained [2,4].
Evidence-based medicine further requires a solid understanding of the pathophysiology of CAD to determine what treatment interventions should be made; interventions which are dependent upon the various factors involved in the inflammatory process impairing coronary blood flow [3-5] producing angina, myocardial infarction (MI) and major adverse cardiac events (MACE).
We encourage Malhotra and others, interested in providing “right care and high-value cardiology” to address treatment and intervention concerns by participating in the quantitative measurement of the impact, both dietary and drug treatments have on patients and study participants; so that clinicians may be able to provide better “right care and high-value cardiology” using FMTVDM evidence-based medicine [4].
References:
1. Malhotra A, Apps A, Saini V, et al. Right care and high-value cardiology: doctors’ responsibilities to the patient and the population. Postgraduate Medical Journal 2015;91:415-417.
2. Fleming RM, Fleming MR, Dooley WC, Chaudhuri TK. Invited Editorial. The Importance of Differentiating Between Qualitative, Semi-Quantitative and Quantitative Imaging – Close Only Counts in Horseshoes. Eur J Nucl Med Mol Imaging. DOI:10.1007/s00259-019-04668-y. Published online 17 January 2020 https://link.springer.com/article/10.1007/s00259-019-04668-y
3. Fleming RM, Fleming MR, Chaudhuri TK. Are we prescribing the right diets and drugs for CAD, T2D, Cancer and Obesity? Int J Nuclear Med Radioactive Subs 2019;2(2):000115.
4. Fleming RM. Chapter 29. Atherosclerosis: Understanding the relationship between coronary artery disease and stenosis flow reserve. Textbook of Angiology. John C. Chang Editor, Springer-Verlag, New York, NY. 1999. pp. 381-387.
5. Fleming RM. Chapter 64. The Pathogenesis of Vascular Disease. Textbook of Angiology. John C. Chang Editor, Springer-Verlag New York, NY. 1999, pp. 787-798.
The medical myths, using anti-MMR as an example, follow a formula of being easy to understand and not difficult to retell. Similar to urban myths, the knowledge of a medical myth is not reduced by distance from the case. For example, as told to me in my paediatric emergency department, a patient's cousin's friend whose child became autistic following vaccination is viewed as an absolute truth.
Compare this with medical rebuttal. Frequently the caveats of more research is needed or the results from a small study litter the conclusion sections. Typically the writing is dense and heavy on jargon. It's also common for there not to be an absolute answer.
Perhaps we should sharpen our writing and be more definitive. ‘Tweetorials’ are useful but they need to be short and snappy.
Conflict of Interest
None declared
The differential diagnosis of pneumothorax with haemodynamic compromise(1) ought to include the two subtypes of tension pneumothorax associated with dissecting aneurysm of the aorta(DAA), namely, tension pneumothorax with concurrent haemothorax(2), and tension pneumothorax without concurrent haemothorax(3)(4).
In the report of DAA-related haemopneumothorax(2), antemortem chest radiography clearly documented the presence of tension pneumothorax without concurrent fluid collection in the pleural space. The patient collapsed and died soon after insertion of a chest drain intended to relieve the pneumothorax. Autopsy revealed an adhesion between the visceral lung pleura and the aortic aneurysm through which the dissection had penetrated the lung parenchyma. The parenchymal haematoma had subsequently “spouted out” from a 20 mm tear on the pleura, giving rise to haemothorax(2). The sequence of events might have been similar, in some respects, to the sequence of events in a 79 year old man who experienced a haemopneumothorax which was, however, much less striking in its severity(5). In the latter case there was no haemodynamic compromise. The patient had initially complained of “spitting” blood, without concurrent chest pain, back pain or breathlessness. Chest radiography revealed an abnormal air-fluid level in middle lung field on the right side. Subsequent contrast-enhanced tomography revealed Type B aortic dissection, a pneumothorax adjacent to the dissection(pre...
The differential diagnosis of pneumothorax with haemodynamic compromise(1) ought to include the two subtypes of tension pneumothorax associated with dissecting aneurysm of the aorta(DAA), namely, tension pneumothorax with concurrent haemothorax(2), and tension pneumothorax without concurrent haemothorax(3)(4).
