SIDS is characterized and diagnosed by exclusion, especially when
expert pediatric pathologists, trained forensic investigators, and learned
epidemiologists are unable to find a sufficient cause of infant death at
autopsy, at the scene, or in the data, respectively. Therefore the cause
of SIDS may be invisible or immeasurable. Furthermore, SIDS is
characterized by the fact that in every such case that the parents had no...
SIDS is characterized and diagnosed by exclusion, especially when
expert pediatric pathologists, trained forensic investigators, and learned
epidemiologists are unable to find a sufficient cause of infant death at
autopsy, at the scene, or in the data, respectively. Therefore the cause
of SIDS may be invisible or immeasurable. Furthermore, SIDS is
characterized by the fact that in every such case that the parents had no
premonition that their infant was at imminent risk of death and "there was
a complete absence of prodromal symptoms or any departure from the normal
sufficient to justify the parent in seeking medical advice (1)."
Therefore, most authors now look at risk factors that are not causes of
death (prone sleep position, maternal smoking, etc.) However, they
overlook three possible causal factors that alone might be insufficient to
cause SIDS, but may act simultaneously in order to do so, that appear in
this paper, as follows:
1) An unknown X-linked recessive allele for SIDS susceptibility with
frequency q = 2/3, in Hardy-Weinberg-Equilibrium (HWE), that predicts the
50% male excess of SIDS for equal numbers of males and females at risk.
The XY male is at risk with q = 2/3 and the XX female is at risk with q x
q = 4/9, a 50% male excess. Given a nominal 5% male excess birth rate the
expected male fraction is 0.612 for 60 x 1.05 males per 40 females (2).
Table 1 reports 898 male and 578 female SIDS, for male fraction = 0.613;
2) Physiological anemia (3) causing the lognormal-type age
distribution of SIDS in their Figure 1 that is its most unique
characteristic. Unfortunately, "cases and controls over 1 year of age
were excluded", which is like 'throwing the baby out with the bathwater.'
The upper 1-year limit for SIDS is an artifact of the perception that SIDS
over 1 year may include more false positives, so they should not be
included in research studies.(4) Physiological anemia occurs when fetal
hemoglobin (HbF) decays rapidly after birth while adult hemoglobin (HbA)
slowly begins to replace the HbF. The term infant has its lifetime maximal
total Hb at birth and it rapidly falls to their lifetime minimal Hb at or
about 2-months of life, and then it follows a slow increase until a new
equilibrium Hb concentration is established [we neglect here the different
binding strengths of oxygen molecules to HbF and HbA, and pre-term Hb
relations]. We estimated 19 as the missing number over 1-year that the
authors excluded, by fitting an exponential decay curve to the numbers of
SIDS from 8 weeks to 52 weeks in Figure 1 and extrapolating it to 178
weeks as determined previously as the upper limit for SIDS.(5) We then fit
these weekly data (w) by the Johnson SB transformation that y = Log[(w +
1.343)/(178 - w)] where y = mu + sigma z, and mu = -1.025, sigma = 0.3, w
is age in weeks, and z is a standard normal deviate. We interpret this
Figure 1 as the number of the most anemic genetically susceptible infants
whose total mix of Hb = HbF + HbA falls below some critical threshold, and
therefore cannot survive a respiratory infection (see below) that reduces
blood oxygenation in the lungs sufficiently to create an acute anoxic
encephalopathy resulting in neuronal death. Hemoglobin concentration
cannot be measured accurately at autopsy because of the gravitational
settling of red blood cells during hemostasis leading to lividity so it is
missing in virtually all SIDS autopsy studies (6); and
3. A prodromal respiratory infection (PRI) contracted from a family
member that begins to fulminate shortly before or after the infant is
placed for its final sleep. Farber (7) reported such a case where a baby
was cared for by a nurse because the mother had a severe sore throat at
the time. After a 2 p.m. uneventful feeding by the nurse, the baby was
found dead 1.5 hours later, "lying on his back. There was no evidence of
bedclothes, pillow or any other object over his face." We propose that
the only thing that could have changed from the immediately previous sleep
condition, sufficiently to cause death and be unnoticed, had to be a PRI
that began to fulminate and cause fatal anoxic encephalopathy "before an
important or appreciable amount of lung parenchyma has been involved." The
author's Table 1 can provide no data on a potentially fatal respiratory
infection presence in the SIDS cases, because, if such visible evidence
existed at autopsy, the diagnosis by definition would not be SIDS.
