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Lee and colleagues raise important issues regarding hospitalisations from poisoning in New South Wales, Australia. Based on NSW Poisons Information Centre statistics, we would estimate that hospital admissions account for less than 1% of recorded poisoning exposures. It is important to consider these less serious cases to provide additional information to inform interventions for injury prevention. In addition, more detailed information is available, such as exact substances and clinical information – key limitations highlighted in this dataset. Unfortunately, Aboriginal status is not yet routinely collected and is a key limitation of PIC data for informing policy and practice.
This paper also highlights the limitations of different mortality datasets. The National Coronial Information System records three deaths from unintentional poisoning (excluding environmental exposures) in NSW over 2000-14 for children under 5 years, versus the one reported here from the NSW Register of Births, Deaths and Marriages. All deaths were from different pharmaceuticals, two were liquids and one a sugar-coated tablet – important considerations for injury prevention.
The Poisons Information Centres in Australia strongly support a national organisation for the collection and analysis of poisoning data, with coordinated regulatory and health promotion strategies for poisoning prevention.
We read with immense interest the article by Bernado et al. that investigate the epidemiology of influenza-like illness (ILI) and the prescription of antivirals or antibiotics between 2015 and 2017. Antibiotic prescribing for ILI was found to be lower in 2017 than in previous years, while the use of antivirals has risen during the same period [1].
Inappropriateness in antibiotic prescribing has been thought to be a major driver for antimicrobial resistance. This has led to a generation of drug resistance, resulting in clinical failure when common antibiotics are used. Several factors affect the use of antibiotics, including clinicians' prescribing behaviours and patients' or caregivers' knowledge, attitudes and demand for antibiotics [2, 3].
In mid-2018, we conducted a retrospective cross-sectional surveillance analysis in a primary care health clinic in Malaysia to garner preliminary data to warrant further research regarding adherence to antibiotic guidelines and stewardship interventions that reduce unnecessary antibiotic prescribing. We found that nearly one in six prescriptions in our setting (n=396/2,391; 16.6%) had antibiotic. The antibiotics were commonly prescribed in patients with upper respiratory tract infection (URTI) (n=239; 60.4%), skin and soft tissue infection (n=107; 27.0%) and urinary tract infection (UTI) (n=31; 7.8%). In URTI patients, the main antibiotics prescribed were penicillins (85.8%) and macrolid...
We read with immense interest the article by Bernado et al. that investigate the epidemiology of influenza-like illness (ILI) and the prescription of antivirals or antibiotics between 2015 and 2017. Antibiotic prescribing for ILI was found to be lower in 2017 than in previous years, while the use of antivirals has risen during the same period [1].
Inappropriateness in antibiotic prescribing has been thought to be a major driver for antimicrobial resistance. This has led to a generation of drug resistance, resulting in clinical failure when common antibiotics are used. Several factors affect the use of antibiotics, including clinicians' prescribing behaviours and patients' or caregivers' knowledge, attitudes and demand for antibiotics [2, 3].
In mid-2018, we conducted a retrospective cross-sectional surveillance analysis in a primary care health clinic in Malaysia to garner preliminary data to warrant further research regarding adherence to antibiotic guidelines and stewardship interventions that reduce unnecessary antibiotic prescribing. We found that nearly one in six prescriptions in our setting (n=396/2,391; 16.6%) had antibiotic. The antibiotics were commonly prescribed in patients with upper respiratory tract infection (URTI) (n=239; 60.4%), skin and soft tissue infection (n=107; 27.0%) and urinary tract infection (UTI) (n=31; 7.8%). In URTI patients, the main antibiotics prescribed were penicillins (85.8%) and macrolides (14.2%). For skin and soft tissue infection, the main antibiotics prescribed were penicillins – cloxacillin (87.9%) and amoxicillin (9.3%). For UTI treatment, the main antibiotics chosen were cephalosporins – cephalexin (74.2%) and cefuroxime (12.9%). All prescriptions had a duration of five or seven days. None of the analysed prescriptions were indicated for chronic and recurrent cases, repeat prescriptions and antibiotic prophylaxis.
The antibiotic prescribing rate for URTI (acute cough and bronchitis, acute tonsillitis, acute pharyngitis, acute otitis media and acute sinusitis) was high (60.4%). Whilst phenoxymethylpenicillin was the preferred treatment suggested in the National Antibiotic Guideline of Malaysia, our audit revealed that it was not prescribed in all the prescriptions [4]. Doctors in our setting tended to prescribe a broad spectrum antibiotic. Most of these prescriptions were for paediatric population aged less than 10 years.