In the report of DAA-related haemopneumothorax(2), antemortem chest radiography clearly documented the presence of tension pneumothorax without concurrent fluid collection in the pleural space. The patient collapsed and died soon after insertion of a chest drain intended to relieve the pneumothorax. Autopsy revealed an adhesion between the visceral lung pleura and the aortic aneurysm through which the dissection had penetrated the lung parenchyma. The parenchymal haematoma had subsequently “spouted out” from a 20 mm tear on the pleura, giving rise to haemothorax(2). The sequence of events might have been similar, in some respects, to the sequence of events in a 79 year old man who experienced a haemopneumothorax which was, however, much less striking in its severity(5). In the latter case there was no haemodynamic compromise. The patient had initially complained of “spitting” blood, without concurrent chest pain, back pain or breathlessness. Chest radiography revealed an abnormal air-fluid level in middle lung field on the right side. Subsequent contrast-enhanced tomography revealed Type B aortic dissection, a pneumothorax adjacent to the dissection(presumably attributable to aorto bronchial fistula), and concurrent pooling of blood in the thoracic cavity. He subsequently experienced massive haemoptysis, and collapsed and died. Autopsy revealed a ruptured aortic dissection and a pleural fissure which was tightly adherent to the aortic wall(5). In the two patients in whom pneumothorax was not associated with haemothorax(3)(4) the initiating event was believed to be rupture of a bulla. The subsequent accumulation of air in the pleural space was believed to have triggered the occurrence of aortic dissection in the context of pre-existing aortic aneurysm(3).
I have no funding and no conflict of interest
References
(1)Nawakami N., Aoki H., Ito M et al
Shock after treatment of spontaneous pneumothorax
Postgrad Med J doi.org/10.1136/postgradmedj-2019-137105
(2)Kurosaki K., Fushimi Y., Hara S et al
Sudden death caused by tension pneumothorax after rupture of a thoracic aortic aneurysm
The American Journal of Forensic Medicine and Pathology 2001;22;250-252
(3)Hifumi T., Kiriu N., Inoue J., Koido Y
Tension pneumothorax accompanied by type A aortic dissection
BMJ Case Reports 2012;doi:10.1136/bcr-2012-007142
(4)Nihira T., Yamada N
Type A aortic dissection associated with tension pneumothorax
Am J Emerg Med 2019;37:1218.e1-1218.e3
(5)Suu K., Kato T., Inoko M
A 79 year old man with “niveau” on a chest radiograph
BMJ case Reports 2015; doi.10.1136/bcr-2014-208423
Given the fact that tuberculosis and sarcoidosis have many stigmata in common (including the occurrence of noncaseating granulomas), a diagnosis of multiorgan sarcoidosis (1) can only be established beyond doubt if care has been taken to rule out the coexistence of sarcoidosis and tuberculosis using the strictest criteria for ruling in or for ruling out tuberculosis. Evaluating tissue samples for M tuberculosis through the use of the polymerase chain reaction (PCR) is one such strategy, given the fact that sensitivity for M tuberculosis infection is significantly higher for PCR than for BACTEC radiometric culture (74.4% vs 55.8%), although the two modalities have comparable specificity, namely, 97.2% vs 100% (no significant difference) (2). Accordingly, when the authors state "All biopsy specimens and bronchial washings were negative for TB (1), we need to know whether those samples were subjected either to mycobacterial culture or to evaluation by PCR.
The coexistence of sarcoidosis and tuberculosis was documented unequivocally in a 35 year old woman who initially presented with histologically and bacteriologically confirmed tuberculous lymphadenitis. She subsequently developed bilateral lung infiltrates. Histological specimens obtained via transbronchial biopsy and open lung biopsy showed features consistent with sarcoidosis. In addition, however, the presence of mycobacterial DNA in those tissue specimens was documented by PCR (3).
In another report, a...
Given the fact that tuberculosis and sarcoidosis have many stigmata in common (including the occurrence of noncaseating granulomas), a diagnosis of multiorgan sarcoidosis (1) can only be established beyond doubt if care has been taken to rule out the coexistence of sarcoidosis and tuberculosis using the strictest criteria for ruling in or for ruling out tuberculosis. Evaluating tissue samples for M tuberculosis through the use of the polymerase chain reaction (PCR) is one such strategy, given the fact that sensitivity for M tuberculosis infection is significantly higher for PCR than for BACTEC radiometric culture (74.4% vs 55.8%), although the two modalities have comparable specificity, namely, 97.2% vs 100% (no significant difference) (2). Accordingly, when the authors state "All biopsy specimens and bronchial washings were negative for TB (1), we need to know whether those samples were subjected either to mycobacterial culture or to evaluation by PCR.