However, these data in Table 1 cast a visible shadow of a fulminating PRI.
The authors list the SIDS and Control Live-Birth-Order (LBO) as shown
below. We assume that Cohabiting Family Members (CFM) = 2 adults + (LBO -
1) Siblings = LBO + 1. We then assume that the probability of not carrying
a communicable respiratory infection (CRI) (symptomatic or asymptomatic)
is P so the probability of at least one CFM carrying a CRI is 1 - P^(CFM).
Setting P = 0.92 by least squares gives the Model values shown. We
previously fit U.S. LBO and SIDS data with P = 0.90 (8). Note that a plot
of SIDS Fraction or SIDS Model vs CFM goes to the origin (0, 0) that
implies that there are no SIDS cases here that are independent of CFM.
LBO = 1, SIDS = 407, Control = 1836, SIDS Fraction = 0.181, Model =
0.152;
LBO = 2, SIDS = 491, Control = 1566, SIDS Fraction = 0.239, Model =
0.219;
LBO = 3, SIDS = 280, Control = 748, SIDS Fraction = 0.272, Model =
0.280;
LBO = 4, SIDS = 149, Control = 304, SIDS Fraction = 0.329, Model =
0.337;
LBO = 5+, SIDS = 122, Control = 200,SIDS Fraction = 0.379, Model =
0.390.
In summary, SIDS may occur from these three causal factors (genetic
susceptibility, physiological anemia, PRI) acting simultaneously that are
a function of chance, age and CFM, respectively. There is no explanation
we can find in the medical literature , other than an X-linkage in HWE,
for a constant male fraction that is different from that of the male birth
fraction. There is no explanation other than the maximum hemoglobin at
birth for the virtual absence of SIDS immediately after live birth that is
the most risky time for all other causes of infant death, the peak SIDS
rate at or about the total Hb nadir, followed by an exponential decrease
in SIDS rate as the infant's total HbA increases. We know of no other
invisible cause of a sudden and unexpected infant death than a fulminating
PRI that leaves no visible trace for the pathologist at autopsy or under
the microscope in a genetically-susceptible physiologically-anemic infant.
REFERENCES
1. Davison WH. Accidental Infant Suffocation. Br Med J.
1945;2(4416):251-2.
2. Mage DT, Donner EM. A genetic basis for the sudden infant death
syndrome sex ratio. Med Hypotheses 1997;48:137-42.
3. O'Brien RT, Pearson HA. Physiologic anemia of the newborn infant.
J Pediat 1971;79:132-8.
4. Willinger M, James LS, Catz C. Defining the sudden infant death
syndrome (SIDS): deliberations of an expert panel convened by the National
Institute of Child Health and Human Development. Pediatr Pathol.
1991;11(5):677-84.
5. Mage DT. A probability model for the age distribution of SIDS. J
Sudden Infant Death Syndrome and Infant Mortality 1996;1(1):13-31.
6. Poets CF, Samuels MP, Wardrop CA, et al. Reduced haemoglobin
levels in infants presenting with apparent life-threatening events--a
retrospective investigation. Acta Paediatr. 1992;81(4):319-21.
7. Farber S. Fulminating streptococcus infections in infancy as a
cause of sudden death. NEJM 1934;211:154-9.
