SummaryBackground Submissions to medical and scientific journals are vetted by peer review, but peer review itself has been poorly studied until recently. One concern has been that manuscript reviews in which the reviewer is unblinded (e.g. knows author identity) may be biased, with an increased likelihood that the evaluation will not be strictly on scientific merits. Objectives The purpose of this study was to compare the outcomes of blinded and unblinded reviews of manuscripts submitted to a single dermatology journal via a randomized multi-rater study. Materials and methods Forty manuscripts submitted to the journal Dermatologic Surgery were assessed by four reviewers, two of whom were randomly selected to be blinded and two unblinded regarding the identities of the manuscripts' authors. The primary outcome measure was the initial score assigned to each manuscript by each reviewer characterized on an ordinal scale of 1-3, with 1 = accept; 2 = revise (i.e. minor or major revisions) and 3 = reject. Subgroup analysis compared the primary outcome measure across manuscripts from U.S. corresponding authors and foreign corresponding authors. The secondary outcome measure was word count of the narrative portion (i.e. comments to editor and comments to authors) of the reviewer forms. Results There was no significant difference between the scores given to manuscripts by unblinded reviewers and blinded reviewers, both for manuscripts from the U.S. and for foreign submissions. There was also no difference in word count between unblinded and blinded reviews. Conclusions It seems, at least in the case of one dermatology journal, that blinding during peer review does not appear to affect the disposition of the manuscript. To the extent that review word count is a proxy for review quality, there appears to be no quality difference associated with blinding.
Sir:We present an interesting case of possible mannitolinduced manic state in a depressed elderly woman.Case report. Ms. A, a previously well-adapted 75-yearold woman without personal or family history of mental disorders, presented with a first episode of severe major depression (DSM-IV criteria). On the 10th day of antidepressant treatment with nortriptyline, 50 mg/day, a diagnosis of bilateral acute angle closure glaucoma was made. Continuous intravenous infusion of mannitol 20% (500 cm 3 in 1 hour), oral acetazolamide (500 mg), and topical treatment with pilocarpine 2% (1 drop/15 min), timolol 0.50% (1 drop/15 min), and dexamethasone 0.1% (1 drop/15 min) were prescribed simultaneously. Thirty minutes later, when her pain had diminished, Ms. A became euphoric, and she remained overactive, overly affectionate, and talkative, showing pressured speech and flight of ideas and telling jokes. Her manic state remitted in 1 hour after cessation of mannitol infusion, and her severe depression came back dramatically.In a search for potential causes of secondary manic states, an exhaustive laboratory evaluation (with toxicologic screening included) and a careful medical examination were carried out. At no time was Ms. A febrile, and no evidence of cognitive impairment, hallucinations, or fluctuation in her level of consciousness was observed. No neurologic deficits were present. No metabolic dysfunction seemed to be related to these symptoms, and electroencephalogram showed no disturbance. Cranial magnetic resonance imaging revealed unspecific mild subcortical and cortical atrophy. Her plasma nortriptyline level was 65 ng/mL. Ms. A's major depression was treated with electroconvulsive therapy, and 1 year later, no further mania or depression had appeared. She is currently taking venlafaxine, 150 mg/day.On the basis of the lack of abnormal findings in medical examination and complementary diagnostic proofs, we considered that Ms. A's manic state might be associated with her medications.1,2 Assuming that there are 15 drops/mL and that 100% systemic absorption is improbable, we believe that the total dose of drugs administered by topical application was very low and not enough to cause mania. Manic features induced by pilocarpine or corticosteroids have been described, 3,4 but daily and higher doses were used. With regard to acetazolamide, pharmacokinetic data show that plasma drug levels after oral treatment peak at 2 hours, 5 after manic state has already abated. Euphoria following daily nortriptyline treatment has been described as well, 6 but the rapid and spontaneous regression of manic symptoms in the present case makes this option unlikely. For all of these reasons, it appears that intravenous mannitol may have provoked the episode of mania, particularly if we consider that progressive remission of manic symptoms was observed after discontinuation of intravenous infusion of mannitol and that the intensity of manic symptoms correlated with expected plasma mannitol levels. Mannitol levels were indirectly measured in ...
Topical 20% arnica ointment may be able to reduce bruising more effectively than placebo and more effectively than low-concentration vitamin K formulations, such as 1% vitamin K with 0·3% retinol.
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