988 e-Letters

  • Quantifying and describing burden of suicide mortality in Canadian Veterans

    Dear Editor-in-Chief,

    We are writing to you in response to Mahar et al.’s (2019) recent publication in your journal (“Suicide in Canadian veterans living in Ontario: a retrospective cohort study linking routinely collected data”).

    The authors found a lower risk of suicide in Canadian Armed Forces (CAF) Veterans (former members) using Ontario Health Insurance Plan coverage, in contrast to the findings of higher CAF Veteran suicide risk in the Canadian Forces Cancer and Mortality Study (CF CAMS) and the Veteran Suicide Mortality Study (VSMS), which use nation-wide Vital Statistics and cancer registry data collected by Statistics Canada. We strongly feel that there is synergistic value in having different studies by different investigator groups using different data sources, but it is essential to understand the limitations in these different approaches and their findings.

    Mahar et al. state that their study was the “...first study of suicide risk in Canadian veterans...” However, CF CAMS, which looked at suicide risk in Canadian Veterans, was published eight years prior to the Mahar et al. study (Statistics Canada, 2011). This was followed by the Veteran Suicide Mortality Study (VSMS) Technical report was published in 2017 (Simkus et al., 2017), its accompanying peer-reviewed publication (VanTil et al., 2018), and the 2018 VSMS Technical report (Simkus et al., 2018).

    We have questions about the authors’ choice of covariates for the adjusted an...

    Show More
  • Extrinsic factors can demotivate students: a response from a medical students perspective

    We thank Belinda WC Ommering et al. for their insightful and original research regarding how medical students motivation translates into research involvement. Whilst the article focusses on motivation of medical students wanting to be involved in research and the resultant degree of participation, we believe it is important to remark on the extrinsic barriers that medical students may face in obtaining research experience despite being highly motivated and the effect this can have on their motivation to participate in research. We are sharing our thoughts on this article from the point of view of two final year medical students involved in undergraduate research. Our response includes results from a short live survey carried out at a student research conference we held locally.

    Previous studies indicate that students encounter personal and organisational barriers to research such as inadequate skill or training, limited access to information and unsupportive or unmotivated supervisors1 2. Students reported that a lack of proper training in understanding and writing papers, and difficulty finding an encouraging supervisor were two of the main barriers to conducting research as an undergraduate3. These students seemed to be motivated more by extrinsic factors, as 66.7% reported that the main reason they published their research was to improve their curriculum vitae3.

    During the student research conference we held, students were provided with a live questionnair...

    Show More
  • Comorbidities and opportunistic detection do not stop AAA screening from being cost-effective and equity enhancing.

    The recently published article by Chan et al. questions the value of AAA screening. [1] We question the validity of the arguments and the data they use to support it, which we believe are either irrelevant or support the case for screening. Furthermore, the Chan et al. paper completely neglects the important equity gains that AAA screening can produce in the New Zealand (NZ) population.

    Chan and his co-authors’ critique of AAA screening is based on 3 arguments: (i) patients with AAA are too sick with other comorbidities to benefit from screening and die of these other illnesses; (ii) most patients with AAA would be diagnosed by the health system anyway without a screening programme; and (iii) the size of the population that can benefit from screening is too small for it to be cost effective. Let us look more closely at each of these.

    Co-morbidities in patients with AAA

    The authors emphasise the point that co-morbidities in AAA patients might limit the benefit they attain from screening. They calculate that 77% of those dying of AAA had some other comorbidity. However, to imply that these were fulminant conditions and that preventing AAA death in this group would have been futile because they are moribund is highly misleading. The collection of co-morbidities includes: atrial fibrillation (a condition very prevalent in any elderly population), cardiovascular disease (CVD), also highly prevalent especially for Māori (which could range in severity f...

    Show More
  • Connecting Gout with Sleep Apnea

    One aspect of gout which is too often overlooked in guidelines and in practice is that most gout flares are initiated during sleep. The sleep connection has been known at least since Dr. Thomas Sydenham, himself a gout sufferer, wrote about it in 1683. A recent study [1] confirms Dr. Sydenham's observation. It is a very important clue to the pathogenesis of gout whether symptomatic or not.

