908 e-Letters

  • Response to Assessing the non-inferiority of prosthesis constructs used in total and unicondylar knee replacements

    We read with interest your paper about benchmarking knee replacements based on NJR data and were surprised that you considered the most striking finding was that the revision rate of UKR was more than 100% higher than TKR. Anyone familiar with registry data would have expected this as one of the few things all registries agree on is that the overall revision rate of UKR is about three times higher than that of TKR. You then mention the numerous advantages of UKR compared to TKR that often outweigh the disadvantage of the higher revision. Surely the sensible way to decide what implant to use is for the surgeon and patient to discuss the pro and cons of UKR and TKR and decide which is most appropriate. If the decision is to do a UKR then the next step is to consider which implant to use, in part based on their relative revision rates. Therefore benchmarking UKR against UKR, which we believe ODEP are doing, would be useful. In contrast benchmarking UKR against TKR, which is what you have done, is unhelpful.

    One of the main advantages of UKR, particularly in the elderly, is that it is much safer than TKR, with the risk of major medical complications being half or less. As a result the death rate is lower following UKR, not just early but also in the midterm. Had you done a similar non-adjusted analysis with death being the outcome rather than revision the most striking finding would have been that the death rate following TKR would be higher than that of UKR. UKR have...

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  • Trans Conversion Therapy Doesn’t Call Itself Conversion Therapy

    Wright, Candy, and King (2018)’s recent systematic review of transgender conversion therapies searched for articles which contained variants of the terms “conversion” and “transgender”. The review only identified four studies on conversion therapy, concluding that the practice was uncommon and reassuring.

    I believe that the article severely underestimates the breadth of the conversion therapy literature and of its practice. This is due to the inadequacy of the search strategy, which seeks articles involving variants of the term “conversion”, whereas proponents of reparative practices rarely conceive themselves in those terms. The search strategy was derived from “those used in previous reviews of LGB conversion therapy”. The decision to mirror terms of LGB conversion therapy should have been subjected to greater scrutiny. By the 1990s, the term “conversion therapy” was struck with infamy and associated with religious approaches, creating a pressure to disidentify with the term among secular practitioners who sought to discourage transitude, even if their clinical approaches were very similar to the approach of famous conversion therapists such as George Rekers.

    Many articles can be identified which sought to alter the patient’s gender identity or prevent trans outcomes but were not captured by the systematic review. The first author of one of the reviewed articles, Dr. Zucker, is a prolific writer who has written a lot about his approach, which is further de...

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  • Response

    We appreciate the questions raised by Dr. Lubinsky and the ability to respond to his concerns.

    1. The manuscripts Dr. Lubinsky considers to be in conflict have different purposes and, in our view, far from being conflicting they are complementary. We did speculate how the etiologic findings published in BMJ Open (Feldkamp et al, 2019) might result in a gastroschisis (“How a GUI might cause gastroschisis during pregnancy remains an open question. We postulate that the mechanism could be related to the specific pathogens or alternatively to the inflammatory response generated by the pathogen that may result in cell destruction at the attachment site of the umbilical cord and umbilical ring.”) However, the purpose of that paper was not to relate this study’s findings to the many proposed hypotheses on pathogenesis, including the estrogen/thrombosis hypothesis, which appears to be favored by Dr. Lubinsky (2014). As amply discussed in the article by Opitz et al. (2019), more work needs to be done to confirm the hypothesis that gastroschisis results from abnormalities in the amnio-ectodermal junction and to determine why, if this is true, does it separate and what causes the separation?

    As stated in Birth Defects Research - Opitz et al. (2019):
    Abstract: Presently, it is unresolved whether this visceral prolapse represents failure of ring closure before return of the physiological hernia into the abdomen or rupture of the delicate amniotic/peritoneal membra...

