1530 e-Letters

  • Misleading economic analysis

    We read with interest this assessment of the virtual ward at Wrightington, Wigan and Leigh (WWL) Hospitals by Jalilian et al. While we welcome the development of the literature on virtual ward and hospital at home models of care, we do not agree with the economic analysis in the paper which as presented in the abstract has the potential to be highly misleading.

    The authors say that they spent £1.051 million for 40 virtual ward beds in 2022. They then calculate that because they had looked after 366 patients and the mean reduction in length of stay was 3.07 days that the cost per bed day saved was £935 (=£1 051 150/ (3.07 days×366 patients)). However they go on to state: “… £935 is calculated based on the WWL’s capacity to use the virtual beds, which was 24% of the potential 14 600 (24-hour) beds per year provided by 40 virtual ward beds… reference to 3508 total days spent by virtual ward patients).”
    What this actually means is that they spent £1,051,000 to staff and run 40 virtual beds for a year, only used 10 of them, and then found that this was not cost effective. This is hardly surprising; however because this detail is not given in the abstract it runs the risk of making the paper seriously misleading – as some of the coverage in the medical press has demonstrated. “Virtual ward costs twice that of inpatient care, study finds” Lawrence L, HSJ 25 January 2024..

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  • Limitations to consider in this systematic review

    Dear editor,
    I have read with great interest Al-Wardat et al.'s recent systematic review entitled “Prevalence of attention-deficit hyperactivity disorder in children, adolescents, and adults in the Middle East and North Africa region: a systematic review and meta-analysis." 1. Well-conducted systematic reviews of prevalence and incidence data are generally considered to provide the best evidence for health care planning and resource allocation 2 3.
    I have following concerns about methodology of the aforementioned systematic review:
    1- In systematic reviews of prevalence and incidence data, the inclusion of gray literature (through specialized databases such as ProQuest), ranging from clinical registries to government reports, census data, and national administrative datasets, is recommended 2. Furthermore, to improve the comprehensiveness of literature searches, additional significant databases, such as PsycINFO and CINAHL, and all related keywords (e.g., attention deficit disorder, ADD, attention-deficit/hyperactivity disorder, etc.), should be considered.
    2- The majority of nations in the Middle East and North Africa (MENA) region have official languages other than English, and many scholarly works originating from these regions are published in their respective native languages 4. Restricting inclusion criteria solely to studies in the English language may have inadvertently overlooked a significant portion of relevant literature (i.e....

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  • RE: Cardiovascular and renal efficacy and safety of sodium-glucose cotransporter-2 inhibitors in patients without diabetes

    The hypothesized mechanisms for reduction of cardiovascular risk by sodium-glucose cotransporter-2 (SGLT2) inhibitors are multifactorial. Among these mechanisms, Professor Tomoyuki Kawada made a comment on the relative contribution of two clinically important markers, serum uric acid and kidney function, to SGLT2 inhibitors-driven risk reduction of cardiovascular disease.
    Inzucchi et al. explored the potential underlying mechanisms behind the empagliflozin on cardiovascular benefit by conducting post hoc mediation analysis of data from the EMPA-REG OUTCOME trial. 1 The authors demonstrated that changes in plasma volume status (hematocrit or hemoglobin) had the largest impact (mediated around 50% of the treatment effect) on the cardiovascular death with empagliflozin versus placebo. In line with Professor Tomoyuki Kawada’s point of view, the authors reported that changes in uric acid had a greater mediation effect on the treatment effect of empagliflozin on cardiovascular risk reduction, whereas changes in kidney function had no or negligible effects (percentage mediation was 24.6% for uric acid, 11.1% for logUACR, and 5.3% for eGFR). The uricosuric effect of the SGLT2 inhibitors is linked to urinary glucose excretion and caused by blockage of renal tubular uric acid transporters. 2
    The relationship between changes in albuminuria and reduction in cardiovascular risk with SGLT2 inhibitors therapy depends on baseline albuminuria status. Waijer el al. assessed whet...

