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Archive for September, 2009

Surfers ankle: a bony spur of the talar neck

29 Sep, 09 | by Emilia Demetriou

“”As a sport surfing is generally safe. It is different for competitive surfers where this rapid sport calls for great agility and balance. This case report of an ankle injury demonstrates the type of damage that can be done. The authors describe the clinical investigation of this case and outline the circumstances that led to the injury.”

Surfers ankle: a bony spur of the talar neck

Autologous stem cell therapy for heart failure plus artificial heart bridge

26 Sep, 09 | by Dr Dean Jenkins

Autologous stem cell therapy for a diseased heart using an artificial heart to bridge for time has been performed in Greece by an Oxford surgeon.

“Prof Stephen Westaby, from the John Radcliffe Hospital, led the operation on Ioannis Manolopoulos in Greece.

He used an artificial heart to relieve Mr Manolopoulos’s heart while it was injected with stem cells to help it rebuild itself.

Prof Westaby said it was thought to be the first time both had been combined.”

Progressive respiratory distress due to neck mass

18 Sep, 09 | by Emilia Demetriou

“This well documented case of a life threatening respiratory obstruction from a neck mass is an important reminder of how to approach such emergencies. The authors describe a case of a thyroid mass and its subsequent management.”

Progressive respiratory distress due to neck mass

Finding your doctor through their published case reports

15 Sep, 09 | by Dr Dean Jenkins

Had a very interesting communication from a BMJ Case Reports author who was contacted by a patient’s family because the patient was suffering from a similar condition to that which the author had just published.

This raises interesting points about the role of the medical literature and the increasing ability of patients and their relatives to research the professional credibility of doctors. This is the modern world but it is it new? Before the Internet patients and relatives would contact by telephone or fax and before the telephone they would probably have written a letter. They always travel if they think the doctor has particular expertise.

There is a limitation of course since you may very well find a doctor with expertise but they may be in another continent and your selective research may have missed a world authority in your local hospital.

Another aspect of this is the networking between the authors themselves. Finding others with similar clinical interests and in publishing their work could lead to the exchange of information and collaboration.

YouTube case series of sporting injuries yields new clinical sign.

7 Sep, 09 | by Dr Dean Jenkins

A case series of YouTube sporting injuries has identified what could be a useful clinical sign for sports coaches. The ‘fencing response’ (tonic posturing) is an immediate sign and is associated with moderate head injury. It seems to be a separate entity from convulsions, which may also occur, and since it is a clinical sign that is quite easily recognised, it can help direct care after the injury.

Hosseini, AH. Lifshitz, J. Brain Injury Forces of Moderate Magnitude Elicit the Fencing Response. Medicine & Science in Sports & Exercise: September 2009 – Volume 41 – Issue 9 – pp 1687-1697

Intravenous zanamivir

4 Sep, 09 | by Dr Dean Jenkins

A young woman with severe H1N1 pneumonitis who was previously neutropenic with chemotherapy for Hodgkin’s disease has responded to intravenous zanamivir (Relenza) and methylprednisolone. Her case is reported in the Lancet.1

Although the use of intravenous zanamivir is unlicensed it exists and is being studied as part of a clinical trial2 (with oral Oseltamivir) in humans and others have investigated its use in experimental influenza3. The clinical team had to apply to their hospital formulary, seek consent from relatives and source the treatment directly from GSK. Since the most severe cases of H1N1 pneumonitis are likely to be ventilated it would make sense to gain experience with intravenous antivirals.

The interesting point in this case is the combination of intravenous zanamivir with methylprednisolone in a severe case of H1N1 influenza in a patient with neutropenia. The authors suggest that this warrants further study.

1) Kidd IM, Down J, Nastouli E, Shulman R, Grant PR, Howell DCJ, Singer M. H1N1 pneumonitis treated with intravenous zanamivir. The Lancet, Early Online Publication, 4 September 2009.

2) Pukrittayakamee S. Phase 1, Open-Label Study to Evaluate Potential Pharmacokinetic Interactions Between Orally-Administered Oseltamivir and Intravenous Zanamivir in Healthy Thai Adult Subjects. identifier NCT00921726

3) Beigel J, Bray M. Current and future antiviral therapy of severe seasonal and avian influenza. Antiviral Res. 2008 Apr;78(1):91-102. Epub 2008 Feb 4.

