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Recent eLetters

Displaying 1-10 letters out of 238 published

  1. Gastric adenocarcinoma: the role of Helicobacter pylori in pathogenesis and prevention efforts.

    The correct statement is as follows: The portion of the stomach within which H. pylori localises has profound impact on its clinical sequelae. H. pylori colonization of the antrum results in increased acid production which may lead to duodenal ulcer formation. On the other hand, infection within the body of the stomach predisposes individuals to atrophic gastritis, which, in turn, may progress to precancerous lesions and gastric cancer.

    Thanks

    Conflict of Interest:

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  2. Location of HPylori

    The article states: =======================================================The portion of the stomach within which H. pylori localises has profound impact on its clinical sequelae.18 H. pylori infection within the body of the stomach results in increased acid production and peptic ulcer disease. On the other hand, infection of the antrum predisposes individuals to atrophic gastritis, which, in turn, may progress to precancerous lesions and gastric cancer. =======================================================

    The gastric location of the above statements is incorrect and reversed. Infection of the antrum, not body, results in increase acid production leading to ulcer disease. Vice-versa, infection of the body, not antrum, results in atrophic gastritis and may lead to malignancy.

    Thanks

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  3. Mobile phones are commonplace in Singapore

    Dear Editor,

    I read with interest the article titled "Mobile revolution: a requiem for bleeps?" by Martin et al. The authors state that 73% of people feel that traditional bleeps should be replaced with new mobile technologies. The authors also states the favourable attitudes hospital doctors have towards mobile technology.

    I would like to share the experience in our country. Singapore is a country in South-East Asia. All public hospital junior staff communicate via mobile technology. There are no bleeps. Mobile technology is an essential communication tool. A majority of junior doctors, housemen and medical officer grades are employed by a government-linked company, which gives out monthly mobile phone subscription fee subsidies. Mobile phone numbers of doctors are published on the hospital intranets. As the mobile phones are always with the doctors, each doctor is more easily accessible and can attend to patients in a swifter manner, potentially improving patient care. Consequently, many doctors carry two mobile phones around - a personal phone and a work phone. The same work mobile phone with an internet subscription allows the doctor to access journals, articles and databases literally at his finger tips.

    There is potential in mobile technology and I urge interested parties to embrace it.

    Yours Sincerely, Dr Ching-Hui Sia

    Conflict of Interest:

    None declared

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  4. Storify relating to article

    Author's Storify: https://storify.com/nephondemand/equal-work-for- unequal-pay-the-gender-reimbursemen

    In response to articles:

    American Council of Science and Health News: http://acsh.org/news/2016/08/17/medicare-supports-unequal-pay/

    Twitter comments: https://twitter.com/Skepticscalpel/status/767785871500251136

    Medscape: http://www.medscape.com/viewarticle/867652?src=rss

    Conflict of Interest:

    author of article

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  5. Emphasis on Lifestyle Management Not Evidence Based

    I read with interest the manuscipt by Jeyaruban and colleagues. However I am disappointed that a major issue identified was a "Failure of adherence to lifestyle changes".

    There is scant evidence that lifestyle changes have any clinically relevant impact on gout management.

    Surgical weight loss is one of the few non medication related interventions that has a substantial impact on serum urate.

    The American College of Rheumatology recognised this in the 2012 ACR Gout guidelines by saying "the TFP [Task Force Panel] recognized that diet and lifestyle measures alone provide therapeutically insufficient serum urate-lowering effects and/or gout attack prophylaxis for a large fraction of individuals with gout".

    One of the problems with lack of high quality gout care in Australia in my opinion is the undue emphasis on non-evidence based interventions, that, even if effective (which they have not shown to be yet), have a small effect size. This is often to the detriment of emphasis on effective evidence based therapies (all of which are currently medication based).

    A focus on effective evidence based therapies would likely lead to a better level of gout care by all involved with caring for these patients.

    Conflict of Interest:

    Menarini and AstraZeneca (Research Funding and Speaking)

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  6. Planning better care at the Casualty Department

    Dear Editor:

    We are living a new epoch all over the world. Also in clinical medicine. As it is known, for example, the model of a single doctor participating heavily at each step of treatment is giving way to expanded- care teams.