For skin and soft tissue infections (cellulitis and impetigo), cloxacillin was the preferred treatment suggested in the National Antibiotic Guideline of Malaysia and 87.9% of the prescriptions were concordant with the recommendation [4].
For UTI (acute cystitis), trimethoprim and nitrofurantoin which were the preferred treatment suggested in National Antibiotic Guideline were not prescribed [4]. However, almost three-fourths of the antibiotics prescribed in our study were cephalexin. As compared to the previous study prior to the introduction of 2nd Edition of National Antibiotic Guideline in Malaysia, co-trimoxazole was observed to be the commonest antibiotic prescribed [5]. Trimethoprim and nitrofurantoin were not available in our setting, hence, cephalexin was used as the alternative.
In many countries, successful programmes to prevent inappropriate antibiotic use usually consist of two important components: one directed at the clinicians and the other at the caregivers, aiming to improve their knowledge and change the attitudes and beliefs that lead to inappropriate demand for antibiotic prescriptions for children [6]. In addition to passive dissemination of guideline, prudent use of antibiotics in primary care setting can be achieved with the implementation of academic detailing by senior family physicians and antibiotic interactive seminars which provide feedback of prescribing data to prescribers [7]. Other approaches to optimise antibiotic use encompass antimicrobial stewardship, obtaining infectious diseases expertise through telemedicine consultation, regular review of prescriptions or guideline education for prescribers and use of an online antimicrobial prescribing survey to document the utilisation of antimicrobials and assess the prescribing practise across all health care facilities. Hence, we concluded that broad-spectrum antibiotic prescribing was very common in our primary care setting. The implementation of stewardship programmes targeting different geographic regions, diagnostic conditions and patient populations are necessary to improve antibiotic prescribing.
References
1. Bernardo CO, Gonzalez-Chica D, Stocks N. Influenza-like illness and antimicrobial prescribing in Australian general practice from 2015 to 2017: a national longitudinal study using the MedicineInsight dataset. BMJ Open 2019;9:e026396.
2. Cross EL, Tolfree R, Kipping R. Systematic review of public-targeted communication interventions to improve antibiotic use. J Antimicrob Chemother 2017;72: 975-87.
3. Van Boeckel TP, Gandra S, Ashok A, et al. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis 2014;14: 742-50.
4. Pharmaceutical Services Division. National Antibiotic Guideline (Second Edition). Ministry of Health Malaysia. Available at: https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/natio.... Accessed 15 March 2019.
5. Teng CL, Tong SF, Khoo EM, et al. Antibiotics for URTI and UTI-prescribing in Malaysian primary care settings. Aust Fam Physician 2011;40: 325-29.
6. Wong GWK. Reducing antibiotic prescriptions for childhood upper respiratory tract infections. Lancet Glob Health 2017;5: e1170-1.
7. Mohd Fozi K, Kamaliah MN. The effect of profiling report on antibiotic prescription for upper respiratory tract infection. Malays Fam Physician 2013;8: 26-31.
Acknowledgement
We would like to thank the Director General of Health Malaysia for his permission to publish this correspondence.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of Interest Statement
All authors of this manuscript declare that they have no conflict of interest.
We thank Dr Sherlock for their interest in our study and her letter. Defining, identifying and measuring low-value care is complex, and there are multiple potential approaches and solutions. Due to heterogeneous treatment effects and other issues, what is considered low-value will (by definition) encompass more than what is universally accepted as wasted or ‘no-value’ care. In our approach, we developed measures or indicators of low-value care to signpost where further investigation may be required. Episodes with indicated low-value hyperbaric oxygen therapy (HBOT) were in the ‘negligible’ or ‘near zero use of low-value procedures’ in the results for both papers [1, 2]. While the definition for the low-value procedure indication here may be debated, importantly we found that indicated low-value HBOT was uncommon.
We included HBOT in this list of procedures because it passed our criteria of being a potential measurable low-value procedure within the claims data, especially since a previous study using Australian hospital data had included it [3]. The fact that there was multiple National Institute for Health and Care Excellence (NICE) ‘do not do’ recommendations on HBOT meant that we included it on our list of low-value procedures.
We used the term ‘multiple indications’ for brevity in the results table in the main text, following guidance from journal editors and sub-editors to do so. We find Dr Sherlock’s critique of this somewhat disingenuous and misleading...
