This excellent paper?s conclusions concur my earlier findings on the
effects of cadmium on the urinary proteoglycan excretion (1). It seems
that changes are e.g. related with proteinuria (2) and thus be considered
as markers for more generalized vascular effects as predicted in the
current investigation.
1 Savolainen H. Studies on urinary proteoglycan excretion in
occupational cadmium exp...
This excellent paper?s conclusions concur my earlier findings on the
effects of cadmium on the urinary proteoglycan excretion (1). It seems
that changes are e.g. related with proteinuria (2) and thus be considered
as markers for more generalized vascular effects as predicted in the
current investigation.
1 Savolainen H. Studies on urinary proteoglycan excretion in
occupational cadmium exposure. Pharmacol Toxicol 1994; 75: 113
2 Savolainen H. A sensitive method for the analysis of urinary
proteoglycans. Biochem Int 1992; 28: 475
Data for this article has been deposited in the Dryad digital repository. Please see:
Doshi P, Jefferson T (2013) Data from: Clinical Study Reports of randomized controlled trials - an exploratory review of previously confidential industry reports. Dryad Digital Repository. doi:10.5061/dryad.331f7 http://dx.doi.org/10.5061/dryad.331f7
Data for this article has been deposited in the Dryad digital repository. Please see:
Doshi P, Jefferson T (2013) Data from: Clinical Study Reports of randomized controlled trials - an exploratory review of previously confidential industry reports. Dryad Digital Repository. doi:10.5061/dryad.331f7 http://dx.doi.org/10.5061/dryad.331f7
Peter Doshi
27-Feb-2013
Conflict of Interest:
As declared in the original article (BMJ Open 2013 3:e002496; doi:10.1136/bmjopen-2012-002496).
Pharmaceutical procurement is a specialized professional activity
that requires a lot of knowledge, skill and experience. It is therefore
mandatory that staff involved in key procurement and distribution
positions be well trained and highly motivated, with the capability to
manage the procurement process efficiently.
Pharmaceutical procurement is a complex process, which involves many
steps, agencies and manufacturers. E...
Pharmaceutical procurement is a specialized professional activity
that requires a lot of knowledge, skill and experience. It is therefore
mandatory that staff involved in key procurement and distribution
positions be well trained and highly motivated, with the capability to
manage the procurement process efficiently.
Pharmaceutical procurement is a complex process, which involves many
steps, agencies and manufacturers. Existing government policies, rules and
regulations for procurement as well as institutional structures prove
frequently inadequate and sometimes hinder overall efficiency in
responding to the modern pharmaceutical market1. There are many steps in
the procurement cycle. No matter what model has been adopted to manage the
procurement and distribution system, efficient procedures should be in
place to select the most cost-effective essential drugs to treat commonly
encountered diseases; to quantify the needs; to pre-select potential
suppliers; to manage procurement and delivery; to ensure good product
quality; and also to monitor the performance of suppliers and the
procurement system. Failure in any of these areas leads to lack of access
to appropriate drugs and to waste. In many public supply systems,
breakdowns regularly occur at multiple points in this process. In India,
various organizations follow different operating procedures for effective
pharmaceutical procurement.
Absence of comprehensive documented, systematic and uniform procurement
procedures, guidelines and proper delegation of power become utopian. In
some organizations, purchase manual is either unavailable or available at
an obsolete state. Even some institutions deploy these procurement staff
by having negligible or no training or education leading to procurement
system in jeopardy. Staff becomes vulnerable to audit and vigilance
issues. In West Bengal, there are no Pharmacists in most of the store
purchase section. There are few hospitals in India where a professionally
qualified pharmacist heads medical store or Pharmacy Therapeutic Committee
determines medical pharmacologist and selection of drugs. We are fortunate
to have essential drug list of 348 drugs but it is not in the line of
British National Formulary like database. It is quite a tedious process to
achieve an unbiased conclusion on different types of branded drug, branded
generic drug or the MRP. Non-existence of computerized database, lack of
co-ordination and collaboration lead to failure of rational procurement at
the most competitive price and in a fair, just and transparent manner.
Indian pharmaceutical jungle is flooded with more than 90,000 formulations
with having little control on price regulation. A recent study published
in Indian Journal of Pharmacology shows that there is no remarkable
variation of quality between branded and branded generics in India.
