References

Pilcher C, Dajer A. How to avoid missing an aortic dissection. ACEP NOW 2023; 42 (6): 14.

Green SM, Schriger DL, Yealy DM. Methodologic standards for interpreting clinical decision rules in emergency medicine: 2014 update. Ann Emerg Med 2014; 64: 286-291

Phillips B. Clinical decision rules: how to build them. Arch Dis Child Educ Pract Ed 2010; 95: 83-87.

Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. Circulation 2010; 121: 1544-1579. 

Rogers AM, Hermann LK, Booher AM, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for the identification of acute aortic dissection at initial presentation. Circulation 2011; 123: 2213-2218. 

Tsutsumi Y, Tsujimoto Y, Takahashi S, et al. Accuracy of aortic dissection risk score alone or with D-dimer: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care 2020; 9: S32-S39.

—Steven G. Rothrock MD, FACEP, FAAP

Re: “Toxicology Q&A: The Fig Tree” 

I read with great interest Dr Hack’s article on the toxicity of fig trees. Growing up in my village of Deir-el-Qamar, or Monastery of the Moon, a reference to a Phoenician temple in the mountains of Lebanon, we had native fig trees everywhere. The delicious “refreshing waterdrop-shaped packages of goodness” as he describes their fruit so aptly was a daily late summer treat for us. There were so many varieties, including white figs, brown figs, and the late early-winter ripening red figs. Figs were called “the king of fruits” with many varietals and even more lovers. To Dr. Hack’s point, we were always warned, as kids, while picking figs to never touch our eyes. The white milky sap that oozes from the stem once you pick the fruit can cause blindness. And indeed, my dad often referenced an elder in the village who had lost his sight because of that; he was sadly blinded as a child in the 1920s. On a historical note, it is well known in modern Lebanese history that around 1798–1799, during Napoleon Bonaparte’s Egypt-Syria campaign and his two-month siege of the old city of Acre, his troops who were starving, were saved by Emir Bashir al-Shihaby, ruler of Deir-el-Qamar and the Emirate of Mount-Lebanon, after he sent him caravans loaded with dried figs.

And to come full circle with the story, my wife and I have a beach house on Emerald Isle, NC, not too far from Dr. Hack’s East Carolina University. And we have a native fig tree in the sandy soil, but the birds eat all the fruit before they ripen. That fig tree in particular has a smell that I hate, but my wife loves it. For years, we argued. So what was the denouement? The rest of the story will be for another day.