We thank Dr Sherlock for their interest in our study and her letter. Defining, identifying and measuring low-value care is complex, and there are multiple potential approaches and solutions. Due to heterogeneous treatment effects and other issues, what is considered low-value will (by definition) encompass more than what is universally accepted as wasted or ‘no-value’ care. In our approach, we developed measures or indicators of low-value care to signpost where further investigation may be required. Episodes with indicated low-value hyperbaric oxygen therapy (HBOT) were in the ‘negligible’ or ‘near zero use of low-value procedures’ in the results for both papers [1, 2]. While the definition for the low-value procedure indication here may be debated, importantly we found that indicated low-value HBOT was uncommon.
We included HBOT in this list of procedures because it passed our criteria of being a potential measurable low-value procedure within the claims data, especially since a previous study using Australian hospital data had included it [3]. The fact that there was multiple National Institute for Health and Care Excellence (NICE) ‘do not do’ recommendations on HBOT meant that we included it on our list of low-value procedures.
We used the term ‘multiple indications’ for brevity in the results table in the main text, following guidance from journal editors and sub-editors to do so. We find Dr Sherlock’s critique of this somewhat disingenuous and misleading, given we provided the full indications in the supplementary information for this publication and the BMJ Quality and Safety publication [1]. The original definition from [3] was also based on NICE guidance NG19 (do-not-do for diabetic foot ulcers) and CG179 (do-not-do for pressure ulcers), which Dr Sherlock chose not to mention in her response. We agree that HBOT is appropriate for radiation injury and air embolism, and when either of these diagnoses was present, we did not count the episode as low value. Unfortunately, the word “no” along with these diagnoses was unintentionally omitted in the supplementary definitions table in [1].
The guideline referenced by Dr Sherlock makes a fairly weak recommendation that HBOT may be offered as a treatment for idiopathic sudden sensorineural hearing loss (ISSHL). From the article: “Although the chance of a 50% improvement was not significantly increased following HBOT, the chance of a 25% increase was. Data indicated that a physician would need to treat 5 patients with HBOT therapy to improve 1 person’s hearing by 25%. Whether this is truly clinically significant is debatable” [4]. This point highlights the inherent challenges of labelling low-value care, where, by definition, a small marginal benefit may exist or there is no strong evidence of a net benefit for patient populations. The evidence presented in this guideline and the NICE clinical guidelines justify HBOT’s inclusion in these publications.
We measured low-value HBOT according to a definition that Dr Sherlock and others may or may not dispute, but we believe is defensible. Using this definition, the prevalence of low-value HBOT was also small (‘near zero’), which agrees with Dr Sherlock’s main points on the appropriate practice of HBOT.
References
1. Badgery-Parker, T., et al., Low-value care in Australian public hospitals: prevalence and trends over time. BMJ Qual Saf, 2019. 28(3): p. 205-214.
2. Chalmers, K., et al., Measuring 21 low-value hospital procedures: claims analysis of Australian private health insurance data (2010-2014). BMJ Open, 2019. 9(3): p. e024142.
3. Duckett, S.J., P. Breadon, and D. Romanes, Identifying and acting on potentially inappropriate care. Med J Aust, 2015. 203(4): p. 183e 1-6.
4. Stachler, R.J., et al., Clinical Practice Guideline: Sudden Hearing Loss. Otolaryngology–Head and Neck Surgery, 2012. 146(3_suppl): p. S1-S35.
The article on gastroschisis risks related to maternal genitourinary infections (GUIs) (1) is remarkable for what it omits.
The authors “postulate that the mechanism could be related to the specific pathogens or alternatively to the inflammatory response generated by the pathogen that may result in cell destruction at the attachment site of the umbilical cord and umbilical ring,” i.e., a secondary disruption. However, nearly simultaneously, Drs. Feldkamp and Botto, the first and last authors, stated elsewhere that “we now conceive of gastroschisis as: a primary midline malformation,” possibly where the “common childhood umbilical hernia is a form of gastroschisis” (2). Neither article cites the other, so the same authors, at the same time, argue for conflicting hypotheses while ignoring their own contrary findings.
I was hoping that the editors might comment on this approach, and that Drs. Feldkamp and Botto could also provide an explanation, and reconcile their hypotheses.
The present article also omits alternative origins for gastroschisis via oestrogen related thrombosis. Oestrogen increases thrombosis in women who smoke, and higher maternal levels are associated with other risk factors for gastroschisis, such as decreased maternal age, primagravida status, and a low body mass index. Hemodynamic issues accompanying normal right umbilical vein involution could predispose to nearby thromboses, explaining a specific location (which the authors do not),...
The article on gastroschisis risks related to maternal genitourinary infections (GUIs) (1) is remarkable for what it omits.
