The author has demonstrated reversibility of autonomic neuropathy
those cases very well. Metabolic and vascular factors contribute to the
pathogenesis of autonomic and peripheral neuropathy. It is related to the
duration and severity of hyperglycemias
Clinically overt diabetic neuropathy is characterized by
neuroanatomical changes of the node of Ranvier and myelinated axons, and
by decreas...
The author has demonstrated reversibility of autonomic neuropathy
those cases very well. Metabolic and vascular factors contribute to the
pathogenesis of autonomic and peripheral neuropathy. It is related to the
duration and severity of hyperglycemias
Clinically overt diabetic neuropathy is characterized by
neuroanatomical changes of the node of Ranvier and myelinated axons, and
by decreased nerve conduction velocity. The activated polyol-pathway plays
a sustaining role in nerve fibre damage in diabetic neuropathy, and that
structural lesions such as axo-glial disjunction and axonal atrophy which
are reversible following intervention with an aldose reductase inhibitor,
constitute the morphological basis for nerve conduction slowing in overt
diabetic neuropathy. Acute reversible diabetic nerve dysfunction has been
associated with a reversible myo-inositol-related (Na+ + K+)-ATPase
defect, while poorly reversible chronic nerve dysfunction correlates with
progressive axoglial disjunction of the nerves.
The structural and the electrophysiological abnormalities in the autonomic
neuropathy revert to normal suggesting that diffuse peripheral and
autonomic neuropathy in early stages behaves in a similar fashion. Care
should be taken in improving glycaemia control in all patients of diabetes
mellitus irrespective of the type of complication.
This article has correctly pointed out the deficit in todays training
system. There is no lack of knowledge but the lack of skills and inability
to use them in acute situations. There are various reasons like shortage of
doctors,long working hours, doctors providing phlebotomy services.
A more formalised and structured approach to training in acute
situations and procedures should be provided. T...
This article has correctly pointed out the deficit in todays training
system. There is no lack of knowledge but the lack of skills and inability
to use them in acute situations. There are various reasons like shortage of
doctors,long working hours, doctors providing phlebotomy services.
A more formalised and structured approach to training in acute
situations and procedures should be provided. This might be achieved by
appointment of local training officers to ensure that these skills and
knowledge are acquired; such a system has been adopted for resusitation
training with considerable success.
In the case report presented, a 12-month follow up (after montelukast
was discontinued) has not shown any exacerbations of CSS simillar to that
occured after initiation of montelukast. However,the patient was mantained
on 10 mg prednisolone (low-dose) to prevent couph, fever and peripheral
blood oesinophilia,suggesting underlying but mild CSS that has been
exacerbated by montelukast.
It is not clear in this article how the conceptual leap from
some of the knowledge tested to inability to care for
critically ill patients has been made.
Does not knowing the survival rate of patients suffering a
cardiac arrest, for example, or the role of the bag attached
to a non-rebreathing oxygen mask really compromise patient
care?
From the limited results presented, there is no data
whats...
It is not clear in this article how the conceptual leap from
some of the knowledge tested to inability to care for
critically ill patients has been made.
Does not knowing the survival rate of patients suffering a
cardiac arrest, for example, or the role of the bag attached
to a non-rebreathing oxygen mask really compromise patient
care?
From the limited results presented, there is no data
whatsoever to suggest that any of the specific areas of
knowledge tested have any bearing on safety. The fact that
SHOs seem to know even less in some respects than PRHOs
supports this.
If the authors believe that patient safety is compromised by
not knowing what the bag does on an oxygen mask, they should
perhaps audit morbidity and mortality outcomes before and
after providing instruction.
Fulminant hemoptoe was the killer of Europe.
Tuberculosis killed people in their best years. And so, thrombosis was the defense against hemoptoe.
A prethrombotic state is a survival-benefit in Europe.
Factor V (Leiden) is such a prethrombotic state in 5 % of the Europeans.
No man in Africa has this thrombotic shield against tuberculosis, but they
do have the sickle-cell-anemia as survival-benefit against...
Fulminant hemoptoe was the killer of Europe.
Tuberculosis killed people in their best years. And so, thrombosis was the defense against hemoptoe.
A prethrombotic state is a survival-benefit in Europe.
Factor V (Leiden) is such a prethrombotic state in 5 % of the Europeans.
No man in Africa has this thrombotic shield against tuberculosis, but they
do have the sickle-cell-anemia as survival-benefit against malaria. [1]
Reference
(1) A Gogna, G R Pradhan, RSK Sinha, B Gupta. Tuberculosis presenting as deep vein thrombosis. Postgrad Med J 1999;75:104-6.
