877 e-Letters

  • High LDL-cholesterol is not a risk factor in elderly people

    In their study of cardiovascular risk factors in elderly people, Ni et al. have included high LDL-cholesterol (LDL-C). However, in a meta-analysis of 19 studies where the authors had followed elderly people for several years after having measured their LDL-C, we found that in the studies including more than 92% of the participants, those with the highest LDL-C lived the longest. None of the studies found the opposite and hitherto, supporters of the cholesterol hypothesis have not been able to find such a study either. A logical conclusion is that high LDL-C cannot be the most important cause of cardiovascular disease (CVD), the commonest cause of mortality in elderly people.

    1. Ni W, Weng R, Yuan X, et al. Clustering of cardiovascular disease biological risk factors among older adults in Shenzhen City, China: a crosssectional study. BMJ Open 2019;9:e024336. doi:10.1136/bmjopen-2018-024336.
    2. Ravnskov U, Diamond DM, Hama R, et al. Lack of an association or an inverse association between low-density-lipoprotein cholesterol and mortality in the elderly: a systematic review. BMJ Open. 2016;6:e010401.

  • Impact of an older peoples care programme

    We thank Dr Jones for his comment on our paper but do not believe that changes in patterns of deaths would alter our conclusions. Absolute numbers of deaths are essentially driven by three factors; the size of a population, the demographic makeup of the population (i.e. age and sex distribution) and life expectancy. Changes in any of these factors can lead to a change in the absolute number of deaths in a given time period. Our analytical approach explicitly accounts for two of these three factors. We accounted for changes in population size (through the offset term in the Poisson regression) such that we were modelling the effect on admission rates rather than crude admission number. Our regression framework adjusted for age and gender, thus accounted for changes in population demographics and furthermore was restricted only to patients aged 65 and over. Given that changes in life expectancy have been minimal in recent years we are confident that the issue raised does not threaten the validity of our results.

  • Impact of an older peoples care programme

    This is an interesting study which may have omitted to correct for a hidden cost driver. The nearness to death effect implies that around half of a person's lifetime acute admissions and bed occupancy occurs in the last year of life. After a 35 year decline deaths in England reached a minimum in the 12-month period ending January 2012 and then proceeded to show a large and ongoing increase. However, the trend for England is the composite of local area trends. For example, Office for National Statistics monthly data for Southwark shows that deaths reached a maximum of 1,441 in the 12-months ending Sep-10, declined to a minimum of 1,249 for the 12-months ending Mar-13 and then rose to another maximum of 1,412 for the 12-months ending May-16. Hence the intervention period is marked by rising deaths and rising costs due to persons in the last year of life. May I suggest that you recalculate the utilization and costs with an emphasis on those who were and those who were not in the last year of life. Hope this helps.

  • Response to Mayer and Muche (2019)

    We thank Mayer and Muche for their response to our article on measuring minimal medical statistical literacy. The authors argue that the Quick Risk Test – which tests the understanding of ten basic concepts such as sensitivity and specificity – does not cover all relevant aspects of minimal medical statistical literacy. According to them, minimal medical statistical literacy also entails a proper understanding of study design features, adequate descriptive measures, the need to adjust results by regression analysis and the validity of results from inferential statistics, including confidence intervals and the principles of statistical testing. We fully agree that physicians need to understand the above concepts in order to correctly interpret scientific medical evidence. At the same time, we define minimal medical statistical literacy as a set of skills that enables physicians to evaluate medical tests, treatments, interventions and results, i.e., skills critical to daily clinical practice. Given that the students and faculty members we tested did not adequately understand these basic concepts, we have no reason to assume that they would have understood more complex concepts such as confidence intervals. In fact, previous studies indicate that the majority of physicians do not even understand p-values1-3. Once medical schools and CME providers teach and physicians understand the basic concepts tested with the Quick Risk Test, we would be happy to develop a test for the mor...

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  • The 16th International Medical conference of Basra Medical school

    Medical education in Iraq was one of the best educational systems in the region, especially during the 1980s. However, it went through difficult decades of wars, sectarian conflicts, and financial sanctions. Today, and after more than a decade of the 2003 Gulf war, medical education and training in Iraq continue its confident strategic plan to shape the future of medical education in Iraq with optimism.
    I attended the 16th International Meeting in Basra Medical School which presented more than 75 abstracts. The conference was well attended by more than 300 delegates and senior officials and professors from Basra university and academics from other universities in Iraq. I presented my experience with the cancer screening programmes in the UK for bowel and liver cancers to transfer knowledge and learned lessons to my Iraqi medical colleagues. The concept was well received and I am working with the local authorities in Basra to implement the action points from the meeting.
    I was very impressed by the quality of the studies and scientific discussions workshops that were held during the meeting. Iraqi doctors and scientists, despite all the difficulties and limited resources, managed to maintain their knowledge and pursue good quality research in various aspects of medicine. A second medical school in Basra was launched recently to meet the demand of doctors in Basra and the southern part of Iraq. The new medical curriculum is based on the up-to-date teaching metho...

