709 e-Letters

  • International Humanitarian Law: Rule 70

    The authors of this article claim that they document this weapon to cause "superfluous injury and unnecessary suffering". This is terminology that refers to International Humanitarian Law. The International Committee of the Red Cross have catalogued these laws. Rule 70 states that "the use of means and methods of warfare which are of a nature to cause superfluous injury or unnecessary suffering is prohibited."(1) Some would say that there is no point to pursuing this legal angle because those who use IEDs tend not to be among those who sign on to the Geneva conventions. However International Humanitarian Law is considered to be customary and therefore applicable to every human being regardless of the law, or absence of law, in their own country.

    (1) https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule70

  • Barriers to real world deployment of HPV consultation guides by ENT surgeons

    I commend the authors on publishing, and, thank the patients who participated, in this exhaustive study of a difficult topic which covers taboo areas in society. As the authors note, talking about HPV in head and neck cancer is not comfortable for clinicians, with one using the phrase “a can of worms”. Interestingly although most patients were surprised and shocked that HPV caused their cancer, they found the information given in the study context and consultation guides reassuring.

    The one disappointing aspect of the study was the low clinician feedback (47%) on the eventual consultation guides produced (17 out of 36 clinicans responded). Anecdotally there remained concerns amongst the ENT surgeons who had contributed to the study that Head and Neck cancer patients would not want to know or were not interested in the HPV aspect as it was rarely brought up in consultations.

    Therefore I conducted a short and rapid assessment to assess the response to the published consultation guides amongst younger ENT surgeons (core trainee to consultant surgeons working all over Wales.

    Two questionnaires (A) and (B) were completed by ENT surgeons before and after reading the consultation guides (for clinicians and patients) produced by Hendry M et al. BMJ 2017 doi: 10.1136/ bmjopen-2016-015413. Questionnaires A and B asked about respondents’ current practice and confidence in handling such consultations completed before (A) and after (B) reading the leaflets....

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  • RE: Epistemonikos: A database not to be missed while searching systematic reviews

    The authors would like to thank Dr. Singh and colleagues for their positive comment on the findings of the review. Dr. Singh and colleagues correctly point out that an eligible review[1] was not included in our comprehensive set of systematic reviews on non-pharmacological interventions to treat behavioural disturbances in older patients with dementia[2].
    We revised our search archive and find out that the review was indeed identified from all the four electronic databases (MEDLINE, the Cochrane Library, CINAHL and PsychINFO) that generated 4 duplicates that were all erroneously deleted. We apologize to the readers for this error.
    After retrieving the review, we assessed it according to the methodology described in our original paper[2]. The review by Kong et al. (AMSTAR 6) identified 14 studies (with overall 586 participants) published between 1998 and 2003. All were randomised trials, seven of which had a cross-over design. Five of the trials [3-7] were already included in other systematic reviews identified in our original manuscript.
    The remaining studies investigated thermal bath (15 participants) [8]; platform style rocking chairs (25 participants) [9]; therapeutic recreation activities (10 participants)[10]; individualized recreational therapy interventions (29 participants)[11]; bright light therapy (8 participants)[12]; educational program on delivering abilities-focused morning care (40 participants)[13]; "stimulation-retreat" model...

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  • Combination therapy lacks sound evidence to be recommended as initial choice

    Dear Editor:

    Dr. Weir and colleagues regret in their article (1) the ‘conservative’ approach adopted by NICE, by favouring initiation of antihypertensive monotherapy no matter the basal hypertension severity (2). Thus, based on their results, the authors state that a combination therapy might be envisaged “for patients with grade 2 or 3 hypertension or high normal/grade 1 hypertension plus at least one cardiovascular condition”.
    Reliable information from observational studies, as is the case of the present cohort study, is always welcome. However, even more attention should be paid to direct comparisons from well-designed clinical trials. In this regard, a Cochrane systematic review published in January 2017 shows the best available evidence on this topic (3). Unfortunately, there is no mention to this review in the ‘Discussion’ section of Dr. Weir’s article.