    Many gout flares are a direct result of sleep apnea, and overcoming the sleep apnea can cure the gout. Four epidemiologic studies have been reported that show gout to be significantly more prevalent in people diagnosed with sleep apnea than it is in people never diagnosed with sleep apnea [2,3,4,5]. Here are the physiological reasons for those results. The chronic intermittent hypoxemia of sleep apnea has three effects which can lead to an overnight gout flare in short order. Effect #1 is intermittent cellular catabolism in which adenosine triphosphate degradation is accelerated, leading to nucleotide turnover which culminates irreversibly in the intermittent cellular generation of excess uric acid fed into the blood [6,7], faster than any food would cause. Effect #2 is concurrent intermittent hypercapnia and acidosis [8], so the blood can hold less uric acid in solution. Effect #3 is a long term deterioration of the kidneys' glomerular filtration rate [9] so that removal of uric acid from the blood is slowed. Thus, with sleep apnea there are repeated abrupt increases i...

    Show More
  • Half of diabetics don't know they are. Is it possible bedside diagosing pre-clinical stage of hyperuricemia and gout?

    T2DM can be divided into Five Stages (1-2). The altered metabolism of uric acid, often associated with DM, may be diagnosed from birth, starting with its Uricemic Constitution-dependent, Inherited Real Risk (3, 4). As all other inherited real risks, such a predisposition to hyperuricemia and gout is removed by Reconstructing Mitochondrial Quantum Therapy (5).

    1) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm
    2) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Travel Factory, Roma, 2004. http://www.travelfactory.it/libro_costituzionisemeiotiche.htm
    3) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [Medline]
    4) Stagnaro Sergio. Epidemiological evidence for the non-random clustering of the components of the metabolic syndrome: multicentre study of the Mediterranean Group for the Study of Diabetes. Eur J Clin Nutr. 2007 Feb 7; [Epub ahead of print] [Medline]
    5) Caramel S., Marchionni M., Stagnaro S. Morinda citrifolia Plays a Central Role in the Pr...

    Show More
  • Obesity simulation suit as opportunity to practice in a safe and standardized environment

    Dear Sir,
    Dear contributors,

    Thank you for the reactions to our article. We absolutely agree with the comments made.

    This study was never meant to give the idea that standardized patients (SP) wearing an obesity simulation suit (OSS) could replace the contact with real patients suffering from obesity.

    Simulation is a gold-standard method in medical education to prepare students for clinical work (1). It offers the opportunity to practice in a safe and standardized environment with structured feedback. Our students are used to encounter SP with various conditions as a teaching tool. It is important to acknowledge the purpose of this session: It is meant to be a basic step and is not about “true life experience” involving real patients. For example, medical faculties all over the world train their students on how to break bad news with SP (2). Here, it is also well accepted that this offers a good training opportunity despite the SP not having a serious condition themselves.

    Our first intention was to make a simulated scenario more realistic to support the concept of “suspended disbelief” (3). The other opportunity it offered was to sensitize towards the issue of patients with obesity and start a first reflection process on otherwise unnoticed prejudices. Many students appreciated the fact that due to the “before/after effect” (SP with OSS in simulation vs. SP of normal weight giving feedback) made them reflect even more on differences a...

    Show More
  • Obesity simulation suits: a superficial way of tackling a complex problem?

    Dear Editor,

    Herrmann-Werner et al (2019) brought to our attention an increasingly relevant topic. The study proposed that the obesity simulation suit (OSS) could be used to address the issue of stigmatisation of obesity(1). We are medical students at Imperial College London. As part of our course, we have regularly attended clinical communication sessions in the form of simulated role play.

    We believe that whilst using a simulated patient in an OSS may be useful, it is a superficial way of addressing the deep-rooted societal problem of how obesity is viewed and may even reinforce the stigma. The use of simulated patients should be adapted to reduce prejudice towards obese patients, especially with reference to their physical and psychological comorbidities.

