Archive for August, 2008

Image highlight: Lethal pneumatosis coli

August 22, 2008

Macroscopic, histological and ultrastructural assessment of small intestine tissue: (a) Macroscopic picture of the oedematous intestinal wall with multiple submucosal and subserosal cysts; (b) Histological picture of the intestinal mucosa with areactive necrosis; (c) Gram stain of cysts with large rod-shaped bacteria; (d) Electron microscopic picture of a bacterium found in a submucosal cyst.

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Stephen Kircher et al., University Würzburg, Germany, present the case of a 12-month-old boy who suffered from perinatal asphyxia during delivery, resulting in severe hypoxic encephalopathy with tetraparesis and epilepsy. In addition he suffered from considerable dysphagia from birth. For this reason his parents provided artificial nutrition by a stomach tube at home, consisting of hydrolysed milk formula based on amino acids and a natural thickening agent composed of carob seed flour. The patient had a history of abdominal pain, fever and nausea one week prior to being referred to a paediatric clinic with symptoms of acute abdomen, increasing fever, cyanosis and epileptic seizures.
For the full clinical details of this case of lethal pneumatosis coli caused by acute intestinal gas gangrene, please read download the case report and figures for free here.

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Cases Journal publishes its 100th case report!

August 18, 2008

Congratulations to Dr Jan Paul Frölke and colleagues, University Hospital Nijmegen, on being the authors of Cases Journal’s 100th manuscript!

In only 3 months, Cases Journal has become a popular place for rapid publication of case reports from all areas of medicine, and is growing fast. With the help of a prestigious and committed Editorial Board, we are able to offer a fast peer review process and deliver a first decision to our authors within 3 weeks of submission.

This is just the start in a revolution in the way case reports are documented and used in healthcare. Case reports with negative outcomes are as welcome as those with positive outcomes; and ‘everyday’ cases as welcome as rare presentations. The journal aims to publish thousands of case reports – many more than any other medical journal.

It’s never too late to report a case – if you have a case presentation that you think deserves to be documented and listed in PubMed then submit your case report today.

Urticaria after off-label ondanestron use

August 15, 2008

Journal of Medical Case Reports has published a case report where the authors present what appeared to be a serious adverse reaction to the widely used medication, ondansetron, because of off-label use.

Ondansetron is a 5 hydroxytryptamine3 (serotonin) receptor antagonist used mainly as an antiemetic to treat nausea and vomiting following chemotherapy.

Ondansetron is generally a well-tolerated drug with few side effects, the most commonly reported being headache, constipation, and dizziness. There have been no significant drug interactions previously reported with this drug’s use.

In this case report, a 19-year-old woman presented to an emergency department with 3–4 episodes of nausea, vomiting and epigastric distress, where she was treated with 4mg of ondansetron intravenously. She immediately developed urticaria, which was treated with intravenous dexamethasone 4mg and chlorpheniramine maleate 20mg. The reaction abated within a few minutes and she was discharged within an hour. She was asymptomatic at 72 hours of follow-up.

Karishma et al write: “The wide availability of these drugs in India has promoted their off label use in the treatment of gastritis, migraine and so on. Our case represents an off label use in a patient who could have been treated with a safer drug….Our case report underscores the importance of physicians judiciously using the drug, particularly in the outpatient setting so as to reduce the incidence of avoidable adverse drug reactions.” Share your experiences of off-label administration of odansetron or any other drug by publishing a case report with us.

A milk allergy n of 1 trial and the ethics of publication

August 14, 2008

Cases Journal recently published an article by Bruce Arroll, Harry Pert and Gordon Guyatt describing a trial carried out on two 6-month-old children to see the effects of replacing cow’s milk with soya milk in their diet. The parents, worried that their babies’ symptoms of diarrhoea, rash, irritability and wheezing could be caused by milk allergy, agreed to take part in the trial, which was randomised and blinded by their neighbours passing cow’s or soya milk in identical bottles over the back fence according to the allocation schedule. The parents then kept diaries recording the children’s symptoms for their GP, Dr Pert, to assess at the end of the trial.26723132

Richard Smith, the journal’s Editor-in-Chief, has written an editorial considering the ethical issues involved in publishing such a case. The authors did not get approval from an ethics committee for carrying out the trial. The families were not asked to give their consent for publication of this report when the trial took place (20 years ago) and the authors are no longer able to contact them to ask for consent now. Read the editorial to find out why we have published the article in spite of these ethical issues.