Glimpses of study shown in the following chart:
Trade name of medicine Pharmacological name, strength and dosage form
Manufacturer PTR (1x10) MRP (1x10) Mark-up (retailer)
Alerid tablets (B) Cetirizine HCL 10 mg/tab Cipla INR 27.16 INR
35.31 30
Cetcip tablets (B/G) Cetirizine HCL 10 mg/tab Cipla INR 2.24 INR
25.00 1016
Fludac capsules (B) Fluoxetine HCL 20 mg/cap Cadila INR 29.80 INR
37.26 25
Cadflo capsules (B/G) Fluoxetine HCL 20 mg/cap Cadila INR 6.00 INR
28.00 367
Ciprobid tablets (B) Ciprofloxacin 500 mg/tab Cadila INR 54.84 INR
68.56 27
Ciprodac tablets (B/G) Ciprofloxacin 500 mg/tab Cadila INR 15.00 INR
68.56 357
Lanzol-30 capsule (B) Lansoprazole 30 mg/cap Cipla INR 42.36 INR 53.77
27
Lansec-30capsule (B/G) Lansoprazole 30 mg/cap Cipla INR 15.68 INR
47.25 201
Restyl tablets (B) Alprazolam 0.25 mg/tab Cipla INR 11.85 INR 14.82
25
Tranex tablets (B/G) Alprazolam 0.25 mg/tab Cipla INR 2.20 INR 11.34
415
Branded medicine (B) Branded-generic medicine (B/G), Price to the retailer
(PTR) Maximum Retail Price (MRP)
Findings of the present study indicate that both the branded and
branded-generic versions of the five paired medicines had identical
quality and they fulfilled all the criteria prescribed by the Indian
Pharmacopoeia. Hence, the general notion and doubt regarding the quality
of the branded-generic version of medicines need to be erased conducting
more such studies and publishing them widely. Suitable changes in the drug
price policy may be adopted to lower the prices for branded-generic
versions. Transparency in fixing the MRP by the manufacturer and clear
guidelines for mark-ups at least for branded-generics is required in
pharmaceutical trade. Availability of generics or branded-generics in the
market with lower price tag and assured quality is the need of the hour to
make the medicines affordable3. The government must conduct more and more
promotional events in favour of generic drug, arrange general awareness
programs on quality of generics to increase confidence amongst
prescribers, pharmacists, and consumers.
The corrective measures as follows:
Easy availability of valid Good Manufacturing Practice Certificate (GMP),
approved product list and loan license details for the manufacturers whose
products are produced elsewhere.
A procedure to have knowledge on more number of brands available for the
same medicine
Open access of last purchase rate of different organizations
More stringent provisions in tender documents relating to 'liquidated
damages', 'pre-qualification norms', 'packaging', 'performance security',
'warranty period', 'imposition of penalty for delay in supply, 'remaining
life' and 'bid security', etc.
Updated list of substandard drug in the website of CDSCO(Central Drug
Standard Control Organization/India) and state drug control
Appropriate time-frame at each stage of procurement and accountability of
staff involved in procurement procedure
Central Public Sector Enterprises may be more encouraged to manufacture
all essential drugs at low cost
Enhancement of quantity and quality of approved drug testing labs
Steady flow of government funding towards procurement of drug
Either the allotted fund may be spent in the stipulated year and the
unspent fund may be carried forward to the next year
Increased monitoring on performance of distributors and manufacturers
Decentralization (fragmented drug procurement in different levels-
district, state, central, public sector undertaking etc.) of procurement
Unbiased market information on product availability, comparative pricing,
product quality and supplier performance
Incentive and out of turn career development in procurement section
Increased exposure to latest market situations for tackling different
crisis
Strengthening the existing regulatory system especially for enabling more
detailed and universal classification of drugs and chemicals between
branded generic and generic.
Strengthening the public information system to reach out more consumers
for simple drugs.
When and where needed, pragmatic and rational procurement and
inventory management always ensure choice of right drug in right
quantities, doses and formulations, good quality, safe and efficacious.
All organizations should prepare codified purchase manuals, containing
detailed purchase procedures, guidelines and also proper delegation of
powers, so as to ensure systematic and uniform approach in decision-making
areas pertaining to procurements.
1. Chapter 13: Managing procurement. Management Sciences for Health
(MSH) in collaboration with the World Health Organization, Action
Programme on Essential Drugs. Managing drug supply, second edition. Edited
by J.D. Quick, J. Rankin, R. Laing, R. O'Connor, H.V. Hogerzeil, M.N.G.