The coexistence of sarcoidosis and tuberculosis was documented unequivocally in a 35 year old woman who initially presented with histologically and bacteriologically confirmed tuberculous lymphadenitis. She subsequently developed bilateral lung infiltrates. Histological specimens obtained via transbronchial biopsy and open lung biopsy showed features consistent with sarcoidosis. In addition, however, the presence of mycobacterial DNA in those tissue specimens was documented by PCR (3).
In another report, a 43-year-old woman who had initially presented with erythema nodosum, cough, and bacteriologically proven evidence of pulmonary tuberculosis, subsequently developed biopsy proven stigmata of cutaneous sarcoidosis. Radiological stigmata of sarcoidosis included hilar lymphadenopathy and a reticular interstitial pattern in the lower zones. Histopathological findings from lung and bronchial wall biopsy included documentation of noncaseating granulomas. However, M tuberculosis was isolated when the biopsy specimens were cultured. She subsequently developed nodular cutaneous infiltrates on her face, and these were histologically shown to be attributable to sarcoidosis (4).
I have no funding and no conflict of interest
References
(1) Kohli M., Schiller I., Dendukuri N et al
Xpert MTB/RIF assay for extrapulmonary tuberculosis and rifampicin resistance(Review)
Cochrane Database of Systematic Reviews2018; Issue 8. Art No.:CD012768
(2) Morasert T., Jongjaroonrangsun M., Smithtithiti S., Bhummichitra K
Sarcoidosis with multiorgan involvement
Postgrad Med J 2019;doi:10.1136/postgradmedj-2019-137219
(3)Wong CF., Yew WW., Wong PC., Lee J
A case of concomitant tuberculosis and sarcoidosis with mycobacterial DNA present in the sarcoid lesion
CHEST 1998;114:626-629
(4)Mise K., Goic-Barisic I., Puizina-Ivic N et al
A rare case of pulmonary tuberculosis with simultaneous pulmonary and skin sarcoidosis: a case report
Cases Journal 2010;3:24
Even when one takes into account the possibility that measurement of plasma cortisol after 60 min administration of synthetic ACTH might be a sufficient screening test for adrenal insufficiency(AI)(1), it is important to recognise that there are risk-free alternatives to the short synacthen test(SST) for validating the diagnosis of AI(2)(3)(4).
According to a retrospective study which evaluated, not only the 30 min and the 60 min cortisol levels, but also the pre-synacthen cortisol levels, a pre-synacthen serum cortisol level of 100 nmol/L or less(obtained during the median time period 08.20 h) is associated with a positive predictive value of 93.2% for the diagnosis of AI, when the gold standard for the latter is a failed SST. In that study of 330 subjects with suspected AI tested with the 250 mcg dose of tetracoscatrin , the subgroup with an eventual diagnosis of AI were tested at the median time of 08.20h(interquatrile range 07.55-09.26). The subjects who passed their SST were tested during the median time of 08.33(interquatrile range 08.01h-09.55h). Conversely. a pre-synacthen serum cortisol of 450 nmol/L or more generated a 98.7% negative predictive value to rule out AI(2). These observations were largely corroborated by a retrospective study of 231 subjects with suspected AI in whom AI was validated by an SST which incorporated 30 min as well as 60 min serum cortisol levels. In that study some patients(unspecified number) were tested at 08.00h...
Even when one takes into account the possibility that measurement of plasma cortisol after 60 min administration of synthetic ACTH might be a sufficient screening test for adrenal insufficiency(AI)(1), it is important to recognise that there are risk-free alternatives to the short synacthen test(SST) for validating the diagnosis of AI(2)(3)(4).
