We welcome Barbaro’s very pertinent comments; especially concerning
HAART therapy and HIV associated heart disease. Like many developing
countries, HAART therapy has only recently been introduced in Cameroon,
and access to the treatment is still very limited. Until now, it has
therefore been difficult to collect any data on the metabolic and
cardiovascular complications of HAART therapy in Cameroon. How...
We welcome Barbaro’s very pertinent comments; especially concerning
HAART therapy and HIV associated heart disease. Like many developing
countries, HAART therapy has only recently been introduced in Cameroon,
and access to the treatment is still very limited. Until now, it has
therefore been difficult to collect any data on the metabolic and
cardiovascular complications of HAART therapy in Cameroon. However, as the
therapy is getting more accessible and better organized in the country we
envisage collection of such data in the very near future.
We did not carry out virological tests or autopsies as part of this
study. We agree however, that it may be useful to explore the relationship
between myocarditis and infections/nutritional deficiencies in the African
setting.
The increasing access of African patients to HAART therapy presents
important opportunities for better understanding of the effect of the
treatment on HIV associated heart muscle, pericardial, endocardial and
metabolic abnormalities in the African context, data which is at this
time, very limited.
We read with interest the article by Mowlavi et al.[1] and agree that
the palpation of pedal pulses is a useful clinical tool. Therefore any
attempt to standardise the technique of palpation must be applauded.
Using the ‘navicular’ method, the authors palpated 78% of pulses in a
group of patients under the care of the surgical team. Unfortunately they
do not describe the past medical h...
We read with interest the article by Mowlavi et al.[1] and agree that
the palpation of pedal pulses is a useful clinical tool. Therefore any
attempt to standardise the technique of palpation must be applauded.
Using the ‘navicular’ method, the authors palpated 78% of pulses in a
group of patients under the care of the surgical team. Unfortunately they
do not describe the past medical history of this cohort. If their patients
have no past medical history of peripheral vascular disease then their
method of palpation is less sensitive than previous studies which detect
the pulse in 86.2% – 96.9% of healthy patients.[2,3] It would have been
useful to know the proportion of arteriopaths in their study.
We routinely palpate the dorsalis pedis pulse on a line joining the
midpoint of the malleoli to the 1st webspace. Although this involves soft-
tissue landmarks, it is nevertheless easy to identify and palpate the
pulse on this line. The navicular, in contrast, is not an easy bone to
palpate, especially in the oedematous or deformed foot. No attempt has
been made to compare this novel approach with the more established method.
Whilst they demonstrate a new landmark to readily palpate the
dorsalis pedis pulse, we do not feel that they have demonstrated any
improvement in either accuracy or ease of use compared with a more
traditional landmark.
References
(1) Mowlavi A, Whiteman J, Wilhelmi BJ, Neumeister MW, McLafferty R.
Dorsalis pedis arterial pulse: palpation using a bony landmark. Postgrad
Med J 2002;78:746-747.
(2) Meade TW, Gardner MJ, Cannon P, et al. Observer variability in
recording the peripheral pulses. Br Heart J 1968;30:661–5.
Dengue haemorrhagic fever (DHF) is one of the leading causes of
morbidity and mortality in the tropical and subtropical countries.
Although, the dengue virus when compared to other arboviruses do not cause
significant central nervous system involvement it can be an important
cause of encephalitis and Encephalopathy when taking in to account the
large epidemics that occur due to the virus.
Dengue haemorrhagic fever (DHF) is one of the leading causes of
morbidity and mortality in the tropical and subtropical countries.
Although, the dengue virus when compared to other arboviruses do not cause
significant central nervous system involvement it can be an important
cause of encephalitis and Encephalopathy when taking in to account the
large epidemics that occur due to the virus.
DHF is characterized by plasma leakage and bleeding manifestations.
However, direct involvement of the brain by the dengue virus has been
shown in both autopsy studies [1] and in children who had clinical
features of enchephalitis.[2] Encephalopathy in children with DHF may
occur due to a variety of reasons such as direct involvement of the brain,
liver failure, renal failure, cerebral oedema, electrolyte imbalances,
vasculitis and due to fluid extravasation.[2] It has been shown that
children who developed encephalopathy had higher levels of elevated liver
enzymes than those who did not.[3] Moreover, higher mortality rates (22%)
were seen in patients with features of encephalopathy.[3]
Therefore, in area endemic for dengue infection when patients present
with features of either encephalitis or Encephalopathy it is important to
suspect dengue infection and investigate for it.[4]
Reference
(1) Ramos C, Sanchez G, Pando RH, Baquera J, Hernandez D, Mota J,
Ramos J, Flores A, Llausas E. Dengue virus in the brain of a fatal case of
hemorrhagic dengue fever. J Neurovirol 1998 Aug;4(4):465-8.