    According to this review, only subgroups of participants from three studies (monotherapy: 335 participants; combination therapy: 233 participants) met the pre-defined inclusion criteria. The certainty of evidence was judged very low due to the insufficient number of participants and events. Thereby, large clinical trials are needed in order to decide which strategy, monotherapy or combination, should be adopted by doctors in different clinical situations. In the meantime, a ‘conservative’ approach represented by the ‘monotherapy’ alternative is probably the wiser recommendation we can make.

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  • Re: Letter to the Editor – The INTERMED as a complexity assessment and intervention tool

    Stiefel et al. presented much evidence concerning INTERMED. In addition to this, they presented a self-assessment version of the INTERMED (the IMSA). Indeed, INTERMED is an established tool for assessing complexity.

    The correlation between PCAM and INTERMED was shown in our article. Spearman’s rank correlation coefficient between these scores was 0.90, which indicates a strong correlation. This shows the possibility of using PCAM as a substitute for INTERMED.

    However, we recognize that INTERMED does not have obvious evidence in primary care because there are no published articles. In addition to this, Stiefel et al. pointed out the time issue for physicians. Time saving is not only useful for physicians but also other medical professions. The shortage and burnout of medical professions, including nurses, are problems in Japan and other countries[1-4]. If time for assessing anything can be saved appropriately, we think reasonably. As Stiefel et al. mentioned, another solution to resolve the time shortage is the self-administered version such as the IMSA; however, no self-administered test for measuring complexity exists in Japanese.

    We plan to study the relationships between the patient complexity and the burden of medical professions. To recognize PCAM as an established and feasible tool, many studies about PCAM are needed in future. We are glad to discuss the complexity. This concept is not major in Japan. We hope that the complexity will become to be...

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  • Wilfully misleading or simply negligent?

    In the study you say:

    "Although statins are known to reduce the risk of stroke by as much as 25%,38 benefits are undermined by suboptimal adherence. In a previous examination on patient perspectives around statin therapy, compliance with statins was associated with information provided during the practitioner consultation as well as the beliefs about cholesterol and current health status"

    'As much as 25%'

    The reference you give is to this paper:

    Afilalo J , Duque G , Steele R , et al . Statins for secondary prevention in elderly patients: a hierarchical bayesian meta-analysis. J Am Coll Cardiol 2008;51:37–45.doi:10.1016/j.jacc.2007.06.063 FREE Full TextGoogle Scholar

    The paper very clearly refers to RELATIVE RISK REDUCTION.

    Read this paper: https://www.ncbi.nlm.nih.gov/books/NBK63647/

    In fact the ABSOLUTE RISK REDUCTION is about 1%

    By stating 25% and NOT saying it is RRR you create a scare story for newspapers which creates stress for stroke survivors plus you mislead the public who think that by taking statins their risk of stroke falls by 25% which is simply not true.

    Did you do so wilfully to fit a pharma-dictated criteria or were you just negligent?

  • Re: Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans

    We read with great interest the longitudinal study by Xie et al on the Risk of death among users of Proton Pump Inhibitors (PPI) (1). The study findings suggest that there is an overall increased risk of death among PPI users when compared with histamine H2 receptor antagonists (H2 blockers) users and people who are not on either medication. We also acknowledge the efforts of the authors to statistically eliminate potential bias associated with an observational study design like this. However, we would like to highlight a few points which we believe should be considered when interpreting the results of the study.

    The authors externally adjusted for the use of other therapeutics including anticoagulants, antiplatelet agents, and non-steroidal anti-inflammatory drugs as potential confounders. However, it is not clear if Selective Serotonin Receptor Inhibitors (SSRIs) used in the treatment of Post-Traumatic Stress Disorder (PTSD) were considered and adjusted for. The Veteran population which forms the data set for this study has a higher prevalence of PTSD than the general population and is often prescribed SSRIs (2). The SSRIs are metabolized by the cytochrome P-450 isoenzyme CYP2C19, which is inhibited by the proton pump inhibitors (PPIs) leading to significantly higher levels of SSRIs in the body and potential risk of increased adverse effects (3). Some of the adverse effects of SSRIs including suicide risk could significantly contribute to mortality in the popu...