    The study argues that using healthy weight actors in the OSS was of benefit because using obese actors ‘entails the potential danger of issues becoming too personal for the patient’(1). However, we believe that using actors with a healthy BMI may reinforce to students that obese patients are embarrassed or ashamed to have a conversation about their weight. At Imperial College, we simulate consultations with real patients to better understand their conditions. Rees et al also prefer the use of real patients, arguing that it provides medical students with a more realistic experience(2). Therefore, we recommend that students talk to obese patients who are willing to partake and understand the sensitiv...

    Show More
  • "You women have a way of understanding without thinking. Woman was created out of God’s own fancy. Man, He had to hammer into shape." - Rabindranath Tagore, Nobel laureate in literature

    Kapoor et al. highlight one aspect of gender discrimination, gender injustice and gender prejudice in Indian society using data acquired from their hospital information system at AIIMS New Delhi.1 Under a title of introduction the authors write, ”There have been a handful of small sample studies on gender bias in access to healthcare in select patient groups or for specific medical conditions….” Then under a title of Discussion, they cite several studies, some conducted at their Institute in the department of Cardiology, some in Pediatrics and some conducted abroad. Here we want to state that we too conducted a manual small study in Emergency Department of our hospital. We assessed demographic profile of alleged self -harm patients presenting to our referral tertiary care public hospital. In our study -among other variables- when we estimated sex ratio among male and female patients, it was 62:38(2). And that’s eerily close to 63:37 in this study. So there is a difference of just 1 percentage point. When 38 women per hundred patients present in our hospital in Lucknow with a history of alleged self- harm , 37 present to AIIMS New Delhi on an average in OPDs.

    Similarly at reference number 8, there is a study to estimate gender- bias in (availing) cardiovascular healthcare at a tertiary care center of north India. In the study Chhabra et al. assess that the ratio of girls to boys to avail cardiac interventions for their congenital and rheumatic heart disease is 38:62...

    Show More
  • Self-management and self-care, two sides of the same coin

    We read with interest the paper by Van de Velde et al delineating the concept of self-management in chronic conditions.1 We agree that there is a lack of consensus on the meaning of self-management, ambiguity regarding the concept, and an urgent need for uniformity with regard to terminology. One major area of ambiguity is the relationship between self-management and self-care. These terms are often thought of as synonyms, used interchangeably, or considered as integrated concepts (e.g. self-care as an overarching or umbrella term, with self-management as onecomponent of self-care).2 This is why, until 2018, major search engines combined the terms. When one searched for “self-management”, literature on “self-care” was provided as well. Since Van de Velde and co-workers aimed to delineate the concept of self-management and develop a definition for its use in healthcare, we expected a more thorough review of related concepts in their concept analysis. Thus, we were surprised to find that several important publications on self-care were excluded.

    We believe that the concept analysis by van de Velde et al would have been stronger if they also had included publications related to self-care. In 2012, after many years studying self-care in heart failure, we developed the Middle-Range Theory of Self-Care of Chronic Illness,3 which was updated this year.4 In this theory we defined self-care as the process of “maintaining health through health promoting practices and managi...

    Show More
  • Obstetrics and Gynecology Disclosure of Conflicts of/Competing Interests by Editors

    Thank you for your recent BMJ Open article,1 which has correctly noted that it is critical for journal editors’ potential conflicts of interest to be publicly disclosed. A limitation of the study is that only the digital version of the journals were considered. Obstetrics & Gynecology has included a conflict of interest statement for the Editor-in-Chief and Deputy or Associate Editors on the masthead of the print journal since the July 2008 issue. The article by Dal-Ré has prompted us to review our digital presence, and the website has since been updated to reflect our long-standing presentation of the editors’ potential conflicts of interest. I thank the authors for highlighting the importance of disclosing potential conflicts of interest but express concern that their work is biased toward the digital presence only.

    1. Dal-Ré R, Caplan AL, Marusic A. Editors’ and authors’ individual conflicts of interest disclosure and journal transparency. A cross-sectional study of high-impact medical specialty journals. BMJ Open 2019;9:e029796. doi: 10.1136/bmjopen-2019-029796.