(2) Lum LC, Lam SK, Choy YS, George R, Harun F. Dengue encephalitis: a
true entity? Am J Trop Med Hyg 1996 Mar;54(3):256-9.
(3) Cam BV, Fonsmark L, Hue NB, Phuong NT, Poulsen A, Heegaard ED.
Prospective case-control study of encephalopathy in children with dengue
hemorrhagic fever. Am J Trop Med Hyg 2001 Dec;65(6):848-51.
(4) Solomon T, Dung NM, Vaughn DW, Kneen R, Thao LT, Raengsakulrach B,
Loan HT, Day NP, Farrar J, Myint KS, Warrell MJ, James WS, Nisalak A,
White NJ. Neurological manifestations of dengue infection. Lancet 2000 Mar
25;355(9209):1053-9
Diagnosis of Pulmonary embolism is very challenging and any clue from
anywhere is worth mentioning. In this regard Dr Athar's above case report
is very interesting. But there are certain points in discussion which needs
reappraisal.
In the report authors have mentioned that QT was prolonged when the
patient had developed pulmonary embolism which was expected considering
the fact that heart rate...
Diagnosis of Pulmonary embolism is very challenging and any clue from
anywhere is worth mentioning. In this regard Dr Athar's above case report
is very interesting. But there are certain points in discussion which needs
reappraisal.
In the report authors have mentioned that QT was prolonged when the
patient had developed pulmonary embolism which was expected considering
the fact that heart rate was lower and QT interval is a function of heart
rate.[1] When we look at the QTc (corrected for the heart rate), it is not
prolonged, rather it has shortened a little. Again while interpreting the
3rd ECG it has been mentioned that QTc had normalised when in fact QTc had
shortened further .
The QT / QTc in the 3 ECGs were as follows:
430/529 ms on the day of admission
540/526 ms on the day of chest pain
414/504 ms on next day after chest pain.
The first explanation for the ECG changes have been refuted by the
author themselves. In the second explanation they have mentioned that
normal conduction in the atrioventricular node and slowed conduction in
right bundle branch possibly has resulted in slower heart rate. But besides
slowing of the rate slow conduction in both right and left bundle should
have shown some reflection in QRS duration.
Prominent T inversion in precordial leads, which this patient had (V1
to V4) is due to right ventricular strain.[2] This could mimic like acute
myocardial infarctionas the authors have rightly emphasised.
References
(1) Greenfield Joseph C, Jr. Electrocardiography. In Cecil Text Book of
Medicine, 19th edition, Wyangaarden, Smith, Benett (Eds). Philadelphia: Saunders. 1992, pp170-175.
(2) Goldhaber SZ. Pulmonary Thromboembolism. In Harrison's Principle of
Internal Medicine, 15th edition ,Braunwald et al.(Eds). New york: McGraw-
Hill. 2001, pp1508-1512.
The article by Nzuobontane et al.[1] reports the involvement of the
cardiovascular system in an african country, reflecting the condition we
observed some years ago before the introduction of HAART.[2] The
introduction of HAART has significantly modified the course of HIV
disease, with longer survival and improved quality of life. Although there
is no evidence from prospective studies to suggest th...
The article by Nzuobontane et al.[1] reports the involvement of the
cardiovascular system in an african country, reflecting the condition we
observed some years ago before the introduction of HAART.[2] The
introduction of HAART has significantly modified the course of HIV
disease, with longer survival and improved quality of life. Although there
is no evidence from prospective studies to suggest that HAART has a
beneficial effect on HIV-associated cardiomyopathy,[2] some retrospective
studies suggest that by preventing opportunistic infections and reducing
the incidence of myocarditis HAART might reduce the incidence of HIV-
associated cardiomyopathy and improve its course.[3,4] On the contrary, the
prevalence of infective endocarditis did not vary in HIV-infected patients
who use intravenous drugs after the introduction of HAART, being similar
to that observed in HIV-uninfected intravenous drug addicts.[2]
Though inconclusive at this time, early data have raised concern that
HAART regimens, especially those including protease inhibitors (PIs), are
associated with an increased incidence of metabolic and somatic changes
that in the general population are associated with an increased risk for
both peripheral and coronary artery disease, producing an intriguing
clinical scenario.[2] It would be interesting to know if authors have any
data concerning the metabolic and cardiovascular complication of HAART,
even though the availability of such a therapy is limited in african
countries.
