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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: What it feels like to be compulsorily detained for treatment Anonymous. 358:doi 10.1136/bmj.j3546

It is good to see space given to the voices of those detained under the Mental Health Act, and particularly the experience of what that means in reality for people.

It does need to be remembered, though, that while doctors can make recommendations to detain they cannot actually 'section' anyone beyond 72 hours (and only then in limited circumstances). The final decision, taking into account all circumstances of the case, belongs to the Approved Mental Health Professional (AMHP). It is important that we are open and honest about the individual responsibilities of those who perform different functions under the Act. It is equally important to convey why there is a separation of these responsibilities and powers and how important it is that the AMHP is able to exercise their powers with autonomy and free of undue influence. Not every Mental Health Act assessment results in admission, not every medical recommendation is acted upon.

If we are to develop truly open and accountable processes and practices around these often difficult moments in people's lives, we should be trying to reassure those who become subject to our services that the promotion of their fundamental rights are as important to us as well evidenced clinical intervention and timely responses to need.

Competing interests: No competing interests

17 August 2017
Robert Lewis
Approved Mental Health Professional
Wonford House Hospital, Dryden Road, Exeter, EX2 5AF
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Re: Advances in the diagnosis and management of neck pain Steven P Cohen, W Michael Hooten. 358:doi 10.1136/bmj.j3221

I read with a particular interest the review “Advances in the diagnosis and management of neck pain” by Steven P. Cohen and W. Michael Hooten.[1] It represents an excellent state of the art of diagnosis and treatment of neck pain, except for work adaptation required among patients who are working.[2,3] Indeed, the authors stated the potential occupational factors involved in neck pain by differentiating:

- the axial non-radicular cause corresponding to perceived stress at work (“low job satisfaction and poorly perceived work support”), both associated with onset and poor prognosis and sometimes prolonged active posture (also called tension neck syndrome, or non-specific neck pain).[4,5]
- from the radicular cause that might be related only to extreme biomechanical factors (athletes, aviators/astronauts) or trauma, but not to minor repetitive trauma or carrying loads.[2,6] Stress at work might also be a poor prognosis factor.

Taking these factors into account, the authors should include them in the treatment to avoid recurrence and improve outcomes. In non-radicular cause, management of stress at work is probably effective,[7] as the opposite of decreasing biomechanical loads is not (except for some cases of posture). For radicular cause, considering that work is not a major risk factor, work adaptation should not be recommended, except for extreme conditions where prevention of trauma is important and sometimes a short decrease of constraints for pain management purposes.

1 Cohen SP, Hooten WM. Advances in the diagnosis and management of neck pain. BMJ 2017;358:j3221.
2 Cote P, van der, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine Phila Pa 1976 2008;33:S60–74.
3 Roquelaure Y, Petit A. Surveillance médico-professionnelle du risque lombaire pour les travailleurs exposés à des manipulations de charges. Recommandations de Bonne Pratique. ArchMalProfEnviron 2014.
4 Sluiter BJ, Rest KM, Frings-Dresen MH. Criteria document for evaluating the work-relatedness of upper-extremity musculoskeletal disorders. ScandJ Work EnvironHealth 2001;27 Suppl 1:1–102.
5 McLean SM, May S, Klaber-Moffett J, et al. Risk factors for the onset of non-specific neck pain: a systematic review. J Epidemiol Community Health 2010;64:565–72. doi:10.1136/jech.2009.090720
6 Nouri A, Tetreault L, Singh A, et al. Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis. Spine 2015;40:E675-693. doi:10.1097/BRS.0000000000000913
7 Despréaux T, Saint-Lary O, Danzin F, et al. Stress at work. BMJ 2017;357:j2489.