Dukes and A. Garnett. Hartford, CT: Kumarian Press; 1997.
2.A comparative evaluation of price and quality of some branded versus
branded-generic medicines of the same manufacturer in India-G.L. Singal,
Arun Nanda, Anita Kotwani, Indian Journal of Pharmacology | April 2011 |
Vol 43 | Issue 2 131
3. Department-related parliamentary standing Committee on health and
family welfare Fifty- ninth report on the functioning of the central drugs
standard control organization (cdsco) (presented to the rajya sabha on 8th
may, 2012) (laid on the table of the lok sabha on 8th may, 2012)
Dear Editor,
Recently dr. Bugge and dr. Laake posted a letter in which they argue that
piperacillin/tazobactam is not nephrotoxic (1). They argue that the
delayed creatinine fall (corresponding to a delayed eGFR increase)
observed in our trial (2), is due to the competitive inhibition of
creatinine (and tazobactam) clearance. We did point this out in our
discussion. Dr?s Bugge and Laake have the opinion, that this could...
Dear Editor,
Recently dr. Bugge and dr. Laake posted a letter in which they argue that
piperacillin/tazobactam is not nephrotoxic (1). They argue that the
delayed creatinine fall (corresponding to a delayed eGFR increase)
observed in our trial (2), is due to the competitive inhibition of
creatinine (and tazobactam) clearance. We did point this out in our
discussion. Dr?s Bugge and Laake have the opinion, that this could be an
isolated effect on creatinine and tazobactam clearance and not of
clearance of other renally excreted substances, as they argue:
"Piperacillin-tazobactam is probably not nephrotoxic regarding the effect
on GFR...". We agree that this could be the case. However, no data exist
to support such a notion. Opposite, there does exist data (including ours)
that demonstrate that clearance of several renally excreted subtances are,
in fact, reduced by piperacillin co-administration.
To best protect patients against potentially hazardous treatments, we
think the most reasonable approach is to report possible detrimental
effects, rather than assuming, without data support, that these effects
are negligible. In the supplementary material from our paper on this, we
included an overview of randomized trials with sensitive renal endpoints
and where piperacillin was included in one arm (supplementary file D2).
This shows, indeed, that clinical data on the effect of piperacillin on
renal function is sparse. We have used a large randomized trial material
of 1200 critically ill patients exploring a piperacillin high exposure
strategy (n=604 patients) towards a standard piperacillin exposure
strategy (n=596 patients), conserving the randomization for the main
analysis. Additionally, we have performed a variety of precision analyses
on single drug effect, controlling for other factors known or suspected to
influence renal function. We believe our analyses give a nuanced picture
of the hypothesis, we explored. However, we do urge dr. Bugge and dr.
Laake and other researchers interested in this field to conduct clinical
trials of high quality to investigate this interesting question closer. We
need data to shape our opinions, not opinions without data.
Yours sincerely,
Jens-Ulrik Jensen, MD, PhD
Copenhagen HIV Programme
Faculty of Health Sciences
University of Copenhagen
and
Jens D. Lundgren, MD, DMSc.
Copenhagen HIV Programme
Faculty of Health Sciences
University of Copenhagen
& Dept. of Infectious Diseases, Rigshospitalet,
Copenhagen
On behalf of the Procalcitonin And Survival Study group.
Conflicts of interest: none.
1. Bugge JF, Laake JH. Piperacillin-tazobactam is not nephrotoxic.
BMJ Open. 2013.
2. Jensen JU, Hein L, Lundgren B, Bestle MH, Mohr T, Andersen MH, et al.
Kidney failure related to broad-spectrum antibiotics in critically ill
patients: secondary end point results from a 1200 patient randomised
trial. BMJ Open. 2012; 2(2): e000635.
It was with great interest that I read Dr. Sara Bleich's study on
primary care physicians' perspectives on treating obesity. Unfortunately,
I wasn't shocked by the findings.
Obesity is an incredibly challenging condition to treat, and when
facing a crisis as great as the United States' obesity epidemic,
extraordinary steps are called for.
Primary care physicians need to be aware of the current
recomme...
It was with great interest that I read Dr. Sara Bleich's study on
primary care physicians' perspectives on treating obesity. Unfortunately,
I wasn't shocked by the findings.
Obesity is an incredibly challenging condition to treat, and when
facing a crisis as great as the United States' obesity epidemic,
extraordinary steps are called for.
Primary care physicians need to be aware of the current
recommendations on body mass index screening, and understand that treating
obesity takes diligence, empathy, creativity, and persistence.