8.Mage DT, Donner M, A unifying theory for SIDS. Int J Pediat 2009;
2009:368270
Please be aware that cytomegalovirus (CMV) has a preference for
endothelial tissue.
It has been proposed that Vitamin D may be interacting with CMV in
the expression of endothelial conditions (1-5).
Also be aware that there may be time-dependant (i.e. year the study
was conducted) relationships between the outcome observed in some studies
(1-11).
References
1. Jones R (2013) Could cytomegalovirus be causing widespread
outbreaks of chronic poor health. In Hypotheses in Clinical Medicine, pp
37-79, Eds M. Shoja, et al. New York: Nova Science Publishers Inc.
Available from: http://www.hcaf.biz/2013/CMV_Read.pdf
2. Jones R (2013) Recurring outbreaks of a subtle condition leading
to hospitalization and death. Epidemiology: Open access 4(3): 137.
3. Jones R (2014) A Study of an Unexplained and Large Increase in
Respiratory Deaths in England and Wales: Is the Pattern of Diagnoses
Consistent with the Potential Involvement of Cytomegalovirus? British
Journal of Medicine and Medical Research 4(33): 5179-5192.
4. Jones R (2015) Roles for cytomegalovirus in infection,
inflammation and autoimmunity. In Infection and Autoimmunity, 2nd Edition,
Eds: N Rose, et al. Elsevier: Amsterdam. Chapter 18, pp 319-357.
5. Jones R (2015) An unexpected increase in adult appendicitis in
England (2000/01 to 2012/13): Could cytomegalovirus (CMV) be a risk
factor? British Journal of Medicine and Medical Research 5(5): 579-603.
6. Jones R (2015) A previously uncharacterized infectious-like event
leading to spatial spread of deaths across England and Wales:
Characteristics of the most recent event and a time series for past
events. British Journal of Medicine and Medical Research 5(11): 1361-
1380.
7. Jones R, Beauchant S (2015) Spread of a new type of infectious
condition across Berkshire in England between June 2011 and March
2013:Effect on medical emergency admissions. British Journal of Medicine
and Medical Research 6(1): 126-148.
8. Jones R. (2015) Unexpected and Disruptive Changes in Admissions
Associated with an Infectious-like Event Experienced at a Hospital in
Berkshire, England around May of 2012. British Journal of Medicine and
Medical Research 6(1): 56-76.
9. Jones R (2015) Recurring Outbreaks of an Infection Apparently
Targeting Immune Function, and Consequent Unprecedented Growth in Medical
Admission and Costs in the United Kingdom: A Review. British Journal of
Medicine and Medical Research 6(8): 735-770.
10. Jones R (2015) A new type of infectious outbreak? SMU Medical
Journal 2(1): 19-25.
11. Jones R (2015) Are emergency admissions contagious? BJHCM 21(5):
227-235.
Please note: Anna Coleman,Julia Segar, and Imelda Mcdermott are in
the Centre for Primary Care, University of Manchester and not in
University of Kent.
We read with interest the study titled "Evaluation of a tobacco
prevention programme among teenagers in Sweden". [1] This study makes a
great contribution to the tobacco prevention programs. However we would
like to bring out few points.
As the investigators had assigned the intervention (exposure), this
study cannot be considered a cohort study and it does not have to
qualities to be called a randomized contr...
We read with interest the study titled "Evaluation of a tobacco
prevention programme among teenagers in Sweden". [1] This study makes a
great contribution to the tobacco prevention programs. However we would
like to bring out few points.
As the investigators had assigned the intervention (exposure), this
study cannot be considered a cohort study and it does not have to
qualities to be called a randomized controlled trial. Therefore, this
study design may be most appropriately called a Quasi-experimental design
with non-equivalent comparison. [2] We appraised the article based on the
TREND checklist [3], which was primarily designed for reporting
nonrandomized evaluations of behavioural and public health interventions.
The article did not comply with many items in this checklist but we
highlight a few important concerns here.