Competing interests: No competing interests

17 August 2017
Alexis Descatha
Professor in occupational medicine, epidemiologist, emergency doctor
Paris Hospital (AP-HP), Versailles St-Quentin University (UVSQ), Inserm; Occupational Health Unit, EMS (Samu92), Inserm UMS 011 UMR-S 1168
University hospital of West Suburb of Paris, Poincaré site, F92380 Garches, France
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Re: Margaret McCartney: The cult of CPR Margaret McCartney. 358:doi 10.1136/bmj.j3831

I cannot entirely agree with Dr McCartney – although I am 100% with:

‘It was acceptable 20 years ago to tell patients and families that
dying was inevitable and imminent. Side wards were organised,
if possible. Families were called to bedsides at home. Syringe
drivers with generous morphine were obtained. Relatives often
stayed with their dying family member at all hours.’

And that is still both acceptable, and also good behaviour.

However, as is almost always the case when clinicians write about CPR, Dr McCartney concentrates on the situation of DNACPR when CPR would be clinically ineffective [and I have always been puzzled by the ‘logic’ there – if CPR would not re-start the heart, and the patient requests that CPR should be attempted, why not attempt it?].

Dr McCartney does not cover the situation of a patient – especially a patient who is at home, and not close-to-death – who has considered a cardiopulmonary arrest, and wants to forbid attempted CPR when such an attempt might be clinically successful. This is, as I have pointed out (1, 2), somewhere between difficult and impossible for the patient to achieve, if there is also a desire to involve the 999 services to ascertain that an arrest has actually occurred.

At the heart of this ‘CPR issue’ is the combination of the near-impossibility of the clinical situation after most arrests being describable in advance, and the consideration of the acceptability of that future situation, as compared to being dead, being for either the patient or ‘best interests’. As I have written (3): ‘Without CPR, 'alignment of mindsets' between relatives [who, I believe, tend to see 'my dad doesn't want you to attempt CPR' as the justification for DNACPR] and clinicians [who, it seems to me, are much more concerned with 'could CPR be successful'] would not be a problem for CPR decision making’.

Dr McCartney has got this, I think, wrong:

‘… with the charade of seeking “consent” for not doing CPR’.

The objective should not be one of seeking consent for DNACPR – we should all be working towards allowing adequately-informed patients to make their own decisions about CPR, which amounts to patients refusing CPR: ‘conceptually different’ from seeking consent for DNACPR. In England, that amounts to ‘ideally we need more Advance Decisions refusing CPR’ (4).

I must say, that I tend to agree with Kate Masters (response 16 August): and the 'solution' Kate asks for (...I am flummoxed as to why I keep reading articles such as this that explain the barriers, but offer few ideas for solutions) is for clinicians to stop making quality-of-life decisions (put 'legally', that amounts to what I've written above: obtain Informed Consent, or embark of a proper, inclusive of family and friends, best-interests decision-making process about CPR).






Competing interests: No competing interests

17 August 2017
Michael H Stone
Retired Non Clinical
None Private Individual
Coventry CV2 4HN
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Re: Hundreds of Chinese researchers are sanctioned after mass retraction Owen Dyer. 358:doi 10.1136/bmj.j3838

The series of retraction scandals happening in China actually revealed the weak points of the current Chinese physician promotion system and reward polices. So far all of the municipal level hospitals and teaching hospitals in China already respectively developed very detailed promotion rules, mainly based on working years and academic achievements composed of original articles, acquired researching projects and scientific rewards. On the other hand, if people presented papers in high profile journals, especially top class journals, then they will earn very considerable cash prizes (1, 2). And in turn the above mentioned incentive mechanisms were definitely to stimulate publishing activities and to pursue financial benefits for each person involved.

Regrettably, this paid-to-publish phenomenon dramatically jeopardizes our clinical system, in which the performance of physicians or surgeons should be evaluated mainly on clinical experiences or the number of difficult cases rather than by academic projects or highest educational degree. It could also very easily induce academic corruption events by purchasing or plagiarizing papers. In fact, a well-organized and lucrative papers polishing industry has already been established, and only in 2015, the total article processing charges paid by Chinese researchers to open access journals already reached $72.17 million(3).

