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Journal Issue: 
Volume 49: Issue 3: 2019
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J R Coll Physicians Edinb 2019; 49: 262–3



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Cannabis hyperemesis syndrome: still under recognised after all these years

Lua et al.1 explored cannabis hyperemesis syndrome (CHS) as an important cause of cyclical vomiting. CHS can be ‘Easily Missed’ as recently reviewed by Chocron et al.2 in the BMJ, and delayed diagnosis is common. CHS can be devastating1,2 with prolonged suffering for patients, the potential for multiple costly admissions and invasive investigations, and CHS may lead to various complications. Fatalities have been reported.3

I commend Joanne Lua and Chris Isles for working with Lauren Olney to share the patient experience, and the Journal of the Royal College of Physicians of Edinburgh for its encouragement of this patient–doctor partnership.1

Lauren’s story illustrates a number of important learning points: cyclical vomiting is a diagnostic challenge; cannabis use should be borne in mind when exploring a patient’s social history; although debilitating and highly disruptive, CHS resolves with cannabis cessation, which can be life-changing (from ‘constant pain, phoning in sick for work and not leaving the house…’ and ‘taking morphine a lot … or using heatpads every day’, after stopping smoking, Lauren reported that “all of the side effects went away, the pain in my side, sickness every day, nausea every day, extreme pain when I went to the toilet, absolutely everything ‘vanished’” and has since ‘been able to focus on … becoming a self employed artist and [is] going to be a mum’); and, cannabis cessation is difficult – psychological and/or pharmacological support may be required.2

Lua et al.1 rightly highlight that CHS is ‘likely to increase in prevalence and relevance to clinical practice’. Cannabis remains the most widely used drug worldwide.4 In the USA, an estimated 2.75 million people may suffer with CHS each year.5 It is, therefore, important that awareness of CHS is raised amongst the medical community. I believe memorable patient stories1 and impactful medical education1,2 are key.

Professor John Plevris (University of Edinburgh) gave a related lecture on cyclic vomiting syndrome at this year’s Vomiting/Nausea Evening Medical Update of the Royal College of Physicians of Edinburgh, which was held on 26 February 2019. This interesting lecture is available to all Members on the College’s Education Portal (

Christopher J Graham
Royal College of Physicians of Edinburgh, Edinburgh, UK
doi: 10.4997/JRCPE.2019.319
Financial and Competing Interests: CJG is the Online Education Officer working on the Royal College of Physicians of Edinburgh’s Education Portal


1 Lua J, Olney L, Isles C. Cannabis hyperemesis syndrome: still under recognised after all these years. J R Coll Physicians Edinb 2019; 49: 132–4.

2 Chocron Y, Zuber J-P, Vaucher J. Cannabinoid hyperemesis syndrome. BMJ 2019; 366: l4336.

3 Nourbakhsh M, Miller A, Gofton J et al. Cannabinoid hyperemesis syndrome: reports of fatal cases. J Forensic Sci 2019; 64: 270–4.

4 United Nations Office on Drugs and Crime. World Drug Report 2019. United Nations Office on Drugs and Crime; 2019. (accessed 23/07/19).

5 Habboushe J, Rubin A, Liu H et al. The prevalence of cannabinoid hyperemesis syndrome among regular marijuana smokers in an urban public hospital. Basic Clin Pharmacol Toxicol 2018; 122: 660–2.

Obligations of academia in peer review

Misra and Ravindran1 highlight many relevant issues relating to peer review in academia. They address the importance of peer review, conflicts of interest and how the peer review process can be facilitated. These are all important for scientific publishing and for the awarding of research grants, which also relies heavily on peer review.

Many of us contribute to peer review as a philanthropic act believing that this contributes to improving patient welfare and helps ensure that false claims are not made from research. Increasingly, the pressures on nonacademic staff, e.g. full-time National Health Service (NHS) consultants, may sadly reduce their contribution. However, there is huge value in those who end up delivering on the outcome of research being involved as they bring a perspective that may not be available in academia. NHS Trusts and Clinical Directors should encourage and facilitate this.

The issue of financial incentives raised by Misra and Ravindran1 is somewhat controversial. Amongst the advantages are that those requesting a report can insist that it is of a suitably high standard and forwarded on time before a payment is made. However, payment may not help in recruiting the right reviewers but rather those seeking additional income. Nonetheless, if the use of financial incentives could be shown to improve the quality, and timeliness of reports, then this approach is worth pursuing further. Already, it is used by some national and other grant-awarding bodies, as part of the research awarding process.

There is also an obligation on academia to make a bigger contribution to safeguarding the peer review process. Universities, medical schools and other academic institutions are ranked according to the quality of publications and research income, both dependent on peer review, even if these rankings are sometimes considered controversial.2 While many if not most academic staff are generous with their time as reviewers for journals and research grant-awarding bodies, and as journal editors, this activity is not usually mandatory or monitored. Nonetheless, there are some academics who believe that this is an activity for others and who do not contribute. At no time when asked to comment on a submission for promotion from another academic institution, have I ever been asked to consider the input of the applicant to the peer review process, and whether it is even adequate. Some details are usually included in the curriculum vitae of the applicant, but this is not explicitly part of the assessment.

Given that academic institutions are dependent on peer review, it is high time that they recognised this formally by insisting that all academic staff contribute to peer review, include it in job descriptions, monitor peer review activity amongst their staff, and consider it as a metric in academic promotion.

Hilary Humphreys
Department of Clinical Microbiology, RCSI Education and Research Centre, Beaumont Hospital, Dublin, Ireland
doi: 10.4997/JRCPE.2019.320


1 Misra DP, Ravindran V. Peer review in academic publishing: threats and challenges. J R Coll Physicians Edin 2019; 49: 99–100.

2 Vernon MM, Balas EA, Momani S. Are university rankings useful to improve research? A systematic review. PLoS ONE 2018; 13: e0193762.