125 e-Letters

  • 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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  • A shot of light in the dark, but still waiting for the big bang

    I commend the authors for their well balanced and informative review on recent evidence on reduced fetal movement (RFM). Over the years I sadly saw the practice in the NHS being driven by fear and emotions rather than evidence, certainly, some units now offer mothers induction of labour even after a single episode of RFM! Junior doctors are prompted to act on RFM at induction day, and hospitals are adopting the official Care Bundle from the NHS promoting action (http://www.geh.nhs.uk/latest-news/saving-babies-lives-campaign/) yet, where is the evidence that any of this is beneficial?! certainly efforts like the AFFIRM study need wider dissemination and adoption by policymakers. The question remains, what can we offer to worried couples presenting with RFM daily? Still waiting for the game-changer.

  • Industry sponsorship bias in the SGLT2 inhibitor study

    The EBM Verdict by O'Sullivan on the CREDENCE trial of canagliflozin and renal outcomes (1) concluded that "Sodium-glucose cotransporter-2 (SGLT2) inhibitors appear effective to reduce cardiovascular events and deterioration of renal disease in patients with type 2 diabetes and renal impairment." O'Sullivan stated that the study was well-conducted based on conventional assessments of validity (blinding, randomization method, choice of outcomes). However, an important overlooked source of potential bias was not mentioned. The CREDENCE study was sponsored by the pharmaceutical company (Janssen). The analyses of the data was conducted by Janssen, and important conflicts of interest were reported by authors of the paper. A Cochrane review of the relationship of industry sponsorship and research results (2) found significantly more favorable efficacy results in studies by the manufacturing company than sponsorship by other sources, and that the industry bias could not be explained by other "risk of bias" assessments. This important source of bias warrants caution in the interpretation of the results in the absence of independent (non-industry sponsored) data.

    1. Perkovic V. et. al. Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy. CREDENCE Trial Investigators. N Engl J Med 2019;380:2295–2306.
    2. Lundh A, Lexchin J, Mintzes B, Schroll JB, Bero L. Industry sponsorship and research outcome. Cochrane Database of Systema...

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