Recent eLetters
Displaying 11-20 letters out of 126 published
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Untangling over-treatment from over- diagnosis
Submit responseThe battle between proponents and opponents of breast screening has reached a well entrenched stalemate. (1). A new randomised trial which could confirm or refute breast screening benefits is not realistically feasible.
The women's views in this study offers an elegant way forward. (2). We need to untangle the issue of over- treatment from over- diagnosis. Rather than concentrating on over- diagnosis, the option of active surveillance for low grade lesions needs to be explored.
The use of PSA screening in men coupled with active surveillance for low risk prostate cancer suggests that this approach is clinically feasible. (3). Non- prostate clinicians should note that active surveillance is different from wait &watch policy. Active surveillance implies close clinical observation followed by active curative treatment when there is progression of lesions (low grade cancer or DCIS) whereas a wait &watch policy implies symptom directed, often palliative, management of cancer.
A feasibility study followed by a large scale randomised study of active surveillance for 'low- risk' screen detected lesions (DCIS or cancer) is urgently needed. Cancer Research UK should use its considerable resources to kick start an active surveillance trial for women.
References
1. Independent UK Panel on Breast Cancer Screening, The benefits and harms of breast cancer screening: an independent review. Lancet 2012;380:1778-86
2. Waller J, Douglas E, Whitaker KL, Wardle J. Women's responses to information about overdiagnosis in the UK breast screening programme: a qualitive study. BMJ Open 22 Apr 2013, doi:10.1136/bmjopen-2013-002703.
3. NICE clinical guideline 58. Prostate cancer: diagnosis and treatment. 2008. http://www.nice.org.uk/CG058 (accessed 29 April 2013).
Conflict of Interest:
None declared
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Should we be afraid of catecholamines?
Submit responseLee and colleagues should be congratulated for their meticulous analysis of a large and complete database.1 They concluded from propensity score analyses in various settings (cardiac, surgical or medical ICU) that vasoactive agents were associated with increased in-hospital mortality. They state that their results are provoking and inconclusive, and we partly agree. Vasoactive treatments have already been associated with harm in congestive heart failure,2,3 which is the first diagnosis in 732 of their 3163 patients (23%). Moreover, 45% of the patients were in the cardiac (medical or surgical) ICU, were vasodilators are often used, and might lead to hypotensive episodes. Vasoactive agents were not differentiated between dopamine, dobutamine, and other vasopressors. Though, one key message might be: beware of vasoactive agents in "cardiac" patients, which is not new or provoking. However, the association between vasoactive agent and mortality was present in the surgical and medical ICU. Mean vasopressor load has already been associated with mortality in septic shock patients.4 We have to underscore a major confounding bias in their study. Although many confounding factors are collected for most of the patients, individual clinical presentation lacks. Vasoactive agents may be preferred in patients more severe, with worse mottling score,5 "grey" presentation, or when red blood cells are not immediately available and transfusion have to be delayed. Those important clinical findings, associated with worse outcome, modify medical judgment and are not apprehended by usual variables. Finally, we agree with their careful conclusion. Individual threshold for treating hypotensive episode have to be evaluated in different clinical situations, based on patient's past history and presentation. This issue is still debated. The study is not conclusive on whether catecholamines cause harm or is used in more severe patients, even with propensity score analysis. However, in the light of their study and the literature, catecholamines have to be thoroughly investigated and used cautiously as they have major beneficial hemodynamic and detrimental general effects.
References 1 Lee J, Kothari R, Ladapo JA, Scott DJ, Celi LA. Interrogating a clinical database to study treatment of hypotension in the critically ill. BMJ Open. 2012 Jun 8;2(3).
2 Thackray S, Easthaugh J, Freemantle N, Cleland JG. The effectiveness and relative effectiveness of intravenous inotropic drugs acting through the adrenergic pathway in patients with heart failure-a meta-regression analysis. Eur J Heart Fail. 2002 Aug;4(4):515-29.