Also, primary care physicians need to be aware of the resources
available to them, such as the American Academy of Family Physicians'
efforts to equip its members with evidence-based tools and information to
promote healthy lifestyle practices among their patients.
The AAFP's Americans In Motion -- Healthy Interventions (AIM-HI)
program, which was created by family physicians for family physicians,
seeks to position fitness as the "treatment of choice" for the prevention
and management of chronic conditions.
Behavioral changes require motivation, and patients perceive
physicians who practice healthy personal behaviors themselves as more
credible and better able to encourage healthy lifestyle choices. With this
in mind, clinicians and office staff are encouraged to use the AIM-HI
educational tools and resources to improve their personal fitness, defined
as physical activity; healthy eating; and emotional well-being, and to
promote fitness for their patients.
To support their patients in achieving better health, AIM-HI offers
physicians a set of helpful tools including: * a fitness inventory, which
gauges a patient's confidence about their fitness and their readiness to
change; * a food and activity journal, which helps patients track
nutrition and fitness goals; and * a fitness prescription, through which
the patient and the physician establish mutually agreed-upon goals that
are assessed periodically.
Research shows the AIM-HI program leads to successful outcomes across
a wide-range of patient populations from rural, suburban, and inner-city
clinics and among a wide-range of ethnic populations. Fitness improvements
for the patients were found in following three areas from baseline to 10
months:
* a 10 percent increase in the number of patients reporting the same
amount of physical activity; * a nearly 42 percent increase in the number
of patients who ate at least a half serving more of healthy foods each
week, and a nearly 45 percent increase in the number of patients who ate
at least half a serving less of unhealthy foods each week; * and nearly 12
percent of patients lost 10 pounds or more.
Helping obese patients adopt the lifestyle changes necessary for them
to lose weight is certainly difficult, but it is not impossible. Primary
care physicians are in an excellent position to educate and motivate their
patients and they should be aware of the educational and motivational
resources available.
Dear Editor,
Metformin is the most widely used hypoglycemic agent in the world. But the
application among the diabetic patients who have the chronic kidney
disease(CKD) is still controversial. What gave us a pleasant surprise was
the observational study written by Ekstrom et al found that there were no
increased risks of acidosis/serious infection in patients with renal
impairment according to the large numbers of patient...
Dear Editor,
Metformin is the most widely used hypoglycemic agent in the world. But the
application among the diabetic patients who have the chronic kidney
disease(CKD) is still controversial. What gave us a pleasant surprise was
the observational study written by Ekstrom et al found that there were no
increased risks of acidosis/serious infection in patients with renal
impairment according to the large numbers of patients from the National
Diabetes Register (NDR).(1) Although the baseline was quite different
between the groups which were classified according to glucose-lowering
treatment, Ekstrom et al used the propensity scores very skillfully to
erased the differences in baseline characteristics.
The study was very instructive. However, we still have some questions
about the articles and the results could be better illustration if the
authors would like to provide more information on the following aspects:
Firstly, the conditions of the patients are the important factors
affecting the accuracy of the conclusion.Selections bias to the CKD
patients is understandable and almost cannot be avoided. The clinicians
would choose the patients with better condition into the group treated
with metformin. However, the risk of concomitant diseases such as
hypotension, hypoxemia, cardiovascular disease which were associated with
complications especially lactic acidosis will increase with the renal
impairment.(2) Thus, we consider that the events of acidosis/serious
infection were the results of not only agents' effect but also the
patient's condition. And the comparison between the different therapeutic
regimens among different levels of eGFR should be adjusted by
stratification with octiles of propensity scores to dodge the influence of
the selections bias.
Secondly, the dose of metformin should be considered in the study.
Metformin reduces the hepatic glucose production and increases the
utilization of glucose to attain the goal of decreasing glucose.#3# But
the renal clearance of metformin is decreasing gradually with the renal
function. Therefor, the dose of metformin should be careful and
restrictive and it will be a very important factor leading to the lactic
acidosis.#4# So the dose should not be ruled out simply when the study
adjusted the risk factors.
Thirdly,the results could be more representative if the study expand
the age ranges. The trend of younger age is more and more apparent and the
prevalence of type 2 diabetes in young people may be more than that of
type 1 within a few decades.#5# This fully shows that patients under 40
years old should also be the focus of this research. And it could make the
detailed analysis according to the different ages.