The authors “postulate that the mechanism could be related to the specific pathogens or alternatively to the inflammatory response generated by the pathogen that may result in cell destruction at the attachment site of the umbilical cord and umbilical ring,” i.e., a secondary disruption. However, nearly simultaneously, Drs. Feldkamp and Botto, the first and last authors, stated elsewhere that “we now conceive of gastroschisis as: a primary midline malformation,” possibly where the “common childhood umbilical hernia is a form of gastroschisis” (2). Neither article cites the other, so the same authors, at the same time, argue for conflicting hypotheses while ignoring their own contrary findings.
I was hoping that the editors might comment on this approach, and that Drs. Feldkamp and Botto could also provide an explanation, and reconcile their hypotheses.
The present article also omits alternative origins for gastroschisis via oestrogen related thrombosis. Oestrogen increases thrombosis in women who smoke, and higher maternal levels are associated with other risk factors for gastroschisis, such as decreased maternal age, primagravida status, and a low body mass index. Hemodynamic issues accompanying normal right umbilical vein involution could predispose to nearby thromboses, explaining a specific location (which the authors do not), while different racial thrombophilic polymorphisms would account for decreased gastroschisis risks for blacks (3), going against the article’s suggested role for social factors.
With this, the relationship of oestrogen to UGIs that they note could mean that infections reflect higher oestrogen levels, with increased risks for thrombosis, and for gastroschisis.
I would be interested in the authors’ thoughts on the oestrogen/thrombosis hypothesis here, since it seems to better explain their findings in a broader context.
Mark Lubinsky, M.D.
Orcid ID: orcid.org/0000-0002-6788-6876
email: mlubinsky@wi.rr.com
References
1. Feldkamp ML, Arnold KE, Krikov S, et al. Risk of gastroschisis with maternal genitourinary infections: the US National birth defects prevention study 1997–2011. BMJ Open 2019;9:e026297. doi:10.1136/ bmjopen-2018-026297
2. Opitz JM, Feldkamp ML, Botto LD. An evolutionary and developmental biology approach to gastroschisis. Birth Defects Res A Clin Mol Teratol 2019;1–18. doi.org/10.1002/bdr2.1481
3. Lubinsky M. A vascular and thrombotic model of gastroschisis. Am J Med Genet A 2014;164:915-7.
doi.org/10.1002/ajmg.a.36370
This paper rightly highlights the reasonable expectations that medical training be appropriate, flexible and sufficiently well-funded. At a time of crisis in the NHS workforce, junior doctors deserve training that reflects the real world of clinical care, together with meaningful opportunities to develop their independence and skills in a well-supported and safe environment. A proper balance of activities that delivers effective training and facilitates professional development as protected time, with this built into work schedules, is key.
Tasks set for foundation doctors should be appropriate with the roles of doctors and allied health professionals clearly delineated. To protect junior doctors from deskilling, while enabling them to learn the skills needed to become competent senior doctors, trainees should be able to access the specific procedures and the training they require. It must be recognised that requiring junior doctors to undertake repetitive work of limited educational value will only hinder their professional development, including when they become registrars. A realistic emphasis on preparation for the reality of clinical practice, particularly in caring for patients at end of life and in engaging with a patient's family or carers after death is vital.
New investment in training the extra 1500 medical students per year is urgently needed and this should not come from existing, already over-stretched, budgets. In addition, careful thou...
This paper rightly highlights the reasonable expectations that medical training be appropriate, flexible and sufficiently well-funded. At a time of crisis in the NHS workforce, junior doctors deserve training that reflects the real world of clinical care, together with meaningful opportunities to develop their independence and skills in a well-supported and safe environment. A proper balance of activities that delivers effective training and facilitates professional development as protected time, with this built into work schedules, is key.
Tasks set for foundation doctors should be appropriate with the roles of doctors and allied health professionals clearly delineated. To protect junior doctors from deskilling, while enabling them to learn the skills needed to become competent senior doctors, trainees should be able to access the specific procedures and the training they require. It must be recognised that requiring junior doctors to undertake repetitive work of limited educational value will only hinder their professional development, including when they become registrars. A realistic emphasis on preparation for the reality of clinical practice, particularly in caring for patients at end of life and in engaging with a patient's family or carers after death is vital.
New investment in training the extra 1500 medical students per year is urgently needed and this should not come from existing, already over-stretched, budgets. In addition, careful thought should be given to the numbers of trainers required and action taken to address current pressures in the training system.