3 Mebazaa A, Parissis J, Porcher R, Gayat E, Nikolaou M, Boas FV, Delgado JF, Follath F. Short-term survival by treatment among patients hospitalized with acute heart failure: the global ALARM-HF registry using propensity scoring methods. Intensive Care Med. 2011 Feb;37(2):290-301.
4 D?nser MW, Ruokonen E, Pettil? V, Ulmer H, Torgersen C, Schmittinger CA, Jakob S, Takala J. Association of arterial blood pressure and vasopressor load with septic shock mortality: a post hoc analysis of a multicenter trial. Crit Care. 2009;13(6):R181.
5 Ait-Oufella H, Lemoinne S, Boelle PY, Galbois A, Baudel JL, Lemant J, Joffre J, Margetis D, Guidet B, Maury E, Offenstadt G. Mottling score predicts survival in septic shock. Intensive Care Med. 2011 May;37(5):801- 7.
Conflict of Interest:
None declared
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The high cost of diarrhoeal illness for urban slum households - a cost- recovery approach: a cohort study.
Submit responseDear editor, I refer to the article: The high cost of diarrhoeal illness for urban slum households - a cost- recovery approach: a cohort study. I appreciate this article since findings are exposing and could highly contribute to measures that can break the vicious cycle of poverty and illness. Slum populations are usually faced with many challenges; health being one of them. The vicious cycle of ill health is affecting many urban slum populations. Diarrhoeal illnesses are one of the biggest causes of morbidity in Sub Saharan Africa (Kaseje 2006) and therefore controlling disease and investing in health is critical to achieving poverty reduction. I am interested in the way you have broken down different but critical elements in your study. The breakdown of the basic costs brings out a subtle but primary important factor; transport that is used to travel to a provider. In fact many urban poor will not access health care even if the cost of health care was free with the reason of preferring to use what they would spent on transport for something else. It is also true that treating and managing diarrhoeal illness becomes more costly (given the avoidance costs that you have clearly observed in your study) than putting mechanisms in place to control it. You also mention that women in the household who were victims of diarrhoeal illness or with a case of diarrhoea illness were unable to complete an average of seven tasks that week due to a case of diarrhoeal in the household. The burden of illness, health care and other household chores seem to be the responsibility of the women in households among the urban slum populations especially in developing countries. Therefore when a woman who is key to the survival of the household is affected, productivity goes down and the entire household or community could be affected due to the triple role of a woman. I agree with the findings of your study that the savings from lower costs of water and sanitation from improved infrastructure can be put toward paying for that infrastructure and over time completely finance it. However, I also tend to think that people who have attained higher education (college level) would think more of investing in health promotion than people with a lower level of education. It is true that your study adds further evidence to breaking the myth that urban slum populations do not have the financial capacity to pay for improved infrastructure. Moreover urban slum populations have a tendency to live from hand to mouth implying that they may not have adequate capacity for savings. Thank you for this exposing study that beings out very key elements that need to be looked at in assessing not only the cost of diarrhoeal illness but many other common illnesses among the urban slum population on different continents.
Conflict of Interest:
None declared
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Parents' first moments with their very preterm babies: a qualitative study 1. Leah Arnold1, 2. Alexandra Sawyer1, 3. Heike Rabe2, 4. Jane Abbott3, 5. Gillian Gyte4, 6. Lelia Duley5, 7. Susan Ayers6, 8. on behalf of the 'Very Preterm Birth Qualitati
Submit responseThis paper is an awakening call to the health workers to start realizing the feelings of parents when the bundles of joy turn out to be bundles of psychological and emotional fragmentation. This being the first study to describe the initial experiences of parents of very preterm infants in the UK and may be the first one I have come across, I find it a really interesting subject. In a scenario where the health systems are poor, I would imagine the feelings of a baby in NICU would differ a little bit. According to my experience, parents feel so pathetic and angry because they feel like they have already lost the battle and they might lose the baby anyway. An assessment could be done in the scenario I have just described to see if it could give a different outcome. It is interesting that fathers also have a share of feelings which are often ignored by health workers and counselors when they are going through loss or fear when the mother has a premature baby. With these findings the professionals will be keen to prepare the fathers during antenatal clinics on what they would expect if the baby is born before time and what their role would be. It would also be interesting to find out how the other members of the family would be affected by the birth of a preterm baby.
