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Recent eLetters

Displaying 1-10 letters out of 234 published

  1. 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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  2. 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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  3. 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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  4. 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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  5. 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:

    None declared

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  6. 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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  7. Old Age: Medicine is activity

    Sir,

    This article points out the well documented fact that increased physical activity has clear-cut protective effect from all cause mortality(1). Developing countries like India are also acknowledging such facts and are issuing guidelines for the same so as to promote health care of elderly even at primary health care level(2).

    With development and prosperity the average individual age is increasing which is attracting focus of governments and policy makers towards growing need to cater to such population. The root cause of major physical impairment in old age is physical inactivity and its consequences, this fact need to be projected in a clear and concrete way in the midst of general population specially the elderly and their families.

    The physician, individual concerned and community all should work in synchronization towards promoting health and vitality to the elderly. There needs to be greater involvement of elderly into accepting increasing bodily movements as a part of life. Another area of concern will be ways to protract such activity and devote greater manpower and political will towards this often neglected but inevitable phase of life.

    References :

    1. Ueshima K, Ishikawa-Takata K, Yorifuji T, et al Physical activity and mortality risk in the Japanese elderly. A cohort study. Am J Prev Med 2010;38:410-18.

    2. www.mohfw.nic.in/WriteReadData/l892s/NPHCE.pdf Ministery of Health and Family Welfare, Government Of India, New Delhi, India. 11/11/2013.

    Conflict of Interest:

    None declared

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  8. Holistic care needs to be met with holistic education

    The increasing numbers of frail elderly patients certainly poses a challenge for all parts of the healthcare landscape within the UK and beyond. Whilst organisational change and modifications to where, when and how we deliver care is important this must be underpinned by appropriate education for doctors and allied healthcare professionals.

    Much of this needs to be aimed at more junior staff, especially medical students and junior doctors. Elderly care medicine has been undervalued for too long and the complexities of older people have been underestimated. Education therefore needs to be focussed on two main areas:

    1. An ability to understand complex medical conditions, the interactions that these conditions have with each other and the medications that can improve and worsen these problems. This must be learnt in the context of the multi-disciplinary team and understand the complex psycho-social dimensions that exist within the ageing community.

    2. An understanding that over medicalisation of the health needs of older people can be detrimental to both physical and psychological care, in particular the understanding that just because we can investigate and treat problems doesn't mean that we should. These decisions are complex and should be made in conjunction with patients, their families and independant advocates if patients lack capacity and family.

    Changes to the care of older people must be made in a sustainable and holistic way which have education as the foundation to ensure modifications are successful.

    Conflict of Interest:

    Academic Clinical Fellow in Medical Education at Plymouth University

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  9. Less health care might be fair in the older patient.

    Predicting prognosis in this older group of patients is complex due to their highly variable health status, driven by their fundamentally different prognosis to younger patients. We have published two recent pieces on this theme, showing that firstly though there was an incremental reduction in the use of evidence-based therapies for ACS (acute coronary syndrome) with older age and that better survival was associated with intensive management at all ages, this benefit was attenuated the older the patient.(1) Secondly, higher troponin levels are associated with increasing risk of mortality, but we found very high mortality rates in older patients even at the lowest troponin values. There was an attenuation of the prognostic value of troponins in older age and thus, the prognostic value of troponins depends on patient age in ACS - essentially, age is the biggest prognostic marker, and arguably markers we use in younger patients are not as relevant in older patients.(2) Current risk scores to guide aggressive management of coronary disease in the older person perform poorly, over-estimating mortality and ignoring morbidity, perhaps of more relevance to this age group.(3) In a population of older adults, adjustment for 27 biological risk factors including co- morbidity, social status, lifestyle and disease factors, cognition and frailty substantially reduced the association between chronological age and 5-year mortality (ages 80-84 years: unadjusted relative risk, 4.1; adjusted relative risk, 1.7).(4)