With reference to the article by Nzuobontane et al, I’d like to know
if authors performed any virological test in patients with dilated
cardiomyopathy and what results they have obtained. Moreover, I’d like to
know if for the patients who died for AIDS complications the authors can
provide any autopsy data concerning the prevalence of dilated
cardiomyopathy in this subset of african population. If any, what was the
prevalence of myocarditis in patients with dilated cardiomyopathy? Was
myocarditis correlated to infectious agents (e.g. cardiotropic viruses)? If
yes, was there any other interfering (e.g. nutrtional) pathogenetic factor?
It is hoped that a greater availability of HAART in african
countries, by improving the clinical course of HIV disease, will reduce
the incidence of pericardial effusions and myocardial involvement of HIV-
associated malignancies and coinfections.[2] However, a careful cardiac
screening is warranted for all HIV-infected patients in order to detect
subclinical echocardiographic abnormalities that independently predict
adverse outcomes and identify high risk groups to target for early
intervention and therapy.
References
(1) Nzuobontane D, Blackett KN, Kuaban C. Cardiac involvement in HIV-
infected people in Yaounde,Cameroon. Postgrad Med J 2002; 78:678-81.
(2) Barbaro G. Cardiovascular manifestations of HIV infection. Circulation 2002;106:1420-5.
(3) Pugliese A, Isnardi D, Saini A, Scarabelli T, Raddino R, Torre D. Impact of highly active antiretroviral therapy in HIV-positive patients with cardiac involvement. J Infect 2000;40(3):282-4.
(4) Bijl M, Dieleman JP, Simoons M, Van Der Ende ME. Low prevalence of cardiac abnormalities in an HIV-seropositive population on antiretroviral
combination therapy. J AIDS 2001; 27:318-20.
The contents of the letter evoked a similiar chord in me. Last year, I
had the mortification of seeing my father in a comatose state after a
sudden onset of Meningitis. He himself was and is a practising Paeditrician
and the other son of his, my elder brother is also a doctor. That night I
was alone with him and saw him deteriorate overnight from an ordinary "flu"
to full blown Meningitis. We had an anxi...
The contents of the letter evoked a similiar chord in me. Last year, I
had the mortification of seeing my father in a comatose state after a
sudden onset of Meningitis. He himself was and is a practising Paeditrician
and the other son of his, my elder brother is also a doctor. That night I
was alone with him and saw him deteriorate overnight from an ordinary "flu"
to full blown Meningitis. We had an anxiety filled fortnight spent at a
local private hospital. He recovered fully and is now back in
practice. Those days gave me a rare insight into what is it like to be at
the other side of the Consultant's table. I suffered the same nightmares as
that of my patient's parents spent the same sleepless nights outside the
ICU, and agonised over whether to transport him to a better facility. At
about the 48th hour of the ordeal, the Consultant who was ttreating
him, Dr Wilson, MRCP came to us and said "He is going to be alright, he will
come up. Don't worry". This was when he was still suporose and I am not sure
whether I would have said the same thing in his position. From then on we
gathered a lot of courage which saw us through the ordeal. That moment I
realised that generating confidence in the caregivers (if it is realistic)
is the most important thing a treating doctor can do.Times are many when
out of a misplaced fear of the unknown we prognosticate rather timidly
, adding a lots of ifs anf buts. The experience has changed my outlook of
patient-caregiver interaction. In a critical illness, it is supremely
important to keep up the spirits of the caregivers and relatives, taking
care not to raise false hopes.
I read with interest the report of an unusual case of gestational
diabetes mellitus (GDM) in early pregnancy in two successive pregnancies
by Shankar et al.[1] Authors have rightly emphasized the importance of the
early screening of GDM at first antenatal visit in women with history of
GDM in previous pregnancies or with a strong family history of diabetes
mellitus. In fact, an early detection...