Complete details regarding the intervention such as the actual
content of intervention, deliverer, delivery method, information on unit
of delivery, number of sessions delivered and length of each session, the
setting were not provided. Primary outcomes of the study were not clearly
defined, in that they have measured only the prevalence of tobacco use
rather than comparing the reduction in the prevalence of tobacco use. This
would have also taken care of baseline variations (such as differences in
the living conditions) between the comparison groups. Also, the authors
have mentioned that the prevalence of smoking in the study area has
decreased in the last 10 years; so to rule out any secular trend in the
prevalence of smoking in this area and to attribute the change in smoking
to the intervention an Interrupted Time Series Analysis [4] could have
been performed.
Bivariate and multivariate analysis (Table 1) showed that there were
no significant differences in the prevalence of smoking between the
control group, participants, and non-participants at the end of the
intervention. But the authors have mentioned that the prevalence of
smoking was significantly lower among participants compared with non-
participants and the control group by using Test for Trend between 3
groups at the end of intervention (Figure 2). We believed that the impact
of this program could have been better estimated using baseline and follow
up data and performing a Propensity Score weighted Difference-in-
Difference analysis. [5] These important limitations cast a doubt over the
method of analysis and the interpretations arising thereof and they have
to be corrected or borne in mind to prevent wrongful conclusions.
References
1. Hedman L, Andersson M, Stridsman C, Ronmark E. Evaluation of a
tobacco prevention programme among teenagers in Sweden. BMJ Open
[Internet] 2015;5(5):e007673-e007673. Available from:
http://bmjopen.bmj.com/cgi/doi/10.1136/bmjopen-2015-007673
2. U.S. Department of Health and Human Services. Centers for Disease
Control and Prevention. Office of the Director. Office of Strategy and
Innovation. Introduction to Program Evaluation for Public Health
Programs?: A Self-Study Guide. 2011;(October):1-100.
3. Jarlais D, Cynthia L, Crepaz N. Improving the Reporting Quality
of Nonrandomized Evaluations of Behavioral and Public Health
Interventions: The TREND Statement. Am J Public Health 2004;94(3):361-6.
4. Lagarde M. How to do ( or not to do ) . . . Assessing the impact
of a policy change with routine longitudinal data. Health Policy Plan
[Internet] 2012;(January 2011):76-83. Available from:
http://heapol.oxfordjournals.org/content/27/1/76.full?sid=3e9e83cf-fbcc-
4140-a869-b02f14f3074c
5. Shahidur K, Koolwal G, Samad H. Handbook on Impact Evaluation:
Quantitative Methods and Practices. The World bank; 2009.
I read with great interest the article by Rees et al (1) which
represents the first assessment of trainee and trainer perceptions towards
'supervised learning events' (SLEs). The Foundation Programme in the UK
has been pioneering in its transition from 'workplace based assessments'
(WBAs) to SLEs, with the aim of emphasising the formative intent of the
tools, to improve engagement of trainees with th...
I read with great interest the article by Rees et al (1) which
represents the first assessment of trainee and trainer perceptions towards
'supervised learning events' (SLEs). The Foundation Programme in the UK
has been pioneering in its transition from 'workplace based assessments'
(WBAs) to SLEs, with the aim of emphasising the formative intent of the
tools, to improve engagement of trainees with their learning potential.
When reading the original recommendation from the GMC, to adopt this
new nomenclature, I asked myself if this simple 'rebranding' would be
sufficient to change the prevailing negativity that exists within the
medical workplace towards, what many trainees, and some trainers, see as
simply 'tick-box' exercises (2).
It was interesting to read that, in general, trainees perceived SLEs
in a more positive light than WBAs. However, what was clear is that some
confusion persists - apparently more so in trainers. A recommendation from
this study that is repeatedly highlighted in numerous other publications
on this subject is the need for training - of both trainees and trainers,
in the use of these tools. The lack of understanding that apparently
exists in the workplace is no doubt at the root of much of the
dissatisfaction and misuse of WBA and SLE tools.
