107 e-Letters

  • Frustrated coup to the LDL role in atherosclerosis paradigm

    In this article, the authors follow a very ambitious objective: to refute the LDL central role in atherosclerosis paradigm. There is an ironic statement that quotes: if you point to the King, be sure not to leave him alive. Here I’m afraid this article leaves the King alive because the methodology chose had inferior quality of evidence in relation to a well-done metanalisys like –for example- the one which was published by the Cholesterol Treatment Trialist (CTT).
    In order to the studies included in this selection there were some inconsistencies. First of all, the WOSCOPS trial and the AFCAPS/TexCAPS trial were used to analyze the effect of a reduction at least of 30% in LDL but these two pivotal articles showed a reduction of 20% and 25%, respectively. In fact, in the pilots’ study there were only 157 deaths from 6605 patients randomized so the study hadn’t enough statistical power to analyze the mortality endpoint. In the same direction, the selection of the SEAS study was controversial because in spite of achieves a 61% reduction in LDL, the population included hadn’t a clear indication of statin treatment in relation of ethical considerations, affecting the results in order to MACE and mortality. Also it was very polemical to include trials as SHARP or AURORA with patients on dialysis because we know this kind of treatment actives a lot of mechanisms of morbidity and mortality with independence of the LDL level. Other weak point is to analyze mortality taking in...

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  • Honey and in vitro antibacterial properties including Helicobacter pylori

    I read with interest the latest evidence for honey and treatment of coughs which was also reported widely in the national press (1). Honey has been shown in laboratory in vitro studies to inhibit bacterial growth including Helicobacter pylori linked with dyspepsia and gastritis (2, 3). Concentrations between 10-20% honey has been shown to be effective against both Gram negative and Gram positive bacteria (3). My late father Professor MNH Chowdhury, a clinical bacteriologist, researched this in the 1990s and advocated Manuka honey especially for its healing and antibacterIal properties. Interestingly, the in vitro findings showed some isolates were resistant to various antimicrobial agents but honey inhibited these organisms also (3). Secondary bacterial infections may respond to this simple remedy after primary viral coughs and colds and need further clinical study.
    1. Abuelgasim H, Albury C, Lee J. Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis. BMJ Evidence Based Med 2020, 18 Aug online; bmjebm-2020-111336.
    2. Rashed RS, Ayoola EA, Mofleh IA, Chowdhury MNH, Mahmood K, Faleh FZ. Helicobacter pylori and dyspepsia in an Arab population. Trop Geogr Med 1992; 44(4), 304-7.
    3. Ali AT, Chowdhury MNH, al Humayyad MS. Inhibitory effect of natural honey on Helicobacter pylori. Trop Gastroenterol 1991; 12(3), 139-43.

  • Symptomatic relief or Cure?

    It is risky to propose that agent offering symptomatic relief should replace microbial cure. Two are different aspects and different approaches.
    Besides honey may not be considered entirely safe. Many environmental Journals are raising voice against contamination of honey either by microbes or by antimicrobials.
    Clinicians must know if the Upper Respiratory Infection is going to be entirely selflimited and will not progress to Pneumonia, or lead to late Sequelae like Rheumatic Fever Rheumatic Heart Disease.
    If only symptomatic relief is to be achieved, one wonders if home made sugar syrup may work as well as honey will. Moreover homemade sugar syrup will not carry microbes or antimicrobials!
    Arvind Joshi MBBS MD FCGP FAMS FICP.

  • Honey! Go for the Cure!

    The Editor
    Read with interest the article
    " Effectiveness of honey for symptomatic relief in upper respiratory tract infections: a systematic review and meta-analysis"
    Symptomatic relief and treatment of infections are entirely different treatment goals.
    A clinician must decide very clearly either on clinical grounds or with investigations, if the infection is going to be a selflimited one which will subside completely without any antimicrobial and also will not cause any late Sequelae. A very important example in this regards used to be Streptococcal throat infections which often would subside without proper antimicrobial treatment, only to cause Rheumatic Fever, Rheumatic Arthritis and Rheumatic Heart Disease later. Not necessarily upper respiratory tract infections, post Streptococcal Glomerulonephritis, post Rickettsial complications are some of the examples where not symptomatic relief, but prompt and adequuate treatment of infections with antimicrobials is crucial for preventing devastating Sequelae.
    It is often very difficult to to foresee which respiratory or for that matter any infection will be self limited and will not cause any serious Sequelae if no antimicrobials are used.
    That is the CATCH!
    Arvind Joshi;
    Founder Convener and President:
    Our Own Discussion Group,
    602-C, Megh Apartments,
    Ganesh Peth Lane, Dadar West;
    Mumbai PIN 400028;

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  • Dr

    Might it be helpful to clarify in the title or abstract that the paper relates solely to estrogen containing contraceptives, and essentially the oral versions?

  • Burden of proof or disproof?

    In a systematic review of cholesterol reduction clinical trials, DuBroff et al claimed that “the evidence presented challenges cardiovascular disease prevention through targeted reductions of LDL-cholesterol”. However, it should be noted that the concept authors claim to challenge has never been proved, nor properly tested (1). This raises the question of whether there is a need to disprove an unproven concept. In science, the burden is on the proof.