    Moreno-Rodriguez identified an universal crisis of the clinical method, with dangerous consequences in the practice of medicine. Among its main causes there are: a deterioration in the doctor-patient relationship, the undervaluation of clinics, the process of specialization, the overvaluation of technology, and the indifference for general medicine. (1)

    Moreover, the rigid implementation of guidelines and protocols adopted as an "standardized new medicine", tend to favor a person "non- centered" medicine. (2) So, the doctor/patient relationship has been diluted. These elements are more evident in the elderly patients, usually with several chronic conditions, when they attend to Emergency Departments,.

    The case referred by John Launer in the Postgraduate Medical Journal recently is common in the Casualty Departments of great general hospitals. (3) In order to minimize these situations in our Hospital General Universitario Dr. Gustavo Aldereguia Lima, daily emergency teams are carefully planned with enough number of specialists in Internal Medicine, Emergency Medicine, General Surgery, Traumatology, and the main specialties of the center, all of them working at the same local of this service, besides residents and internships. Specialists supervise -joined with nurses- the continuous care of the patients that stay for abnormal long periods in this department and in a beside Observation room, and decide the final output of them: return to the community or admission to the hospital wards.

    No one system is perfect, but the knowledge of this new scenario in clinical medicine, with the possibility to order different tests -many of them unnecessary- particularly by the young doctors, (4) and the care segmentation by different doctors of several specialties, is the first step to avoid tortuous evolution in this new context.

    As a BMJ Editor's choice several years ago expressed: "What is it that doctors offer that other professionals cannot? Diagnosis, diagnosis, diagnosis," so for good results the clinical gist in essential, (5) including the indispensable humanitarianism of our profession.

    Professor Alfredo D. Espinosa-Brito, MD, PhD, Professor Angel J. Romero-Cabrera, MD, PhD, Professor Alfredo A. Espinosa-Roca, MD, PhD

    References:

    1. Moreno-Rodriguez MA. Crisis del metodo clinico. Medisur (Suplemento "El metodo clinico") 2010; 8(5):32-36. 2. Espinosa-Brito A. La medicina centrada en las personas y la medicina personalizada. Medisur. 2015;13(6):920-924. 3. Launer J. Clinical gist. Postgrad Med J 2016;92:121 -122. 4. Nelson B. Waste: Unnecessary Overuse of Medical Care Causes Both Waste and Harm. The Hospitalist 2015;19(6):23-27. 5. Editor's choice. Diagnosis, diagnosis, diagnosis. BMJ. 2002;324 (2 March). [accesed 11 Aug 2007]. Available in: http://dx.doi.org/10.1136/bmj.324.7336.0/ghttp:/ BMJ 2002;324:g

    Conflict of Interest:

    None declared

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  7. Re: Healthy eating: an NHS priority

    Promoting healthy eating certainly needs to be a greater priority within the NHS but I suspect changing culture will be easier said than done. I the hospital I worked at last year, the central point of the hospital was a Greggs. There was no canteen and whilst there was a cafe selling healthier food above the Greggs I found many patients did not know it existed and for the staff it did not have the same opening hours as Greggs. This makes healthy eating in this context the more difficult option, especially as its location is so central to the hospital, it makes it hard to ignore. Changing this would involve a massive overhaul in the structure and culture of the hospital, especially as it is reportedly the second busiest Greggs in the country(1) It is not just availability of healthy food in the hospital however than needs the be made easier, in hospitals where there are limited choices of food options out of hours, many choose to send relatives or parents to local shops for food. Frequently the only places open out of hours are fast food restaurants and take-aways. In fact in another hospital I have worked at, there was a fish and chip shop opposite the hospital which boasted 'low calorie oil' and advised people the 'look after their heart' by eating there. A cross-sectional study in the BMJ last year found that just living or working in close proximity to fast-food restaurants (2) I feel it is not just hospitals but a whole cultural shift that needs to occur to promote healthier eating in this country.

