1536 e-Letters

  • Author response to: Comment on: Cardiac involvement assessment in systemic sclerosis using speckle tracking echocardiography: a systematic review and meta-analysis

    Dear Editor,

    Thank you for providing us with the opportunity to respond to Dr. Peverill’s comment concerning our article entitled “Cardiac involvement assessment in systemic sclerosis using speckle tracking echocardiography: a systematic review and meta-analysis”. We also acknowledge and appreciate Dr. Peverill’s time spent reading our article and providing his comments to help us strengthen the article.
    As proposed by Dr. Peverill and also stated in the article, our systematic review was conducted because of results from related studies were controversial. Based on the meta-analysis results, we found left ventricular (LV) global longitudinal strain (GLS) was lower in SSc patients than in healthy control subjects. We are sorry we included multiple sclerosis in the study by mistake. We will correct it as soon as possible with the help of our editors. As for the reported large standard deviation (SD) of GLS of 8.9% in the control group 1, we have carefully reviewed the article again, and this value has been mentioned many times and is difficult to identify as an error. Moreover, as suggested by Dr. Peverill, we will present the result with the study excluded in the supplementary file.

    As Dr. Peverill suggests, age and sex may affect GLS. The effects of age and sex on the results of SSc and control groups need to be considered, however most studies include age- and sex- matched control groups [2-7], which may reduce the effect. In our study, we also perfor...

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  • Autologous anterior lens capsule transplantation to treat refractory macular holes : Issues for challenging cases

    To close complex MHs, different options have been described in different small series which pioneered various adjuvants : mainly fresh or lyophilized human amniotic membrane (AM) transplantation either transplanted into the subretinal space1-3 either put in epiretinal position4,5, autologous or allogenic lens capsular (ALC) flap transplantation inside6 or over7 the MH, autologous neurosensory retinal (ANR) free flap transplantation8.

    We would like to discuss several points with the authors, referring to additional references:
    1/ First, the cut off of 400 μm chosen to include high myopia macular hole retinal detachment (HMMHRD), is questionable as most of the time HMMHRD are associated with extra-large macular holes (MH) (>>400 μm) with a various amount of sub retinal fluid (SRF). The authors could have chosen another cut off to increase extrapolation of their future findings, according to the trends of new classifications. Based on the closure rate and the functional results, some authors proposed to update the International Vitreomacular Traction Study group9, as Steel et al.10 with MH>500 μm, or Ch’ng et al.11 with MH>650 μm, or Rezende et al.12 with MH>800 μm, and so use new surgical techniques such as ILM or ALC flap or ANR transplantation : why do not choose the cut off of 500 or 650 μm to include HMMHRD patients for the proposed trial? For the sample size calculation, the closure rate chosen in the control group (65%) is questionable rega...

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  • Dynamic integration of primary healthcare into vision care services

    Dear Editor,
    We have read with great interest the scoping review by Lee et al.[1], investigating efforts to integrate eye care into healthcare systems in low-income and middle-income countries (LMIC). We also share a belief in the importance of further integrating service delivery in this area.
    Most of the cited studies addressed the integration of eye care into wider healthcare settings. The review highlights improved outcomes in management of retinopathy of prematurity achieved through enhancements to paediatrician-led care [2]. Furthermore, the review displays how improved provision of resources, training and enhanced engagement with other stakeholders has resulted in improved knowledge and guideline usage in primary care [3].
    The review highlighted various interventions delivered as short training sessions or educational modules [4-6]. Whilst undeniably important for capacity building, these measures cannot in and of themselves achieve a highly integrated system, which would require changes in infrastructure, guidelines and referral systems.
    We would appreciate a further understanding of the authors’ rationale for including certain studies in the review, which appear to contain remote or indirect references to eye care service delivery [7-12]. Some included studies [11, 12] appear to link improved management of hypertension and diabetes with prevention of associated retinopathy, though the articles do not appear to mention diabetic retinopathy e...

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  • Should I stay or should I go?

    We read with interest Pathmanathan and Snelling’s deep exploration of the reasons that doctors leave UK medicine.[1] Considering all the negative ‘push’ factors provoking doctors to leave careers that they have spent years building, is a somewhat depressing (though compelling) read. As we consider what clinicians, policy-makers and medical educators should do with this information, it is important to reflect on another side to this story: Why do doctors ever stay in the profession?

    Despite the cited problems, every year the majority of doctors do decide to stay. Is this due to loyalty to the profession, or perhaps to our patients? Is it simply a lack of imagination to consider what else we might do? Is it too hard to walk away from careers that we have invested so much of ourselves into (the sunk-cost effect[2])? Or perhaps, as the authors of the article allude to, our sense of identity is so intertwined with ’being a doctor’[3] that it is impossible to walk away without leaving a piece of ourselves behind.

    While the insights from this paper do give stakeholders food for thought, we propose that it is also imperative to seek the views of those who choose to remain in UK medicine. We may be able to use these insights to help strengthen the reasons to stay in a profession that many of us consider a ‘calling’.[4]

    1 Pathmanathan A, Snelling I. Exploring reasons behind UK doctors leaving the medical profession: a series of qualitativ...

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  • Gut feeling as antennae twitch

    In this review paper on the accuracy of gut feeling in diagnosing cancer in primary care, the authors conclude that “the findings support the continued and expanded use of gut feeling items in UK cancer referral pathways”. Whilst most clinicians will have experienced the gut feeling that their patient has a serious illness and be thankful for having done so, there is debate over what a gut feeling is and what it represents within the diagnostic process. Is it a subjective intuitive experience, or an objective recognition and response to an abnormal finding? In our teaching programme on ways to prevent diagnostic errors, we discuss the role that gut feeling has in the prevention of these errors through subconsciously alerting the clinician to the presence of an abnormal finding that has not been recognised by the cognitive part of the diagnostic process, or responded to by the clinician. To help explain this, gut feeling is conceptualised as representing a “twitch” of the clinician’s “medical antennae”.

