Reply to dear Dr. Tanvir ABBASS and co-authors:

First, thanks for your attention to our article.

We reply your questions as below: There was no history of radiotherapy or surgery to urinary bladder, which was a risk factor for cystitis and superimposed coliform infection, in our present case. There was no evidence of presentations of colitis, such as abdominal pain or diarrhea, and no gallbladder stones demonstrating on CT scan. The finding of gaseous distension of large bowel might be secondary to severe infection and irritation with spraying to adjacent large bowel from emphysematous cystitis with perforation. We agree that emphysematous cystitis requires aggressive treatment with antibiotics, fluids and surgical therapy either along with emphysematous cholecystitis or not. We also agree that clinicians should keep into consideration possibility of emphysematous cholecystitis when dealing with patients with cystitis.

Your sincerely,

Sung-Yuan Hu, MD Department of Emergency Medicine, Taichung Veterans General Hospital, Taiwan, Republic of China No 160, Section 3, Chung-Kang Road, Taichung, Taiwan, Republic of China 00407 E-mail: song9168@pie.com.tw

4 Jul 2009

Given the fact that thrombolysis confers survival benefit in patients with myocardial infarction(MI), not only when the clinical presentation is associated with an electrocardiogram(ECG) characterised by ST segment elevation, but also when the admission ECG shows LBBB, regardless of whether or not LBBB is of recent onset(1),among the patients targeted by the treatment goals proposed by the authors of the review(2), we also ought to include those with old LBBB in the event of enzymatic validation of MI. In MI, prevalence of old LBBB can be nearly as high as prevalence of new-onset LBBB as shown by a study where, among 1125 patients in whom criteria including "typical increases" in serum creatine phosphokinase, serum glutamic oxaloacetic acid transaminase, and lactic dehydrogenase, had been utilised to validate MI, there were 34 with new-onset LBBB,and 30 with old LBBB(3). In the modern era enzymatic validation of MI can be made within 4 hours of symptom onset using heart fatty acid binding protein(H- FABP) which is characterised by sensitivity, specificity, positive predictive value, and negative predictive value amounting to 73%, 71%, 71%, and 73%, respectively, within that time frame(4), predictive accuracy of that biomarker having the potential to be enhanced by simultaneous as well as serial evaluation of other early biomarkers(5).Accordingly, the 12 hour therapeutic time window for pharmacological reperfusion with fibrinolytic, antiplatelet, and antithrombotic modalities should be recognised as a golden opportunity to offer these tests to suspected MI patients who present with old LBBB so that they should have the opportunity to benefit from the full range of therapeutic modalities outlined in the review should they test positive for MI. References (1) ISIS-2(Second International Study of Infarct Survival) collaborative group Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction Lancet 1988 II:349-60 (2)Edmond JJ., Juergens CP., French JK The pharmaco-invasive approach to STEMI: when should fibrinolytic-treated patients go to the "cath lab"? Postgraduate Medical Journal 2009;85:331-334 (3)Gann D., Balachandran PK., Sherif NE., Samet P Prognostic significance of chronic versus acute bundle branch block in acute myocardial infarction CHEST 1975;67:298-303 (4)McCann CJ., Glover BM., Menown IBA et al Novel biomarkers in early diagnosis of acute myocardial infarction compared with cardiac troponin T European Heart Journal 2008;29:2843-50 (5) Balk EM., Ioannidis JPA., Salem D., Chew PW., Lau J Accuracy of biomarkers to diagnose acute cardiac ischemia in the Emergency Department: A Meta-Analysis Annals of Emeregency Medicine May 2001;37.5:478-94

Letter to Swaminathan et al. entitled Search for secondary osteoporosis: are Z scores useful predictors? N. Defne Altintas, Mustafa Sahin Medicana International Ankara Hospital, Department of Internal Medicine1, Ankara, Gaziantep State Hospital, Departments of Endocrinology2, Gaziantep, TURKEY

Dear Sirs, In their recent article, a marker to define secondary osteoporosis is being evaluated by Swaminathan et al (1), to eliminate missed diagnosis of secondary osteoporosis and to decrease the unnecessary laboratory costs. However certain points deserve discussion. First of all, steroid induced osteoporosis is not included in the patient evaluation, and a laboratory search for subclinical Cushing’s disease is not performed. However, steroid excess is a well known cause of secondary osteoporosis and its diagnosis may affect the treatment scheme (2). Next, of the 55 patients with secondary osteoporosis only 24 is included in the analysis, excluding the patients already known to have a cause and the ones on steroids. Of these included in the analysis, 63 % have been found to suffer vitamin D deficiency. However monitoring and replacement of vitamin D levels are routinely recommended with the diagnosis of osteoporosis (2). Besides it is difficult to differentiate osteoporosis form osteomalacia in these patients. Therefore, an analysis of the 9 patients with unrecognized secondary osteoporosis excluding those with vitamin D deficiency may have been more valuable to decide if Z score is valuable in detecting other secondary causes of osteoporosis. Thirdly, the predictive value of this test requires further attention, since in the study cohort about 84 % of the patients with primary osteoporosis requires complete laboratory evaluation to rule out secondary causes, and still 13 % of patients with secondary osteoporosis is missed. It is necessary to explain why utilization of Z scores is still being proposed and to perform a receiver operating characteristic (ROC) curve analysis to further evaluate clinical benefit. Last of all, it would be more informative if sensitivity of Z scores for patients on steroids and for patients previously known to have a cause were presented. References: 1- Swaminathan K, Flynn R, Garton M, et al. Search for secondary osteoporosis: are Z scores useful predictors? Postgrad Med J 2009; 85:38- 39. 2- Mauck KF, Clarke BL. Diagnosis, screening, prevention, and treatment of osteoporosis. Mayo Clin Proc 2006;81:662-72.

We thank Dr. Rakesh Biswas for his valuable comments.

Considering the potential benefits of regular ω-3 fatty acid consumption, the recommendations apply to all those who can consume fish.

For those who do not like the taste of fish and for vegetarians and vegans, the issue of ω-3 fatty acid alternatives were discussed and included at the end of the full text article - Although the recommendations from various professional bodies are for consumption of fish, vegetarians who do not consume fish may use fish oil capsules or certain vegetable oils with significant ω-3 FA content. The following vegetable seed oils are listed in decreasing order of their ω-3 FA content: linseed oil, flaxseed oil, pumpkin seed oil, canola oil, soybean oil, safflower oil and sunflower oil.¹

In addition, seaweed¹ (marine algae) and microalgae² have also been recommended as a source of ω-3 fatty acids that are suitable for vegetarians.

Incidentally, three of the review's authors are strict vegetarians too.

References:

1. Gebauer SK, Psota TL, Harris WS, Kris-Etherton PM. n-3 fatty acid dietary recommendations and food sources to achieve essentiality and cardiovascular benefits. Am J Clin Nutr 2006;83(6 Suppl):1526S–35S. [Abstract/Free Full Text]
2. Doughman SD, Krupanidhi S, Sanjeevi CB. Omega-3 fatty acids for nutrition and medicine: considering microalgae oil as a vegetarian source of EPA and DHA. Curr Diabetes Rev. 2007 Aug;3(3):198-203. [Abstract]