It is obvious that the Chinese government and healthcare administration should realize the academic crisis and take steps to erase the underlying industry chain. However, one of the most important urgent points in rebuilding Chinese academic justice and fairness should not be neglected -- i.e. reform of the personal promoting system, which should be developed into muliti-modules based not only on academic achievements but also on clinical experiences, and always with highest supervision as well as penalty rules in order to meet the requirement of "zero tolerance" to fraud events.

Collectively, the scandal revealed a “black hole”. Therefore, long term rectification should be anticipated and ultimately accomplished.

1. Alison McCook. Paid to publish: It’s not just China. Retraction Watch 10. August 2018.
2. Stephen Chen. The million-dollar question in China’s relentless academic paper chase. South China Morning Post 15 July 2017.
3. Academics pay journals to publish ghost-written articles to get promotions. 10 October 2016 Globaltimes.

Competing interests: No competing interests

17 August 2017
Wei Huang
Critical Care Medicine
1st Affiliated Hospital of Dalian Medical University
222 Zhongshan Road, Dalian 116023 CHINA
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Re: Gabapentinoids should not be used for chronic low back pain, meta-analysis concludes Jacqui Wise. 358:doi 10.1136/bmj.j3870

So Gabapentinoids, like NSAIDs offer no clinical benefit for spinal pain, a systematic review and meta-analysis reveals, level I evidence. [1][3]
Non-drug therapies should be first line treatment for chronic low back pain, according to a revised US guidance to clinicians. [2]

Competing interests: No competing interests

17 August 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Kalamaria, Thessaloniki, Greece
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Re: E-cigarette use and associated changes in population smoking cessation: evidence from US current population surveys Gary J Tedeschi, et al. 358:doi 10.1136/bmj.j3262

Bruce Baldwin makes a good point. It is misleading to talk of e-cigarettes as a way to stop smoking – they are merely another way of continuing nicotine addiction. E-cigarette users typically suck into their lungs vapourised nicotine together with propylene glycol, glycerine and flavourings many times a day, every day, for years on end. Whether this is safe is unknown.

In this paper it is arbitrary that quit attempts and successful quitting are defined as not smoking for at least twenty-four hours and three months, respectively. Intermittent smokers are still smokers and the concept of a ‘quit attempt’ is meaningless (1). With smoking there are only two states you can be in: either you smoke, or you don’t.

Even with the authors conflating quit attempts with successful quitting, the study showed only an increase in quit rates from 4.5% to 5.6%. That means the vast majority of the study population was still smoking.

If governments are serious about ending the smoking epidemic, they should think about closing down the cigarette factories.


Competing interests: No competing interests

17 August 2017
Gabriel Symonds
General practitioner
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Re: We read spam a lot: prospective cohort study of unsolicited and unwanted academic invitations Lynn Sadler, et al. 355:doi 10.1136/bmj.i5383

Highly <>

Greetings for another day!!!!!!

The Academic Spam Study1 investigators have not been idle. Between considering invitations to give presentations at Petrochemistry 2017 and submit manuscripts to Advances in Recycling & Waste Management, we have relentlessly been vigilant in enlightening the lamp of Spam research. We have identified Impact Spam, a novel variant of academic spam.

On June 14 2017 the 2016 journal impact factors were released. Between June 15 and August 1 2017, we received 40 emails that primarily or prominently advertised journal impact factors. 28/40 (70%) were from journals listed in Journal Citation Reports (JCR). Two were duplicates received by the same investigator, 1 a duplicate received by each of two investigators and 1 a duplicate received by each of three investigators. 12/40 (30%) emails were from journals not listed in JCR. Two were duplicates received by the same investigator, and 1 a duplicate received by each of three investigators. Thus, 31 unique emails (23 from JCR journals, 8 from non-JCR journals) were assessed.

The accuracy of impact factor measurement was impressive. Among the 27 emails that reported the metric, 23 (85%) did so to 3 decimal places, the other 4 (15%) did so to 2 decimal places. Punctuational enthusiasm for the new journal impact was modest – only 7/31 (23%) emails contained an exclamation mark, although 5 of these 7 did so in the subject line!! We were thrilled to read about new records – the impact factor of Diabetes, Obesity and Metabolism reached “an all-time high”, while that of Diabetes Care “leapt” to “the highest impact factor ever achieved by an American Diabetes Association journal”. Research Journal of Social Science and Management, from which we received 3 emails at different times, deserves special mention – its impact factor increased from 5.38 on 15 June 2017 to 6.86 on 2 July 2017, an annualised increase of 30.01.