Friedrich Flachsbart
Eisenacher Str. 6
37085 Göttingen
Sir- Shah and colleagues report (1) about the prevalence of
psychiatric disorders affecting elderly people institutionalised in a
rehabilitation unit, concludes about depression that it is common among
older adults, it is a treatable condition and that in cases which there
are cognitive impairments associated to concomitant depression, the
cognitive impairments are worsened by the depressive disease. Although the
relev...
Sir- Shah and colleagues report (1) about the prevalence of
psychiatric disorders affecting elderly people institutionalised in a
rehabilitation unit, concludes about depression that it is common among
older adults, it is a treatable condition and that in cases which there
are cognitive impairments associated to concomitant depression, the
cognitive impairments are worsened by the depressive disease. Although the
relevance about the high prevalence of cognitive impairments and
depression in these patients is important and it is necessary to call
attention on it, I believe that from the psychiatric perspective, the
problem has been oversimplified. Therefore, we cannot accept the Shah et
al elementary proposition about a drug trial with the selective serotonin
reuptake inhibitors (SSRI’s) to elucidate the correct diagnosis when
diagnostic doubts remain.
Depressive states in older patient groups have a tremendous clinical
heterogeneity. Besides the depressive elderly patient without complicated
somatic pathology or psychiatric co-morbidity, which will respond usually
to antidepressant drugs, a significant proportion of other symptomatic
depressed patients (whose cases are precisely studied by Shah and
colleagues in this article) should be considered into the following
distribution : A first subgroup of elderly depressed patients, may show
greater cognitive deficits as compared to age-similar normal subjects (2)
. These patients also present (subcortical) dysfunction of learning and
memory, comprising the so-called "depressive pseudodementia", and may show
reversible cognitive deficits after successful somatic treatment of
depression. A second patients subgroup, display cognitive deficits
characterised by severe prefrontal dysfunction, with perseveration,
psychomotor retardation and long P300 latency (3) . A third subgroup,
presents features of depression that are related to underlying vascular
disease and neurological lesions, corresponding to the hypothesised
"vascular depression" (4). In the fourth place, many patients with late-
life onset of cognitive deficits, psychomotor retardation and limited
depressive ideation, correspond to the "apathy syndrome (5) " that
frequently follows brain damage in caudate, putamen and thalamus, usually
secondary to cerebrovascular heterogeneous diseases.
While SSRI’s may be useful for the first subgroup, they are useless
in the second and third one, while in the fourth, the dopamine agonists
like bromocriptine are required. Hence, it is erroneous to overgeneralise
that "depressed elderly respond well to SSRI’s" like Shah et al suggest.
And what about the caution needed in the SSRI’s prescription (where Shah
and colleagues state that these drugs are safe in the elderly, in spite of
their habitually need of multiple medications) because of its significant
drug interactions resulting from interference with components of the
hepatic "P-450 enzyme system" (6)?.
Moreover, Shah and colleagues also state that patients with dementia
may become depressed, particularly if they have insight into their
condition. Evidence based medicine shows that the frequent depressive
symptoms founded in these patients, are indeed early manifestations of
Alzheimer disease (7), in which case, cholinesterase inhibitor drugs
instead antidepressants is indicated.
Incidentally, Shah and colleagues state that there are no biological
diagnostic tests for depression. Besides the dexametasone-cortisol test,
the high prevalence of brain dysfunction in the geriatric depressed and
cognitive impaired patient suggests that the computer analysed,
quantitative electroencephalographic record (QEEG) may help not only in
the brain damage differential diagnosis but also in signalling depressive
disease by showing the characteristic increased anterior alpha power and
decreased generalised coherence (8).
Drug treatments for every elderly disturbance, like for any other
human complaint, must to be always a carefully skilled decision.