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  • RE: Cardiovascular and renal efficacy and safety of sodium-glucose cotransporter-2 inhibitors in patients without diabetes

    Tsai et al. conducted a meta-analysis to evaluate the cardiovascular and renal efficacy and safety of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients without diabetes (1). Risk ratios (RRs) (95% confidence intervals [CIs]) of SGLT2 inhibitors for the composite cardiovascular outcome, cardiovascular death, hospitalization for heart failure, and the composite renal outcome were 0.79 (0.71 to 0.87), 0.85 (0.74 to 0.99), 0.72 (0.62 to 0.82), and 0.64 (0.48 to 0.85), respectively. The authors clarified that SGLT2 inhibitors had cardiorenal benefits and increased risk for urinary tract and genital infection in patients without diabetes. I present comments with special reference to the level of serum uric acid and kidney function.

    Zhao et al. conducted a meta-analysis to evaluate the effects of SGLT2 inhibitors on serum uric acid (SUA) in patients with type 2 diabetes mellitus (T2DM) (2). Any of the SGLT2 inhibitors significantly decreased SUA levels against controls, and empagliflozin presented a predominant reduction in SUA. Increase of the urinary excretion of uric acid by SGLT2 inhibitor is not simply caused by the increased urinary volume, but the inhibition of uric acid reabsorption by SGLT2 inhibitor would be made at the collecting duct in the renal tubule (3). I suspect that the urinary excretion rate of uric acid would be increased by SGLT2 inhibitor-induced glycosuria plus active uric acid reabsorption mechanism via insulin resistance.

    Tang e...

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  • Término do estudo

    Olá, gostaria de saber se há um artigo sobre o término do estudo? Estou a realizar mestrado em enfermagem de saúde familiar. obrigada. Carlota Monteiro

  • Reduction i mortality part of national trend, may not be attributed to Naloxone

    Dear editor,
    According to the authors, the "study lends support to the hypothesis that a large-scale naloxone programme in a region may decrease rates of overdose deaths in the population, in comparison to a historic control period when naloxone distribution was unavailable".
    They found that the rate of opioid overdoses in Skåne, the southernmost Swedish region, dropped significantly in three years ensuing the implementation of a Naloxone take home program (2019–2021) for opioid addicts, compared to "a historic control period” (2013–2017).
    The authors correctly state the risk of biases in observational retrospective studies. Their results should be interpreted with caution. However, even with such assurances, their results may be questioned. The years 2013-2017 happens to represent the peak of the Swedish opioid epidemic when Sweden as a whole experienced high rates of overdose deaths in the population (1).
    The years 2019-2021, on the other hand, represents a period when Sweden experienced a significant drop in overdose deaths (2). The present study specifically evaluates a local Naloxone take home programme, the first of its kind in Sweden. The observed decline in death rates may be part of a national trend that in turn may have many different explanations. For instance, in 2018 two Swedish brothers were convicted of manslaughter for selling Fentanyl online, in an unprecedented verdict. Fentanyl associated deaths dropped sharply th...

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  • RE: Medico legal assisting non-fatal strangulation prosecution: a scoping review. BJM open 2023, 13: e 072077. DOI: 10.1136/bmjopen-2023-072077

    To the Editor,
    We have read with great interest the review article entitled “Medico legal assisting non-fatal strangulation prosecution: a scoping review” by Sharman L.S et al. published in BJM open 2023, 13: e 072077.
    The detailed literature revision performed by the authors undoubtedly increased awareness about the risk of losing medico-legal evidence in cases of non-fatal strangulation (NFS), when cutaneous injuries are not visible or the few ones commonly not follow NFS as neck redness/bruising/haematoma; abrasions/petechiae also interesting eyes, gumline and the ears; subconjunctival haemorrhage.
    Therefore, all the medical evidence recorded by health professionals across the variety of healthcare settings, including emergency, general practice, and consultations in forensic context, is irreplaceable for the prosecution of NFS charges and for better healthcare for victims' survivors.
    This is especially true if one considers the possibility that the clinical presentation in cases of NFS could be limited to an oculo-sympathetic deficiency characterized by miosis and ipsilateral ptosis, better known as Claude Bernard syndrome (or Bernard-Horner syndrome). This ophthalmic sign is due to anatomic interruption/steering of the cervical sympathetic tracts of the autonomic nervous system at the level of the common carotid artery bifurcation and the angle of the jaw where the superior cervical ganglion is sited. However, very little attention in bett...

