951 e-Letters

  • Three questions

    The findings here by Denise van Hout et al that in Dutch ICUs, SDD has a very high probability of cost-effectiveness as compared to SOD is of great interest. However, do their findings support the implementation of SDD in settings with low levels of antimicrobial resistance? There are three specific questions.
    Firstly, is the hospital mortality of the SDD and SOD groups comparable to expected? In this regard, the untreated group from the original de Smet et al study [ref 13] had an in-hospital mortality that was not significantly different to either the SDD or SOD groups in an unadjusted analysis. Of note, Denise van Hout et al concede the play of chance as the best explanation for the difference in the findings of two included studies even with the two studies as large as they were.
    Second, why has the standard care group from the original de Smet et al study [ref 13] not been included in their analysis? As they note, SDD is not yet widely implemented in the Netherlands due to concerns in relation to prolonged selective antibiotic pressure. So, with this in mind, what is standard care in this context? Moreover, a large multi-center comparison to standard care [ref 20] has been excluded after failing to meet the study inclusion criteria. This [ref 20] study failed to demonstrate a mortality difference between these groups in a crude or an adjusted analysis.
    Thirdly, as the authors note, surveillance of respiratory and rectal carriage with Gram-negative ba...

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  • some thoughts about your plans.

    Dear Ferozkhan,
    I read about your interesting plans to study the prevalence of common mental health disorders in adults who are high or costly users of healthcare services in BMJ Open.
    Please allow me to share with you some thoughts about your plans produced by our own research.
    - We studied the prevalence of (physical, mental and social) problems in the Netherlands (as defined by the GP on the Problem list; ICPC) in (persisting) frequent attenders 1 and whether we could predict, with these GP data, which frequent attender would persist in this behaviour.2
    - We found that high users and costly users are two different groups. Frequent users of primary care3 have higher average/median costs (also and especially in sec care), but high costs are mostly generated in sec care.4
    - We also found that costs are more substantial in persisting frequent users. Perhaps you can consider to differentiate between temporarily and persisting frequent users.
    - Costs are very high in a few outliers. Do you exclude these patients from your research?? Median costs? Average costs?
    - We also found that anxiety, and especially panic disorder, is associated with persistence of frequent attendance in primary care.5
    Much success with your plans!

    Kind regards,
    Frans Smits, GP PhD

    1 Smits FT, Brouwer HJ, Ter Riet G, Van Weert HCP. Epidemiology of frequent attenders: A 3-year historic cohort study comparing attendance, morbidity and pr...

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  • Query regarding Orthoptics Omission

    Dear BMJ Open,

    I wish to raise a concern in relation to an article in the BMJ Open Volume 9 Issue 8 titled 'Comparison of amblyopia in schoolchildren in Ireland and Northern Ireland: a population-based observational cross-sectional analysis of a treatable childhood visual deficit' written by Siofra Harrington(1), Karen Breslin(2), Veronica O'Dwyer(3) and Kathryn Saunders(4).

    On behalf of Orthoptists within Northern Ireland we feel we should bring to your attention the omission in this article of any reference to Orthoptics or Orthoptists, and the excellent long established Orthoptic Led Vision Screening Service that exists across the whole of Northern Ireland for the detection of amblyopia as a preventable and treatable condition as recommended by Hall and Elliman in "Health for all children".

    In mainstream schools across Northern Ireland all consented children at four to five years of age are tested by their school nurse with the Keeler LogMAR crowded visual acuity test. Children tested that achieve a score of less than 0.2 LogMAR are referred into Orthoptic Services and the Multi-Disciplinary Eye Team (including Optometry and Ophthalmology) for assessment, diagnosis and treatment of many eye conditions including amblyopia. This is part of the school nurse training provided by Orthoptists described in their training manual relating to the vision screening pathway developed by the Public Health Agency and relevant stakeholders....