1.- Shah DC, Evans M, King D. Prevalence of mental illness in a
rehabilitation unit for older adults. Postgrad Med 2000 ; 76 : 153 - 156
2.- Kramer-Ginsberg E, Greenwald BS, Krishnan RR, Christiansen B, Hu
J, Ashtari M et al. Neuropsychological Functioning and MRI Signal
Hyperintensities in Geriatric Depression. Am J Psychiatry 1999 ; 156 :
438 - 444
3.- Kalayam B, Alexopoulos GS. Prefrontal Dysfunction and Treatment
Response in Geriatric Depression. Arch Gen Psychiatry 1999 ; 56 : 713 -
718
4.- Alexopoulos GS, Meyers BS, Young RC, Campbell S, Silbersweig D,
Charlson M. Vascular Depression Hypothesis. Arch Gen Psychiatry 1997 ; 54
: 915 - 922
6.- The P-450 System : Definition and Relevance to the Use of
Antidepressants in Medical Practice. Arch Fam Med 1996 ; 5 : 406 - 412
7.- Chen P, Ganguli M, Mulsant BH, DeKosky ST. The Temporal
Relationship Between Depressive Symptoms and Dementia. Arch Gen
Psychiatry 1999 ; 56 : 261 - 266
8.- Hughes JR, John R. Conventional and Quantitative
Electroencephalography in Psychiatry. J Neuropsychiatry Clin Neurosci
1999 ; 11 : 190 - 208
Dear Sirs:
A good friend of mine in Europe, Dr. Gonzalo Herranz MD/Phd emailed me
your article, which I found exceedingly well researched as well as well
written.
There is no doubt that Western Civilization is in a culture war, a
war "within", a "spreading spiritual malaise" in the words of Irving
Kristol. Writing in 1840, Tocqueville imagined a society consumed with
such a malaise, in which government, com...
Dear Sirs:
A good friend of mine in Europe, Dr. Gonzalo Herranz MD/Phd emailed me
your article, which I found exceedingly well researched as well as well
written.
There is no doubt that Western Civilization is in a culture war, a
war "within", a "spreading spiritual malaise" in the words of Irving
Kristol. Writing in 1840, Tocqueville imagined a society consumed with
such a malaise, in which government, compassionate toward its subjects,"
provides for their security, foresees and supplies their necessities,
facilitates their pleasures, manages their principal concerns, directs
their industry, makes rules for their testaments, and divides their
inheritances....It does not break men's will, but softens, bends, and
guides it; it seldom enjoins, but often inhibits action; it does not
destroy anything, but prevents much being born...."
Leaders in the Western world need to take a stand on what is right,
what is moral and to lift up the youth not tear them down with false
alchemies. There is something deep in the human spirit that wants to
know, love and live the truth. Young people need to know the truth about
human sexuality, about true love, the need to be challenged to live an
ideal, not to be given to animal instincts. The greatest evil legacy that
President Clinton will leave the youth of America is his scandalous
behaviour in the White House with an intern. Young people deserve better
leaders. In a few years the Dow Jones will not provide a false sense of
security to those who have put their treasure in something that by nature
is ephemeral.
Youth will respond to a challenge from leadrs to overcome themselves,
just as they respond to a challenge to sacrifice themselves for a team.
There is no conflict between faith and reason. The best science and
medical facts support the teachings of all the historical religions that
life is precious and must be protected and nurtured at all stages. This is
the mission of our foundation and can be found in the ever evolving web
site http.//www.culture-of-life.org. Your work is very well done and we
shall with your permission, post it on our web site.
Thanks for confirming that "life is beautiful."
Sincerely,
Robert A. Best
President Culture of Life Foundation and it's Research &
Communications Institute
A recent review article in your journal gives the impression that the
case for heparinisation of patients with cerebral venous thrombosis (CVT)
is proven [1]. The largest and most robust study did not come to this
conclusion and its results did not achieve statistical significance [2].
Given that CVT has a spectrum of presentations from headache to coma, a
blanket approach to treatment in the absence of good evidence and...
A recent review article in your journal gives the impression that the
case for heparinisation of patients with cerebral venous thrombosis (CVT)
is proven [1]. The largest and most robust study did not come to this
conclusion and its results did not achieve statistical significance [2].
Given that CVT has a spectrum of presentations from headache to coma, a
blanket approach to treatment in the absence of good evidence and
continued debate [3] does not seem sensible.
2. de Bruijn SF, Stam J, for the CVST Study Group. Randomised,
placebo-controlled trial of anticoagulant treatment with low-molecular-
weight heparin for cerebral sinus thrombosis. Stroke 1999;30:484-488.
3. Lewis MB. Cerebral venous thrombosis: nothing, heparin, or local
thrombolysis? Stroke 1999;30:1729.
Whilst Huang and Dutta correctly state that re-sheathing of
needles is almost universally condemned, one must also remember
that needle-stick injuries can also occur as a result of needles
not being re-sheathed. This happened to me as a young house-
officer, when a nurse dropped an unsheathed needle from a tray,
and it promptly embedded itself int...
Whilst Huang and Dutta correctly state that re-sheathing of
needles is almost universally condemned, one must also remember
that needle-stick injuries can also occur as a result of needles
not being re-sheathed. This happened to me as a young house-
officer, when a nurse dropped an unsheathed needle from a tray,
and it promptly embedded itself into my thigh!
