448 e-Letters

published between 2020 and 2023

  • Response letter to Ravnskov U et al "Dyslipidemia is an unlikely cause of atherosclerosis"

    We appreciate the authors’ interest for our paper, and we would like to thank them for the opportunity to discuss the problems raised in their letter (1).

    First of all, we would like to emphasize that in our study we didn’t try to investigate the pathophysiology of atherosclerosis, but tried to see how the generally accepted risk factors of atherosclerosis correlate with significant coronary heart disease evaluated by CAD-RADS score in the Romanian population (2). The design of our research was cross-sectional, retrospective, therefore our purpose was not to establish the causality between dyslipidemia and cardiovascular disease. We agree with the authors that there is a difference between causality and association and our current study was based on evaluating the association between the presence of risk factors and the burden of atherosclerotic coronary disease evaluated using CCTA method. We chose dyslipidemia among the atherosclerosis risk factors studied based on the most current guidelines on cardiovascular disease prevention at the time (3).

    Regarding the pathophysiology of atherosclerosis, the role of lipids and lipoproteins in the development of atheromatous plaque is proven by many studies (4-7). This complex process, based on an inflammatory response, is initiated by the infiltration of apoB containing lipoproteins into the arterial wall, which cause wall injuries and promote infiltration of monocytes into the subendothelial space. Secondly, the ma...

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  • Authors' Response

    Thank you for your comments on our manuscript.
    Firstly, we applied meta-analysis to pool diagnostic accuracy for NBI, HAL and 5-ALA techniques for patients with NMIBC in comparison with WLC as the reference standard, which demonstrated the superior diagnostic performance of new imaging techniques in bladder detection compared with conventional WLC. These new imaging techniques are promising diagnostic interventions to improve clinical procedures in bladder cancer detection.
    We described The SROC curves for NBI, HAL and 5-ALA in Figure 3A and the pooled DOR for NBI, HAL and 5-ALA were 40.09 (95% CI, 20.08-80.01, Figure 2A), 78.14 (95% CI, 31.42-194.28, Figure 2B) and 18.14 (95% CI, 4.28-76.87, Figure 2C), showing significant diagnostic superiority compared with white light cystoscopy (WLC) at the lesion level. While SROC curves for NBI, HAL and 5-ALA were showed in Figure 3B, DOR for NBI and HAL were 358.71 (95% CI, 44.50-2891.71, Figure 2D) and 59.95 (95% CI, 24.30-147.92, Figure 2E), presenting better performance compared with WLC. Figure 3 showed HAL and NBI exhibits similar SROC curves in lesion level, NBI performed significant excellent SROC curve in patient level. For patient-level analysis, NBI showed highest median sensitivity (SSY) 100%, median positive predictive value (PPV) 90.75%, median negative predictive value (NPV) 100% and median false positive rate (FPR) 31.55% in supplementary Table 1. And supplementary Table 2 showed similar narrative outcome...

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  • Response

    Dear Editor,
    Socioeconomic status (SES) has long been found to be significantly associated with increased risk of morbidity and mortality. It is related to health at all levels (1). A weak association between SES and maternal health care is found in countries where females are more educated (2). In developing countries like Pakistan where maternal mortality is still high despite efforts been made (3). This poor maternal health care use leads to maternal depression leading to CMH (Child Mental Health) issues (4). Therefore, efforts should be targeted to improve maternal health care use in order to ensure physical and mental health of the future generation irrespective of their SES.
    1. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health. No easy solution. Jama. 1993;269(24):3140-5.
    2. McTavish S, Moore S, Harper S, Lynch J. National female literacy, individual socio-economic status, and maternal health care use in sub-Saharan Africa. Social science & medicine. 2010;71(11):1958-63.
    3. Mumtaz Z, Salway S, Shanner L, Zaman S, Laing L. Addressing disparities in maternal health care in Pakistan: gender, class and exclusion. BMC pregnancy and childbirth. 2012;12(1):80.
    4. Maselko J, Sikander S, Bangash O, Bhalotra S, Franz L, Ganga N, et al. Child mental health and maternal depression history in Pakistan. Social psychiatry and psychiatric epidemiology. 2016;51(1):49-62.