Junior doctors work and study incredibly hard and must be fully supported in learning vital clinical and decision-making skills. The BMA will therefore continue to lobby for the foundation programme to include flexible training and for study leave to be properly funded so that junior doctors can build effective portfolios that support them as registrars in their chosen medical specialty.
Therapeutic outcomes for acupuncture are not entirely about relieving pain but also to induce healing and recovery.. When understood the concepts of the 'qi' and the meridians of the organs and their acupoints will give more meaning to acupuncture therapeutics. and as a consequence variables are identified as acupoints.
From the patient's history in conventional medicine the causation might relate to an event (environmental) but in acupuncture medicine an excess in energy ( external pathogenic factor) might be the cause for a given meridian and its acupoints (energy points). Robust studies cited will clearly describe in comnventional medicine terms processes affecting biomechical mechanisms and for acupuncture energy relations of the'qi' within and between the meridians. The outcomes for both are to restore imbalances, harmony and benefits.
This particular study would better be described as a potential Pilot Trial and hence the data generated would be of an empirical nature. There was an opportunity to randomise the GP acupuncturists into a control group matched to an intervention group which could be a double blinded RCT trial. More dialogue is needed on acupuncture therapeutics throughout the study. eg the qi and its behaviour about bothersome menopausal symptoms including anxiety.
As a nursing student in the country of the Bahamas, I have seen firsthand the effects of high blood pressure, stroke and ischaemic heart disease in my country. In an editorial by The Nassau Guardian (2018) it states
Minister of Health Dr. Duane Sands laid out the sobering statistics previously in the House of Assembly – data he has presented to the public before. We are the sixth most overweight or obese people in the world; The Bahamas has the worst non-communicable diseases profile in the Americas; we have an incidence of diabetes and hypertension so severe that our age-adjusted death rate in 2014 ranked The Bahamas seventh in the world in deaths from hypertension. (par. 1)
The English government in 2003 began a program to get companies gradually to reduce the salt levels in processed foods. According to the World Health Organization “For adults: WHO recommends that adults consume less than 5 g (just under a teaspoon) of salt per day (1). For children: WHO recommends that the recommended maximum intake of salt for adults be adjusted downward for children aged two to 15 years based on their energy requirements relative to those of adults” (World Health Organization, 2016). This study looks to quantify the effects of England’s Salt reduction program in 2003 -2011 and its association with reports of hypertension, stroke and Ischaemic heart disease in the population of England. This study could be used as evidence for the success of a national plan to reduce th...
As a nursing student in the country of the Bahamas, I have seen firsthand the effects of high blood pressure, stroke and ischaemic heart disease in my country. In an editorial by The Nassau Guardian (2018) it states
Minister of Health Dr. Duane Sands laid out the sobering statistics previously in the House of Assembly – data he has presented to the public before. We are the sixth most overweight or obese people in the world; The Bahamas has the worst non-communicable diseases profile in the Americas; we have an incidence of diabetes and hypertension so severe that our age-adjusted death rate in 2014 ranked The Bahamas seventh in the world in deaths from hypertension. (par. 1)
The English government in 2003 began a program to get companies gradually to reduce the salt levels in processed foods. According to the World Health Organization “For adults: WHO recommends that adults consume less than 5 g (just under a teaspoon) of salt per day (1). For children: WHO recommends that the recommended maximum intake of salt for adults be adjusted downward for children aged two to 15 years based on their energy requirements relative to those of adults” (World Health Organization, 2016). This study looks to quantify the effects of England’s Salt reduction program in 2003 -2011 and its association with reports of hypertension, stroke and Ischaemic heart disease in the population of England. This study could be used as evidence for the success of a national plan to reduce the salt intake of a population. The authors have highlighted the public health implications of salt reduction and the resultant reduction in mortality due to stroke and IHD.
As many studies today have linked lowering salt intake has a statistical and scientific correlation with the lowering of blood pressure and health risks, it is a reasonable assumption in thinking that a national program to lower the populations dietary salt intake would have a positive impact. The findings of this article suggest a substantial impact this program has had, a reservation I have is that the study may be discounting the effects of other outside factors and variables that may have contributed to the findings of the study. The study used blood pressure levels as a significant data point but as most health professionals know blood pressure can be affected by a bevy of different factors. Blood pressure measurements can be affected by exercise, drinking tea or coffee, meals, time of day and these factors could have easily thrown off or skewed the data. A program and subsequent study could more easily be managed in the Bahamas; this provides a smaller more isolated sample population.