According to a retrospective study which evaluated, not only the 30 min and the 60 min cortisol levels, but also the pre-synacthen cortisol levels, a pre-synacthen serum cortisol level of 100 nmol/L or less(obtained during the median time period 08.20 h) is associated with a positive predictive value of 93.2% for the diagnosis of AI, when the gold standard for the latter is a failed SST. In that study of 330 subjects with suspected AI tested with the 250 mcg dose of tetracoscatrin , the subgroup with an eventual diagnosis of AI were tested at the median time of 08.20h(interquatrile range 07.55-09.26). The subjects who passed their SST were tested during the median time of 08.33(interquatrile range 08.01h-09.55h). Conversely. a pre-synacthen serum cortisol of 450 nmol/L or more generated a 98.7% negative predictive value to rule out AI(2). These observations were largely corroborated by a retrospective study of 231 subjects with suspected AI in whom AI was validated by an SST which incorporated 30 min as well as 60 min serum cortisol levels. In that study some patients(unspecified number) were tested at 08.00h(morning cortisol subgroup), and the rest were tested at 09.00h-13.00h(basal cortisol subgroup). A basal cortisol level of < 85 nmol/L was associated with a specificity of 99.7% and a sensitivity of 24.7% for the diagnosis of AI when the gold standard for AI was a failed SST. for ruling out AI, a serum cortisol of 350 nmol/L or more was associated with a sensitivity of 98.9% and a specificity of 32.2%(3). In that study the receiver operating curve generated a significantly higher area under the curve for basal cortisol than for morning cortisol in predicting a failed SST.
In the specific context of hypoglycaemia, regardless of the time of day, a single measurement of serum cortisol can unequivocally establish the diagnosis of AI. The rationale is that hypoglycemia is a stressor that activates the entire hypothalamic-pituitary-adrenal axis , thereby exceeding the stressor potential of the SST. All that it needs is for clinicians to be alert to opportunities to utilise the stressor potential of hypoglycaemia. A missed opportunity to do so was exemplified by the cautionary tale of a 19 year old man with type 1 insulin-treated diabetes and autoimmune hypothyroidism, both being the components of the autoimmune polyglandular syndrome. When he was admitted to hospital with hypoglycaemic coma the opportunity was not taken to explore fully the underlying cause of that complication . After his discharge he experienced recurring episodes of hypoglycaemia despite reducing his insulin dose. Eventually, 5 months post discharge, a SST was performed and it showed that he had AI. That diagnosis could have been established with a single measurement of serum cortisol during the episode of hypoglycaemia necessitating his hospital admission.
The additional advantage of a single measurement of serum cortisol that validates AI is that it obviates the need for a subsequent SST , and its attendant risk(albeit rare) of potentially fatal allergic reaction to exogenous tetracosactrin(5).
Finally, robust prospective studies are still needed to validate the hypotheses enunciated in (1)(2)(3)
I have no funding and no conflict of interest
References
(1) Kumar R., Carr P., Moore K et al
Do we need 30 min cortisol measurement in the short synacthen test: a retrospective study
Postgrad Med J 2019;1doi.org/10.1136/postgradmedj 2019
(2)struja T., Briner L., Meier A et al
Daignostic accuracy of basal cortisol level to predict adrenal insufficiency in consyntropin testing results from an observational cohort study with 804 patients
Endocrine Pract 2017;23: 949-961
(3) Mansrol W., Phimphllal M., Khorana J., Atthakolol P
Diagnostic performance of basal cortisol level at 09.00-13.00h in adrenal insufficiency
PLOS ONE 2019;doi.org/10.1371/journal.pone.0225255 November 18, 2019
(4) McAulay V., Frier BM
Addisons's disease in type 1 diabetes presents with recurrent hypoglycaemia
Postgrad Med J 2000;76:230-232
(5) Anonymous
Today's drugs
Tetracosactrin
BMJ 10.1136/bmj.2.5545.160 on 15th April 1967
The heading which reads "Heart failure with Reduced Ejection Fraction(LVEF < 40%) & Iron Deficiency Anaemia"(fig 1)(1) fails. by implication, to recognise that heart failure-related iron deficiency has an outcome which is detrimental irrespective of whether or not the patient is anaemic(2). In the latter study, among heart failure patients who had a marker of iron deficiency(ID), namely, mean corpuscular haemoglobin concentration(MCHC) equal to or less than 330 g/L, there was a significant association with increased mortality(Hazard Ratio 1.7, 95% Confidence Interval 1.4 to 2.0) which persisted even after adjusting for anaemia(HR 1.5, 95% CI 1.3 to 1.8)(2). The use of the cut-off MCHC value of 330 g/L or less as a marker of ID (1) is supported by studies where mean values for MCHC amounted to 319 g/L and 327.9 g/L, respectively, among subjects with ID(3)(4). In those two studies the iron-replete subjects were characterised by MCHC values amounting to 339 g/L and 340 g/L, respectively. The mean values for MCHC in ID subjects(namely, 319 g/L and 327.9 g/L, respectively) were significantly(p=0.001, p < 0.001) lower than the mean values for MCHC(339 g/L and 340 g L, respectively) in their iron-replete counterparts. In those two studies, as well, mean values for mean corpuscular volume(MCV) in ID subjects ranged from 85.5 fl to 90.2 fl in spite of proven ID(serum ferritin < 30 mcg/L) and MCHC < 330 g/L. Accordingly, to optimise the i...