Not every cough in bronchiolitis season is bronchiolitis

3 Sep, 09 | by Emilia Demetriou

This case is a useful reminder that all coughs during the peak season for bronchiolitis are not necessarily bronchiolitis. Although rare, the cause in this young patient, reminds us that when the unexpected happens the first thing that should be questioned is the original diagnosis.”

Not every cough in bronchiolitis season is bronchiolitis

Bloody tears. Tears as in ‘rip’ or tears as in ‘cry’?

3 Sep, 09 | by Dr Dean Jenkins

News reports of the mother of Calvino Inman desperately looking for doctors that have experience of managing patients with “bloody tears” have been reported over the last few days treating the condition as a medical mystery. (Thanks to CasesNetwork for Tweeting!).

However, it seems that she should go no further than her home state of Tennessee where doctors published a case series of this condition only a few years ago.

Ho VH, Wilson MW, Linder JS, Fleming JC, Haik BG. Bloody tears of unknown cause: case series and review of the literature. Ophthal Plast Reconstr Surg. 2004 Nov;20(6):442-7.

Do doctors read the literature these days? I’m sure they do but they probably do not search effectively. Putting ‘blood tears’ into PubMed gives a lot of links to Mallory-Weiss tears which is very different from the search ‘bloody tears’. (Internet search engines give very poor results to either search other than finding the news stories of this particular case.)

This is a common theme in case reports where a particular case is thought to be unique but it is only because the other cases have been published with a different name. Unfamiliar cases have unfamiliar language. If you were familiar with the term haemolacria (which I wasn’t) then searching would be much easier but you’d probably already be an expert!

Case Report CAT

2 Sep, 09 | by Dr Dean Jenkins

This is a draft critical appraisal sheet for case reports. Would be interested in your views.

Critical Appraisal is used to glean scientific evidence from papers. Case reports or case series are not normally considered as part of this process. The reason is that there is usually no hypothesis testing or comparison within a case report and generalising the conclusions to other circumstances is difficult.

However, case reports have value which could be scientific or educational. When reading a case report it is important to be critical and judge the value of the report to the medical literature and to your own clinical practice. This checklist may help.

Checklist Item Comment
Has the case report been peer-reviewed? Is it clear from the publisher what the peer-review process was?

Case reports may be in topic areas, or include topic areas, that are unfamiliar and they should have been reviewed by experts in those topics. You may need to check the publication or the website to understand the peer-review process for their case reports.

Does the case report have a clearly defined focus?

It should be easy to understand if the case reports a rare condition, a novel finding, a reminder of an important clinical lesson, a myth exploded, an unexpected adverse / beneficial outcome of treatment etc. Cases without a focus may not have been properly thought through by the authors.

Are all the necessary facts presented?

Check that there is sufficient detail in the presentation, past medical / drug / social history, examination, investigations and follow-up of the case.

Is the case report linked to the existing literature?

The discussion should highlight if the case is claimed to be unique or if other similar cases have been reported. If unique the authors should describe the search process, terms and synonyms that they used to research the literature. If other cases have been reported then information about how those cases were similar or different to this case report. All cases should be referenced and the authors should again describe the search that they used to find them.

Is the discussion relevant?

The discussion should explore the potential learning points or novel findings from the case but not over-generalise, make recommendations that are not upheld by a single experience, or discuss issues that are not directly involved in the case. The case report should not be a lame excuse for a review of the literature. If there is a call for further research it should be clear in the discussion what this is.

Does the case provide any quantitative evidence?

Are there numbers that could be useful from this case report? It may provide a measure of a physiological variable, a time period or a drug quantity that could help in probability estimates or clinical judgements in future cases. The numbers, if adequately described, could be combined with other published case reports to improve the estimate in a process similar to meta-analysis.

Is the case report important to your clinical practice?

Although interesting and of educational value the paper may be about a condition that you would never be likely to encounter. Judge how relevant the case, the lessons or scientific leads are to your clinical practice. Is it one that your colleagues should read?

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