It was not clear from the study if the issue of training was examined
by the authors. It would have been interesting to gain an insight into
what (if any) training both trainees and trainers received in the use (and
introduction) of these 'new' tools. I wonder if no specific training was
provided to either group.
This work appears to demonstrate that rebranding WBAs as SLEs has
gone some way to improve trainee perceptions, but that there remains much
potential for improvement. I would propose that until trainees and
trainers have a more complete understanding of WBA tools, negative
perceptions and misuse of WBA or SLE tools will remain prevalent in the
workplace.
References
1. Rees CE, Cleland JA, Dennis A, Kelly N, Mattick K, Monrouxe LV.
Supervised learning events in the Foundation Programme: a UK-wide
narrative interview study. BMJ Open. 2014 16;4(10)
2. Ali J. Workplace-based assessments: Lost in translation? Clinical
Teacher 2014; 11(1): 68-9
Letter to the Editor: The need for and provision of intrathecal
baclofen therapy for the management of spasticity in England: an
assessment of the Hospital Episode Statistics database
Xiulu Ruan, MD, Adjunct Clinical Associate Professor of Anesthesia
(corresponding author)
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
Letter to the Editor: The need for and provision of intrathecal
baclofen therapy for the management of spasticity in England: an
assessment of the Hospital Episode Statistics database
Xiulu Ruan, MD, Adjunct Clinical Associate Professor of Anesthesia
(corresponding author)
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
Alan David Kaye, MD, Ph.D., Professor and Chairman of Anesthesia
Dept. of Anesthesiology, Louisiana State University Health Science Center
1542 Tulane Ave. New Orleans, LA 70112
Word Count Without References: 695
We read with interest the article by Narendran and colleagues, "The
need for and provision of intrathecal baclofen therapy for the management
of spasticity in England: an assessment of the Hospital Episode Statistics
database" published on June 30, 2015 in BMJ Open (1).
First, we would like to point out that the statement, "Baclofen is
well absorbed orally, but because of its hydrophilic nature, it crosses
the blood-brain barrier poorly." is somewhat inaccurate. It is believed
that the transport of baclofen may be carrier mediated (2, 3). Therefore,
despite its unfavorable physicochemical properties, baclofen is
therapeutically active following oral administration. In this regard, it
is true that intrathecal baclofen therapy (ITB) has evolved into an
effective alternative treatment for severe spasticity, especially in
patients with spinal cord injury and multiple sclerosis, as Narendran et
al. have suggested.
We believe the reason for the observed gap between the need for and
provision of ITB is multifactorial. Our speculation is that the
challenging and tedious IT baclofen trial protocols can be one of the
reasons. It is well accepted that prior to permanent ITB pump placement, a
trial should be performed to document efficacy of spinal baclofen (4, 5).
Usually, the candidate is admitted inpatient to the hospital, an
intrathecal bolus injection of a dose of baclofen between 50 mcg and 100
mcg is given (6), a physician or physical therapist performs focused
serial neuromuscular examinations, using commonly accepted spasticity
rating scale, i.e., the Ashworth Scale, or the Modified Ashworth Scale
(7), to assess the reduction of spasticity, following the IT baclofen
bolus. Trialing for baclofen is usually performed as a single shot bolus.
However, in patients with severe hemiparetic spasticity or in patients
where weakness in the unaffected limb might significantly affect quality
of life, single shot bolus trialing technique may be inadequate. In these
patients, placement of a temporary intrathecal catheter and inpatient
admission may be a more effective trial method (4).