In the article, the authors have pointed out that they did not account for the confounding effect of physical activity. The remaining other factors should have been considered they may have affected the changes in blood pressure measurements and the mortality rates due to stroke. A factor the study used which I felt was well done was the factor of increasing levels individuals of higher educational status in the population from 2003 to 2011. This factor may contribute a great deal to the decreasing levels of heart disease and high blood pressure. An educated populous may make better decisions in their eating habits moving to more healthier choices and a greater awareness of their personal and familial health.
Reference
World Health Organization. (2016, June 30). Salt reduction. Retrieved from https://www.who.int/news-room/fact-sheets/detail/salt-reduction
The Nassau Guardian. (2018, October 15). The Bahamian diet must change. Retrieved from https://thenassauguardian.com
We note the comment from Tim Ambler (Adam Smith Institute) on our recent article about alcohol marketing exposure among 11-19 year olds in the UK. We thank him for his interest in the research and compliments regarding the data.
We note the mutual interest in the topic given his previous roles as joint managing director for International Distillers and Vintners (now part of Diageo PLC) and self-reported involvement in the launch and marketing of a range of alcohol brands, both in the UK and internationally [1-3].
We make several brief remarks in response:
1) Throughout the paper, we only refer to an association between alcohol marketing and either consumption or susceptibility. It is not claimed that the analysis demonstrate a causal or directional effect, as is suggested in the comment. We are also transparent in the summary of strengths and limitations at the start of the article (which also features on the web page of the paper) and again in the discussion about the constraints of cross-sectional research to determine causality.
2) Although the discussion suggests that further examination of the UK’s current self-regulatory system may be required, given the constraints of the research design, we limit these suggestions to reducing marketing exposure for an age-restricted product. This argument is valid based on the data presented, given that they show alcohol marketing exposure among young people under the minimum legal...
We note the comment from Tim Ambler (Adam Smith Institute) on our recent article about alcohol marketing exposure among 11-19 year olds in the UK. We thank him for his interest in the research and compliments regarding the data.
We note the mutual interest in the topic given his previous roles as joint managing director for International Distillers and Vintners (now part of Diageo PLC) and self-reported involvement in the launch and marketing of a range of alcohol brands, both in the UK and internationally [1-3].
We make several brief remarks in response:
1) Throughout the paper, we only refer to an association between alcohol marketing and either consumption or susceptibility. It is not claimed that the analysis demonstrate a causal or directional effect, as is suggested in the comment. We are also transparent in the summary of strengths and limitations at the start of the article (which also features on the web page of the paper) and again in the discussion about the constraints of cross-sectional research to determine causality.
2) Although the discussion suggests that further examination of the UK’s current self-regulatory system may be required, given the constraints of the research design, we limit these suggestions to reducing marketing exposure for an age-restricted product. This argument is valid based on the data presented, given that they show alcohol marketing exposure among young people under the minimum legal purchasing age. Any inference as to whether this would directly reduce alcohol consumption and higher drinking in current drinkers, or susceptibility in never drinkers, has been made at the reader’s discretion. It is not an argument put forward in the paper.
3) Related to the above, the comment uses quotation marks which imply that the paper does claim that reducing alcohol marketing exposure would reduce “consumption and higher risk drinking in [young] current drinkers and susceptibility in never drinkers”. As outlined, this is not an argument put forward in the paper. The comment does quote alcohol consumption behaviours that are measured and reported in the study, but paraphrasing/prefixing this with the term ‘would reduce’ does not represent the arguments put forward in the paper.
4) In the paper, any reference to a directional link between alcohol marketing and consumption in the wider literature is supported by references to systematic reviews of longitudinal research, a method that can infer a degree of causality. For simplicity, these references are repeated below [4,5].
5) As alluded in the comment, we agree that marketing operates on more sophisticated levels than simply initiating a behaviour, either in this context of otherwise. Other goals may include increasing market share (i.e. brand switching) or reinforcing behaviours developed through other intrapersonal or interpersonal determinants. All of these other potential outcomes are still clearly of interest for varied reasons.
Regards,
Dr. Nathan Critchlow (on behalf of the authors)
[4] Anderson P, de Bruijn A, Angus K, et al. Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol Alcohol 2009;44(3):229-243.
[5] Jernigan DH, Noel J, Landon J, et al. Alcohol marketing and youth alcohol consumption: A systematic review of longitudinal studies published since 2008. Addiction 2018;112(S1):7-20.
BMJ Open's editorial team has received the comments from Dr Sherlock on this paper. The authors of the paper have been contacted and have been asked to provide a response.