The heading which reads "Heart failure with Reduced Ejection Fraction(LVEF < 40%) & Iron Deficiency Anaemia"(fig 1)(1) fails. by implication, to recognise that heart failure-related iron deficiency has an outcome which is detrimental irrespective of whether or not the patient is anaemic(2). In the latter study, among heart failure patients who had a marker of iron deficiency(ID), namely, mean corpuscular haemoglobin concentration(MCHC) equal to or less than 330 g/L, there was a significant association with increased mortality(Hazard Ratio 1.7, 95% Confidence Interval 1.4 to 2.0) which persisted even after adjusting for anaemia(HR 1.5, 95% CI 1.3 to 1.8)(2). The use of the cut-off MCHC value of 330 g/L or less as a marker of ID (1) is supported by studies where mean values for MCHC amounted to 319 g/L and 327.9 g/L, respectively, among subjects with ID(3)(4). In those two studies the iron-replete subjects were characterised by MCHC values amounting to 339 g/L and 340 g/L, respectively. The mean values for MCHC in ID subjects(namely, 319 g/L and 327.9 g/L, respectively) were significantly(p=0.001, p < 0.001) lower than the mean values for MCHC(339 g/L and 340 g L, respectively) in their iron-replete counterparts. In those two studies, as well, mean values for mean corpuscular volume(MCV) in ID subjects ranged from 85.5 fl to 90.2 fl in spite of proven ID(serum ferritin < 30 mcg/L) and MCHC < 330 g/L. Accordingly, to optimise the identification of ID(irrespective of coexistence of anaemia), the screening test should be an MCHC of 330 g/L or lower(ideally < 330 g/L). To confirm the diagnosis of ID the next step should be evaluation of serum ferritin and transferrin saturation, respectively.
With regard to treatment, for the non-anaemic ID patient the optimum treatment should be either intravenous iron(1) or oral iron taken as a single dose on alternate days(5). The latter is an innovation which optimises iron absorption in nonanaemic ID subjects who do not have heart failure(5). It is reasonable to extrapolate the efficacy of that dosing regime to heart failure patients with non-anaemic ID if they cannot tolerate intravenous iron. Whether or not that regime optimises iron absorption in the anaemic phase of ID remains to be proven by future studies. I agree that anaemic subjects with ID should receive intravenous iron. In the presence of heart failure and intolerance of intravenous iron it is unproven whether or not the dosing regime of Stoffel et al(5) would be appropriate.
Finally, although the guideline appears to confine its recommendation for further investigation only to patients who are in the anaemic phase of ID(final paragraph of fig 1)(1), it seems logical to investigate the underlying cause of ID regardless of whether or not the patient is anaemic. After all, anaemia is a manifestation of ID which occurs relatively late in the natural history of the underlying cause of ID. Furthermore, the underlying cause of ID needs to be eliminated even in the absence of anaemia.