I read with interest the report of an unusual case of gestational
diabetes mellitus (GDM) in early pregnancy in two successive pregnancies
by Shankar et al.[1] Authors have rightly emphasized the importance of the
early screening of GDM at first antenatal visit in women with history of
GDM in previous pregnancies or with a strong family history of diabetes
mellitus. In fact, an early detection of GDM has been a matter of concern
and debate at various international forums in last few decades. American
college of obstetricians and gynecologists (1990) have recommended the
universal screening for GDM between 24 –28 weeks of gestation in all
pregnancies. Subsequently, these recommendations were revised in 1994 to
include a much needed earlier screening for GDM in women with previous
history of GDM.[2] In view of these recommendations, pregnant women with
strong family history of diabetes mellitus and development of GDM in
previous pregnancies with or without a poor obstetric outcome need to be
screened at first antenatal visit. Although patients’ anxiety and the fear
also needs to be addressed with a due consideration but this alone should
not be the criteria guiding the treating physician to screen these women,
as it apparently appears from this report.
References
(1) Shankar P, Sundarka MK, Sundarka A. An unusual case of Gestational
diabetes mellitus. Post Grad Med J2002;78:562-563.
(2) American college of obstetricians and gynecologist: Diabetes and
pregnancy. Technical Bulletin 1994, no.200, December 1994.
Earlier this year your journal published an article by Smith and
Poplett [1] which discussed the findings of a questionnaire that had been
answered by newly qualified pre-registration house officers and senior
house officers. The questions concerned various aspects of basic acute
medical care. The results suggested significant gaps in knowledge and
understanding of both the signs and immediate managem...
Earlier this year your journal published an article by Smith and
Poplett [1] which discussed the findings of a questionnaire that had been
answered by newly qualified pre-registration house officers and senior
house officers. The questions concerned various aspects of basic acute
medical care. The results suggested significant gaps in knowledge and
understanding of both the signs and immediate management of these
conditions. The authors concluded that medical graduates are poorly
prepared to identify and treat critically ill patients and felt that
"these deficits have the potential to contribute to error and to influence
medical outcome". The authors did not, at any point, consider whether such
young and inexperienced doctors should be assessing and treating such
acutely ill patients in the first place.
At the time of publication, this article was reported widely by the
UK print media and I was interviewed by The Western Mail[2] (the main Welsh broadsheet) for an article that appeared on the front page under the
headline Doctor training 'puts lives at risk'. I was unhappy with the
paper's interpretation of Smith and Poplett's research, and because of the
potential for public confusion I responded with a long letter to the
editor[3] where I made the following points:
1. The findings of the research did not surprise me and the situation
is actually much better now than it was in 1993 when I qualified as a
doctor. At the time, there was virtually no preparation for the realities
of working in the NHS, with very little instruction on how to assess and
treat sick people, prescribe drugs, take blood or resuscitate collapsed
patients. Instead, we learned very quickly "on the job" and many of us
recall with horror our first few weeks as house officers, the pressure we
were under and the mistakes we must have made.
2. There has been a recognition of these deficits over the last few
years and the medical school courses across the UK have evolved
appropriately. There has been a move away from the traditionally
theoretical and highly academic approach to a more "hands on" and
integrated course that concentrates on knowledge together with the
practical and communicative skills needed to actually work as a doctor.
Unfortunately, this paper suggests the process has still not gone far
enough.
3. Improving the training of medical students is only part of the
answer and it must be remembered that the doctors interviewed were at the
beginning of their post graduate training. Both the BMA and the Government
are committed to a health service that is delivered by 'competently
trained doctors' rather than 'doctors in training'. It is essential that
we move away from the traditional model of care where patients are first
seen by the most junior doctors in the hospital. These doctors do not have
the experience, training or basic skills to properly assess, diagnose and
treat patients with complicated and life threatening diseases.
4. Patients should be seen at a much earlier stage in their admission
by consultants. This would not only provide better levels of individual
care but would also ensure more efficient service delivery.
This article highlights the fact that inexperienced trainees lack the
competence to deal with much of their workload and supports the argument
that we should have a consultant delivered service.