Lee and colleagues raise important issues regarding hospitalisations from poisoning in New South Wales, Australia. Based on NSW Poisons Information Centre statistics, we would estimate that hospital admissions account for less than 1% of recorded poisoning exposures. It is important to consider these less serious cases to provide additional information to inform interventions for injury prevention. In addition, more detailed information is available, such as exact substances and clinical information – key limitations highlighted in this dataset. Unfortunately, Aboriginal status is not yet routinely collected and is a key limitation of PIC data for informing policy and practice.
This paper also highlights the limitations of different mortality datasets. The National Coronial Information System records three deaths from unintentional poisoning (excluding environmental exposures) in NSW over 2000-14 for children under 5 years, versus the one reported here from the NSW Register of Births, Deaths and Marriages. All deaths were from different pharmaceuticals, two were liquids and one a sugar-coated tablet – important considerations for injury prevention.
The Poisons Information Centres in Australia strongly support a national organisation for the collection and analysis of poisoning data, with coordinated regulatory and health promotion strategies for poisoning prevention.
Dear Editor,
We read with immense interest the article by Bernado et al. that investigate the epidemiology of influenza-like illness (ILI) and the prescription of antivirals or antibiotics between 2015 and 2017. Antibiotic prescribing for ILI was found to be lower in 2017 than in previous years, while the use of antivirals has risen during the same period [1].
Inappropriateness in antibiotic prescribing has been thought to be a major driver for antimicrobial resistance. This has led to a generation of drug resistance, resulting in clinical failure when common antibiotics are used. Several factors affect the use of antibiotics, including clinicians' prescribing behaviours and patients' or caregivers' knowledge, attitudes and demand for antibiotics [2, 3].
In mid-2018, we conducted a retrospective cross-sectional surveillance analysis in a primary care health clinic in Malaysia to garner preliminary data to warrant further research regarding adherence to antibiotic guidelines and stewardship interventions that reduce unnecessary antibiotic prescribing. We found that nearly one in six prescriptions in our setting (n=396/2,391; 16.6%) had antibiotic. The antibiotics were commonly prescribed in patients with upper respiratory tract infection (URTI) (n=239; 60.4%), skin and soft tissue infection (n=107; 27.0%) and urinary tract infection (UTI) (n=31; 7.8%). In URTI patients, the main antibiotics prescribed were penicillins (85.8%) and macrolid...
Show MoreWe thank Dr Sherlock for their interest in our study and her letter. Defining, identifying and measuring low-value care is complex, and there are multiple potential approaches and solutions. Due to heterogeneous treatment effects and other issues, what is considered low-value will (by definition) encompass more than what is universally accepted as wasted or ‘no-value’ care. In our approach, we developed measures or indicators of low-value care to signpost where further investigation may be required. Episodes with indicated low-value hyperbaric oxygen therapy (HBOT) were in the ‘negligible’ or ‘near zero use of low-value procedures’ in the results for both papers [1, 2]. While the definition for the low-value procedure indication here may be debated, importantly we found that indicated low-value HBOT was uncommon.
We included HBOT in this list of procedures because it passed our criteria of being a potential measurable low-value procedure within the claims data, especially since a previous study using Australian hospital data had included it [3]. The fact that there was multiple National Institute for Health and Care Excellence (NICE) ‘do not do’ recommendations on HBOT meant that we included it on our list of low-value procedures.
We used the term ‘multiple indications’ for brevity in the results table in the main text, following guidance from journal editors and sub-editors to do so. We find Dr Sherlock’s critique of this somewhat disingenuous and misleading...
Show MoreThe article on gastroschisis risks related to maternal genitourinary infections (GUIs) (1) is remarkable for what it omits.
Show MoreThe authors “postulate that the mechanism could be related to the specific pathogens or alternatively to the inflammatory response generated by the pathogen that may result in cell destruction at the attachment site of the umbilical cord and umbilical ring,” i.e., a secondary disruption. However, nearly simultaneously, Drs. Feldkamp and Botto, the first and last authors, stated elsewhere that “we now conceive of gastroschisis as: a primary midline malformation,” possibly where the “common childhood umbilical hernia is a form of gastroschisis” (2). Neither article cites the other, so the same authors, at the same time, argue for conflicting hypotheses while ignoring their own contrary findings.
I was hoping that the editors might comment on this approach, and that Drs. Feldkamp and Botto could also provide an explanation, and reconcile their hypotheses.
The present article also omits alternative origins for gastroschisis via oestrogen related thrombosis. Oestrogen increases thrombosis in women who smoke, and higher maternal levels are associated with other risk factors for gastroschisis, such as decreased maternal age, primagravida status, and a low body mass index. Hemodynamic issues accompanying normal right umbilical vein involution could predispose to nearby thromboses, explaining a specific location (which the authors do not),...