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  • In response to Dr. Mark F. Sheehan, MD on his comment titled: Is the dose of PBM appropriate in this study

    Thank you for your comments, Dr Sheehan. Be assured, we have taken great care in the development of this study and dose selection was a crucial component. While Dr. Sheehan cites a “recommended” dose for our study, there is no citation presented that validates his clinically suggested dose for a very different device. In fact, dosage at the “target” is not considered the standard means of dose measurement [1]. The suggestion that the use of a Class 4 laser at 60 to 80 J/cm2 at the surface would result in better outcomes and match your suggested dose range at target does not have validity. Anders, et al. [2] found that only about 2.5% of the light penetrated to the level of the muscles and it was through white albino rabbit skin. Even negating the effects of skin pigmentation, the resulting dose of 1.5 to 2 J/cm2 would be approximately half of the dose suggested by Dr. Sheehan. It should be noted that doses for high-powered lasers has not been established in the literature and specifically for low back conditions.

    In fact, most of the claims by the class 4 industry are not scientifically supported, and head to head comparisons have showed better outcomes in favor of low-powered devices (class 3B and/or below) when compared to high-powered devices (class 4) [3].
    Furthermore, the selection of our study dose was based upon guidelines suggestions by the World Association for Laser Therapy [4], consultation with the research group that performed a similar study for...

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  • Shameful

    The authors' assertion that sham acupuncture represents an active intervention and therefore would not be useful as a comparison I find uncompelling. This study is drivel as the difference between groups is likely driven completely by the placebo effect. I am disappointed to see this published by a journal that I associate with quality. It's a shame that media outlets will call this trial "controlled".

  • ACOM was not a properly randomized trial

    To my surprise BMJ has published a poorly controlled study. Instead of "non intervention" the control group had to be subjected to a "sham acupuncture" (my suggestion is putting the needles at random or in a "scientific way"). Otherwise the well known Hawthorne effect must have been anticipated. Did the reviewers comment on this?

  • #She looks like a surgeon

    As an aspiring female plastic surgeon, this article makes compelling reading. Many of the experiences and options highlighted are representative of my experience so far in pursuing a surgical career. As with 88% of respondents I also feel that surgery is a male dominated career and have experienced discrimination. In F1, my general surgical consultant scoffed at my intention to become a surgeon and when I looked indignant called me a "difficult woman" accompanied by sniggers from the male registrar. More often it is patients who do not recognise me as a surgeon, being routinely addressed as nurse or asking when they were going to see the doctor despite introducing myself or whilst wearing a lanyard with DOCTOR written all over it. Even other doctors have assumed that the plastic surgeon will be a male, for example addressing referral letters ‘dear sir’. I have found it frustrating that my male colleagues do not experience the same attitude, and felt pressure to prove myself as good as the men.

    However there have been several encouragements for me as a trainee surgeon. Despite some of the comments of consultants in my foundation years, the vast majority of consultants in Core Surgical Training have been supportive and I haven't felt disadvantaged compared to my male counterparts. The British Association of Plastic and Reconstructive Surgeons (BAPRAS) has recently launched a pilot project called the Juggling Club. This initiative has been introduced by...

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  • Unravelling neutrophil heterogeneity in chronic airway disease

    To the Editor:

    Human neutrophils play an immunoregulatory role in innate immunity, inflammation and resolution. Airway neutrophilia is a distinguishing feature of chronic airways disease, including COPD and severe asthma [1]. Evidence incriminating neutrophils in the immunopathogenesis of these diseases have provided a rationale for novel drugs discovery selectively targeting inflammatory pathways [1, 2]. However, the extent to which this may be linked to disease pathobiology remains unresolved.

    Advances in facets of neutrophil biology have uncovered novel observations, challenging the traditional view of the neutrophil as a short-lived, terminally differentiated homogeneous cell with a limited lifespan. Newly emerging functions of neutrophils have been reported, including neutrophil extracellular trap (NET) formation, consisting of ejected DNA microwebs that can entrap pathogens [3]. Importantly, there has been a paradigm shift in recent years with the realisation of heterogenous neutrophil subsets that may perform disparate immunomodulatory roles in homeostasis, infection and disease [4]. The group led by Koenderman and his colleagues in 2012 were the first to report the comprehensive characterisation of three distinct cellular subsets of circulating human neutrophils following endotoxin challenge in an experimental model of acute systemic inflammation in human healthy volunteers [5]. In parallel, a similar compartmentalisation has been shown in cancer immu...

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