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A Cautious Approach 

I was interested to read “Thyroid Eye Disease: Current and Emerging Therapies” (Clinical Update, November/December) . Thyroid eye disease is a complex syndrome for which it is difficult to establish a homogeneous and comprehensive therapeutic modality. For this reason, treatment should be conservative, aimed primarily at protecting the function of the eye and ameliorating the cosmetic and emotional effects of the disease.

When a new mode of treatment is presented, it should be done with caution, lest we raise false hopes for the patient as well as the physician. One treatment mentioned in the story is the biologic agent rituximab. Despite its many adverse side effects, I tried it alongside a placebo infusion as a control. I abandoned the project, however, because I found as many positive responses to the placebo infusion as to the drug itself. Furthermore, I found carbonic anhydrase drugs gave better control of the edema than rituximab.

Heskel M. Haddad, MD   
New York   


Smother the Bug 

I enjoyed reading about the tick-bite case in the July/August Blink. Burning, crushing and cutting are all ways to remove the bug quickly. However, these techniques can also cause the tick to release the contents of its stomach. Because spirochetes may be in the bug’s digestive tract, you want to get the tick out without causing the release of these bacteria.

As with most other arthropods, the tick gets its oxygen by diffusion through its exoskeleton. Therefore, one way of getting these bugs to unbury their heads is to smother them. You can use pyridostigmine and give them a parasympathetic overload, but plain old Vaseline will work as well. The downside of smothering ticks is that it takes patience and time.

The caveat to all of this, though, is that, even if ticks do inject their spirochetes, our body’s innate immunity is fairly good at clearing these bacteria from our system. If we can’t take care of it ourselves, doxycyline is very effective.

Anthony F. Kokx, MD   
Morgantown, W.V.   


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