Dr Ieuan Davies
Specialist Registrar in Paediatrics
(Immediate Past) Chair BMA Wales JDC
References
(1) Smith GB , Poplett N. Knowledge of aspects of acute care in
trainee doctors. Postgrad Med J 2002;78:335-338.
(2) Livingstone T. Doctor training 'puts lives at risk'. The Western Mail (19th June 2002) p.1.
(3) Davies I. We need more consultants. The Western Mail (2nd July 2002). Letter to the Editor.
I complement the authors on an excellent case. Could I however, point
out that in the table on causes of osteolysis, there is no mention of
crystal arthropathy. Calcium pyrophospahte dihydrate(CPPD) and basic
calcium phosphate (BCP) associated crystal arthritis are known to cause
osteolysis in a small no of patients. These would form part of the
differentail diagnosis for any patient with this presentat...
I complement the authors on an excellent case. Could I however, point
out that in the table on causes of osteolysis, there is no mention of
crystal arthropathy. Calcium pyrophospahte dihydrate(CPPD) and basic
calcium phosphate (BCP) associated crystal arthritis are known to cause
osteolysis in a small no of patients. These would form part of the
differentail diagnosis for any patient with this presentation.
Dear Editor
We welcome Barbaro’s very pertinent comments; especially concerning HAART therapy and HIV associated heart disease. Like many developing countries, HAART therapy has only recently been introduced in Cameroon, and access to the treatment is still very limited. Until now, it has therefore been difficult to collect any data on the metabolic and cardiovascular complications of HAART therapy in Cameroon. How...
Dear Editor
We read with interest the article by Mowlavi et al.[1] and agree that the palpation of pedal pulses is a useful clinical tool. Therefore any attempt to standardise the technique of palpation must be applauded.
Using the ‘navicular’ method, the authors palpated 78% of pulses in a group of patients under the care of the surgical team. Unfortunately they do not describe the past medical h...
Dear Editor
Dengue haemorrhagic fever (DHF) is one of the leading causes of morbidity and mortality in the tropical and subtropical countries. Although, the dengue virus when compared to other arboviruses do not cause significant central nervous system involvement it can be an important cause of encephalitis and Encephalopathy when taking in to account the large epidemics that occur due to the virus.
DHF i...
Dear Editor
Diagnosis of Pulmonary embolism is very challenging and any clue from anywhere is worth mentioning. In this regard Dr Athar's above case report is very interesting. But there are certain points in discussion which needs reappraisal.
In the report authors have mentioned that QT was prolonged when the patient had developed pulmonary embolism which was expected considering the fact that heart rate...
Dear Editor
The article by Nzuobontane et al.[1] reports the involvement of the cardiovascular system in an african country, reflecting the condition we observed some years ago before the introduction of HAART.[2] The introduction of HAART has significantly modified the course of HIV disease, with longer survival and improved quality of life. Although there is no evidence from prospective studies to suggest th...
Dear Editor
The contents of the letter evoked a similiar chord in me. Last year, I had the mortification of seeing my father in a comatose state after a sudden onset of Meningitis. He himself was and is a practising Paeditrician and the other son of his, my elder brother is also a doctor. That night I was alone with him and saw him deteriorate overnight from an ordinary "flu" to full blown Meningitis. We had an anxi...
This is a case of Tuberculous Mediastinal lymphadenopathy with a left sided tuberculous pleural effusion.
Dear Editor
I read with interest the report of an unusual case of gestational diabetes mellitus (GDM) in early pregnancy in two successive pregnancies by Shankar et al.[1] Authors have rightly emphasized the importance of the early screening of GDM at first antenatal visit in women with history of GDM in previous pregnancies or with a strong family history of diabetes mellitus. In fact, an early detection...
Dear Editor
Earlier this year your journal published an article by Smith and Poplett [1] which discussed the findings of a questionnaire that had been answered by newly qualified pre-registration house officers and senior house officers. The questions concerned various aspects of basic acute medical care. The results suggested significant gaps in knowledge and understanding of both the signs and immediate managem...
Dear Editor
I complement the authors on an excellent case. Could I however, point out that in the table on causes of osteolysis, there is no mention of crystal arthropathy. Calcium pyrophospahte dihydrate(CPPD) and basic calcium phosphate (BCP) associated crystal arthritis are known to cause osteolysis in a small no of patients. These would form part of the differentail diagnosis for any patient with this presentat...
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