One of the authors (XR) has performed an outpatient baclofen epidural
infusion trial with significant positive result (5). We believe such a
trialing method offers the patients and their caregivers the opportunity
to experience and to observe the therapeutic change from a functional
point of view, i.e., how they perform with their activities of daily
living (ADL). There were reported cases of worsening ambulation or
transfers following permanent ITB pump placement following ITB bolus
trial, as some of the tonicity were used by patients to perform pivot
transfer or assist ambulation, when their lower extremities became totally
flaccid with ITB infusion,
they lost their ambulating abilities (8). This underscores the importance
of performing a thorough evaluation, including functional improvement
during a patients' ADL, rather than a mere reduction of Ashworth score.
Regardless what trialing method, it will require a team effort of the
treating physician, physical therapist, implanting physician, the patient,
and the patient's family members to conduct such a trial before deciding
on the candidacy for the patient to receive a permanent ITB pump.
Therefore, it is highly likely that because there are so many stakeholders
involved in the trialing process, this has, in part, resulted in limited
growth in ITB in recent years despite its demonstrated efficacy.
Another reason we believe which might explain the observed gap
aforementioned is the special skill and expertise in managing patients
with indwelling ITB pumps. ITB overdose or withdrawal, either due to pump
failure or refill error, can be fatal. Unlike spinal cord stimulator
therapy, which does not involve IT infusion of medication, a
malfunctioning device can be easily adjusted by turning the stimulator
off, without the concern of worrying about potential medication delivery
to the IT space and its related adverse effects, which can include
overdose or withdrawal. Thus, the treating physician has to be willing to
take the extra responsibility and liability of managing patients with ITB
pumps.
Lastly, reimbursement charges to the hospital, anesthesiologist, or
the implanting physician may be another area of consideration as to
explain limited growth in ITB pump placement. In the USA, we have
encountered some hospitals refusing to allow physician implantation of IT
pumps for spasticity or pain control related to reimbursement cuts to the
hospitals.
References:
1. Narendran RC, Duarte RV, Valyi A, Eldabe S. The need for and
provision of intrathecal baclofen therapy for the management of spasticity
in England: an assessment of the Hospital Episode Statistics database. BMJ
Open. 2015;5(6):e007517.
2. Zhang H, Schmidt M, Murry DJ, Donovan MD. Permeation and systemic
absorption of R?and S?baclofen across the nasal mucosa. Journal of
pharmaceutical sciences. 2011;100(7):2717-23.
3. van Bree JB, Heijligers-Feijen CD, de Boer AG, Danhof M, Breimer DD.
Stereoselective transport of baclofen across the blood-brain barrier in
rats as determined by the unit impulse response methodology.
Pharmaceutical research. 1991;8(2):259-62.
4. Harned ME, Salles SS, Grider JS. An introduction to trialing
intrathecal baclofen in patients with hemiparetic spasticity: A
description of 3 cases. Pain physician. 2011;14(5):483-9.
5. Ruan X, Chen T, GW B, Hamilton J, Peavy A, Harville S, et al. Novel
Epidural Baclofen Infusion Trial for Intractable Spasticity with Long-Term
Follow-Up Observation and a Focused Review of the Literature. Journal of
Pain & Relief. 2013;2(2).
6. Rawicki B. Treatment of cerebral origin spasticity with continuous
intrathecal baclofen delivered via an implantable pump: long-term follow-
up review of 18 patients. Journal of neurosurgery. 1999;91(5):733-6.
7. Damiano DL, Quinlivan JM, Owen BF, Payne P, Nelson KC, Abel MF. What
does the Ashworth scale really measure and are instrumented measures more
valid and precise? Developmental medicine & child Neurology.
2002;44(02):112-8.
8. Pin TW, Mccartney L, Lewis J, WAUGH MC. Use of intrathecal baclofen
therapy in ambulant children and adolescents with spasticity and dystonia
of cerebral origin: a systematic review. Developmental Medicine &
Child Neurology. 2011;53(10):885-95.
Figures 3 and 4 in the above publication are misplaced and marked
with the wrong captions
What is Figure 3 should be Figure 4 and Figure 4 should be Figure 3.
