561 e-Letters

published between 2018 and 2021

  • Copd Remedy

    I want to thank Dr Successful for helping me with his herbal medicine to get rid of my copd completely, i have been living with the disease for the past 2yrs. Right now am Copd Chronic obstructive Pulmonary disease negative after using the herbal medicine Dr Successful sent to me. I give thanks to God and healed completely you are the best Traditional doc in the world contact Dm https://web.facebook.com/Drsuccessful-109263294750359 He you can as well dm him on https://www.facebook.com/Priestsuccessful or https://wa.me/qr/UFTMANFGSLY4E1 you can also talk with him on drsuccesfulcuringhome@gmail.com also have powerful herbs remedies his herbal medications prevent and cure Cancer, Diabetes, High-Blood Pressure, Kidney Diseases, Prostate, Gall Stone, Myoma, Cyst, Paralysis, Stroke, Leukemia, Dengue, Anemia, Primary Complex, Gout, Arthritis, Migraine, Sleep Disorder, Dysmenorrhea, Goiter, Heart Problem, Hepatitis, Psoriasis, Vertigo, Low Sperm Count,Sexual Impotence, parasite and other serious problems.

  • Pacing: one term, many meanings

    The version of pacing proposed by Antcliff and colleagues for patients with chronic pain and fatigue contradicts how the term is applied in the myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) community.

    Jamieson-Lega et al. previously noted that pacing represents “a variety of differing and, at times, contradictory concepts.” (1) Broadly, two main traditions exist. One has a history in operant conditioning and is mostly used in the treatment of chronic pain. It consists of a preplanned strategy that is time- or quota-contingent with the aim of breaking the association between resting behavior and symptoms. It involves dividing tasks into manageable parts, doing things slowly but steadily, and building a consistent routine to achieve a target, often an increase in (physical) activity. (2) The other main tradition is energy conservation management as used in patients with neurological conditions such as multiple sclerosis. Here, pacing can be symptom contingent as it is mainly aimed at avoiding overexertion and relapses while engaging in meaningful activities. It involves balancing activity and rest, delegating tasks, setting priorities, and using assistive devices. (3)

    The “activity pacing framework” developed by Antcliff and colleagues is in line with the first tradition but ignores the second. It follows principles of quota-contingency and focuses on gradually increasing activity levels. It is presented as a rehabilitative intervention provided b...

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  • Professor

    The conclusion states "The considerable number of included papers reporting a statistically insignificant result decreases the usual concern over publication bias". I disagree with this. Firstly, the number of p-values labeled "non significant" in Table 3 was 15 out of 48 (31%), which I would not call "considerable". More importantly, if nudges are not effective then there should be many negative studies, so there still could be a large publication bias. Searching for registered studies that used a nudge but were never published would give some evidence of potential publication bias.

  • Are we missing “late” hypotension?

    Ter Avest et al demonstrate hypotension occurring in 9% (29/322) of trauma patients undergoing pre-hospital emergency anaesthesia (PHEA) with fentanyl, ketamine and rocuronium. The mean time to blood pressure nadir was 6-8 minutes across all patients. However the time window for blood pressure measurement was limited to the first 10 minutes following anaesthetic induction.

    We have previously demonstrated the median time for blood pressure nadir is 12 minutes in medical patients post cardiac arrest undergoing PHEA with the same drug regime [1]. We are concerned that by limiting haemodynamic data collection to only 10 minutes, the authors may have missed cases of “late” hypotension. Beyond 10 minutes is typically the point at which one might expect the sympathetic stimulus from laryngoscopy and packaging for transfer to abate and the unopposed effects of 3mcg/kg fentanyl to reveal themselves.

    This may have been further exacerbated by sampling at only 3 minute intervals and requiring two low blood pressure readings to meet their primary endpoint of “hypotension”, increasing the chances of missing those single reading blood pressure drops occurring towards the end of their period of data sampling.

    In our study the time window was 30 minutes following anaesthetic induction to ensure all “late” hypotension was identified. Perhaps for future research in this area there lies a happy medium that would encompass all cases of post-induction hypotension, withou...

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  • BMJ Open Rapid Response

    Thank you for your response to our published study.

    In response to your first comment, while we did not aim to test this specific hypothesis regarding a head-to-head comparison of dual versus single sensory impairment, a post hoc analysis prompted by this comment has found higher odds of suicidal thoughts and of suicide attempts in people with dual sensory impairments as compared to single sensory impairments.

    Odds of suicidal thoughts in people with dual sensory impairment compared to single sensory impairment (n=2,054): AOR= 1.72, (95% CI 1.06 – 2.78).
    Odds of suicide attempt in people with dual sensory impairment compared to single (n=2,025): AOR=1.95 (95% CI 0.70 – 5.43).

    These results suggest that those with dual sensory impairment may have higher odds of suicidal thoughts or attempt than those with a single impairment. However, in view of the large confidence intervals, we do agree that a larger (ideally longitudinal) dataset is required to test this further.

    In response to your second comment, we agree that poor mental health could indeed play a role in our main association between sensory impairment and suicidality. We commented in our paper that depression and anxiety are likely to lie on the causal pathway, and included the findings of a post hoc analysis in which we added CIS-R scores to final models and found that most of our estimates were attenuated and no longer significant. This hypothesis will need formal testing using m...