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  • Current T2DM guidelines are unsuccessful - my clinical way of fighting T2DM, based on Diabetic Constitution-Dependent, Inherited Real Risk

    The irrefutable fact that about half of the diabetics in the world have not yet received diagnosis shows that all guidelines for T2DM have inexorably failed. As long as physicians around the world ignore the five diabetic stages, and are not be able to bedside recognize the Diabetic Constitution-Dependent, Inherited Real Risk using a stethoscope and remove it with Reconstructing Mitochondrial Quantum Therapy, T2DM will continue to be a growing pandemic (1-5).

    1) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
    2) Sergio Stagnaro and Simone Caramel (2013). Inherited Real Risk of Type 2 Diabetes Mellitus: bedside diagnosis, pathophysiology and primary prevention. Frontiers in Endocrinology. Front. Endocrinol., 26 February 2013 | https://doi.org/10.3389/fendo.2013.00017
    3) Sergio Stagnaro. Siniscalchi's Sign. Bedside Recognizing, in one Second, Diabetic Constitution, its Inherited Real Risk, and Type 2 Diabetes Mellitus. 24 December, 2010, http://www.sci-vox.com, http://www.sci-vox.com/stories/story/2010-12-25siniscalchi%27signi.bedsi... www.sciphu.com;...

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  • Quantifying and describing burden of suicide mortality in Canadian Veterans

    Dear Editor-in-Chief,

    We are writing to you in response to Mahar et al.’s (2019) recent publication in your journal (“Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data”).

    The authors found a lower risk of suicide in Canadian Armed Forces (CAF) Veterans (former members) using Ontario Health Insurance Plan coverage, in contrast to the findings of higher CAF Veteran suicide risk in the Canadian Forces Cancer and Mortality Study (CF CAMS) and the Veteran Suicide Mortality Study (VSMS), which use nation-wide Vital Statistics and cancer registry data collected by Statistics Canada. We strongly feel that there is synergistic value in having different studies by different investigator groups using different data sources, but it is essential to understand the limitations in these different approaches and their findings.

    Mahar et al. state that their study was the “...first study of suicide risk in Canadian veterans...” However, CF CAMS, which looked at suicide risk in Canadian Veterans, was published eight years prior to the Mahar et al. study (Statistics Canada, 2011). This was followed by the Veteran Suicide Mortality Study (VSMS) Technical report was published in 2017 (Simkus et al., 2017), its accompanying peer-reviewed publication (VanTil et al., 2018), and the 2018 VSMS Technical report (Simkus et al., 2018).

    We have questions about the authors’ choice of covariates for the adjusted an...

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  • Extrinsic factors can demotivate students: a response from a medical students perspective

    We thank Belinda WC Ommering et al. for their insightful and original research regarding how medical students motivation translates into research involvement. Whilst the article focusses on motivation of medical students wanting to be involved in research and the resultant degree of participation, we believe it is important to remark on the extrinsic barriers that medical students may face in obtaining research experience despite being highly motivated and the effect this can have on their motivation to participate in research. We are sharing our thoughts on this article from the point of view of two final year medical students involved in undergraduate research. Our response includes results from a short live survey carried out at a student research conference we held locally.

    Previous studies indicate that students encounter personal and organisational barriers to research such as inadequate skill or training, limited access to information and unsupportive or unmotivated supervisors1 2. Students reported that a lack of proper training in understanding and writing papers, and difficulty finding an encouraging supervisor were two of the main barriers to conducting research as an undergraduate3. These students seemed to be motivated more by extrinsic factors, as 66.7% reported that the main reason they published their research was to improve their curriculum vitae3.

    During the student research conference we held, students were provided with a live questionnair...

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  • Comorbidities and opportunistic detection do not stop AAA screening from being cost-effective and equity enhancing.

    The recently published article by Chan et al. questions the value of AAA screening. [1] We question the validity of the arguments and the data they use to support it, which we believe are either irrelevant or support the case for screening. Furthermore, the Chan et al. paper completely neglects the important equity gains that AAA screening can produce in the New Zealand (NZ) population.

    Chan and his co-authors’ critique of AAA screening is based on 3 arguments: (i) patients with AAA are too sick with other comorbidities to benefit from screening and die of these other illnesses; (ii) most patients with AAA would be diagnosed by the health system anyway without a screening programme; and (iii) the size of the population that can benefit from screening is too small for it to be cost effective. Let us look more closely at each of these.

