Very interesting case and well written.
One could postulate that the hypoxia associated with massive PE might have caused ischaemic changes without infarction or that the death was too soon for changes of infarction to be visible at post mortem examination.
Either way, a good learning point, though clearly thrombolysis for either PE or MI would not have been feasible due to the recent GI bleed and therefore the outcome was inevitable.

Reviewer
Dr Noeleen Foley
Royal United Hospital

Variable ECG findings associated with pulmonary embolism

Surgery on patients with OSA can be problematic, and a preoperative assessment is useful as a predictor of complications and as a means of planning best clinical practice. This proposed assessment takes into account the 3 major areas of concern, namely the severity of OSA, the planned procedure, and the need for perioperative sedation and analgesia.

I would encourage others to have such an approach to preoperative assessment and management of surgical patients with OSA.

Reviewer
Dr David Barnes
Associate Professor
Royal Prince Alfred Hospital

Perioperative risk stratification for a patient with severe obstructive sleep apnoea undergoing laparoscopic banding surgery

The recommendations of the American Heart Association and European Society for Cardiology on the use of antibiotic prophylaxis for patients considered to be high risk is very relevant in dental practice. The NICE guidelines as described by the author, at times need not be too nice for a high risk patient.

Reviewer
Dr Peter George MD
Associate Professor
Father Muller Medical College

A not very NICE case of endocarditis

Anything that is linear and remotely flexible may get knotted up. This is well demonstrated in the images accompanying the present case. Murphy’s law applies, and the advice given by the authors is very sound.

Reviewer
Kirsten Moller

All tied up in knots

This is well written case report of a rare presentation of a rare condition. It provides a important reminder to consider a differential diagnosis in patients with asthma.

Large airway tumours are rare (0.2%) amongst patients with lung cancer, and amongst tracheal tumours it is thought that adenocarcinomas represent 4-10%.^1-5 The majority of tracheal adenocaricinomas are diagnosed in smokers.^3-4 In one case series of tracheal tumours 21% had symptoms of progressive bronchial asthma.⁵

Reviewer
Dr Ian Clifton
St James’s University

References

1. Li W, Ellerbroek NA, Libshitz HI. Primary malignant tumors of the trachea. A radiologic and clinical study. Cancer 1990;66:894–9.
2. Hajdu SI, Huvos AG, Goodner JT, et al. Carcinoma of the trachea. Clinicopathologic study of 41 cases. Cancer 1970;25:1448–56.
3. Gelder CM, Hetzel MR. Primary tracheal tumours: a national survey. Thorax 1993;48:688–92.
4. Licht PB, Friis S, Pettersson G. Tracheal cancer in Denmark: a nationwide study. Eur J Cardiothorac Surg 2001;19:339–45.
5. Houston HE, Payne WS, Harrison EG Jr, et al. Primary cancers of the trachea. Arch Surg 1969;99:132–40.

Adenocarcinoma: not all that wheezes is asthma

Patients with non-organic or functional disorders do indeed present frequently to stroke services. The hazard for the patient is that they may receive IV thrombolysis – although limited available data.¹

Chen et al ² suggests as the authors here observe, that patients presenting with non-organic or functional disorders are at a relatively low risk of significant harm as a result of IV thombolysis.

The other risk for patients presenting with conversion disorders or associated non-organic symptoms is that they may be subject to inappropriate investigations. However, since the consequences of missing a stroke diagnosis may be non-trivial and the diagnosis of a conversion disorder is almost always made retrospectively, it is very hard to avoid a degree of investigation that may confer harm upon the patient (whether in terms of exposure to ionizing radiation, contrast media, or discovery of incidental abnormalities).

Use of the MDT can be very helpful in identifying as well as treating these patients. They respond well to occupational therapy and physiotherapy input.

It is worth spending some time with the patient to explain that they have not had a stroke and that the cause of the symptoms may not be physiological.

Reviewer
Dr James Scott MRCP MSc
Consultant Stroke Physician

References

1. Winkler DT, Fluri F, Fuhr P, et al. Thrombolysis in stroke mimics: frequency, clinical characteristics, and outcome. Stroke 2009;40:1522–5.

2. Chen Y, Bogosavljevic V, Leys D, et al. Intravenous thrombolytic therapy in patients with stroke mimics: baseline characteristics and safety profile. Eur J Neurol 2011;18:1246–50.

Stroke mimic: an interesting case of repetitive conversion disorder

In this article we are reminded how to confirm brain death and the pitfalls of using CT angiograms for the assessment of cerebral perfusion.

Seema Biswas
Editor-in-Chief

Brain dead or not? CT angiogram yielding false-negative result on brain death confirmation

Circumcision is a routine procedure in some cultures. Different techniques are used as surgical methods. Unfortunately some of them cause tragic and irreversible complications. This article that includes distinct photographs highlights the undesirable consequences clearly and accurately. Because of pointing out the worrying cases in a certain way, I consider that publishing this article in BMJ will be educatory for medical society.

Professor Şamil Aktaş
Reviewer

Electrocautery-induced gangrene of the glans penis in a child following circumcision

This is a well written case report of a common presentation in emergency departments (altered mental state associated with alcohol intoxication and a possible head injury). It highlights the importance of a good history and maintaining a high index of suspicion for relatively uncommon diagnoses in patients with this common emergency department presentation. Can the authors please clarify if they considered any other diagnoses (that is, their differential diagnosis) before they became aware of the arterial blood gas result and the CT brain result?

Dr Abel Wakai
Reviewer

Pop goes the O₂: a case of popper-induced methaemoglobinamia

A useful approach to all patients with non-healing wounds can be summarised by the following concept: “Wounds do not heal for no reason.” The development of an ulcer is a priori evidence of some pathological process (e.g. unrelieved pressure). For a wound or an ulcer to persist, there must be a disruption in the elegant cascade of natural events which normally effect healing. Despite its complexity, healing is the NORM. The in-ability to heal is evidence of a disease state.  For a patient to have a non-healing wound or ulcer, there must be factors responsible for the failure of one of the most reliable of physiological processes, that of tissue repair.  Although textbooks and clinical research may force us to think of these ulcers as belonging to clearly defined categories (e.g. venous stasis, diabetic, pressure) the approach to treating them must be based on correcting the agent(s) which produce non-healing, many of which overlap and thus defy categorisation. (In other words, patients with venous ulcers need arterial screening and many patients with pressure ulcers need control of their diabetes.)
 
Clinical practice guidelines from major organisations invariably begin with arterial screening of all non-healing lower extremity ulcers, no matter what the presumed etiology might be (Chronic Wound Care Guidelines). They all include moist wound care, debridement of necrotic material, control of bioburden, control of edema, and off-loading of pressure. When appropriate measures such as these fail to result in healing within 6 weeks, all chronic ulcers should undergo biopsy for histological diagnosis. When a consistent protocol is followed, patients are more likely to get appropriately directed therapy. This case is an excellent example of following such a protocol. A rare condition was discovered and successfully treated “simply” by following a logical plan of assessment and treatment.

Caroline E. Fife, MD
Professor of Medicine, Division of Cardiology
University of Texas Health Science Center, Houston
Director of Clinical Research, Memorial Hermann Center for Wound Healing

The importance of challenging your diagnosis even in straightforward cases