Letters to the Editor
The article by Lohiya et al1 is a stern warning to all of us in occupational medicine and other fields on the importance of cultivating a habit of thoroughness. The article is well written and exposes the tendency many outpatient specialty practice physicians have of focusing only on the complaint at hand, instead of keeping in mind the fact that a patient with one complaint is an entire person with underlying comorbidities and other organ systems that may be affected by treatment decisions.
I have a few questions for the authors. First, in the discussion the authors describe the patient's blood pressure from days 1 through 6 as normotensive: What criteria are the authors using? What was the patient's preinjury blood pressure? I disagree with their description of her blood pressure levels. At best, her blood pressure could be considered prehypertensive on the basis of the day-6 measurement of 130/80 mmHg or, at worst, full-blown hypertension on the basis of her day-1 measurement of 130/90 mmHg. The small echogenic kidneys seen on ultrasonography during hospitalization from days 37 to 40 correlate with the blood pressure findings noted on days 1 and 6. The article did not provide actual kidney dimensions, which would also have been helpful. Renal function correlates with kidney size and the number of functional nephrons. Moreover, the patient was noted to be overweight, which is in itself a risk factor for hypertension. A preinjury blood pressure would have been a better basis for comparison.
Second, this injury must have occurred several years ago, because valdecoxib is no longer available in the US market. It would be interesting if there are any similar case reports based on currently marketed non-steroidal anti-inflammatory drugs. How much of the injury is related to the assumption that the patient took both ibuprofen and valdecoxib? Many patients do not take medications as prescribed.
Third, it seems as if this patient had the great misfortune of not just being treated by one group of negligent physicians but multiple groups of negligent physicians, yet we have no professional negligence-claim outcome information. We also have no mention of peer-review action. This patient was given multiple high doses of non-steroidal anti-inflammatory drugs without renal function monitoring by the occupational medicine physicians. She also received subpar care from the emergency department physicians who, according to the article, treated her nausea, vomiting, epigastric pain, blood pressure of 188/120 mmHg, pulse of 160 per minute, and respirations of 40 per minute as an adverse reaction to cyclobenzaprine without checking basic chemistries. Information regarding negligence-claim outcome and peer-review action would be helpful.
Last, did the authors file an adverse drug event report with the Food and Drug Administration2? What was the authors' role in this case? Were there any conflicts of interest?
Eidi Millington, MD
Baylor Medical Center
1. Lohiya G, Lohiya P, Krishna V, et al. Death related to ibuprofen, valdecoxib and medical errors: case report and medicolegal issues. J Occup Environ Med. 2013;55:601–603.