References:
1.Ekstrom N, Schioler L, Svensson A-M, et al. Effectiveness and safety of
metformin in 51 675 patients with type 2 diabetes and different levels of
renal function: a cohort study from the Swedish National Diabetes
Register. BMJ Open 2012;2:e001076. doi:10.1136/ bmjopen-2012-001076.
2.Salpeter SR, Greyber E, Pasternak GA, et al. Risk of fatal and
nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus.
Cochrane Database Syst Rev 2010;4:CD002967.
3.Pilmore HL. Review: metformin: potential benefits and use in
chronic kidney disease. Nephrology 2010;15#4#:412-8.
4.National Institute for Health and Clinical Excellence: NICE
Clinical Guidelines CG87 #May 2009#: Type 2 diabetes newer agents #partial
update of CG66#. http://www.nice.org.uk/CG87.
5.Zimmet P, Alberti KG, Shaw J. Global and social implications of the
diabetes epidemic. Nature 2001;414#6865#:782-7.
The authors of a publication of a contact investigation described two
children they labelled as having latent Mycobacterium (M.) tuberculosis
infection: One 9-year old child had initially a negative interferon gamma
release assay (IGRA) result when the initial Mantoux test was found to be
positive with 8 mm. Three months later another IGRA was performed and
found to be positive. The second patient was found to have a posi...
The authors of a publication of a contact investigation described two
children they labelled as having latent Mycobacterium (M.) tuberculosis
infection: One 9-year old child had initially a negative interferon gamma
release assay (IGRA) result when the initial Mantoux test was found to be
positive with 8 mm. Three months later another IGRA was performed and
found to be positive. The second patient was found to have a positive IGRA
test 4 weeks after a Mantoux test with 3 mm induration. The late
performance of the IGRA may have caused a false positive test in these two
children with a very low risk of M. tuberculosis infection (1). A recent
review demonstrated that a Mantoux test as first line for screening may
generate false positive IGRA results for an unknown period of time in up
to 12% of people undergoing this test (2). This was found in previously
IGRA negative people and linked to boosting of interferon gamma responses
to M. tuberculosis antigens in the IGRA by tuberculin antigens used in the
tuberculin skin test (TST). In one study the IGRA negative subjects who
boosted were all TST-positive initially like the second case described by
the authors(3). From seven previous studies which concluded that boosting
does occur data suggested that if blood for IGRA testing is drawn before
or within 72 hours of the TST being planted this should not result in
false positive IGRA results due to boosting, which may occur after this
time (2). Thus, it does appear that the optimal time to collect blood for
IGRA is at the time of reading the TST.
References
1. Doellner H, Ramm CT, Harstad I, Afset JE, Sagvik E. Risk of
developing tuberculosis after brief exposure in Norwegian children:
results of a contact investigation. BMJ Open
2012;2:e001816.doi:10.1136/bmjopen-2012-001816.
2. Van Zyl-Smit RN, Zwerling A, Dheda K, Madhukar P. Within-subject
variability of interferon-g assay results for tuberculosis and boosting
effect of tuberculin skin testing: a systematic review. PloS ONE
2009;4(12): e8517. doi:10.1371/journal.pone.0008517.
3. Van Zyl-Smit RN, Pai M, Peprah K, Meldau R, Kieck J, et al. (2009)
Within subject Variability and Boosting of T Cell IFN-{gamma} Responses
Following Tuberculin Skin Testing. Am J Respir Crit Care Med 2009;180: 49-
58.
I read with great interest the article titled "Spatial analysis of
health effects of large industrial incinerators in England, 1998-2008: a
study using matched case-control areas" by Nicola F Reeve et al, published
in BMJ Open 2013;3:e001847. The issue is of great relevance. The paper,
however, contains some critical points that need to be underlined.
1. The definition of "control" circles does not exclude the pr...
I read with great interest the article titled "Spatial analysis of
health effects of large industrial incinerators in England, 1998-2008: a
study using matched case-control areas" by Nicola F Reeve et al, published
in BMJ Open 2013;3:e001847. The issue is of great relevance. The paper,
however, contains some critical points that need to be underlined.