I have no funding and no conflict of interest
References
(1) Simon S., Ioannou A., Deora S et al
Audit of the prevalence and investigation of iron deficiency anaemia in patients with heart failure in hospital practice
Postgrad Med J 2019;doi:10.1136/postgradmedj-2019-136867
(2)Kleber M., Kozhuharov N., Sabti Z et al
Relative hypochromia and mortality in acute heart failure
Int J Cardiol 2019;286:104-110
(3) Urrechaga E., Borque L., Escanero JF
Clinical value of hypochromia markers in the detection of latent iron deficiency in non-anaemic premenopausal women
Journal of Clinical Laboratory Analysis 2016;30:623-726
(4) Malczewska -Leneczowska J., Orysiak J et al
Reticulocyte and erythrocyte hypochromia markers in detection of iron deficiency in adolescent female athletes
Biol Sport 2017;34:111-118
(5)Stoffel N., Cercamondi C., Brittenham G et al
Iron absorption from oral iron supplements given on consecutive days versus alternate days and as a single dose versus twice-daily dosing in iron depleted women, two open-label, randomised controlled trials
Lancet Haematol 2017;4:524-533
In a recently published paper entitled ‘Status and situation of postgraduate medical students in China under the influence of COVID-19” (1) is inappropriate, as the authors have hardly described the plights of the postgraduate (PG) students during this pandemic. They have broadly discussed the impact of it on the medical students in general (including both under and postgraduate students). The PG has much different education and training than the undergraduate (UG) students. And, also the responsibilities of these two groups of students are quite different. The PG courses are designed to create experts, who would be able to deliver specialized healthcare to the community. Hence, generalizing the impact of the pandemic on these two dissimilar groups is unfair.
COVID-19 pandemic has indeed disrupted the medical PG education and training globally, mainly in the following ways:
1. Due to a substantial decrease in the number of patients attending the hospitals, the requisite clinical experience of history taking, clinical examination, and attending their surgical interventions have been cut down significantly, leading to inadequate specialist training.
2. The PG teaching is also badly affected by the pandemic, with the abolition of conventional teaching like lectures, ward rounds, inter-departmental meetings, seminars, case presentations, and other academic activities (2).
3. The PGs are finding it challenging to complete their required d...
Show MorePredicated improvement on steroids
Philip D Welsby
Philipwelsby@aol.com
Assistant Editor, Postgraduate Medical Journal
1, Burnbrae,
Edinburgh EH12 8UB
0131 339 8141
John Launer’s recent On Reflexion details his heart block and lessons therefrom1. Might I be permitted to offer a similar lesson?
Show MoreTen months ago I was asked “How are you today” Mostly this is a meaningless question, almost rhetorical, used by people to acknowledge your existence in a caring way. I was able to give a quantitative rather than vague qualitative response. “I am now well thank you, on 15 (of prednisolone) having had an ESR in the 80s and a CRP similarly raised.
I was very fit (at age of 72) with a resting pulse of 60 attributed to daily gym attendance, but then developed a less that definite pain and a less than definite stiffness in my shoulder and pelvic girdle. I correctly suspected Polymyalgia rheumatic and was put on 15mg of prednisolone. Having read the books my girdle symptoms responded within 24 hours (and thank you for your interest). I tapered down to 3mg when I developed a headache, mostly occipital, and less than definite masseter claudication (I became aware that I had such muscles and noted discomfort when playing the clarinet) along with less than well localised temporal tenderness. You all know that this was Temporal Arteritis, another manifestation of Giant Cell Arteritis, and s...
We thank Dr Ding and Dr Zhang for their article on the impact of cancelling foundation year rotations as a result of the COVID-19 pandemic (1). As two members of the future generation of doctors, we would like to present our thoughts on the difficulties and opportunities that medical students face.
Show MoreThere are 35 medical schools in the UK that can award a UK medical degree with another six new schools and programmes currently under review by the GMC for approval (2). The UK medical degree is typically 5 years long with the first two years consisting of lecture-based study and the final three years being placement-based clinical teaching. Under normal circumstances in the placement years, medical students, like in the foundation programme, rotate around different medical and surgical specialties.
Medical schools have responded to the COVID-19 pandemic as they deemed appropriate – this has largely been the suspension of clinical placement, face-to-face teaching, and examinations. In making these difficult decisions medical schools will have had to take into account a number of factors: not only considering student, staff, and patient safety but also the repercussions this will have for the future generation of doctors. The enormity of these decisions is not lost on medical students, as many are left wondering what the implications will be for them.
One of the decisions of most concern is the cancellation of placements. Similar to the foundation doctors, the r...
The communication from Pal and colleagues is timely. (1) However, a few more points might have been included.