    Nevertheless, if it was to disprove, we must recognize the limitations of the present study. Regarding testing "the target paradigm", the authors first categorized the trials as to whether they did or did not meet average LDL-cholesterol reduction recommended by AHA/ACC 2018 guidelines (2) for individuals. Then, they intended to test the association between reaching this arbitrary target (suggested by one specific guideline) with the trial being positive or negative regarding death or cardiovascular events. However, no statistical inference was performed for this main analysis and no significance level was presented for the interaction between reaching the target and having clinical benefit. Instead, in this systematic review that intended to test a hypothesis that implied interaction phenomenon, the authors "intentionally did not perform a meta-analysis" under the justification that trials “involved three different drug classes”.

    Finally, as the authors noted, it was a systematic review of s...

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  • Setting the Record Straight on Saturated Fat and LDL-cholesterol. Ignorance is not bliss.

    Like so many purported pundits, DuBroff R, de Lorgeril M [1] have attempted to dispute the significance of the role of saturated fat (triglycerides) and LDL-cholesterol in the development of coronary artery disease, while noting the importance of inflammation itself [1,2]. In law, ignorance of the law is not a defense - the same is true for medicine. Not understanding something does not make you an expert [2] and it does not make your argument valid. Appealing to the court of public opinion does not make it so either. Accordingly, we present a brief explanation of why the authors [1,2] – and others – have presented an invalid discussion of the role fat and LDL-cholesterol plays in coronary artery disease.

    In the mid-1990s, as one of the reviewers for the American Heart Association, the first author of this letter, Dr Richard M Fleming (RMF) introduced a then controversial theory stating that Coronary Artery Disease (CAD) is the result of an inflammatory process, which builds up within the walls of the arteries impairing their ability to dilate and increase coronary blood flow when needed; thus producing regional blood flow differences resulting in angina [3-6] and ultimately myocardial infarction (MI) and death.

    In recent years, people promoting various dietary and lifestyle practices – particularly those promoting LowCarb-Keto diets, have used the obesity epidemic to focus attention on obesity and weight loss. These same individuals have not demonstrated th...

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  • UK TIME study will also provide further evidence

    Thank you for this measured summary of the recently published HYGIA trial. I am pleased to see you mention the BedMed study ongoing. Readers may be interested to know that there is another study, already in follow-up, which will provide further evidence on whether night-time dosing of blood pressure medications really is better in the prevention of cardiovascular events and mortality.

    The University of Dundee's Treatment in Morning vs Evening (TIME, www.timestudy.co.uk) study, funded by the British Heart Foundation, aims to answer the same research question. TIME has recruited 21,104 participants across the UK and should finish in the first half of 2020.

  • Considerations for future age-based risk reviews

    I read this rapid review with interest and agree this topic has reached a point at which a full systematic review could be useful. I have a few suggestions to the authors and/or future reviewers in this area, as there are several nuances in the studies presented that have not been acknowledged.

    Future reviews need to consider what primary outcome the study was powered for, and what the comparator is. For example, Bonner et al. looked at physical activity and diet changes as well as smoking in a combined measure and found no statistical difference between absolute risk and heart age when presented in the same format, but the smoking result is isolated and reported as “clinically significant” in the review. In contrast, Lopez-Gonzalez et al. compared an interactive online format for heart age to usual care which generally involves a verbal description of absolute risk by the doctor, so it is difficult to determine whether heart age or a more engaging presentation format produced the results.

    Psychological outcomes should also be considered. Modest gains in behaviour change may not be outweighed by reduced accuracy of risk perception, negative affect or reduced credibility of the assessment as per Bonner et al. While these age-based formats appear to elicit a stronger emotional response, this may not be sufficient to produce greater behaviour change or even intentions without additional support (e.g. Soureti et al. and Witteman et al.). It is unclear from the r...

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  • Response: Research Integrity & BJPsych

    Dear Editors,

    We thank Dr. Bhui and Mrs. Shuttleworth for commenting on our paper and giving us the opportunity to clarify some aspects of our methods. In their response, they invite us to elaborate on our rationale for journal selection and if we infer that spin is more prevalent in psychiatry journals versus psychology journals. Here, we attempt to clarify our methodology and conclusion regarding our article over spin.

    The journals in our study were selected due to their ranking on Google Scholar Metrics under the subcategory “Psychiatry” at the time of the search [1]. It should be noted that as this search was conducted on May 21 2018, the rankings found today may differ from what we found. We selected the highest 10 ranking journals on Google Scholar, according to their h-5 index. However, not all journals primarily published RCTs in humans and were therefore excluded from our study, leaving us with a total of 6 journals.

    The aim of our paper was not to compare the prevalence of spin between trials published in psychiatry and those published in psychology journals. Rather, our study examined the rates of spin in RCTs published in high-ranking journals, as indexed by a popular journal ranking platform.

    We commend the editors of British Journal of Psychiatry on taking steps to confront spin, such as mandatory use of the CONSORT checklist. For example, CONSORT item 22 requires that interpretations presented in discussion sections of clinical t...

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