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  • Data synthesis and conclusions of umbrella review, systematic review, and meta-analysis ignore risk of bias assessments

    This article [1] reports three evidence syntheses which investigated outcomes of e-cigarette use among non-smokers: an umbrella review of three systematic reviews [2,3,4]; a “top-up” systematic review that included additional studies; and a quantitative meta-analysis of studies from the umbrella review and the top-up systematic review. Unfortunately, the approach for assessing the risks of bias of the individual research studies suffers from serious flaws: it is inconsistent, uncritical, lacks transparency, and does not inform any of the data syntheses. We are therefore uncertain whether the results and conclusions of the umbrella review, systematic review, and meta-analysis could be biased. This appears likely, since each of the three systematic reviews included in the umbrella review [2,3,4] had identified risks of bias or other “quality” issues in the evidence. Two of those reviews had identified moderate [3] or high [4] risks of bias due to confounding in their included studies, according to the ROBINS-I tool. The third review [2] (which did not use the ROBINS-I tool) found that outcomes of e-cigarette use differed between studies that were rated “fair quality” or “poor quality” on the Newcastle-Ottawa Scale (NOS) compared to those rated “good quality”. None of these bias or “quality” concerns are considered in the methods, results or conclusions of the umbrella review or meta-analysis. The authors did conduct a “quality assessment” of the studies included in their top...

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  • RE: Association of fruit and vegetable intake with predicted 10-year cardiovascular disease risk among hypertensive patients in Addis Ababa, Ethiopia: a cross-sectional study

    Mekonene et al. assessed the 10-year cardiovascular disease (CVD) risk of hypertensive patients with special reference to fruits and vegetables (FV) consumption, salt intake and stress levels (1). Increase of FV intake from 120 to 450 g/day was significantly related to 11.1%-15.2% lower CVD risk in a dose-response manner. In addition, total fruit, but not total vegetable intake in the highest tertile, was significantly associated with decreased CVD risk. I present a comment with special reference to sex difference.

    Yu et al. conducted a prospective study to examined the associations of fruit and vegetable intake with coronary heart disease (CHD) incidence in Shanghai, China (2). The hazard ratio (HR) (95% confidence interval [CI]) of women in the highest quartile of total fruit and vegetable intake against those in the lowest quartile for CHD was 0.62 (0.38-1.02). In addition, the HR (95% CI) of women in the highest quartile of fruit intake against those in the lowest quartile for CHD was 0.62 (0.37-1.03). The risk reduction of CHD in women was attenuated in patients with a history of diabetes or hypertension. In contrast, there was no risk reduction of CHD in men by increased fruit and vegetable intake. Although there was no significant risk reduction of CHD by consuming fruit and vegetable, this study can lead to the recommendation of specific nutritional intervention in women. I suppose that higher prevalence of smoking habit in men than women may contribute to t...

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  • Response to: Inaccuracies in systematic review by Louise Condon, Emeritus Professor Swansea University

    Dear Editor,
    Thank you for drawing our attention to this rapid response by Condon L, which was published on the 6th December 2023.
    In response to the author’s comments on the inclusion of one of her studies - (Reference #52: Condon L, Rhodes C, Warren S, et al. ‘But is it a normal thing?’ Teenage mothers’ experiences of breastfeeding promotion and support. Health Education Journal 2013; 72: 156–62) in our review. We will take each point in turn.

    Comment: It is unclear why our article has been included in this systematic review. In their Methods section, Malouf et al. describe their study selection criteria as follows: “‘Studies were eligible for inclusion if they involved women with low-risk pregnancies [...] and gave birth in hospitals or birth centres in the UK’. Our study explored experiences of breastfeeding promotion and support among pregnant teenagers and teenage mothers, and does not provide information about risk in pregnancy or place of birth. Our study therefore does not meet the eligibility criteria and should not have been included.

    Response: We have clearly stated our approach to the eligibility criteria highlighted by Condon in our strengths and limitations sections:
    ‘Although we set out to review the literature relating to postnatal care for women at low risk of complications to explore routine practice, this was not always possible. Most of the studies reported results undifferentiated by risk and without excluding those wom...

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