Research on academic spam often presents challenges. Thus, we would dearly like to know the impact factors of non-JCR journals such as International Journal of Computational Engineering Research, International Journal of Pharmaceutical Research and Applications and IOSR Journal of Pharmacy, each of which is a self-proclaimed “top” or “best” impact factor journal but unfortunately forgot to include the metric in its email. We were uncertain about the visibility of publications in International Journal of Pharmaceutical Research and Applications, where “all published papers are indexed in well repute Indexing of world”. Our excitement about the stunning increase in impact factor of the World Journal of Pharmaceutical and Medical Research (from 3.535 to 4.103) was diminished when we read that it had been “positively evaluated by Scientific Journal Impact Factor Organisation, Morocco”, an organisation that unfortunately has no internet presence. We thought that Immunology and Cell Biology might have updated last year’s spam email – its subject line this year announced its 2015 impact factor.

Mindful of the modern imperative to promulgate the influence of our research, we raced to assemble manuscripts to submit to these journals which had so helpfully informed us of their impressive impact. To enhance the crafting of our personal impact statements, we determined how much the journals’ impact had burgeoned. We extracted data from JCR and calculated the change in impact factor and discipline-specific ranking of each journal between 2015 and 2016. Our enthusiasm bubbles were initially burst! The median (interquartile range) change in impact factor was 0.427 (-0.118, 0.847, n=23); for change in journal ranking it was 0 (-3.25, 3.25, n=22). Perhaps this explains why only 5/23 (22%) of the JCR-listed journals provided both the 2015 and the 2016 impact factors in their emails.

However, our enthusiasm returned when we discovered that the median (95% CI) change in impact factor between 2015 and 2016 among all 11,021 journals in JCR was 0.1 (-0.7, 1.3). This means that the impact factor trajectory of the journals which kindly sent us Impact Spam emails is 427% more positive than that of the journals which did not. Our personal impact statements can benefit after all!

Especially-eminent colleagues, Impact Spam might be more frequently served by ‘establishment’ (JCR-listed) organisations than other organisations. It might also hype minor or no changes in impact and ranking of the issuing journal. Impact Spam might become theme for major novel international conference!

1. Grey A, Bolland MJ, Dalbeth N, Gamble G, Sadler L. We read spam a lot: prospective cohort study of unsolicited and unwanted academic invitations. BMJ. 2016;355:i5383.

Competing interests: AG, MB, TC, ND and GG face imminent scrutiny of their research impact by the New Zealand Performance-Based Research Funding process, even though many spam emails attest to their awesomeness. LS wishes fervently to retain Iconic Professor status

17 August 2017
Andrew Grey
Associate Professor
Mark J Bolland, Tim Cundy, Nicola Dalbeth, Greg Gamble, Lynn Sadler
University of Auckland
Private Bag 92019, Auckland, New Zealand
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Re: Margaret McCartney: The cult of CPR Margaret McCartney. 358:doi 10.1136/bmj.j3831

The history in this piece is missing some detail. CPR was introduced in the 1960s, an emergency life saving treatment. Then doctors decided there were times when CPR should not be used such as the natural end of life, and introduced secret codes.

As patients we expect CPR to be provided if we collapse with a cardiac arrest, yet most of us have no idea how unlikely it is to work. That's because doctors decided CPR is important and special enough to be elevated to the status of not needing consent, whatever the likelihood of it working. This means we miss the description of the procedure and the 'burdens and benefits' chat. That’s a lot of vital missing information about what has often been described as a brutal process. Maybe if we knew the likelihood of CPR working when we are well, we'd understand why it will not work when we are dying.