The limitation, which you have sited of assessing white parents only could have produced a bias in generalization of results and therefore I would be interested to see the findings in a different situations and especially in Africa. The study population was only drawn from parents who could speak fluent English, meaning that may be their education level is good, but what could be the results among parents who are not educated. I would wish that the same study be carried out in some parts of Africa and among black women and also among women with little education for comparison In conclusion, this study brings to attention feelings of parents with preterm babies and this information will help health workers to plan for interventions.
Conflict of Interest:
None declared
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Comment
Submit responseFone David L et al have done a study on socioeconomic patterns of excess alcohol and binge drinking in Wales UK which is very informative and stimulates related studies for public policy. The study concurs with the previous ones that harmful patterns of alcohol consumption is common among the economically disadvantaged as in the previous studies as it concludes that low income and unemployment are determinants of harmful alcohol consumption. In the findings binge drinking was found among those with low SES while excessive consumption was among those with better SES. I think binge drinking and excessive consumption are equally harmful hence the conclusion is biased when it does not categories excess drinkers who have income. Although the predisposing factors of these SES categories are different as explained, the dangers associated with excessive consumption are equally significant for public health policy just as binge drinking. Both are harmful yet they affect diverse socio-economic classes as indicated by the study.
Conflict of Interest:
None declared
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The influence of time pressure on adherence to guidelines in primary care: an experimental study
Submit responseThe influence of time pressure on adherence to guidelines in primary care: an experimental study by Evangelia Tsiga, Efharis Panagopoulou, Nick Sevdalis, Anthony Montgomery, and Alexios Benos.
The editor,
I wish to congratulate the researchers of this marvelous work on the experimental study that very few researchers have ever ventured into. From this study, there seems to be a lot that is not fully accomplished when clinicians treat patients in the clinical placement areas during the practitioner's clinical practice, and if done fully the practice is not well done to the satisfaction of the patient and at times to the satisfaction of the clinician in the practice. As such this study is an eye opener to what many clinicians have never dwelt on in the way they use their time to accomplish their guidelines in their daily practice. I therefore support the study in totality and concur with the findings. From my own perspective work overload, patient crisis, emergencies and competing interests pose a risk in effective management of the sick at the health facilities. However much of the solution to the influence on time pressure on adherence to guidelines in primary care may be found in Marslows hierarchy of needs number 5 on self actualization, and Hersey and Blanchard's level of readiness (1988), which is considered appropriate in diagnosing health care environment in its 2 components of ability and willingness. In such situations one must have the ability to solve problems (i.e knowledge and experience) yet the clinician should have the ability to carry out task with self confidence, commitment and self respect. So this study was very important when applied to the current situations in clinical practice since it addresses the clinician's unexpected tasks that emanate from time pressure on adherence to guidelines.
