942 e-Letters

  • The other 99% of poisoning incidents

    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.

  • Antibiotic prescribing in a primary care setting in Malaysia: a cross-sectional surveillance study.

    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...

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  • Response to letter regarding hyperbarix oxygen therapy

    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...

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  • Omissions and contradictions

    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),...

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  • What are junior doctors for? Response from the BMA Junior Doctors Committee

    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...

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  • Therapeutic indices for acupuncture

    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.

  • Comments on the Study as Published in BMJ OPen

    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.

  • A thought of the implication of a salt reduction program in The Bahamas

    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...

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  • Response to Tim Ambler, Adam Smith Institute

    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...

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  • Editor's Note

    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.