545 e-Letters

published between 2014 and 2017

  • Decreased risk of dementia in patients with non-haemorrhagic stroke using acupuncturetreatment: benefit or time-related and residual compounding biases ?

    Corresponding author:
    Ju-Young Shin, PhD
    Professor of Pharmacy
    School of Pharmacy
    Sungkyunkwan University

    Dear Sir

    We read with great interest the study by Chun-Chuan Shin et al1 assessing the effects of acupuncture treatment on the risk of dementia in patients with stroke. They conducted a retrospective cohort study with 5,610 patients in acupuncture group and 5,610 in the non-acupuncture group using data from the National Health Insurance (NHI) system. The authors found that acupuncture treatment reduces the risk of dementia (hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.66 to 0.80) compared with the non-treatment group. However, we are concerned that these observed beneficial effects of acupuncture treatment are the results of immortal time bias.

    In the study, cohort entry was defined as patients with no records of stroke within 5 years before the index date and patients who received at least five (5) courses of acupuncture treatment after stroke admission (exclude patients with stroke with only one (1) to four (4) courses of acupuncture treatment). The index date for both groups was defined by the discharge date following stroke admission, and the follow-up for the acupuncture group started from the first date of receiving acupuncture treatment after the index dateuntil 31 December 2009 or until the dementia event occurred. The authors calculatedthe follow-up time, in person-years, for each patients with s...

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  • Authors’ response to Dhillon and Sahu

    Thank you for your ELetter. We agree with you, this is why we took issue with the misleading media coverage and made our best efforts to rectify the message where we felt it had been distorted (both in print and in radio interviews). See our rebuttal to the (London) Times for an example of this:

    In relation to “Light drinking does no harm in pregnancy”, The Times 12/09/2017
    We write to you to complain about the highly misleading front page coverage that your paper dedicated yesterday to our scientific study, and to rectify the wrong messages you have propagated.
    Frustratingly, in today’s paper your columnist has said: “Alcohol […] drinking in pregnancy, which many health professionals considered a crime only a month ago, now appears to be acceptable in moderation” (from “Take health advice with a big pinch of salt” The Times 13/09/2017). This continues the misinformation that yesterday’s article started. To say that “light drinking does no harm in pregnancy” is a gross misrepresentation of our findings – detailed in the scientific paper, summarised in the press release, and distilled and interpreted in plain language by one of our lead authors in conversation with your journalist.

    We went to great lengths to stress that ‘little or no evidence does not mean little or no effect’. In other words, we have little evidence that light drinking in pregnancy is harmful, but we also have little evidence that it is safe! Conversely, your bol...

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  • The problem is 'insurance'

    Physicians would happily spend more time with patients, just as restaurants happily serve appetizers, sides, and desserts, IF they were reimbursed for the extra time, but the insurance system was set up to deal with big, unexpected, single-diagnoses events, so doesn't address the complexity and time of a non-procedural primary-care visit.
    Direct-pay environments, where the physician can make $20/hr after expenses, encourage proper allocation of time, but the 'co-pay' environment, where the insurer caps everything at a 99214 (which one can perform in 4 minutes) so the patient with 9 interacting problems who you spend 40 minutes with and try to bill a 99215 (which may pay $100/40min versus $50/4 minutes, so you don't even meet overhead), you get a kangaroo-court "audit" where your services are deemed 'not medically necessary' and you are threatened with fines (or jail, in the case of Anthem/Medicare).

    So doctors do what they are paid to do, which is 4 minute visits.

  • A new paper about the unavailability of the ICMJE disclosure form of the guarantor of this paper

    The open access journal 'Roars Transactions, a Journal on Research Policy and Evaluation' has published on 2 November 2017 a paper with reflections on the unavailability of the ICMJE disclosure form of Dr. Moylan.

    The title of this paper is: 'Is partial behaviour a plausible explanation for the unavailability of the ICMJE disclosure form of an author in a BMJ journal?'.

    The paper can be accessed at https://riviste.unimi.it/index.php/roars/article/view/9073 The paper is published in the section ‘Discussion notes’. The editors of 'Roars Transactions, a Journal on Research Policy and Evaluation' are encouraging readers to submit comments / responses. These comments / responses will be published alongside the paper. I am hereby inviting the readers of this eletter to submit comments / responses about this topic to both journals (BMJ Open and Roars Transactions, a Journal on Research Policy and Evaluation). Copy/pasted from the Abstract of my new paper:

    'This case study about the ethical behaviour in the field of scholarly publishing documents an exception on the rule for research articles in the medical journal BMJ Open that ICMJE disclosure forms of authors must be made available on request. The ICMJE, the International Committee of Medical Journal Editors, has developed these forms for the disclosure of conflicts of interest for authors of medic...

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  • Response to the article: Progression of disease preceding lower extremity amputation in Denmark: a longitudinal registry study of diagnoses, use of medication and healthcare services 14 years prior to amputation

    Response to the article: Progression of disease preceding lower extremity amputation in Denmark: a longitudinal registry study of diagnoses, use of medication and healthcare services 14 years prior to amputation.

    This article presents an impressive 14 year-long longitudinal study demonstrating the crucial importance of identifying and understanding the progression of lower extremity amputation (LEA)- related diseases. In doing so, health care providers are better prepared to address and potentially eliminate contributing risk factors. As mentioned by the researchers, only a few previous studies have inquired about the progression of diseases and use of health care services related to lower extremity amputations using historical longitudinal data.

    I personally found this article extremely interesting and very well detailed regarding patient demographics, comorbidities, prevalence of prescribed medication, and contacts made to hospitals and general practitioners (GPs). I particularly liked the strong emphasis made on the importance of disease prevention and early symptom recognition in order to treat patients earlier and avert complications.