    As outcomes are influenced by both age and co-morbidity, is the under -treatment of older people with ACS relative to younger patients thus 'appropriate'? Evidence suggests that risks associated with more intensive management in older people may be related more to their greater co- morbidity than age alone(5) and thus chronological age alone may not be the best measure by which to plan clinical management in older people. Trials also tend to focus on hard outcomes and also rarely take into account wider prognostic measures such as disability, repeated hospitalisation and return to independent living that are more relevant in older people. Others have also written that sometimes following exacting clincial guidelines that lead to more treatment may not be in the best interests of the older patient.(6)

    The ideal pathway in the older patient for example with an ACS should not assume early intervention with revascularisation is the optimum strategy (as is usually the case in the younger patient) but should be a more holistic management strategy based upon thorough comprehensive geriatric assessment. Frailty,(7) functional status, and social aspects of care in the elderly are rarely included as clinical parameters (read wider prognostic markers) in decisions pertaining to future care. Furthermore, outcomes beyond survival need assessing, and ones of particular relevance to the older patient.

    1. Zaman MJ, Stirling S, Shepstone L, Ryding A, Flather M, Bachmann M, et al. The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP). European Heart Journal. 2014 March 18, 2014.

    2. Myint PK, Kwok CS, Bachmann MO, Stirling S, Shepstone L, Zaman MJS. Prognostic value of troponins in acute coronary syndrome depends upon patient age. Heart. 2014 June 26, 2014.

    3. Zingone B, Gatti G, Rauber E, Tiziani P, Dreas L, Pappalardo A, et al. Early and late outcomes of cardiac surgery in octogenarians. Ann Thorac Surg. 2009 Jan;87(1):71-8.

    4. Fried LP, Kronmal RA, Newman AB, Bild DE, Mittelmark MB, Polak JF, et al. Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study. JAMA. 1998 Feb 25;279(8):585-92.

    5. Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, et al. Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey. Eur Heart J. 2006 Apr;27(7):789-95.

    6. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA. [doi: 10.1001/jama.294.6.716]. 2005;294(6):716-24.

    7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001 March 1, 2001;56(3):M146-M57.

    Conflict of Interest:

    None declared

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  10. Evaluating the 5Fs mnemonic for cholelithiasis in a peruvian population

    Dear editor: We read with great interest the paper by Bass et al[1] on the mnemonics of cholelithiatis in the november 2013 issue of PMJ. The authors conclude that Family History should be considered as a predictive factor. We would like to share our own experience on this matter. We collected 173 consecutive patients diagnosed of cholelithiasis, inpatients and ambulatory care patients, during January and February, 2014. In all cases the diagnosis of biliary stones was established by an abdominal ultrasound or surgical confirmation. Patients were interviewed on sex, age, parity, family history of cholelitiasis. Skin fair and the body mass index were determined by our team. Parity was considered positive when there was at least one born child. Fat was considered as such with a BMI of 25 or more. A family history was considered positive if a first degree relative had been diagnosed or had surgery for cholelithiasis. A total of 173 patients were included; with an age average of 50,16 +- 14 years and 79.8 % female. The frequency of each of the 6 Fs studied are a)Fertility:95.7% ; b)Female: 97.8% ; c)Forty: 75.1% ; d)Fat: 69.9% ; e)Family History: 46.2%, f) Fair: 4% (*Fertility: only females ; fat: excluded 69 patients with surgical confirmation) According to our results, fertility, female gender, age above 40 years and an increased BMI were the 4 Fs that best predicted cholelithiasis. In Peru, and particularly in Callao, where predominant skin phototypes are III, IV and V and fair skin is very rarely found, the F of fair, should be disregarded[2]. Therefore, we agree with the authors that Family History should also be considered as a predictive factor. Conflict of Interest: None declared REFERENCES 1. Bass G, Gilani SNS,Walsh TN.Validating the 5Fs mnemonic for cholelithiasis: time to include family history. Postgrad Med J 2013;89:638-641. 2. Ramos C, Ramos M. Conocimientos, actitudes y practicas en fotoproteccion y fototipo cutaneo en asistentes a una campana preventiva del cancer de piel. Callao-Peru. Febrero 2010.Dermatol Peru 2010;20(3):169-173

    Conflict of Interest:

    None declared

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