20 years ago we did not have the Data Protection Act (just, it came in in 1998) which gives patients access to their records; we did not have information at our fingertips in the form of Google and we did not have social media to share our experiences more widely than our family and social circle. Patients were more likely to trust their doctor without question to do what was right for them, and the doctor was more likely to know more about the patient than just their clinical situation. It was a very different world to the one we live in today.

It is clear that – even more than 20 years ago – it was not acceptable to some patients that the decision to withhold CPR were recorded with secret codes. In the early 1990s the PHSO upheld a complaint about the secrecy around withholding CPR.

If at that time it had been made clear that the problem was the secrecy around the issue the 'cult' of CPR we have today would not be so. But doctors decided that a form was the way forward, giving it numerous acronyms along the way, DNAR, DNR, DNACPR, without addressing the root cause which is that whether a 'code' or a ‘form,’ it’s the communication of what that means for the patient that counts.

Add to this some doctors deciding that DNACPR means 'do not treat' it's easy to see how DNACPR has got such a terrible reputation over the years.

From a patient’s point of view, if the doctor thinks something so important it needs a name, code, documenting in their records, or form, then it is something they want to know. And these days, they often want to know everything in minute detail.

DNACPR is often that first decision that indicates that someone’s life is coming to an end. Knowing you’re dying opens chances – where to die, who you want to be with you, putting your house in order. Saying goodbye. Not knowing denies all these things and much more, and is a legacy my family live with every day since my mum died.

Maybe the detail is not important to every person, maybe that’s where the harm described by the judge comes in? It is a well advertised fact that doctors should do no harm so I’d hope it is something that can be differentiated from distress. I hate DNACPR forms, and still have nightmares about them. It was always in doctors hands to get this right, and chance after chance over the years has been missed. When secrecy reigns where openness is vital, eventually something drastic has to happen. This was always going to end up in court at some point, and I am very proud of my dad for securing the rights of patients to know about DNACPR decisions, for in the wider context I hope that this means that the conversation mum was denied will be offered to others so they get the choices she did not. And their families get the chances we did not.

I am flummoxed as to why I keep reading articles such as this that explain the barriers, but offer few ideas for solutions, especially as I have seen so much good practice in the process of attending DNACPR focus events. How about articles in the future sharing all the ideas and great practice I know is out there aimed at getting the dialogue right?

Competing interests: daughter of David Tracey who took the legal case mentioned in the article.

16 August 2017
Kate Masters
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Re: Global climate is warming rapidly, US draft report warns Michael McCarthy. 358:doi 10.1136/bmj.j3824

Dear Sir,

McCarthy reports that global climate is warming rapidly1. Warmer temperatures and increased rainfall are likely to cause important changes in the incidence and distribution of infectious diseases, including vector-borne and zoonotic diseases, water- and food-borne diseases and diseases with environmental reservoirs.

Increased temperature shortens pathogen development time in vectors. This increases the duration of infectiousness, allowing for prolonged periods of transmission to humans2. Many studies have reported associations between climate and tick-borne diseases, including tick-borne encephalitis in Sweden. In North America, there is good evidence of northward expansion of the distribution of the tick vector (Ixodes scapularis) in the period 1996–2004 based on an analysis of active and passive surveillance data3. Temperature, humidity, and rainfall are positively associated with dengue incidence. The strongly nonlinear response to temperature means that even modest warming may drive large increases in transmission of malaria, if conditions are otherwise suitable3. During the Medieval Warm Period, mention of malarialike illness was common in the European literature from Christian Russia to caliphate Spain and the English word for malaria was ague4.

In China, the modeling of medium-scenario warming indicates that the transmission zone of freshwater snail–mediated schistosomiasis will put another 20 million people at risk by 2050, as the mid-winter freezing line moves northward5.