1. The definition of "control" circles does not exclude the presence,
in these areas, of other environmental pressure factors able to produce
emissions similar to those from incinerators. A qualitative and
quantitative analysis of pollutants was not available in the study from
Authors, neither in case nor in control regions. Furthermore, it has to be
reported that the European Pollutant Release and Transfer Register
(http://prtr.ec.europa.eu) reveals the presence, in all the "control"
regions selected by Authors, of a number of facilities producing
environmental pollution potentially affecting human health and the
outcomes explored by Authors in their paper:
Doncaster: 40 facilities, including manufacture of glass, treatment and
disposal of hazardous and non-hazardous waste, manufacture of wire
products, chain and springs, metallurgical, chemical or electrolytic
production of non ferrous metals, industrial scale production of basic
organic chemicals, production of non-ferrous crude metals from ore,
concentrates or secondary raw materials, surface treatment of metals and
plastics using electrolytic or chemical processes, production of carbon or
electro-graphite through incineration or graphitization.
Wolverhampton: 22 pollution producing facilities, including surface
treatment of metals and plastics using electrolytic or chemical processes,
disposal of non-hazardous waste, surface treatment of substances, objects
or products using organic solvents, application of protective fused metal
coats, incineration of non-hazardous waste included in Directive
2000/76/EC
Derby: 25 pollution producing facilities, including disposal or recovery
of hazardous and non-hazardous waste, surface treatment of substances,
objects or products using organic solvents, industrial scale production of
basic organic chemicals, urban waste-water treatment plants, thermal power
stations and other combustion installations, industrial scale production
of basic inorganic chemicals, production of non-ferrous crude metals from
ore, concentrates or secondary raw materials.
Manchester: 66 pollution producing facilities, including disposal of
hazardous and non-hazardous waste, manufacture of paints, varnishes and
similar coatings, printing ink and mastics, surface treatment of metals
and plastics using electrolytic or chemical processes, landfills, thermal
power stations and other combustion installations, gasification and
liquefaction, industrial scale production of basic organic chemicals,
mineral oil and gas refineries, thermal power stations and other
combustion installations, metallurgical, chemical or electrolytic
production of non ferrous metals.
Sunderland: 14 pollution producing facilities, including gasification and
liquefaction, disposal of hazardous and non-hazardous waste, surface
treatment of substances, objects or products using organic solvents,
opencast mining and quarrying.
2. Authors did not take into account a series of diseases previously
linked to pollutant emission from incinerators, such as all cancer
combined, stomach cancer, colorectal cancer [1, 2], sarcoma [3], breast
cancer [4], congenital abnormalities [5].
3. The analysis about the effect of distance is strongly limited by
the lack of an adequate dispersion modelling of emissions and by the
absence of a qualitative and quantitative analysis of pollutants. As
demonstrated by several previous papers, the dispersion modelling of
emissions can provide a better surrogate measure of exposure than distance
[3-8]. Furthermore, a comprehensive analysis of confounding factors has
not performed both in case and in control areas.
4. Conclusions drawn by Authors ("our results show no elevated risk
for individuals living in areas containing an incinerator compared to
individuals living in matched areas without an incinerator") are not
consistent with their results, which showed in case areas:
- "a statistically significant increase in risk for each unit increase in
IMD of 1.7% for infant mortality, 1.5% for lung cancer incidence and less
than 1% for liver cancer incidence and mortality and all-cause mortality
(table 3)".
- "The RR of living in a case circle compared with living in a control
circle for leukaemia incidence was 1.137 (95% CI 1.065 to1.213)"
- Figure 2: SMR>100 for infant mortality (apparently all case sites),
liver cancer mortality (3/5 case sites), all cause mortality (4/5 case
sites)
- Table 2: increased leukaemia incidence (1.135, 95%CI 1.080 to 1.192) and
infant mortality (1.118, 95%CI 1.054 to 1.186)
- Table 2: increased trend over time for leukaemia, liver cancer and lung
cancer incidence, and all-cause, infant and liver cancer mortality (see
also Figure 3)
5. In the discussion section, Authors state that "One might have
anticipated a dose- response relationship with distance from the
incinerator if the incinerators were responsible for causing an elevation
in disease or mortality risk. The fact that no such relationships emerged
supports our general conclusions". A "dose-response relationship with
distance from the incinerator" has never been fully documented in previous
works, mainly in the absence of adequate models (see point 3). It has been
suggested that this assumption can lead to significant exposure
misclassification [9].
In conclusion, the methodological concerns in the study design and
the discrepancy between the results and the conclusions drawn by Authors
might be considered important limitations of this study. There is a
growing interest on the health effects of waste burning and, although the
issue is currently under debate, a number of previous studies well
documented major environmental and sanitary consequences deriving from
incineration. Other scientific papers aimed to clearly and correctly
address the health impact of various waste treatments, mainly
incineration, are certainly expected.