Show MoreAt present, Non-communicable diseases (NCDs) are responsible for 55.4% Disability Adjusted Life Years (DALY) in India. (2) The major risk factors for NCDs are tobacco, alcohol abuse, physical inactivity, and unhealthy diet. Therefore, the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) focuses on the prevention of risk factors and awareness generation. (3)
As the ongoing pandemic of Coronavirus disease (COVID 19) is ravaging most of the countries, India has imposed a lockdown for 21 days since 25 March 2020, in an attempt to avoid the catastrophe. While it is being considered as a masterstroke for putting the spread of the epidemic on hold, it would also restrict access to tobacco or alcohol for many, in favor of NCD prevention. However, some routine activities like physical activity would need to be re-planned for this duration, as parks and gyms are not accessible. As public transport is being operated at the minimal frequency, many patients of NCD might find it difficult to reach the nearest hospital for collecting their medicines. For NCD patients purchasing medicines (out-of-pocket expenditure) from a pharmacy, access to medicine may be restricted. Migrants working as daily wager may be the worst hit as the possibility of being laid off looms large, even if the government is asking the...
Malhotra, et al [1] correctly defines a concern regarding the treatment of patients and the selection of appropriate interventions. However, to provide this “right care and high-value” cardiac care requires the shedding of incorrect beliefs and opinions – including diagnostic, etiologic and treatment - and the quantification of CAD itself.
Show MoreQuantification [2] makes it possible to diagnostically define the true extent and severity of CAD present in an individual and to accurately measure CAD treatment outcomes. Only by using true quantification can we remove the errors (sensitivity and specificity) in imaging [2] and treatment studies [3] and provide patients with “right care and high-value cardiology” free of physician bias and misperceptions. To provide this type of care we must focus our full attention on evidence-based medicine; avoiding the errors of the past.
The very foundation of evidence-based medicine is the ability to accurately, consistently and reproducibley measure quantifiable outcomes [2] as shown in Figure 1, and to avoid the use of qualitative or semi-quantitative methods, which misdiagnose the presence (sensitivity) or absence (specificity) of disease [2]. This is now possible using “The Fleming Method for Tissue and Vascular Differentiation and Metabolism (FMTVDM) Using Same State Single or Sequential Quantification Comparisons” [2].
FMTVDM is able to accurately, consistently and reproducibly define the extent and severity of CAD by fir...
The medical myths, using anti-MMR as an example, follow a formula of being easy to understand and not difficult to retell. Similar to urban myths, the knowledge of a medical myth is not reduced by distance from the case. For example, as told to me in my paediatric emergency department, a patient's cousin's friend whose child became autistic following vaccination is viewed as an absolute truth.
Compare this with medical rebuttal. Frequently the caveats of more research is needed or the results from a small study litter the conclusion sections. Typically the writing is dense and heavy on jargon. It's also common for there not to be an absolute answer.
Perhaps we should sharpen our writing and be more definitive. ‘Tweetorials’ are useful but they need to be short and snappy.
Conflict of Interest
None declared
The differential diagnosis of pneumothorax with haemodynamic compromise(1) ought to include the two subtypes of tension pneumothorax associated with dissecting aneurysm of the aorta(DAA), namely, tension pneumothorax with concurrent haemothorax(2), and tension pneumothorax without concurrent haemothorax(3)(4).
Show MoreIn the report of DAA-related haemopneumothorax(2), antemortem chest radiography clearly documented the presence of tension pneumothorax without concurrent fluid collection in the pleural space. The patient collapsed and died soon after insertion of a chest drain intended to relieve the pneumothorax. Autopsy revealed an adhesion between the visceral lung pleura and the aortic aneurysm through which the dissection had penetrated the lung parenchyma. The parenchymal haematoma had subsequently “spouted out” from a 20 mm tear on the pleura, giving rise to haemothorax(2). The sequence of events might have been similar, in some respects, to the sequence of events in a 79 year old man who experienced a haemopneumothorax which was, however, much less striking in its severity(5). In the latter case there was no haemodynamic compromise. The patient had initially complained of “spitting” blood, without concurrent chest pain, back pain or breathlessness. Chest radiography revealed an abnormal air-fluid level in middle lung field on the right side. Subsequent contrast-enhanced tomography revealed Type B aortic dissection, a pneumothorax adjacent to the dissection(pre...