    What did stand out to me, however, was that a significant portion of the sample had low education in regards to years of schooling. 88% of the sample had less than 9 years of school education which makes me question if educational status played a more significant role in disease progression than what was mentioned...

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  • Interpreting the carcinogenicity of social and medical development - Reply to the letter by Freitas-Junior et al. on 15 October 2017

    Dear Editor:

    We thank Freitas-Junior et al. for their detailed letter, which we read with great consideration, specially coming from leaders of the Brazilian Mastology Society.
    We will reply starting from the points that we believe that we all agree. First, that breast cancer mortality is linked to “social and medical developments”. Better health and higher life expectancy are associated with indicators of social development, such as Human development index (IDH), higher income and education. But better health is not necessarily associated to more health care (1). People of higher income may have more cancer not because of their wealth (which was expected to protect them), but because they are subjected to higher “observational intensity”, the combined effect of factors such as the frequency of screening and diagnostic exams, the ability of the exams to detect small irregularities, and the threshhold used to label results as abnormal, which can be an undesirable consequence (overdiagnosis) of medical development. As pointed by Welch and Fisher (2017), “Excessive testing of low-risk people produces real harm, leading to treatments that have no benefit (because there is nothing to fix) but can nonetheless result in medication side effects, surgical complications, and occasionally even death” (1).
    We also agree that radioprotection and radioinduced breast cancer are important issues to be addressed in a benefit-harm rationale, but we believe that the harm...

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  • Vitamin D induced effect on inflammation Via Oxidative Stress

    We have read the respective authors. We agreed with their all listeratire and proposed protocols but we would like to add in the effect of Vitamin D on oxidative stress followed by its impact on inflammation in obesity or diabetes or diet restriction/non restriction states to be highlighted. With them the impact of article will be more wider and more focused though insulin resistance is not being addressed with these vitals.

  • Breast cancer mortality and associated factors in São Paulo State, Brazil: two flaws need to be acknowledged

    Dear Editor:
    On reading the study conducted by Diniz et al. on the possible association between mammography and breast cancer-related mortality in the state of São Paulo, Brazil, I found two weaknesses that cannot go unnoticed. The authors have gathered information on mammography ratio and discussed the presumable effect on mortality of mammographic screening. These are two different situations. Having a mammogram is not the same thing as being screened with mammography. There are other reasons for having a mammogram, as having a palpable lump, being prepared for breast cancer surgery or systemic treatment, following up patients treated for breast cancer, orienting breast biopsies. When studying a population comprised of people who have actually died of breast cancer, one should expect to find a cluster of mammograms performed for non-screening purposes. And one should expect a higher mortality rate from breast cancer in this population.
    The other weakness is perhaps easier to understand for those familiar with health care in Brazil. It is very well known that death certificates in Brazil do not always reflect the actual cause of death. It is to be expected a serious under notification in the public health sector as compared to the private health sector. I do acknowledge that the mortality information system in Sao Paulo state is extensive in its coverage and that could be perceived as a strength of the article. However, one has to make sure that the rate of ad...

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  • Response to Kan et al.

    Kan et al. nicely showed that in HIV-infected treatment-naïve first-line regimen initiators, four-year risk of virological failure (VF) and HIV drug resistance (HIVDR) were 11.8% and 5.0%, and they demonstrated that male and female participants had different risk factors for VF and HIVDR[1]. However, there are some limitations in this study that might be worth mentioning. First, in the inclusion phase, as the authors acknowledged, over half of the participants included in 2008 were lost to follow-up or excluded in 2012, which may generate selection bias. Hence, it would be important to compare the baseline characteristics in participants lost to follow-up/excluded and those who were included, in order to see whether there were any significant differences that may bias this study. Second, the authors did not account for baseline transmitted drug resistance mutation (DRM). Albeit rare, the prevalence of DRM was still 3% in treatment-naive participants in the year 2008, based on a meta-analysis[2]. As shown in a previous study in China with participants starting antiretroviral therapy (ART) between 2008-2010, baseline DRM is significantly associated with virological failure[3]. Coincidentally, this study found that HIVDR rate was 5.0%, comparable to the baseline DRM rate in the aforementioned meta-analysis. Thus, baseline DRM may actually affect HIVDR rate in this group of participants. Third, this study did not include men who have sex with men (MSM), which have become one o...

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  • Misinterpreting the message

    Dear Authors,

    Many thanks for your article regarding the safety of low alcohol consumption in pregnancy. Interestingly we heard about this article on BBC radio 4 news, while driving during rush hours, which came to us as a surprise. Having read through this comprehensive literature review, it is clear that current guidelines do not appreciate low alcohol consumption in pregnancy.

    Being doctors, it is clear to us that the risks are low, however media portrayal of this article came across that alcohol is medically acceptable in pregnancy. This argument may lead to unnecessary justification of alcohol use during pregnancy increasing vulnerability of foetus to future risk. It is eye-catching article for media and hence got a lot of attention however potentially a misleading article, which could be misinterpreted in the wrong hands, with risks not only to mothers but also to their children.

    We appreciate that although this article has looked into available literature showing little evidence for the effects of low alcohol consumption in pregnancy, and that further research in this field may come across ethical issues. However, we do feel that extrapolating this lack of evidence to make assertions such as “safety” of alcohol in pregnancy could potentially be harmful.

    Alcohol consumption in pregnancy is advised against due to the risk of foetal alcohol syndrome and other complications to the mother. Given these risks it is important to send a clear...

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