The association between warmer temperatures and disease suggests that rates of water and food-borne illness are likely to increase with rising temperatures. Human exposure to climate-sensitive pathogens occurs by ingestion of contaminated water or food. Climate may act directly by influencing growth, survival, persistence, transmission, or virulence of pathogens. In countries with endemic cholera, there appears to be a robust relationship between temperature and the disease. Temperature is directly linked with risk of enteric disease in Arctic communities, as melt of the permafrost hastens transport of sewage (which is often captured in shallow lagoons) into groundwater, drinking water sources, or other surface waters. Increasing temperature favored growth of toxic over non-toxic strains of Microcystis in lakes in the USA3.
Ecological and meteorological changes may affect local soil ecology, hydrology and climate, resulting in the persistence of invasive fungal pathogens in the environment and release of infectious spore forms. Warmer, drier summers may have facilitated the establishment of Cryptococcus gattii in Canada. This fungus had previously been seen only in tropical and subtropical regions, but emerged on Vancouver Island in 1999, where it has caused more than 100 cases of human illness in addition to illness in domestic animals2.

Although in less developed countries, changes in infectious disease burden due to climate change will be greater than those seen in the developed world, climate change will increase the risk of infectious disease globally by expanding the ranges of species known to carry zoonotic diseases, changing pathogen dynamics in environmental reservoirs and altering pathogen transmission cycles. Climatic changes may also permit establishment of novel imported infectious diseases in regions that were previously unable to support endemic transmission2.

The best defence against increases in infectious disease burden related to climate change lies in strengthening existing public health infrastructure. Physicians, as opinion leaders, can also influence public policy related to greenhouse gas emissions.

Ricardo Pereira Igreja

1 McCarthy M. Global climate is warming rapidly, US draft report warns. BMJ 2017;358:j3824 doi: 10.1136/bmj.j3824.

2 Greer A, Victoria Ng V, Fisman D. Climate change and infectious diseases in North America: the road ahead. CMAJ 2008;178:715-22.

3 Smith KR, Woodward A, Campbell-Lendrum D, Chadee DD, Honda Y, Liu Q, Olwoch JM, Revich B, Sauerborn R. Human health: impacts, adaptation, and co-benefits. In: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth AssessmVRent Report of the Intergovernmental Panel on Climate Change [Field, CB, Barros, Dokken DJ, Mach KJ, Mastrandrea MD, Bilir TE, Chatterjee M, Eb KLi, Estrada YO, Genova RC, Girma B, Kissel ES, Levy AN, MacCracken S, Mastrandrea PR, White LL(eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 709-754, 2014.

4 Reiter P. From Shakespeare to Defoe: Malaria in England in the Little Ice Age. Emerging Infectious Diseases 2000;6:1-11.

5 McMichael AJ. Globalization, Climate Change, and Human Health. NEJM 2013; 368: 1335-43. DOI: 10.1056/NEJMra1109341

Competing interests: No competing interests

16 August 2017
Ricardo P. Igreja
Faculdade de Medicina da Universidade Federal do Rio de Janeiro
Rua von Martius 325, Rio de Janeiro, RJ, Brazil
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Re: New concepts in the management of restless legs syndrome Diego Garcia-Borreguero, Irene Cano-Pumarega. 356:doi 10.1136/bmj.j104

In our clinical practice as neurosurgeons dealing with peripheral nerve surgery, we have noticed that approximately 20-30% of patients with tarsal tunnel syndrome refer to what clinically may be considered as "restless feet syndrome". More so it is present in those patients with tarsal tunnel syndrome with a neuropathic background, such as diabetic neuropathy with overlapping entrapment neuropathies: tarsal tunnel and/or common and superficial peroneal nerve entrapment syndromes. The careful neurological examination and decompression of these tunnel syndromes, in our experience, gives a great deal of relief from the discomfort in feet and toes, especially during the night, in the short and long term.

I believe that on clinical neurological grounds, in cases of "restless leg syndrome", the clinician should search for signs of entrapment neuropathies in the lower limb and ask for electrophysiological studies. The latter do not always give useful information especially in the case of irritative stage of tarsal tunnel in particular, also due to technical difficulties. We believe that future study of this subject may yield interesting results.

Competing interests: No competing interests

16 August 2017
Ridvan Alimehmeti
Consultant Neurosurgeon
Crotti Francesco
University of Medicine, Tirana
Kongresi Manastirit, 270
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