    The basis for this concept is as follows: All clinicians possess a set of medical antennae that twitch in response to an abnormal finding. Medical antennae function within the dual-process diagnostic reasoning model, where they monitor information as it is being gathered and processed. Their role within the diagnostic process is to act as a back-up warning system to alert the clinician to an abnormal finding that has not been recognised or responded to. It is postula...

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  • Current Antidepressants Cannot Remain STAR of the Show

    Pigott and colleagues, in previous criticism of the STAR*D study [1,2], identified deviations from prespecified protocolised measures of remission and response rates, mid-study eligibility criteria adjustments, and other methodological issues. In their new re-analysis, they calculate that STAR*D’s cumulative remission rates are half those originally reported [3].

    Antidepressant medication remains the mainstay treatment of depression and is an optional first-line treatment for people with less severe depression [4]. This is despite a well-established effect size of around d=0.3, equivalent to approximately 2 points on the HAMD-17, which is deemed below the threshold for clinically significant improvement [5,6]. Antidepressant use continues to increase, with 15% of the UK population currently receiving an antidepressant prescription [7]. This is against a backdrop of increasing awareness of the potential harms of antidepressant medication [6], yielding new guidance published earlier this year in the British Journal of General Practice [8].

    Pigott and colleagues’ findings should again prompt urgent investment into alternative efficacious treatments and research into better and novel multidisciplinary treatments, which draw on the synergy between biological, social, and psychological interventions.

    Furthermore, in light of these determinations, regulatory authorities and drug developers should re-examine the line of pharmacotherapy at which novel t...

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  • Response to the comments on community surveillance system

    We thank the authors for their interest in our study. The authors highlight the considerable proportion of cases being identified by a single informant as a problem for data quality. However, this is not unusual considering that suicides and attempted suicides are associated with high stigma and hence there is very little discussion in the community. Most of these single informants were public health workers (Health or ICDS or Asha workers) who regularly visit and interact with families. Hence, they are more likely to have knowledge of events such as attempted suicide and suicides which are not otherwise in the public domain for other community informants. We have also conducted additional validity exercises where cases reported by single informants were cross-checked with the records maintained by Talati (village revenue officers) to ascertain the accuracy of the reported data.
    We agree with the authors that further studies in other geographic locations will be ideal to identify the challenges in scaling up the surveillance system to the entire country.
    We also agree with the authors that some legislative or policy measures to mandate data sharing by private health institutions are needed for effective implementation of community surveillance.
    We agree with the authors when data on police records for suicidal attempts is n= 0 cases, the post hoc McNemar’s test is not the most appropriate statistical measure. Where we say “Whereas there was statistical ev...

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  • Mislabelled diagnostic category

    I think you have mislabelled one of the diagnostic categories in Table 1. Irritable bowel syndrome should be "Inflammatory Bowel Disease"

  • RE: Effect of CPAP on cognitive function in stroke patients with obstructive sleep apnoea

    Yang et al. conducted a meta-analysis of randomised controlled trials (RCTs) to investigate the effect of continuous positive airway pressure (CPAP) treatment on cognitive function in stroke patients with obstructive sleep apnoea (OSA) (1). There were no significant effects on global cognitive gain in stroke patients with OSA, although an early start within 2 weeks post stroke of CPAP treatment after stroke significantly improved global cognition. Additionally, CPAP did not significantly improve memory, language, attention or executive function. Stroke event itself may be a risk of poor cognitive function, and there is a need of understanding the clinical benefits of CPAP treatment on cognitive function in subjects without stroke history. I present information regarding the relationship between CPAP treatment and cognitive impairment with special reference to baseline state of cognitive function and CPAP adherence.

    First, there was insufficient evidence to suggest that treating sleep dysfunction can improve cognition by a meta-analysis of RCTs (2). Yang et al. should consider the severity of stroke for the analysis, although stroke itself might contribute to the level of cognitive function.

    Second, Hoyos et al. evaluated the cognitive benefits by CPAP treatment in patients with OSA and mild cognitive impairment (MCI) (3). The authors conducted RCT study to specify the causal association, and CPAP treatment was significantly associated with improvements in P...

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  • Updated protocol in response to Covid-19 government restrictions

    This update relates to the study protocol for “Can a teacher-led mindfulness intervention for new school entrants improve child outcomes? Protocol for a school cluster randomised controlled trial”

    Mindfulness-based approaches have been shown to be effective in improving the outcomes for adults, with emerging evidence for adolescents and children. However, the majority of these interventions have not been evaluated through controlled trials to understand their effectiveness and cost-effectiveness. Furthermore, fewer studies have examined mindfulness intervention using play-based activities and targeting teacher practice to ensure practices are sustained over time. To address this gap, the design was a cluster randomised controlled trial in primary schools (clusters), with schools randomised to either the Minds@Play intervention or ‘business as usual (control). This study aims to contribute to the evidence related to the effectiveness and cost-effectiveness of whether a mindfulness intervention is able to provide outcomes for students, and the implementation factors which may influence the outcomes observed.

    Several changes to the original study protocol were made to reflect learnings from the set up and conduct of the study, as well as reflect the government-mandated restrictions in Melbourne, Victoria, where the study was conducted.

    In Melbourne, Australia – where the study was based – there were a numbe...

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