This case is extremely useful as an illustration of the varying
presentations of phaeochromocytomas. The inclusion of the CT and the
details of the differential effects given depending upon the catecholamine
released were helpful.
I might venture a further, perhaps more important, mediator of the
dramatic drop in K+ noted in this patient and other phaeos. There are a
large number of beta ad...
This case is extremely useful as an illustration of the varying
presentations of phaeochromocytomas. The inclusion of the CT and the
details of the differential effects given depending upon the catecholamine
released were helpful.
I might venture a further, perhaps more important, mediator of the
dramatic drop in K+ noted in this patient and other phaeos. There are a
large number of beta adrenoceptors and sympathetic nerves in the renin-
secreting apparatus of the kidney. Stimulation of these should
precipitate, eventually, a raised aldosterone level and thus a drop in K+
(with an increased Na+). Neither Na+ nor any of the components of this
renin-(ACE)-AGII-Aldosterone axis were measured in the article. I wonder
what any relevant tests actually did show? When discussing how beta-
blockers work in hypertension, this is undoubtedly part of the wider
explanation.
Dear Editor
The author has demonstrated reversibility of autonomic neuropathy those cases very well. Metabolic and vascular factors contribute to the pathogenesis of autonomic and peripheral neuropathy. It is related to the duration and severity of hyperglycemias
Clinically overt diabetic neuropathy is characterized by neuroanatomical changes of the node of Ranvier and myelinated axons, and by decreas...
Dear Editor
This article has correctly pointed out the deficit in todays training system. There is no lack of knowledge but the lack of skills and inability to use them in acute situations. There are various reasons like shortage of doctors,long working hours, doctors providing phlebotomy services.
A more formalised and structured approach to training in acute situations and procedures should be provided. T...
Dear Editor
In the case report presented, a 12-month follow up (after montelukast was discontinued) has not shown any exacerbations of CSS simillar to that occured after initiation of montelukast. However,the patient was mantained on 10 mg prednisolone (low-dose) to prevent couph, fever and peripheral blood oesinophilia,suggesting underlying but mild CSS that has been exacerbated by montelukast.
Dear Editor
It is not clear in this article how the conceptual leap from some of the knowledge tested to inability to care for critically ill patients has been made. Does not knowing the survival rate of patients suffering a cardiac arrest, for example, or the role of the bag attached to a non-rebreathing oxygen mask really compromise patient care?
From the limited results presented, there is no data whats...
Dear Editor
Fulminant hemoptoe was the killer of Europe. Tuberculosis killed people in their best years. And so, thrombosis was the defense against hemoptoe. A prethrombotic state is a survival-benefit in Europe. Factor V (Leiden) is such a prethrombotic state in 5 % of the Europeans. No man in Africa has this thrombotic shield against tuberculosis, but they do have the sickle-cell-anemia as survival-benefit against...
Sir- Shah and colleagues report (1) about the prevalence of psychiatric disorders affecting elderly people institutionalised in a rehabilitation unit, concludes about depression that it is common among older adults, it is a treatable condition and that in cases which there are cognitive impairments associated to concomitant depression, the cognitive impairments are worsened by the depressive disease. Although the relev...
Dear Sirs: A good friend of mine in Europe, Dr. Gonzalo Herranz MD/Phd emailed me your article, which I found exceedingly well researched as well as well written.
There is no doubt that Western Civilization is in a culture war, a war "within", a "spreading spiritual malaise" in the words of Irving Kristol. Writing in 1840, Tocqueville imagined a society consumed with such a malaise, in which government, com...
A recent review article in your journal gives the impression that the case for heparinisation of patients with cerebral venous thrombosis (CVT) is proven [1]. The largest and most robust study did not come to this conclusion and its results did not achieve statistical significance [2]. Given that CVT has a spectrum of presentations from headache to coma, a blanket approach to treatment in the absence of good evidence and...
Dear Editor,
Whilst Huang and Dutta correctly state that re-sheathing of needles is almost universally condemned, one must also remember that needle-stick injuries can also occur as a result of needles not being re-sheathed. This happened to me as a young house- officer, when a nurse dropped an unsheathed needle from a tray, and it promptly embedded itself int...
Dear Sir,
This case is extremely useful as an illustration of the varying presentations of phaeochromocytomas. The inclusion of the CT and the details of the differential effects given depending upon the catecholamine released were helpful.
I might venture a further, perhaps more important, mediator of the dramatic drop in K+ noted in this patient and other phaeos. There are a large number of beta ad...
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