  • How to improve diagnosis of non-muscle invasive bladder cancer?

    In their recent paper Chen et al. presented a meta-analysis on the diagnostic performance of image technique based transurethral resection for non-muscle invasive bladder cancer: They claim in their conclusion that narrow band imaging (NBI) showed the best diagnostic performance outcomes in a comparison to blue light cystoscopy with hexaminolevulinate (HAL) and 5-aminolevulinic acid (5-ALA). We cannot find the evidence for this in the result they present which deserves commenting.
    In the abstract it is written that NBI showed significant diagnostic superiority compared with white light cystoscopy (WLC) at the lesion level (Pooled sensitivity 0.94, 95% CI 0.82 to 0.98; Pooled specificity 0.79, 95% CI 0.73 to 0.85; Diagnostic odds ratio (DOR) 40.09, 95% CI 20.08 to 80.01; Area under the receiver operating characteristic curve 0.88, 95% CI 0.85 to 0.91). That HAL showed superior lesion level detection results in all measured parameters is not mentioned. It is further stated that NBI presented the highest DOR (358.71, 95% CI 44.50 to 2891.71) in the patient level. The subgroup analysis, evaluating diagnostic performance in studies with low to moderate risk of bias and in studies with more than 100 patients, is only presented in supplementary material and similarly show how HAL and 5-ALA achieve comparable or improved diagnostic performance compared to NBI. Despite these results, the authors emphasize and conclude on behalf of NBI throughout the paper.
    While the con...

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  • Response to: Medical students’ experiences of the benefits and influences regarding a placement mentoring programme preparing them for future practice as junior doctors: a qualitative study

    Dear Editor,

    I would like to thank Ng, Lynch, Kelly and Mba for their article analyzing the views of medical students who had participated in a mentoring programme whilst on their Obstetrics & Gynaecology attachment in the UK.
    Devising methods of improving the learning experiences for medical students whilst on placement is vital to ensuring their professional readiness1 in facing their upcoming roles as junior doctors, practically and emotionally.

    In the introduction, the authors provide a beautiful definition of a mentor from SCOPME2. I’d like to highlight that this definition includes the mentor being a ‘guide’ and being ‘empathic’. A guide is traditionally someone who shows another the way in a new environment to prevent them from getting lost; in many settings a guide is imperative. One could argue that students are given a Personal Tutor at the beginning of university who is a mentor in a way. This could be a good starting point, especially for more pastoral care – yet a clinical guide who is working closely with the student may be imperative as well, for the reasons emphasized by the student quotes in this article. The authors, therefore, concluded that clinical placement mentors for medical students should be more of a widespread practice.

    Another key feature of these mentors is that they ‘volunteered’ to sign up, which identifies a key element of willingness to participate in the programme. If this programme became more widespread or...

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  • Women and Health

    Dear Editor ,

    This article mainly focuses on knowledge about health related states and events for women in South Asian region i.e in Pakistan and India . Mostly women presenting in public hospitals for their antenatal checkup belongs to poor socioeconomic status and cannot afford a good living to maintain a healthy lifestyle . So, despite of having adequate knowledge about good health they can not afford one . So, i think hospitals should compile data of such women and share with concerned authorities who can provide them in this regard.
    Psychological support should be freely available for pregnant women during their antenatal visit by experts .