Conflict of Interest:
None declared
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An assessment of a large-scale HIV prevention programme for high-risk men who have sex with men and transgenders in Andhra Pradesh, India: using data from routine programme monitoring and repeated cross-sectional surveys
Submit responseThis article of Goswami et al is about an assessment of an HIV intervention programme.The author has clearly come up with the assessment of a large-scale HIV prevention programme, using programme monitoring data and data from two cross-sectional surveys. Avahan's programme evaluation framework, was used in this assessment ending up with three key outcomes that is the: (1) scale and intensity of coverage of the Avahan programme; (2) self-reported consistent condom use (defined as always use of a condom during each and every sex act, and measured as yes/no) and (3) prevalence of STIs including HIV. The author has generated data through documentation which is one of the data sources recommended in research. The author has discussed how the intervention programme has been successful and basing the arguments on one of the outcomes of the assessment which relied on a self-reported consistent condom use which was measured as yes/no. The author got restricted by the sources of data used which did not include having a one to one in-depth -interview with the studied population. Sometimes, in a question of yes/no, the respondent may lean towards wanting to please the researcher, and being a closed ended question, there may not be an opportunity to explore further. Probably, the outcome could have been more stronger when the author could have included, another source of data like a one to one in-depth interview with some of the study population so as to counter check or guard against questions which may be answered with the intention of wanting to please the researcher instead of revealing what is actually happening on the ground. In-depth interview is effective for getting people to talk about their personal feelings and experiences as well as addressing sensitive topics (Mack et al 2005) and may help the researcher have a better understanding when arriving at a conclusion. The assessment of the above intervention programme could have been strengthened if the author could have interacted with the study population through unstructured interview.
Conflict of Interest:
None declared
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The high cost of diarrhoeal illness for urban slum households-a cost-recovery approach: a cohort study
Submit responseI do appreciate the findings of the author of this paper however it is important to break down the recommendations suggested especially on promoting health promotion. This is a strategy that has been tested and proved to reduce if not to eradicate ill health and poverty in our society. Urbanization is rapidly growing in the world over especially in Africa, and it is necessary for various governments to ensure that there are policies put in place that foresee the control of urbanization in 100 years ahead. Health promotion in this case should consist of strengthening capacity building in the community and empowering them to solve their own problems. This calls upon community health strategy implementation as a strategy which includes formation of community health committee (CHC) which identifies health issues affecting the community and report to the nearest health facility through community health extension worker (CHEW) who links the community with the health facility. The CHEW leads community unit in a sub location which consist of trained community health workers who are committed to work on behalf of the community on educating the households on good health. Each community health worker (CHW) takes care of 50 households. This will ensure solutions to MDGs 4 and 5 including prevention of diseases such diarrhea which is a common disease that affects highly populated areas with poor sanitation. Countries that have adopted this strategy, the government together with the support of other partners, have experienced reduction in diseases prevalence. It is important therefore that most effort should be put in prevention rather than curing which has proved to be costly.
Conflict of Interest:
None declared
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Qualitative analysis of patients' feedback from a PROMs survey of cancer patients in England
Submit responseI read with much interest about the factors impacting quality of life for cancer patients. I agree on the need for efforts to support patients to manage following completion of cancer treatment through provision of preparation and well as consistent provision of post cancer treatment support.
Lack of information is also a challenge faced in low and middle income countries such as Kenya where I come from.
I noted that while in England friends and family members play that all important support role, in Kenya, this role extends to wider local community and religious groups. Being a resource constrained and highly communal setting, this heavy role played by social capital to meet the after treatment needs is worthy of comment.
Conflict of Interest:
None declared
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Title: Performance -based assessment and demand for personal care in older Japanese people: a cross sectional study.
Submit responseDear Editor
I refer to the Article: Performance -based assessment and demand for personal care in older Japanese people: a cross sectional study by Hiroyuki et al.
I commend Japan for a responsive traditional culture that has maintained citizens to a world record of high population of 127 million and mean age of 79.4 (male) and 85.9 (female) elderly. Japan further deserves commendation for introducing and refocusing the scope of Long Term Care Insurance (LTCI) to address the physical and mental ability for the elderly citizens which my country Kenya, and I believe many developing countries is lacking.
Areas that were assessed are relevant to the elderly across demographic variations and gender. A common problem in the elderly that missed assessment or mention is the physiologic impairment of vision. This tends to be a common problem of the elderly characterized by blurred vision which can possibly result in common home accidents like falls leading to fractures.
This article is an eye opener and a challenge to countries that have not considered the rapidly growing number of elderly and which is a current world phenomena
Conflict of Interest:
None declared
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