The right captions would then be:
Figure 3: Summary of the PAMANECH Intervention (in blue)
Figure 4: PAMANECH Project Data collection plan (table in black and
white).
Figures 3 and 4 in the above publication are misplaced and marked
with the wrong captions
What is Figure 3 should be Figure 4 and Figure 4 should be Figure 3.
The right captions would then be:
Figure 3: Summary of the PAMANECH Intervention (in blue)
Figure 4: PAMANECH Project Data collection plan (table in black and
white).
Surgery should not be performed unless a medical condition has
developed. This is a fundamental concept in surgery [1, 2]. Unless a
disease or medical condition is present the risk of surgery cannot be
balanced against a risk of disease. If no disease is present no risk can
be accepted [1]. This would make male circumcision in infants
unacceptable, especially given the risk of death due to blood loss [3,4].
Surgery should not be performed unless a medical condition has
developed. This is a fundamental concept in surgery [1, 2]. Unless a
disease or medical condition is present the risk of surgery cannot be
balanced against a risk of disease. If no disease is present no risk can
be accepted [1]. This would make male circumcision in infants
unacceptable, especially given the risk of death due to blood loss [3,4].
Hidden motivations for circumcision can result from the trauma
associated with the amputation of an area of the genitals [5]. People who
have been circumcised, had people close to them circumcised or performed
circumcision could encourage others to embrace circumcision, without fully
considering the dangers, in order to deal with the trauma. This may occur
consciously or subconsciously.
Research into amputation would require consenting adults who would be
fully informed about what will be amputated and the associated dangers. An
alternative to this would be people having tissue removed to help solve a
medical problem that has developed. The person's health after the
procedure can then be monitored and studied. For many occurrences of male
circumcision it appears the surgery has been carried out on children and
now attempts are being made to explain why it was done. An example of this
is the argument about circumcision to prevent sexually transmitted
diseases (STDs) and the human immunodeficiency virus (HIV). A person who
is circumcised can still contract HIV.
Circumcision cannot be compared to vaccination as unlike vaccination
it deprives the child of healthy tissue.
Care must be taken to watch out for any bias in research (conscious
or subconscious). This is relatively easy to notice in male circumcision
research. For example the basic surgical concept (mentioned above) will
often not be addressed or mentioned. Alternative arguments will not be
addressed or discussed. There are three examples of this for male
circumcision. Firstly, alternative factors, such as
personal hygiene and exposure to carcinogens will not be discussed or
considered. Secondly, lack of education amongst adults and medics means
they often retract the foreskin with force causing damage to the gland,
foreskin and opening the urethra further increasing the risk of infection
especially during bathing. This concept of lack of education is often
ignored and forgotten when a bias exists. Thirdly, less extreme methods
(such as education and testing before sexual intercourse for HIV
prevention and less invasive surgery for foreskin tightness [6]) will be
ignored.
REFERENCES
1. J M Hutson, Circumcision: a surgeon's perspective, J Med Ethics,
2004;30:238.
2. American Academy of Pediatrics, Committee on Fetus and Newborn.
Standards and recommendations for hospital care of newborn infants. [5th
ed]. Evanston, IL: American Academy of Pediatrics, 1979
3. Baker RL. Newborn male circumcision: needless and dangerous.
Sexual Medicine Today. 1979;3(11):35-36.
4. Bollinger, Dan. Lost Boys: An Estimate of U.S. Circumcision-
Related Infant Deaths. Thymos: Journal of Boyhood Studies. 2010;4(1):78-
90.
5. R Goldman, Circumcision: The Hidden Trauma, Boston, Vanguard
Publishing, 1997
6. P. M. Cuckow, G Rix, and P. D.E. Mouriquand Preputial Plasty: A
Good Alternative to Circumcision Journal of Pediatric Surgery, Vol 29 (4):
(April), 1994: pp 561-563
Like second hand smoke, burning the incense ( a common practice in
India, particularly as a ritual at temples and at religious ceremonies) is
also a source of indoor pollution. It is documented to cause inflammation
of the human lung cells ( A study from University of North Carolina, USA,
2013). In the past, already respiratory symptoms, headaches, exacerbation
of the cardiovascular diseases and changes in the lung-cell f...
