eLetters

1208 e-Letters

  • Brexit and food security: long-term implications for public health

    Dear Editor,
    We welcome the BMJ Appeal [1] to support independent food banks; as Watson & Lloyd point out [2], it has the potential to have significant and immediate benefits for food insecurity and children’s health. Perhaps more important for longer term change, is the powerful voice of doctors and nurses in advocating for the ability for all citizens to be able to access a healthy diet for physical and mental health and wellbeing.

    The immediate and direct effects of the national coronavirus pandemic response strategies on food security and nutrition are well documented in Baraniuk’s exposition [3]. Food banks report an enormous uplift in demand for emergency food aid (Trussell Trust: 47% increase in first six months of the crisis compared to the same period in 2019[4]; IFAN: 110% rise February to November 2020 compared to 2019 [5]).

    However, the end of the Brexit transition period on 31 December 2020 now adds to this already uncertain landscape, with the prospect of reduced levels of employment, general downward pressure on wages and perturbations in food supply[6]. In speaking of this disruption, Lang et al [7] state the “The jury is out as to whether these are mere ‘teething problems’ or permanent features of the new normal”.

    In an initial expert elicitation in 2019 [8], we asked the question ‘what will be the “new normal” in terms of food prices after Brexit and what are the implications for health?’ When the deadline for the completio...

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  • diabetes remission after bariatric surgery

    Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a p...

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  • diabetes remission after bariatric surgery

    Kenkre et al. designed a multicenter investigation in order to prospectively evaluating preoperative parameters that can predict a stable diabetes remission in obese patients with type 2 diabetes (T2DM) undergoing bariatric/metabolic surgery (1). Candidate predictors , ave been detected from previous retrospective studies and their predicting efficacy will be tested in a large and disseminated cohort of operated patients. Multivariate logistic regression model will be then used to assess the value in terms of prediction of diabetes remission of these preoperative parameters. In severely obese patients with T2DM biliopancreatic diversion (BPD) causes a steadily long term serum glucose level normalization in the majority of the cases. In patients with a preoperative T2DM duration of approximately one year, the diabetes remission was observed in nearly all cases, while in those with a T2DM duration of more than five years the remission rate was lower than 75% (2). This suggest a major role of T2DM duration as a predictor of insulin secretion reserve. In severely obese operated subjects, most likely for a still adequate beta-cell reserve (3), a rapid recovery of insulin secretion after BPD subjects develops (4), thus determining a stable improvement in metabolic pattern. A long T2DM duration entails a severe reduction of functioning pancreatic B cells and a reduced beta bell mass , insulin secretion and a lower postoperative T2DM remission rate. At a lower obesity degree, a p...

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  • Withdrawing the Damocles' sword: our integrated approach.

    Dear Editor,
    Regarding ‘A sword of Damocles’: patient and caregiver beliefs, attitudes and perspectives on presymptomatic testing for autosomal dominant polycystic kidney disease: a focus group study” by Logeman et al, we think it may be interesting to focus on some themes. What raised our attention, is the striking difference of patients attitude we experience everyday at our center, San Raffaele Hospital ADPKD outpatient clinic. With these few words, we really wish to emphasize the need for a joint approach on ADPKD patient management.
    For many patients, futility in uncertainty and anticipating in impact on quality of life are good reasons to prefer keeping on being unaware and surely the most common we have experienced. The other motivations reported in the article can be differently mentioned according to the healthcare system, ethical-social habits and political and economic regulation of the country of origin.
    We do firmly believe in the importance of early diagnosis and management, through lab tests, blood pressure control and imaging. Moreover, genetic testing is increasingly important, especially in asymptomatic subjects at risk or in patients with not clear phenotypes due to ADPKD heterogeneity or differential diagnosis. Precocity is fundamental in order to avoid future evitable complications. Too often the attitude “wait and see” is perpetuated even by nephrologists and this is no longer acceptable, also because sometimes it amplifies the fear...

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  • Big data and end-of-life care

    We were delighted to learn from enthusiastic responses to our article (1) that other researchers are also finding that the analysis of routine NHS datasets can shed light on the high volume and variety of care that people seek out-of-hours in their last year of life.

    Miller focussed on Primary Care Out-of-hours and Emergency Department data of people dying specifically of cancer. She included prescribing data, and her detailed textual analyses allowed a nuanced understanding of the presenting complaints and diagnoses to be gained. (2) She also quantified the very substantial role that unscheduled care plays in meeting the acute palliative care needs of people in the last year of life.

    Chu in her study, like us, concluded that unscheduled care databases should incorporate more domains relevant to palliative care, and increase the capability of linking with Electronic Palliative Care Co-ordination Systems (EPaCCS). (3) This would help to understand the benefits of these systems and describe their use by health care professionals. We found in Scotland that GPOOH is the only unscheduled care database that captures such information.

    Diernberger recently analysed the patterns and NHS costs of out-patient and in-patient hospital care in the last year of life in Scotland, noting as we had done that people dying of cancer had the highest number of admissions. (4) The mean cost of planned and unplanned admissions was £10,000 per patient in the last year of...

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  • Response to comment of Schmieding and colleagues.

    We thank Schmieding and colleagues for commenting on our study. As noted, we took great effort to compare different symptom checkers fairly.