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  • Critique of this analysis is misguided

    To The Editor -

    I am a founder of the Effective Treatment of Eating Disorders Foundation based in Australia, which supports sufferers to find ‘effective’ treatments for eating disorders. We have a keen interest in the analysis by Södersten et al (hereafter ‘the analysis’) of the Swedish national quality registry (Riksät) because the underlying data, although published in annual reports, has never been scrutinised externally. This large database in theory should have the potential to yield valuable insights for eating disorders sufferers who need to make decisions about treatment effectiveness. These are important health decisions for patients everywhere.

    The analysis showed that only a very small proportion of those patients who commenced treatment actually achieved remission, with more than half of patients not followed up, and with inconsistent outcomes within and between clinics. Two officials of Riksät, Drs Birgegård and Norring, (hereafter ‘the Riksät managers’) then responded, asserting that the analysis’ treatment outcomes were ‘incorrectly calculated’ and ‘misleading’.

    We disagree with those assertions for the following reasons.

    • The Riksät managers began by stating that the analysis makes an unfounded and biased assumption that ‘patients who are not followed up are still ill’. This is an incorrect reading: the analysis makes it clear that there is no data to indicate whether ‘patients not followed up’ remain ill, have dropped out, or...

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  • Gestational diabetes mellitus or chronic heart failure?

    Gestational diabetes mellitus or chronic heart failure?
    Recently, the paper entitled “Evaluation of guidelines on the screening and diagnosis of gestational diabetes mellitus: systematic review” was published in BMJ Open, when we read the work, an unexpected phrase “chronic heart failure” appeared in the Additional file 2. Therefore, I raised this response.

  • Contested organ-obtainment methods in published transplant-research: A timely reminder to those in the affiliated ocular field.

    We reflect on the Rogers et al, [1] paper, published in BMJ Open, which examined the contested ethical compliance of published transplant research, using human organ donors in China, and the call to retract over 400 published papers.
    Seeing that Rogers et al. did not examine other substances of human origin, such as ocular tissue, and only examined the donation conduct of one nation with contested donation practices, we are left wondering if our own eye health and vision science sector, at the global level, would withstand such rigor, if a similar examination of ocular tissue use was conducted. Could our sector be swept up in such controversy, and would that controversy be isolated to one nation? Would our activities and practices, our global research collaborations and our transnational movement of human tissue leave our sector open to scrutiny? Would it challenge the validity of our transplant research in our sub-specialty journals, or discourage governments, investors and philanthropic stakeholders and organizations from engaging with the eye health and vision science sector, regardless of the nation or the degree of contestable activity?
    Rogers et al., further highlight the need for sectorial compliance with bioethical principles, and the responsibilities of academic editorial boards to confirm the origins and acquisition practices of submitted transplant research that involves human donors, and particularly those concerning deceased donors.
    To that...

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  • The other 99% of poisoning incidents

    Lee and colleagues raise important issues regarding hospitalisations from poisoning in New South Wales, Australia. Based on NSW Poisons Information Centre statistics, we would estimate that hospital admissions account for less than 1% of recorded poisoning exposures. It is important to consider these less serious cases to provide additional information to inform interventions for injury prevention. In addition, more detailed information is available, such as exact substances and clinical information – key limitations highlighted in this dataset. Unfortunately, Aboriginal status is not yet routinely collected and is a key limitation of PIC data for informing policy and practice.
    This paper also highlights the limitations of different mortality datasets. The National Coronial Information System records three deaths from unintentional poisoning (excluding environmental exposures) in NSW over 2000-14 for children under 5 years, versus the one reported here from the NSW Register of Births, Deaths and Marriages. All deaths were from different pharmaceuticals, two were liquids and one a sugar-coated tablet – important considerations for injury prevention.
    The Poisons Information Centres in Australia strongly support a national organisation for the collection and analysis of poisoning data, with coordinated regulatory and health promotion strategies for poisoning prevention.

  • Antibiotic prescribing in a primary care setting in Malaysia: a cross-sectional surveillance study.