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  • Engineering Measures to Control Transmission and Prevent Future Pandemics

    As Engineers, we welcome this initiative to seek input of academic experts as to their understanding of Covid Transmission. The prime focus of the Engineers’ Covid Task Force has been to identify best measures to control it, since the outset of this pandemic. The two studies appear complementary and provide a basis for collaboration between Engineers and Scientists on best ways to manage it. Moreover, the BMJ Interactive Visualisation, https://sandpit.bmj.com/graphics/2021/trans/ provides a powerful new way to explain them to governments and the public.

    However, we believe it is vital to take the exercise a stage further and use the visualisation to show the effect of the many Engineering-based mitigation measures that could be put in place at various stages along the paths of transmission, particularly to control current high infection rates and the Omicron variant.

    Whereas the current visualisation is based on subjective assessment, the measures recommended by our Task Force have been laboratory tested and their performance certified.  We can add absolute values to allow estimation of the overall reduction achievable, compared to that without mitigation in place.

    In advance of that, the aim of this response is to highlight both the most effective measures that can be introduced quickly to control transmission and the more permanent measures that will be needed to prevent future pandemics....

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  • RE: Estimated total cardiovascular risk in a rural area of Bangladesh

    Zaman et al. estimated 10-year cardiovascular disease (CVD) risk among rural community healthcare workers, using the 2014 WHO/International Society of Hypertension (WHO/ISH) risk prediction charts (1). The authors used age, sex, systolic blood pressure, smoking status and the presence or absence of diabetes for the analysis. Regarding smoking status, binary data (smoker or non-smoker) were prepared, and information was limited to current vs noncurrent smoking status without distinguishing former smokers from never smokers. I present a recent report on CVD risk estimation with special reference to smoking information.

    Duncan et al. conducted a risk assessment of more precise smoking information for CVD risk estimation in Framingham Heart Study offspring cohort participants (2). Self-reported current/former/never smoking status, pack-years smoked, and years since quitting were used and main outcome was incident atherosclerotic CVD. Combinations of former smoking status, pack-years, and years since quitting significantly improved CVD risk prediction. As the Framingham Heart Study offspring cohort is mainly composed of non-Hispanic White participants, validation study in cohorts of other race and ethnicity groups should be specified by considering socioeconomic status.

    1. Zaman MM, Moniruzzaman M, Chowdhury KN, et al. Estimated total cardiovascular risk in a rural area of Bangladesh: a household level cross-sectional survey done by local communit...

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  • A reply to: Failure to disclose competing interests

    Dear Prof Smyth,

    Thank you for your comments on our recent publication. AKS is the only author paid by Drug Science, all other authors are unpaid by the charity, and as thus, could not been construed as being conflicted. To ensure full transparency, we will add the following statement to all future publications and communications:

    DJN is Chair of the charity Drug Science, SB and LP are Drug Science Scientific Committee members, and AKS is Head of Research of Drug Science. Drug Science receives an unrestricted educational grant from a consortium of medical cannabis companies to further its mission, that is the pursuit of an unbiased and scientific assessment of drugs regardless of their regulatory class. All committee members, including the Chair, are unpaid by Drug Science for their effort and commitment to this organisation. AKS is scientific advisor to the Primary Care Cannabis Network, and an executive member of the Cannabis Industry Council, both unpaid roles. None of the authors would benefit from the wider prescription of medical cannabis in any form.

  • RE: Association between sensory impairment and suicidal ideation and attempt

    Khurana et al. investigated the association of visual and hearing impairments with suicidal ideation and attempt (1). The adjusted odds ratios (ORs) (95% confidence intervals [CIs]) of patients with hearing impairments compared with people without impairments for suicidal ideation and attempt were 2.06 (1.17 to 2.73) and 3.12 (1.57 to 6.20), respectively. The significance was also found for visual impairments and co-occurring of hearing and visual impairments. I have a comment about their study.

    First, there was no increased risk of suicide attempt by dual sensory impairment (visual and hearing) compared with single sensory impairment (visual or hearing) in their study. I suppose that cause of suicide attempt may be complex and sensory impairment may be one of the risk factors for suicide attempt. In addition, many factors may relate to the process from suicide ideation to attempt. Anyway, a prospective study is indispensable to specify the preventive effect of sensory impairment on subsequent risk of suicidal attempt.

    Second, Simning et al. examined the association of auditory, vision, and dual sensory impairment with late-life depressive and anxiety symptoms in older adults (2). The adjusted ORs (95% CIs) of patients with dual sensory impairments compared with people without impairments for depression and anxiety were 2.70 (1.72 to 4.25) and 2.24 (1.46 to 3.42), respectively. In addition, there were increased risk of depression by dual sensory impairment (v...

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  • Achieving adequate nurse staffing

    The authors are discussing a very important quality of care determinant - nurse staffing. The dangers of inadequate patient-per-nurse staffing ratios (PNRs) have been documented in several studies, across various diagnoses and levels of acuity (mortality, medical errors, hospital overcrowding). If raising the number of nurses per patient leads to better outcomes, why doesn’t every hospital hire as many nurses as needed? From the hospital perspective, there are two reasons: nursing shortage and insufficient financial resources. Every subsequent year, hospitals allocate nursing budgets based off the previous year’s average bed occupancy (census). Typically, this is over 50% of their budgets. However, bed occupancy significantly varies daily, with peaks well above and troughs well below the average https://www.bostonglobe.com/opinion/2018/10/25/question-and-way-out-nurs.... During the peak times, nurse staffing is insufficient, which leads to the aforementioned dangers. The conflict between quality and cost seems irreconcilable as there are not enough nurses to meet the demand. In case of regulations/legislation on PNRs, hospitals that lack nurses act the only way they legally can; by diverting patients or making patient wait times for care artificially excessive:...

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