On the other hand, it is strongly needed to consider the recent
recommendation of the European Parliament (text tabled A7-0161/2012,
adopted at May 2012,
http://www.europarl.europa.eu/sides/getDoc.do?type=TA&reference=P7-TA-2012
-0223&language=EN&ring=A7-2012-0161 ), to take into account "the waste
hierarchy and the need to bring residual waste close to zero", and to
undertake the "phasing-out, by the end of this decade, of incineration of
recyclable and compostable waste".
In this respect, a convinced phasing-out of incineration and sustainable
policies [10] aimed at eliminating waste and at viewing waste as a
potential economic resource are rapidly diffusing [11-14] and necessary.
Best regards
Agostino Di Ciaula, MD, internist
References
1 Elliott P, Shaddick G, Kleinschmidt I, Jolley D, Walls P, Beresford
J et al. Cancer incidence near municipal solid waste incinerators in Great
Britain. British journal of cancer 1996;73:702-10.
2 Ranzi A, Fano V, Erspamer L, Lauriola P, Perucci CA and Forastiere F.
Mortality and morbidity among people living close to incinerators: a
cohort study based on dispersion modeling for exposure assessment.
Environmental health : a global access science source 2011;10:22.
3 Zambon P, Ricci P, Bovo E, Casula A, Gattolin M, Fiore AR et al. Sarcoma
risk and dioxin emissions from incinerators and industrial plants: a
population-based case-control study (Italy). Environ.Health 2007;6:19.
4 Ranzi A, Fano V, Erspamer L, Lauriola P, Perucci CA and Forastiere F.
Mortality and morbidity among people living close to incinerators: a
cohort study based on dispersion modeling for exposure assessment.
Environ.Health 2011;10:22.
5 Cordier S, Lehebel A, Amar E, Anzivino-Viricel L, Hours M, Monfort C et
al. Maternal residence near municipal waste incinerators and the risk of
urinary tract birth defects. Occup.Environ.Med. 2010;67:493-9.
6 Viel JF, Arveux P, Baverel J and Cahn JY. Soft-tissue sarcoma and non-
Hodgkin's lymphoma clusters around a municipal solid waste incinerator
with high dioxin emission levels. Am.J.Epidemiol. 2000;152:13-9.
7 Viel JF, Floret N, Deconinck E, Focant JF, De PE and Cahn JY. Increased
risk of non-Hodgkin lymphoma and serum organochlorine concentrations among
neighbors of a municipal solid waste incinerator. Environ.Int. 2011;37:449
-53.
8 Forastiere F, Badaloni C, de Hoogh K, von Kraus MK, Martuzzi M, Mitis F
et al. Health impact assessment of waste management facilities in three
European countries. Environmental health : a global access science source
2011;10:53.
9 Goria S, Daniau C, de Crouy-Chanel P, Empereur-Bissonnet P, Fabre P,
Colonna M et al. Risk of cancer in the vicinity of municipal solid waste
incinerators: importance of using a flexible modelling strategy.
Int.J.Health Geogr. 2009;8:31.
10 Kriebel D. Incinerators, birth defects and the legacy of Thomas Bayes.
Occup.Environ.Med. 2010;67:433-4.
11 Curran T and Williams ID. A zero waste vision for industrial networks
in Europe. Journal of hazardous materials 2012;207-208:3-7.
12 Young CY, Ni SP and Fan KS. Working towards a zero waste environment in
Taiwan. Waste management & research : the journal of the International
Solid Wastes and Public Cleansing Association, ISWA 2010;28:236-44.
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Kontogianni S et al. Developing a holistic strategy for integrated waste
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RE:"National survey of US primary care physicians' perspectives about
causes of obesity and solutions to improve care" Bleich SN, Bennett WL,
Gudzune KA, et al. BMJ Open 2012;2:e001871. doi:10.1136/bmjopen-2012-
001871
http://bmjopen.bmj.com/content/2/6/e001871.abstract?sid=05bcca2b-326b-408b
-9825-6569fe7970fd
It was with great interest that I read Dr. Sara Bleich's study on
primary care physicians' perspectives...