  • PTSD risk factors in obstetrics & gynaecology

    Farren et al (1) state that they, ”were surprised by the prevalence of PTSD symptoms in our study”, and that, ”Future research should be aimed at assessing the risk factors for PTSD”.
    My research of 1993, into Post Traumatic Stress Disorder in women who have undergone Obstetric and/or Gynaecological Procedures (2), which was widely reported in the press, obstetric and midwifery literature, including the N.I.C.E Guidelines, identified several risk factors for the development of PTSD in the women affected.
    The key areas in the procedures seem to be those concerning the level of control which the woman has, the attitude of the doctor, the degree to which the patient’s views are heeded, and whether or not consent was perceived to have been given for the procedure. The gender of the examiner did not seem to be relevant.
    The women were asked in the questionnaire to describe their experiences, some of which were quite explicit and reminiscent of assault: “dehumanising and painful”; “degrading and distressing….no account was taken of my feelings”; “my opinions were dismissed as irrelevant although it was my body which was being invaded”; “I came away hurting and feeling violated”; “very brutal internal was excruciating”; “you begin to feel like a thing”; “I cried and shouted but was held down and told to stop making a noise”; “humiliation…as if it happened yesterday”; “I felt assaulted and then abandoned”; “I felt abused…like a piece of meat on a slab”; “the mo...

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  • Dyslipidemia is an unlikely cause of atherosclerosis

    The study by Popa et al. (1) is potentially of value in identifying adverse influences on cardiovascular health. Their study, however, suggests that dyslipidemia causes cardiovascular disease (CVD). We feel compelled to show that the broader literature is not consistent with this perspective and that their finding of an association between dyslipidemia and CVD is influenced by a methodological flaw in their design.

    First, there is no evidence that dyslipidemia causes atherosclerosis. Already in 1936 Lande ́ and Sperry found that when corrected for age, healthy people with low total cholesterol (TC) were just as atherosclerotic as healthy people with high TC (2) and their finding has been verified and replicated later by many research groups (2). A strong contradiction has also been documented by sixteen angiographic trials where the authors had calculated exposure-response, which was present in only two of them (2). Furthermore, a study of the coronary arteries of 304 asymptomatic women by Hecht and Superco showed that the role of high LDL-cholesterol (LDL-C) is questionable as well. By using electron beam tomography, they found that neither the calcium percentile or the calcium score were associated with LDL-C (3). Also contradictory is, that In five studies of people with familial hypercholesterolemia there were no association between degree of atherosclerosis and LDL-C (4).

    Second, numerous observations and experiments have shown that dyslipidemia does no...

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  • Response

    Dear Editor,
    Excellent research topic with a catchy title. This research paper helps in identifying the role of TW’s in the spread of HIV. In Pakistan HIV/AIDS is now an established epidemic. This life threatening condition is still considered a stigma and the fear of disclosure restricts the patients from getting timely treatment. Although the number TW’s in Pakistan is not much but there role in spreading HIV should not be overlooked. The researchers have done justice in identifying the root causes and the idea of giving incentives to participants definitely needs appraisal.

  • Response to the comments of the COMPACT-2 researchers

    Dear Compact-2 researchers,
    Thank you very much for your comments, which we have read with great interest as they certainly contribute to the opening of an interesting debate. Below there are some points which go to clarify some issues highlighted in your letter:

    1 – We are confused by the reasons you decided to stop your trial. In your comment you have indicated that this was due to futility reasons. However, in the conclusion of the report which was uploaded to your web page, we read the following phrase: “The interim analysis requested by the EDSMC shows higher mortality for the CPFA group compared to the controls, particularly in the first days of treatment.” Furthermore, on April 27th, 2018 Medtronic issued an Urgent Field Safety Notice for the intervention product: “In a clinical study, higher early mortality (within 72 hours of randomization) was observed in septic shock patients receiving CPFA Coupled Plasma Filtration Adsorption therapy compared to patients receiving standard care. Septic shock patients often have clinical characteristics (hemodynamic instability, coagulation disorders) that increase the risk of extracorporeal treatment. Based on the preliminary data from this study, CPFA should not be used in patients with septic shock.” Finally, in the Annual Update in Intensive Care and Medicine 2019 (Chapter 29), we can read the following information about the COMPACT-2 trial. “The trial was prematurely terminated because of higher early mortality...

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