    Co-morbidities in patients with AAA

    The authors emphasise the point that co-morbidities in AAA patients might limit the benefit they attain from screening. They calculate that 77% of those dying of AAA had some other comorbidity. However, to imply that these were fulminant conditions and that preventing AAA death in this group would have been futile because they are moribund is highly misleading. The collection of co-morbidities includes: atrial fibrillation (a condition very prevalent in any elderly population), cardiovascular disease (CVD), also highly prevalent especially for Māori (which could range in severity f...

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  • Connecting Gout with Sleep Apnea

    One aspect of gout which is too often overlooked in guidelines and in practice is that most gout flares are initiated during sleep. The sleep connection has been known at least since Dr. Thomas Sydenham, himself a gout sufferer, wrote about it in 1683. A recent study [1] confirms Dr. Sydenham's observation. It is a very important clue to the pathogenesis of gout whether symptomatic or not.

    Many gout flares are a direct result of sleep apnea, and overcoming the sleep apnea can cure the gout. Four epidemiologic studies have been reported that show gout to be significantly more prevalent in people diagnosed with sleep apnea than it is in people never diagnosed with sleep apnea [2,3,4,5]. Here are the physiological reasons for those results. The chronic intermittent hypoxemia of sleep apnea has three effects which can lead to an overnight gout flare in short order. Effect #1 is intermittent cellular catabolism in which adenosine triphosphate degradation is accelerated, leading to nucleotide turnover which culminates irreversibly in the intermittent cellular generation of excess uric acid fed into the blood [6,7], faster than any food would cause. Effect #2 is concurrent intermittent hypercapnia and acidosis [8], so the blood can hold less uric acid in solution. Effect #3 is a long term deterioration of the kidneys' glomerular filtration rate [9] so that removal of uric acid from the blood is slowed. Thus, with sleep apnea there are repeated abrupt increases i...

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  • Half of diabetics don't know they are. Is it possible bedside diagosing pre-clinical stage of hyperuricemia and gout?

    T2DM can be divided into Five Stages (1-2). The altered metabolism of uric acid, often associated with DM, may be diagnosed from birth, starting with its Uricemic Constitution-dependent, Inherited Real Risk (3, 4). As all other inherited real risks, such a predisposition to hyperuricemia and gout is removed by Reconstructing Mitochondrial Quantum Therapy (5).

    1) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm
    2) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Travel Factory, Roma, 2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
    3) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
    4) Stagnaro Sergio. Epidemiological evidence for the non-random clustering of the components of the metabolic syndrome: multicentre study of the Mediterranean Group for the Study of Diabetes. Eur J Clin Nutr. 2007 Feb 7; [Epub ahead of print] [Medline]
    5) Caramel S., Marchionni M., Stagnaro S. Morinda citrifolia Plays a Central Role in the Pr...

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  • Obesity simulation suit as opportunity to practice in a safe and standardized environment

    Dear Sir,
    Dear contributors,

    Thank you for the reactions to our article. We absolutely agree with the comments made.

    This study was never meant to give the idea that standardized patients (SP) wearing an obesity simulation suit (OSS) could replace the contact with real patients suffering from obesity.

    Simulation is a gold-standard method in medical education to prepare students for clinical work (1). It offers the opportunity to practice in a safe and standardized environment with structured feedback. Our students are used to encounter SP with various conditions as a teaching tool. It is important to acknowledge the purpose of this session: It is meant to be a basic step and is not about “true life experience” involving real patients. For example, medical faculties all over the world train their students on how to break bad news with SP (2). Here, it is also well accepted that this offers a good training opportunity despite the SP not having a serious condition themselves.

    Our first intention was to make a simulated scenario more realistic to support the concept of “suspended disbelief” (3). The other opportunity it offered was to sensitize towards the issue of patients with obesity and start a first reflection process on otherwise unnoticed prejudices. Many students appreciated the fact that due to the “before/after effect” (SP with OSS in simulation vs. SP of normal weight giving feedback) made them reflect even more on differences a...

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