RE:"National survey of US primary care physicians' perspectives about
causes of obesity and solutions to improve care" Bleich SN, Bennett WL,
Gudzune KA, et al. BMJ Open 2012;2:e001871. doi:10.1136/bmjopen-2012-
001871
http://bmjopen.bmj.com/content/2/6/e001871.abstract?sid=05bcca2b-326b-408b
-9825-6569fe7970fd
It was with great interest that I read Dr. Sara Bleich's study on
primary care physicians' perspectives on treating obesity. Unfortunately,
I wasn't shocked by the findings.
Obesity is an incredibly challenging condition to treat, and when
facing a crisis as great as the United States' obesity epidemic,
extraordinary steps are called for.
Primary care physicians need to be aware of the current
recommendations on body mass index screening, and understand that treating
obesity takes diligence, empathy, creativity, and persistence.
Also, primary care physicians need to be aware of the resources
available to them, such as the American Academy of Family Physicians'
efforts to equip its members with evidence-based tools and information to
promote healthy lifestyle practices among their patients.
The AAFP's Americans In Motion -- Healthy Interventions (AIM-HI)
program, which was created by family physicians for family physicians,
seeks to position fitness as the "treatment of choice" for the prevention
and management of chronic conditions.
Behavioral changes require motivation, and patients perceive
physicians who practice healthy personal behaviors themselves as more
credible and better able to encourage healthy lifestyle choices. With this
in mind, clinicians and office staff are encouraged to use the AIM-HI
educational tools and resources to improve their personal fitness, defined
as physical activity; healthy eating; and emotional well-being, and to
promote fitness for their patients.
To support their patients in achieving better health, AIM-HI offers
physicians a set of helpful tools including:
* a fitness inventory, which gauges a patient's confidence about their
fitness and their readiness to change;
* a food and activity journal, which helps patients track nutrition and
fitness goals; and
* a fitness prescription, through which the patient and the physician
establish mutually agreed-upon goals that are assessed periodically.
Research shows the AIM-HI program leads to successful outcomes across
a wide-range of patient populations from rural, suburban, and inner-city
clinics and among a wide-range of ethnic populations. Fitness improvements
for the patients were found in following three areas from baseline to 10
months:
* a 10 percent increase in the number of patients reporting the same
amount of physical activity;
* a nearly 42 percent increase in the number of patients who ate at least
a half serving more of healthy foods each week, and a nearly 45 percent
increase in the number of patients who ate at least half a serving less of
unhealthy foods each week;
* and nearly 12 percent of patients lost 10 pounds or more.
Helping obese patients adopt the lifestyle changes necessary for them
to lose weight is certainly difficult, but it is not impossible. Primary
care physicians are in an excellent position to educate and motivate their
patients and they should be aware of the educational and motivational
resources available.
Data deposited in the Dryad repository: http://dx.doi.org/10.5061/dryad.80q86
Conflict of Interest:
None declared
Dear Editor,
This excellent paper?s conclusions concur my earlier findings on the effects of cadmium on the urinary proteoglycan excretion (1). It seems that changes are e.g. related with proteinuria (2) and thus be considered as markers for more generalized vascular effects as predicted in the current investigation.
1 Savolainen H. Studies on urinary proteoglycan excretion in occupational cadmium exp...
Doshi P, Jefferson T (2013) Data from: Clinical Study Reports of randomized controlled trials - an exploratory review of previously confidential industry reports. Dryad Digital Repository. doi:10.5061/dryad.331f7 http://dx.doi.org/10.5061/dryad.331f7
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It was with great interest that I read Dr. Sara Bleich's study on primary care physicians' perspectives on treating obesity. Unfortunately, I wasn't shocked by the findings.
Obesity is an incredibly challenging condition to treat, and when facing a crisis as great as the United States' obesity epidemic, extraordinary steps are called for.
Primary care physicians need to be aware of the current recomme...
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I read with great interest the article titled "Spatial analysis of health effects of large industrial incinerators in England, 1998-2008: a study using matched case-control areas" by Nicola F Reeve et al, published in BMJ Open 2013;3:e001847. The issue is of great relevance. The paper, however, contains some critical points that need to be underlined.
1. The definition of "control" circles does not exclude the pr...
RE:"National survey of US primary care physicians' perspectives about causes of obesity and solutions to improve care" Bleich SN, Bennett WL, Gudzune KA, et al. BMJ Open 2012;2:e001871. doi:10.1136/bmjopen-2012- 001871 http://bmjopen.bmj.com/content/2/6/e001871.abstract?sid=05bcca2b-326b-408b -9825-6569fe7970fd
It was with great interest that I read Dr. Sara Bleich's study on primary care physicians' perspectives...
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