    Dear Editor,

    We read with immense interest the article by Bernado et al. that investigate the epidemiology of influenza-like illness (ILI) and the prescription of antivirals or antibiotics between 2015 and 2017. Antibiotic prescribing for ILI was found to be lower in 2017 than in previous years, while the use of antivirals has risen during the same period [1].

    Inappropriateness in antibiotic prescribing has been thought to be a major driver for antimicrobial resistance. This has led to a generation of drug resistance, resulting in clinical failure when common antibiotics are used. Several factors affect the use of antibiotics, including clinicians' prescribing behaviours and patients' or caregivers' knowledge, attitudes and demand for antibiotics [2, 3].

    In mid-2018, we conducted a retrospective cross-sectional surveillance analysis in a primary care health clinic in Malaysia to garner preliminary data to warrant further research regarding adherence to antibiotic guidelines and stewardship interventions that reduce unnecessary antibiotic prescribing. We found that nearly one in six prescriptions in our setting (n=396/2,391; 16.6%) had antibiotic. The antibiotics were commonly prescribed in patients with upper respiratory tract infection (URTI) (n=239; 60.4%), skin and soft tissue infection (n=107; 27.0%) and urinary tract infection (UTI) (n=31; 7.8%). In URTI patients, the main antibiotics prescribed were penicillins (85.8%) and macrolid...

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  • Response to letter regarding hyperbarix oxygen therapy

    We thank Dr Sherlock for their interest in our study and her letter. Defining, identifying and measuring low-value care is complex, and there are multiple potential approaches and solutions. Due to heterogeneous treatment effects and other issues, what is considered low-value will (by definition) encompass more than what is universally accepted as wasted or ‘no-value’ care. In our approach, we developed measures or indicators of low-value care to signpost where further investigation may be required. Episodes with indicated low-value hyperbaric oxygen therapy (HBOT) were in the ‘negligible’ or ‘near zero use of low-value procedures’ in the results for both papers [1, 2]. While the definition for the low-value procedure indication here may be debated, importantly we found that indicated low-value HBOT was uncommon.
    We included HBOT in this list of procedures because it passed our criteria of being a potential measurable low-value procedure within the claims data, especially since a previous study using Australian hospital data had included it [3]. The fact that there was multiple National Institute for Health and Care Excellence (NICE) ‘do not do’ recommendations on HBOT meant that we included it on our list of low-value procedures.

    We used the term ‘multiple indications’ for brevity in the results table in the main text, following guidance from journal editors and sub-editors to do so. We find Dr Sherlock’s critique of this somewhat disingenuous and misleading...

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  • Omissions and contradictions

    The article on gastroschisis risks related to maternal genitourinary infections (GUIs) (1) is remarkable for what it omits.
    The authors “postulate that the mechanism could be related to the specific pathogens or alternatively to the inflammatory response generated by the pathogen that may result in cell destruction at the attachment site of the umbilical cord and umbilical ring,” i.e., a secondary disruption. However, nearly simultaneously, Drs. Feldkamp and Botto, the first and last authors, stated elsewhere that “we now conceive of gastroschisis as: a primary midline malformation,” possibly where the “common childhood umbilical hernia is a form of gastroschisis” (2). Neither article cites the other, so the same authors, at the same time, argue for conflicting hypotheses while ignoring their own contrary findings.
    I was hoping that the editors might comment on this approach, and that Drs. Feldkamp and Botto could also provide an explanation, and reconcile their hypotheses.
    The present article also omits alternative origins for gastroschisis via oestrogen related thrombosis. Oestrogen increases thrombosis in women who smoke, and higher maternal levels are associated with other risk factors for gastroschisis, such as decreased maternal age, primagravida status, and a low body mass index. Hemodynamic issues accompanying normal right umbilical vein involution could predispose to nearby thromboses, explaining a specific location (which the authors do not),...

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