47 e-Letters

published between 2017 and 2020

  • Thumbs down for anatomical accuracy

    Smith and Bongale correctly emphasise the importance of anatomical accuracy when examining the hand.[1] However their article requires correction. The muscle adductor pollicis longus (answer D in their question) does not exist. The abbreviation APL usually denotes abductor pollicis longus, a muscle of the forearm which contributes to abduction and extension of the thumb, and which runs alongside extensor pollicis brevis as it crosses the anterior (radial) border of the anatomical snuffbox. Adductor pollicis (shown in Figure 2 of the article) is an intrinsic muscle of the hand, and is not involved in thumb extension.

    Hand injuries are common in Emergency Departments. Anatomical accuracy is essential when examining and describing these important presentations.

    1. Smith E, Bongale S. Thumbs down: testing anatomy in the ED. Emerg Med J 2019;36:224-238.

  • Emergency Department Setting: an opportunity to detect the patient with heart failure who may benefit from palliative care.

    Dear Editor,
    We have read the study published by Lipinski et al.(1) in which the authors observed that only a little percentage of patients with heart failure (HF) were monitored by a specific palliative care (PC) team. Also, this usually happened in the last two weeks of life. This suggests the need to identify earlier high-risk patients who can benefit from monitoring by a palliative care team (1).
    In relation to this study, we would like to share our experience in a Spanish Emergency Department (ED). Our study included 143 patients with acute HF (AHF), mean age 82.5 (range 65-99) years old, of whom 69 (48.2%) were women. None of these patients were being monitored by a PC team before their admission in ED and only 8 (5.6%) were transferred to PC after the index visit. Out of 8 patients included in CP, 3 (37.5%) died within 30 days after visiting ED. Although our cohort had a lower 1-year mortality than the Canadian study (18.2% vs 27.0%), our findings confirm that older patients with AHF are not frequently followed-up by a PC team, although HF is known to be a disease with a progressive course which is associated with a significant morbidity and mortality, and a high consumption of socio-health resources (2). This may be due to the lack of awareness, among health professionals, that HF is a chronic disease with a poor 5-year prognosis, and the need of palliative care for older patients with HF in an earlier phase than the terminal care (3).
    In conclusi...

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  • missed diagnosis of infective endocarditis-related stroke in the emergency department

    Failure to diagnose infective endocarditis(IE) as the underlying cause of embolic stroke merits recognition alongside failure to diagnose other subtypes of stroke,. The reason is that failure to recognise an infective basis for cerebral emboli precludes time-sensitive interventional strategies such as thrombectomy(1)(2) and, instead, exposes the patient to relatively contraindicated treatment options such as intravenous thrombolysis(IVT)(3)(4). One study compared outcomes from IVT in 222 patients(mean age 59) with IE-related stroke versus 134,048 subjects(mean age 69) with ischaemic stroke in the absence of IE. The rate of post-thrombolytic intracranial haemorrhage was significantly(P=0.006) higher in patients with IE-related stroke. The rate of favourable outcome was also significantly(P=0.01) lower in IE-related stroke(3). A high index of suspicion is required to diagnose IE-related stroke because both fever and heart murmurs are present in only a minority of IE patients at the time of presentation with stroke(4). For patients in whom a timely diagnosis of IE-related stroke is made thrombectomy appears to be a treatment option which generates a favourable outcome(1)(2).
    For the sake of completeness one also ought to mention the potential for meningovascular syphilis to be overlooked in a patient presenting with stroke both in HIV positive(5) and in HIV-negative subjects(6). In both instances neither IVT nor thrombectomy will suffice. Definitive treatment o...

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  • HM Coastguard inclusion

    Dear Authors,

    Thank you for your interesting article about hypothermia in the UK. I couldn't find reference in the case to the HM Coastguard cliff rescue operatives nor to HM Coastguard helicopter search and rescue service (Currently run by Bristow). Was there a reason for excluding these organisations or is there data included under the heading of another organisation? Thank you again,

  • Response to Matthew. L Khan-Dyer

    We do not disagree with the comment, hence our conclusion that, “CT is a valid first line imaging technique in suspected occult hip fracture and is easily accessible in most centres.” The intention of the BET was to present evidence on whether one modality was better than the other and so we looked for studies comparing the two imaging techniques. The study by Thomas et al. forms part of the evidence that CT scanning is a valid method of detecting occult hip fractures and so was not included in the table of evidence.
    Thomas RW, Williams HLM, Carpenter EC, Lyons K. The validity of investigating occult hip fractures using multidetector CT. Br J Radiol

  • Mr

    I read this article with interest as I am currently launching a QUIP on this exact subject.

    As a declaration of possible bias I am looking to use highly sensitive CTs to screen off negative findings to frailty services and thus avoiding orthopaedic beds.

    I am surprised that more credence was not given to the study by Thomas et al. who's sensitivity and specificity was 100% for ct. The study is one that clearly identifies MDCT as the protocol of choice when identifying occult hip fractures. I am not sure whether this is directly comparable to other studies in this way, and therefore some doubt exists as to whether current discrepancies in reporting are more attributable to the scanning protocol used.

    I feel that the current nice guidelines are out of date with modern CT scanning and is having undue influence on first line diagnostics of occult hip fractures.

    I do appreciate the move forward for CT scanning hips as first line diagnostics thus cutting bed-days/patient, expediting correct treatment and improving patient experience.