    Vignettes studies have advantages, but as discussed at length in the manuscript, vignette studies also have some inherent limitations. For this reason, as described, we are carrying out real patient studies to further investigate results.

    We support the efforts of Schmieding and colleagues to work towards transparency and a standardization of methods in the field of technology-supported clinical decision support: the literature is advancing in this direction. We agree the study of (Semigran et al., 2015) is important, but it evaluated a relatively small number of vignettes and used a small number of researcher vignettes enterers, likely not highly reflective of real world symptom assessment app use.

    There was discussion of the limitations of our study in the manuscript which we do not further elaborate here, except with respect to two of the points made by Schmieding and colleagues.

    Firstly, regarding open access to the repertoire of case vignettes, in our study, although not open access, researchers can request access to the vignettes as described in the Data Sharing Agreement and this is similar to the approach described for other recently reported studies (Richens et al., 2020). Although there are some advantages in releasing all the vignettes, as done by (Semigran et al., 2015) there is a degree to whi...

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  • Use of routinely collected data to study care at the end of life

    This study demonstrates the utility of routinely collected databases in palliative and end of life care research. Obtaining large sample sizes covering a whole population of interest is a significant advantage of using routine databases. I found the unscheduled care patterns of different disease groups (cancer, organ failure, frailty/progressive neurological condition, etc.) particularly interesting.

    As explored in a recent article, routine databases should work to incorporate more domains relevant to palliative care, and increase the capability of linking with Electronic Palliative Care Co-ordination Systems (EPaCCS) [1]. This will help further our understanding the potential benefits of these systems and their use by health care professionals.

    References:
    1. Chu CS. Using routine databases to evaluate Electronic Palliative Care Co-ordination Systems (EPaCCS). BMJ Evidence-Based Medicine Published Online First: 29 January 2021. doi: 10.1136/bmjebm-2019-111332

  • Response to eLetter from Dr M Cairns regarding international arrival data

    We would like to thank the reader for taking interest in our work. We used 2018 international arrival data, as these were the latest published figures at the time of the study. Based on yearly trends in international arrivals before 2018, we have no reason to believe that these figures and more importantly, the between-country differences, would differ from early 2020 figures. We therefore assumed that the 2020 figures recorded prior to the awareness of the spread of SARS-CoV-2 would have been the same as previous years, despite subsequent decreases in international flights occurring after January 2020 as observed by Dr Cairns.

    We used 2018 international data as a proxy for countries’ global connections and have therefore found that countries which were better connected globally had significantly higher increases in COVID-19 related mortality during the first wave of the pandemic. A plausible mechanistic link for our findings may therefore be that the virus would have spread significantly out of China before February 2020, after which community transmission would have become predominant in each individual country. Therefore, our findings support the hypothesis that very early travel restrictions should be considered to control the spread of SARS-CoV-2 during future waves of the current and future pandemics. This is of particular importance currently, especially as the world is facing the emergence and international spread of new SARS-CoV-2 strains.

    Yours Si...

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  • Time-dependency of within-subject biological variation

    The authors state that least 21 of the 106 analytes exhibited time dependent increases in biological variation. Such increases can be due to at least two different factors: 1) seasonal variation if more than 2 or 3 months elapse between sequential tests in a subject living in a non-equatorial region and 2) diurnal variation with sequential intra-subject measurements occurring within a day in analytes that exhibit large diurnal variation. In fact, many of the authors of the Labtracer+ validation recently published a remarkable paper documenting large intra-day, intra-subject variation in components of the complete blood count (Reference). What are the 21 analytes that exhibit increased biological variation and would the authors provide the literature citations documenting these variations?

    Hilderink JM, Klinkenberg LJ, Aakre KM, de Wit NC, Henskens YM, van der Linden N, Bekers O, Rennenberg RJ, Koopmans RP, Meex SJ. Within-day biological variation and hour-to-hour reference change values for hematological parameters. Clinical Chemistry and Laboratory Medicine (CCLM). 2017 Jun 27;55(7):1013-24.

  • Lessons learnt from Ada’s study - Towards a framework to evaluate symptom checkers

    Summary

    The study by ADA undertook great effort to compare different symptom checkers competitively. Some of the study’s limitations are unavoidable, such as the authors’ conflict of interest or the limits of vignette-based assessments in general. Other limitations, however, could be avoided in the future. To advance the field of technology-supported clinical decision support, we reason that more transparency and a standardization of methods are needed in at least four areas: (1) open access to the repertoire of case vignettes used to benchmark symptom checker performance; (2) reporting of the performance variation of those who entered the vignettes into the symptom checkers and defining clear guidelines on how to handle the ambiguities that occur when data from vignettes are entered in symptom checkers ; (3) transparent reporting of the performance results, for instance, using confusion tables with absolute numbers and percentages of the correct and the observed triage recommendations; and (4) full reporting of results showing each app’s assessment of each case vignette to make the analyses reproducible, and allow for secondary analysis of the data, as was commendably done by Semigran et al. (2015).

    In the following we elaborate these arguments in detail. Ultimately, we think that increasing transparency and standardization of assessment methods will not only advance the field, but also help to address the current discrepancy between industry-funded stud...

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