Like second hand smoke, burning the incense ( a common practice in
India, particularly as a ritual at temples and at religious ceremonies) is
also a source of indoor pollution. It is documented to cause inflammation
of the human lung cells ( A study from University of North Carolina, USA,
2013). In the past, already respiratory symptoms, headaches, exacerbation
of the cardiovascular diseases and changes in the lung-cell functions are
well documented.It is timely that ban on incense production and its use be
enforced.
Figure 3 reports yearly lung cancer incidence per 100 000 inhabitants and not percentage as stated in the main text (page 5, end of results).
Conflict of Interest:
None declared
SIDS is characterized and diagnosed by exclusion, especially when expert pediatric pathologists, trained forensic investigators, and learned epidemiologists are unable to find a sufficient cause of infant death at autopsy, at the scene, or in the data, respectively. Therefore the cause of SIDS may be invisible or immeasurable. Furthermore, SIDS is characterized by the fact that in every such case that the parents had no...
Dear Sirs,
Please be aware that cytomegalovirus (CMV) has a preference for endothelial tissue.
It has been proposed that Vitamin D may be interacting with CMV in the expression of endothelial conditions (1-5).
Also be aware that there may be time-dependant (i.e. year the study was conducted) relationships between the outcome observed in some studies (1-11).
References
1. J...
Please note: Anna Coleman,Julia Segar, and Imelda Mcdermott are in the Centre for Primary Care, University of Manchester and not in University of Kent.
Conflict of Interest:
None declared
We read with interest the study titled "Evaluation of a tobacco prevention programme among teenagers in Sweden". [1] This study makes a great contribution to the tobacco prevention programs. However we would like to bring out few points.
As the investigators had assigned the intervention (exposure), this study cannot be considered a cohort study and it does not have to qualities to be called a randomized contr...
Dear Editor
I read with great interest the article by Rees et al (1) which represents the first assessment of trainee and trainer perceptions towards 'supervised learning events' (SLEs). The Foundation Programme in the UK has been pioneering in its transition from 'workplace based assessments' (WBAs) to SLEs, with the aim of emphasising the formative intent of the tools, to improve engagement of trainees with th...
Letter to the Editor: The need for and provision of intrathecal baclofen therapy for the management of spasticity in England: an assessment of the Hospital Episode Statistics database
Xiulu Ruan, MD, Adjunct Clinical Associate Professor of Anesthesia (corresponding author) Dept. of Anesthesiology, Louisiana State University Health Science Center 1542 Tulane Ave. New Orleans, LA 70112
Alan David Kaye, M...
Dear Editor in Chief-BMJ Open,
Figures 3 and 4 in the above publication are misplaced and marked with the wrong captions What is Figure 3 should be Figure 4 and Figure 4 should be Figure 3.
The right captions would then be: Figure 3: Summary of the PAMANECH Intervention (in blue)
Figure 4: PAMANECH Project Data collection plan (table in black and white).
Kind regards,
Paulin...
Surgery should not be performed unless a medical condition has developed. This is a fundamental concept in surgery [1, 2]. Unless a disease or medical condition is present the risk of surgery cannot be balanced against a risk of disease. If no disease is present no risk can be accepted [1]. This would make male circumcision in infants unacceptable, especially given the risk of death due to blood loss [3,4].
Hid...
Like second hand smoke, burning the incense ( a common practice in India, particularly as a ritual at temples and at religious ceremonies) is also a source of indoor pollution. It is documented to cause inflammation of the human lung cells ( A study from University of North Carolina, USA, 2013). In the past, already respiratory symptoms, headaches, exacerbation of the cardiovascular diseases and changes in the lung-cell f...
Pages