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  • Letter to the Editor – The INTERMED as a complexity assessment and intervention tool

    Yoshida et al. (1), comparing the PCAM with the INTERMED for the prediction of hospital length of stay (LOS), state (i) that the INTERMED “can be applied only to the secondary care setting” and (ii) is “relatively impractical” due to the length of the interview, and consider (iii) that the PCAM – with its “fewer items and simpler questions” – has “the potential to substitute for INTERMED”.

    First, the INTERMED has been and is utilised in the tertiary (2), secondary (3) and primary care setting (4). Second, assessing case complexity may need some time and a certain number of questions; the questions raised with the INTERMED have been validated by patients as being relevant (5) and the interview as having a positive effect (6). If physicians’ time is the issue: the INTERMED has been demonstrated good inter-rater reliability across medical professions (7) and is utilised in some settings by nurses (3). In addition, a self-assessment version of the INTERMED (the IMSA), reducing the length of the interview, has been validated in a recent multi-centred study (8). Third, when comparing the INTERMED with other instruments assessing case complexity, not only prediction of LOS has to be taken into account. The INTERMED provides a thorough biopsychosocial case complexity assessment (9); it has – unlike the PCAM, as acknowledged by the authors – been proven to be valid across various clinical settings (10) and to predict, in these settings, psychosocial, medical and health care...

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  • Antidepressant use during pregnancy and the risk of major malformations in a cohort of depressed women: Prevalence of major malformations and indication bias.

    Dear Editor,

    We thank Drs Burt, Rasminsky, Andrade, and Barros for their letters on our study published in BMJ Open in January 2017.1 We agree with them that our baseline prevalence of major malformations in the Quebec Pregnancy Cohort (QPC) is higher than the reported 3-5%. Bérard et Sheehy2 have described the QPC, and have presented baseline statistics showing that the baseline prevalence of major malformations in Quebec was 9.3%. We have disclosed that already in our Discussion section – ‘Our major congenital malformation population prevalence may seem somewhat higher than the routinely reported 3-5%, but in fact our rate is consistent with what is expected in the province of Quebec, due to high concentration of genetic risk factors stemming from the ‘founding’ French ancestors.’1,3 It is true that we are referencing another of our studies to highlight the Founders’ effect. Indeed, Zhao et al.3 have shown that the prevalence of major malformations in the province of Quebec vary by geographical regions, and are higher in the regions where the founding French ancestors first inhabited. This is a well know fact and is representative of specific genetic traits of those founding fathers. Again, this was well discussed and represented in Zhao et al.,3 and it is why we are referencing this study in Bérard et al.1 Bérard et al.1 further showed that the prevalence of major malformations among those with depression during pregnancy was even higher (greater than 11%). Howev...

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  • New onset diabetes and statins – real risk not so trivial

    We have read the article by Ooba N et al with interest. The authors have conducted a retrospective cohort study to assess the risk of new-onset diabetes associated with lipid-lowering drugs in Japanese population.

    Authors have excluded patients with diabetes characterized by HbA1c ≥6.5% or fasting blood glucose ≥126 mg/dL. However, in Table 1 (Baseline characteristics), patients are not categorized based on their HbA1c or blood sugar fasting levels as pre-diabetic (HbA1C between 5.7 to 6.4) or normoglycemic. It is important to note that the risk of new-onset diabetes among lipid-lowering users is particularly high in pre-diabetic patients (1) and hence, authors should have categorized the patients as either pre-diabetic or normoglycemic. Looking at the mean HbA1c not more than 5.2% in various groups (Table 1), it appears that the number of patients with pre-diabetes were not high. This finding of normoglycemics converting rapidly into diabetes in a mean duration of 4 to 5 months of statin use points to the gravity of the problem of statin associated diabetes which will have huge implication in clinical practice, wherein a short exposure to statins (4 to 5 months) can have the risk of shifting glucose homeostasis towards diabetes. Unlike other previous studies, wherein pitavastatin use was not associated with adverse effects on glycemic control (2, 3, 4), in this study, the risk of new-onset diabetes was highest with pitavastatin (HR-3.11). Authors should comment o...

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