This paper rightly highlights the reasonable expectations that medical training be appropriate, flexible and sufficiently well-funded. At a time of crisis in the NHS workforce, junior doctors deserve training that reflects the real world of clinical care, together with meaningful opportunities to develop their independence and skills in a well-supported and safe environment. A proper balance of activities that delivers effective training and facilitates professional development as protected time, with this built into work schedules, is key.
Tasks set for foundation doctors should be appropriate with the roles of doctors and allied health professionals clearly delineated. To protect junior doctors from deskilling, while enabling them to learn the skills needed to become competent senior doctors, trainees should be able to access the specific procedures and the training they require. It must be recognised that requiring junior doctors to undertake repetitive work of limited educational value will only hinder their professional development, including when they become registrars. A realistic emphasis on preparation for the reality of clinical practice, particularly in caring for patients at end of life and in engaging with a patient's family or carers after death is vital.
New investment in training the extra 1500 medical students per year is urgently needed and this should not come from existing, already over-stretched, budgets. In addition, careful thou...
Show MoreTherapeutic outcomes for acupuncture are not entirely about relieving pain but also to induce healing and recovery.. When understood the concepts of the 'qi' and the meridians of the organs and their acupoints will give more meaning to acupuncture therapeutics. and as a consequence variables are identified as acupoints.
From the patient's history in conventional medicine the causation might relate to an event (environmental) but in acupuncture medicine an excess in energy ( external pathogenic factor) might be the cause for a given meridian and its acupoints (energy points). Robust studies cited will clearly describe in comnventional medicine terms processes affecting biomechical mechanisms and for acupuncture energy relations of the'qi' within and between the meridians. The outcomes for both are to restore imbalances, harmony and benefits.
This particular study would better be described as a potential Pilot Trial and hence the data generated would be of an empirical nature. There was an opportunity to randomise the GP acupuncturists into a control group matched to an intervention group which could be a double blinded RCT trial. More dialogue is needed on acupuncture therapeutics throughout the study. eg the qi and its behaviour about bothersome menopausal symptoms including anxiety.
As a nursing student in the country of the Bahamas, I have seen firsthand the effects of high blood pressure, stroke and ischaemic heart disease in my country. In an editorial by The Nassau Guardian (2018) it states
Show MoreMinister of Health Dr. Duane Sands laid out the sobering statistics previously in the House of Assembly – data he has presented to the public before. We are the sixth most overweight or obese people in the world; The Bahamas has the worst non-communicable diseases profile in the Americas; we have an incidence of diabetes and hypertension so severe that our age-adjusted death rate in 2014 ranked The Bahamas seventh in the world in deaths from hypertension. (par. 1)
The English government in 2003 began a program to get companies gradually to reduce the salt levels in processed foods. According to the World Health Organization “For adults: WHO recommends that adults consume less than 5 g (just under a teaspoon) of salt per day (1). For children: WHO recommends that the recommended maximum intake of salt for adults be adjusted downward for children aged two to 15 years based on their energy requirements relative to those of adults” (World Health Organization, 2016). This study looks to quantify the effects of England’s Salt reduction program in 2003 -2011 and its association with reports of hypertension, stroke and Ischaemic heart disease in the population of England. This study could be used as evidence for the success of a national plan to reduce th...
Dear Editors,
We note the comment from Tim Ambler (Adam Smith Institute) on our recent article about alcohol marketing exposure among 11-19 year olds in the UK. We thank him for his interest in the research and compliments regarding the data.
We note the mutual interest in the topic given his previous roles as joint managing director for International Distillers and Vintners (now part of Diageo PLC) and self-reported involvement in the launch and marketing of a range of alcohol brands, both in the UK and internationally [1-3].
We make several brief remarks in response:
1) Throughout the paper, we only refer to an association between alcohol marketing and either consumption or susceptibility. It is not claimed that the analysis demonstrate a causal or directional effect, as is suggested in the comment. We are also transparent in the summary of strengths and limitations at the start of the article (which also features on the web page of the paper) and again in the discussion about the constraints of cross-sectional research to determine causality.
2) Although the discussion suggests that further examination of the UK’s current self-regulatory system may be required, given the constraints of the research design, we limit these suggestions to reducing marketing exposure for an age-restricted product. This argument is valid based on the data presented, given that they show alcohol marketing exposure among young people under the minimum legal...
Show MoreBMJ Open's editorial team has received the comments from Dr Sherlock on this paper. The authors of the paper have been contacted and have been asked to provide a response.
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