  • methodological variables involved in the measurement of blood pressure

    The conclusion that there is an association between systolic blood pressure and in-hospital mortality requires further qualification in view of the multiciplicity of variables which impact on the measurement of blood pressure in the older patient first evaluated in the emergency department. Firstly, blood pressure measurement in the Post-SPRINT era specifies that the blood pressure should be measured after 5 minutes rest in a quiet room, and that 3 readings should be taken at 1-minute intervals(1). Is that feasible at A & E?. Secondly, "It is axiomatic that ...measurement should be recorded in both arms.....the higher of the two readings should be used for diagnosis and management...."(2). Is that feasible at A & E?. Finally, allowance should be made for seasonal differences in blood pressure, given the fact that many hypertensive patients have higher blood pressure levels in winter than in summer(3). Those who "buck" this trend experience worse cardiovascular outcomes than those who conform to this trend(3).
    (1) Myers MG., Cloutier L., Gelfer M., Padwai RS., Kaczorowski J
    Blood pressure measurement in the Post-SPRINT Era
    Hypertension doi.org/10.1161/HYPERTANSIONAHA.116.07598
    (2)Giles TD., Egan P
    Inter-arm differences in blood pressure may have serious research and clinical implications
    The Journal of Clinical Hypertension 2012;14:491-492
    (2) Giles TD., Egan P
    Inter-arm dif...

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  • The “Do’s and Don’ts” of active compression decompression CPR with an accelerometer feedback device

    We read with interest the recent article by Setala et al, where active compression decompression cardiopulmonary resuscitation (ACD-CPR) was compared with manual CPR. 1 In this study, to ensure continuous high-quality resuscitation, an audiovisual feedback defibrillator (Zoll X Series, Real CPR Help, ZOLL Medical Corporation, USA) was used. This is a key element for cardiac arrest studies. It is known that quality of CPR is an important modifier in cardiac arrest studies. 2 High-quality CPR is necessary to be able to compare and generalize the results. There is, however, a major methodologic flaw in the Setala et al study. None of the accelerometers used in feedback defibrillator are adapted to analyze ACD-CPR. The issue arises from the fact that the accelerometers are designed to measure only one distance from the chest resting point at the end of the passive decompression to the compression maximum depth. In the Setala et al study, there was no difference in distance between groups 76 (SD 1.3) mm versus 71 (SD1.0) mm. However, in ACD CPR, you need active compression (5 cm) combined with active decompression (3 cm or 15kg of pulling). Given the reported data, there are two distinct possibilities. The first is that Setala et al were able to perform active decompression (rising the chest higher than the chest resting point) but that their compressions were not adequately deep enough. As a result, ETCO2 would be lower compared to CPR with high-quality compression. The second...

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  • Ill Advised Use of Tampons for Gunshot Wounds

    We applaud the authors for their effort to educate the bystander and even medical professionals with a means to provide care for the injured in terrorist attacks. While the majority of the information provided is based in historical evidence, in today’s era of superior wound packing materials the use of tampons for gunshot wounds (GSWs) is an inferior and dangerous suggestion.

    Tampons have been around for many thousands of years for vaginal bleeding, but nothing has been documented for their use in GSWs.[1] Stories of tampon use have been around since the Vietnam era. There have even been anecdotes posted on Snopes.com from the war in Iraq.[2] The story is full of unsubstantiated information, yet it is a common reference for many.

    One can find in the fringe of the Internet, other claims of tampon effectiveness. Bioprepper claims tampons are “designed to be ultra-absorbent” and “can be used to plug a bullet hole until…accounts of this use date back to World War I.”[3] They go on to say, “Many items in modern society were first developed as a facet of military research – tampons being a prime example.” This is absolutely false. Not only that the article itself never demonstrates a tampon being used to stop life threatening hemorrhage – rather it illustrates a plethora of Boy Scout novelties of the tampon.

    Elsewhere, there are anecdotes of tampons being used during World War I and II, but nothing specifically written from the era. Still, there is no def...

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  • Response to: Hospital readmissions among mechanically ventilated in the ED: Is it feasibly a preventative strategy?

    Dr. Purro,

    First off, thank you for taking the time to read and respond to our article.  We are in agreement that invasive mechanical ventilation and hospital readmissions are important as they pertain to both patient-centered outcomes and resource utilization. 

    We also agree with your statement that Emergency Department (ED) length of stay is comparatively short when compared to the time spent in the hospital. However, in time-critical conditions such as sepsis, trauma, acute ischemic stroke, and myocardial infarction, this time period is highly influential on long-term patient outcomes. Regarding the management of mechanical ventilation, our group has previously demonstrated that the initial management of ventilator settings in the ED influences outcome (i.e. ventilator-associated lung injury and exposure to hyperoxia are also time-sensitive) (1-3). As it was previously unknown if hospital readmissions are influenced by initial ED management, and readmission is a patient-centered reflection of morbidity, we felt this topic merited further evaluation.

    We agree that the relationship between chronic illness and clinically significant outcomes is important (i.e. length of stay, duration of mechanical ventilation, etc.). Unfortunately, we felt that this data and subsequent analysis was beyond the scope of our paper.  Our aim was simply to evaluate whether or not processes of care in the ED influenced the rate of hospital readmissions in patients requir...

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