Given the fact that tuberculosis and sarcoidosis have many stigmata in common (including the occurrence of noncaseating granulomas), a diagnosis of multiorgan sarcoidosis (1) can only be established beyond doubt if care has been taken to rule out the coexistence of sarcoidosis and tuberculosis using the strictest criteria for ruling in or for ruling out tuberculosis. Evaluating tissue samples for M tuberculosis through the use of the polymerase chain reaction (PCR) is one such strategy, given the fact that sensitivity for M tuberculosis infection is significantly higher for PCR than for BACTEC radiometric culture (74.4% vs 55.8%), although the two modalities have comparable specificity, namely, 97.2% vs 100% (no significant difference) (2). Accordingly, when the authors state "All biopsy specimens and bronchial washings were negative for TB (1), we need to know whether those samples were subjected either to mycobacterial culture or to evaluation by PCR.
Show MoreThe coexistence of sarcoidosis and tuberculosis was documented unequivocally in a 35 year old woman who initially presented with histologically and bacteriologically confirmed tuberculous lymphadenitis. She subsequently developed bilateral lung infiltrates. Histological specimens obtained via transbronchial biopsy and open lung biopsy showed features consistent with sarcoidosis. In addition, however, the presence of mycobacterial DNA in those tissue specimens was documented by PCR (3).
In another report, a...
Even when one takes into account the possibility that measurement of plasma cortisol after 60 min administration of synthetic ACTH might be a sufficient screening test for adrenal insufficiency(AI)(1), it is important to recognise that there are risk-free alternatives to the short synacthen test(SST) for validating the diagnosis of AI(2)(3)(4).
Show MoreAccording to a retrospective study which evaluated, not only the 30 min and the 60 min cortisol levels, but also the pre-synacthen cortisol levels, a pre-synacthen serum cortisol level of 100 nmol/L or less(obtained during the median time period 08.20 h) is associated with a positive predictive value of 93.2% for the diagnosis of AI, when the gold standard for the latter is a failed SST. In that study of 330 subjects with suspected AI tested with the 250 mcg dose of tetracoscatrin , the subgroup with an eventual diagnosis of AI were tested at the median time of 08.20h(interquatrile range 07.55-09.26). The subjects who passed their SST were tested during the median time of 08.33(interquatrile range 08.01h-09.55h). Conversely. a pre-synacthen serum cortisol of 450 nmol/L or more generated a 98.7% negative predictive value to rule out AI(2). These observations were largely corroborated by a retrospective study of 231 subjects with suspected AI in whom AI was validated by an SST which incorporated 30 min as well as 60 min serum cortisol levels. In that study some patients(unspecified number) were tested at 08.00h...
The heading which reads "Heart failure with Reduced Ejection Fraction(LVEF < 40%) & Iron Deficiency Anaemia"(fig 1)(1) fails. by implication, to recognise that heart failure-related iron deficiency has an outcome which is detrimental irrespective of whether or not the patient is anaemic(2). In the latter study, among heart failure patients who had a marker of iron deficiency(ID), namely, mean corpuscular haemoglobin concentration(MCHC) equal to or less than 330 g/L, there was a significant association with increased mortality(Hazard Ratio 1.7, 95% Confidence Interval 1.4 to 2.0) which persisted even after adjusting for anaemia(HR 1.5, 95% CI 1.3 to 1.8)(2). The use of the cut-off MCHC value of 330 g/L or less as a marker of ID (1) is supported by studies where mean values for MCHC amounted to 319 g/L and 327.9 g/L, respectively, among subjects with ID(3)(4). In those two studies the iron-replete subjects were characterised by MCHC values amounting to 339 g/L and 340 g/L, respectively. The mean values for MCHC in ID subjects(namely, 319 g/L and 327.9 g/L, respectively) were significantly(p=0.001, p < 0.001) lower than the mean values for MCHC(339 g/L and 340 g L, respectively) in their iron-replete counterparts. In those two studies, as well, mean values for mean corpuscular volume(MCV) in ID subjects ranged from 85.5 fl to 90.2 fl in spite of proven ID(serum ferritin < 30 mcg/L) and MCHC < 330 g/L. Accordingly, to optimise the i...
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