Don’t forget your patient

August 6, 2008

24757931Our patient information and consent form is now available to download in multiple languages, including Chinese and Spanish.

Make sure your patient is involved and have their story heard by including a description of events in their own words as the ‘Patient’s perspective’ part of your case report. You could even include them as co-author.

If you are a patient and would like your experience published for use by clinicians, researchers and fellow patients alike then please tell your doctor about Cases.

Watch a video case report: metastatic myocardial abscess

August 5, 2008

Accompanying one of Journal of Medical Case Reports‘ latest case reports is a mini-video. Iqbal et al. report a case of a 29-year-old intravenous drug user presenting with a 2-week history of fever, malaise and myalgia.

After detection of sever tricuspid regurgitation, cardiac magnetic resonance imaging (CMRI) revealed a 4.5cm diameter left ventricular posterior wall abscess contained by only a 2mm thin layer of myocardium.

Watch this short clip to see the CMRI, and read the full case report for more details.

We particularly welcome video in case reports, so if you have something to share, submit your case report today.

Richard Smith’s guest blog post: The still small power of medicine

August 1, 2008

Medicine has made progress from Voltaire’s famous aphorism that “the art of medicine consists of amusing the patient while nature cures the disease,” but two articles just published in Cases Journal show that progress is slow and not all that it appears to be. Tom Jefferson and Enzo Grossi describe the agonising and currently insoluble problem of advising individuals based on evidence gathered in populations.

Let me try and illustrate with the following dialogue:

Inquisitive patient: If I take this drug will I be cured?

Complacent doctor: Yes.

Inquisitive patient: How do you know?

Complacent doctor: The drug company told me. They kindly sent me reprints from a prestigious medical journal.

Inquisitive patient: Did you read them critically?

Complacent doctor: Well no. In fact I didn’t read them at all. I don’t have time. But the drug rep who gave them to me was charming and convincing.

Inquisitive patient: What did he say?

Complacent doctor: He said that there was strong evidence from large randomised trials that the drug I’m prescribing you works.

Inquisitive patient: What’s a randomised trial?

Complacent doctor: Some say it was the most important medical discovery of the 20th century. In a randomised trial a large number of people randomly receive either the drug or a dummy pill. Researchers then see what happens to the patients. Nearly a thousand people were given the drug I’m prescribing for you and about the same number were given the placebo. In the treated group 50 died while in the untreated group it was 200. So the drug clearly works.

Inquisitive patient: What happened to the others?

Complacent doctor: They’re still alive.

Inquisitive patient: But are they cured?

Complacent doctor: Well, no. They still have the condition, but it’s clearly much better to have the treatment.

Inquisitive patient: OK, so I won’t be cured. I accept that, but are you sure the drug will benefit me?

Complacent doctor: Of course. Look at the difference between those who took the drug and those who didn’t. Those who didn’t had four times the chance of dying.

Inquisitive patient: It seems to me that there are four possible outcomes here. I might take the drug and still die. I might take the drug and not die but still have the condition. I might not take the drug and die. Or I might not take the drug and not die but still have the condition. How do I know which group I’ll be in?

Complacent doctor: Well, clearly you should take the drug because you quarter your chances of dying. That’s a big difference.

Inquisitive patient: But I might take the drug and still die or I might not take the drug and live. How do you know what will happen to me?

Complacent doctor: I don’t.

Inquisitive patient: And just because this drug worked in some people in this trial how do you know it will work in the future? Aren’t you making the mistake of Bertrand Russel’s “inductive turkey,” who assumed that because he got fed at 9 every morning he would always be fed—until Christmas Eve when he had his throat cut at 9 am?

Complacent doctor: I’m only a doctor not a philosopher.

Inquisitive patient: That’s your problem.

The articles in Cases Journal describe two ways to move on.

Tom describes the first method, which would be to create a giant reliable database of what happens to individual patients rather than to populations, but we would need it to be truly giant (ideally including every patient ever treated) and we would need a very sophisticated search engine. Cases Journal is working towards both ends.

The second method described by Enzo would be to gather huge amounts of variables on patients within large trials and then match the individual patient to patients in the trials using new methods of searching.

Both methods will need currently unimaginable computing power, new methods of searching, and – most difficult of all – a fundamental change in the working practices of doctors.
Richard Smith

Editor-in-Chief
Cases Journal