    1. Express and Star Aug 4 2014. Available from URL http://www.expressandstar.com/news/2014/08/04/new-cross-hospitals-greggs- the-second-busiest-in-country/ 2.Associations between exposure to takeaway food outlets, takeaway food consumption, and body weight in Cambridgeshire, UK: population based, cross sectional study. BMJ 2014;348:g1464

    Conflict of Interest:

    None declared

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  8. Old Age: Strong and incessant exercise in the open air

    Dear Editor,

    I read with interest the article "Physical activity is medicine for older adults" by Taylor in the Postgraduate Medical Journal (1). I agree that physical activity is and remains an organismic necessity and the best buy for public health (2-3)!

    The German physician Christopher William Hufeland (1762 - 1836) wrote in his famous work 'Art of Prolonging Life' in 1797: "Harmony in the movements is the grand foundation on which health, uniformity of restoration, and the duration of the body, depend; and these certainly cannot take place if we merely sit and think. The propensity to bodily movement is, in man, as great as the propensity to eating and drinking. Let us only look at a child. Sitting still is to it the greatest punishment. And the faculty of sitting the whole day, and not feeling the least desire for moving, is certainly an unnatural and diseased state. We are taught by experience, that those men attained to the greatest age, who accustomed themselves to strong and incessant exercise in the open air. I consider it, therefore, as an indispensable law of longevity, that one should exercise, at least, an hour every day, in the open air."(4)

    References:

    1. Taylor D. Physical activity is medicine for older adults. Postgrad Med J 2014;90(1059):26-32. 2. Morris JN. Exercise in the prevention of coronary heart disease: today's best buy in public health. Med Sci Sports Exerc 1994;26(7):807-14. 3. Chase JA. Interventions to increase physical activity among older adults: a meta-analysis. Gerontologist 2015;55(4):706-18. 4. Hufeland CW. The art of prolonging life. Transl. from the German. London: Bell; 1797.

    Conflict of Interest:

    None declared

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  9. Re: Old Age: Medicine is activity (Do not forget Susruta of India)

    Dear Professor Jorwal,

    In history of exercise physiology is often forgotten that Susruta of ancient India was the first physician to prescribe physical activity for health reasons. He promoted dietary changes and daily exercise of moderate intensity such as brisk walking to minimize the consequences of diabetes and obesity (1). Today, elderly people are very likely to benefit even from simple, full-body exercises, such as rising from a chair and sitting back down again (10 repetitions, two to three times a day).

    1. Tipton CM. Susruta of India, an unrecognized contributor to the history of exercise physiology. J Appl Physiol 2008;104:1553-6.

    Conflict of Interest:

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  10. Adrenaline in the management of anaphylaxis. What about medical students?

    The paper by Plum et al. (1) prompted us to verify how fourth year medical students performed in choosing the initial dose and route of administration of adrenaline in the treatment of adult anaphylaxis. The question was one of the 20 they had to answer by blackening the correct box (C for this specific question) to pass the Clinical Immunology (CI) exam. Many (approximately two-thirds) of the 192 students who responded to the multiple choice question had attended the 16 hour CI course, which included one and a half hour lecture on the causes, clinical presentation, diagnostic criteria, differential diagnosis and management of anaphylaxis according to the WAO guidelines (2) only about one month before . The multiple choice question was A. 500 mg IM, B. 500 mg IV, C. 500 micrograms IM, D. 500 micrograms IV, E. 500 micrograms SC. Only 45% chose the correct dose and route. 62 out of 192 (32%) chose the wrong dose (500 mg) and the correct route (IM) while 13% (25 out of 192) the correct dose (500 micrograms)and the wrong route (either IV or SC). Eighteen medical students (9%) would have inappropriately given 500 mg IV to their anaphylaxis patients. Our medical students did only a little better than Pump et al'. junior doctors (45% vs 34% chose the correct route and dose, chi square p=0.09) but still only about half of those who had supposedly been lectured just one month before undertaking the test were aware of the correct dose and route of adrenaline for emergency management of anaphylaxis.

    Reference

    1.Plumb B et al. Correct recognition and management of anaphylaxis: not much change over a decade. Postgrad Med J 2015;91:3-7 doi:10.1136/postgradmedj-2013-132181.

    2. Simons FER et al. World Allergy Organizationguidelines for the assessment and management of anaphylaxis.WAO Journal 2011;13-37.

    Conflict of Interest:

    None declared

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